Diagnostic Criteria for Borderline Personality Disorder

The current diagnostic criteria set for Borderline Personality Disorder (BPD) is taken from the American Psychiatric Association’s DSM-5 (APA, 2013). Patients must meet five of nine criteria in order to be diagnosed with BPD. Patients who partially, but incompletely, meet this criteria set may be considered to have borderline personality traits or features. Although not fulfilling criteria for the full disorder, such a formulation may nonetheless be useful in guiding treatment decisions.

DSM-5

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behaviour, as it is covered in Criterion 5.
  2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
  3. Identity disturbance: markedly and persistently unstable self image or sense of self.
  4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour, which is covered in Criterion 5.
  5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.
  6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
  7. Chronic feelings of emptiness.
  8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

The American Psychiatric Association is working toward a revision of the DSM, including a different way of classifying personality disorders. The proposed revision is intended to combine some of the categories used in DSM-IV-TR with elements of a dimensional conceptualization of personality features. The current proposal is outlined below.

Proposed Criteria for Future Consideration (DSM-5 Appendix)

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose BPD, the following criteria must be met:

A. Significant impairments in personality functioning manifest by:

    1. Impairments in self functioning (a or b):
      1. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.
      2. Self-direction: Instability in goals, aspirations, values, or career plans.
      AND
  1. Impairments in interpersonal functioning (a or b):
    1. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.
    2. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.

B. Pathological personality traits in the following domains:

  1. Negative Affectivity, characterized by:
    1. Emotional lability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
    2. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.
    3. Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.
    4. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.
  2. Disinhibition, characterized by:
    1. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.
    2. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger.
  3. Antagonism, characterized by:
    1. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.

D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.

E. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance
(e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).