It is crucial to follow the right criteria for diagnosing a borderline personality disorder. Because, BPD has several similarities to other mental conditions like mood disorders.
Unfortunately, a large number of BPD patients are not identified even during counseling and psychiatric tests.
Most cases of borderline disorder come under observation after a suicide attempt or threats. It usually happens when the patient is taken to an emergency department.
It is good to learn about the current diagnostic criteria for borderline personality disorder. Most commonly followed criteria for BPD diagnosis are the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) published in 2000. And in 2013, DSM-5 criteria were introduced with further updates of symptoms for diagnosing BPD.
American Psychiatric Association approves and publishes the DSM which gives diagnostic information for psychiatric disorders.
DSM contains a list of symptoms associated with the diagnosis of a particular mental disorder. It also suggests the number of symptoms required for confirming the actual existence of the disorders like BPD.
DSM-IV-TR (2000) criteria for Borderline Personality Disorder
The symptoms should have a pervasive pattern of instability of interpersonal relationships and self-image. The patient begins to show impulsivity beginning of early adulthood, and the symptoms may be present in a variety of life situations and context. At least five or more of the following symptoms must exist to validate a possible case of BPD. The criteria are:
- frantic efforts to avoid real or imagined abandonment.
- a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
- identity disturbance: markedly and persistently unstable self-image or sense of self
- impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating
- recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
- affective instability due to a marked reactivity of mood
- chronic feelings of emptiness
- inappropriate, intense anger or difficulty controlling anger
- transient, stress-related paranoid ideation or severe dissociative symptoms
DSM-5 (2013) criteria for Diagnosing Borderline Personality Disorder
The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) is the product of more than 10 years of effort by hundreds of international experts in all aspects of mental health.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the 2013 update to the Diagnostic and Statistical Manual of Mental Disorders. The DSM-5 was published on May 18, 2013, by the American Psychiatric Association (APA) supersedes the DSM-IV-TR, which was released in 2000.
Summary of the Criteria included in DSM-5 are:
Moderate or greater impairment in personality functioning; two or more of the following criteria:
- Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.
- Self-direction: Instability in goals, aspirations, values, or career plans.
- 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.
- 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.
Four or more of the following seven pathological personality traits must be present:
- Emotional lability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
- 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.
- Separation insecurity: Fears of rejection by— and/or separation from—significant others, associated with fears of excessive dependency and complete loss of autonomy.
- Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feelings of inferior self-worth; thoughts of suicide and suicidal behavior.
- 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.
- 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.
- Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.
The impairments in personality functioning and the individual’s personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations.
The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time with onsets that can be traced back at least to adolescence or early adulthood.
The impairments in personality functioning and the individual’s personality trait expression are not better explained by another mental disorder.
The impairments in personality functioning and the individual’s personality trait expression are not attributable to a substance (e.g., a drug of abuse, medication, exposure to a toxin) or a general medical condition (e.g., severe head trauma).
The impairments in personality functioning and the individual’s personality trait expression are not better understood as normal for the individual’s developmental stage or the socio-cultural environment.
Strength and Reliability of Criterion for Diagnosing BPD
The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been developed and evolved over two decades. A team of expert psychiatrists and psychologists jointly developed DSM criteria. Most of the team members are preeminent BPD researchers with several years of experience in dealing with BPD patients.
The American Psychiatric Association also make continues effort to refine criteria according to the latest research findings in mental disorders.
According to a 2019 study, the dimensional components of the DSM-5 Alternative Model demonstrated significantly more diagnostic reliability than the DSM-IV categorical diagnoses. DSM-5 Alternative Model has easy ways to conceptualize borderline personality with greater reliability than the extant DSM-IV definition.
BPD Diagnosis Process
It is difficult to diagnose BPD because of many other psychological disorders and medical problems which have similar symptoms. Therefore, it is necessary to avail the service of a qualified and well experienced mental health expert to diagnose the disorder.
A proficient psychiatrist or psychologist will carefully conduct a thorough assessment and make a correct diagnosis.
A proper and complete assessment of the BPD involves several steps such as:
- Conducts friendly interviews to inquire about the symptoms, genetics and biological factors, health conditions, environmental factors, and living conditions
- Uses written questionnaires on BPD symptoms
- Enquires about patient’s behavior from family members, friends, lover and colleagues
- Categorizes the identified symptoms and tallies them with DSM diagnosis criteria
- Robert S. Biskin, MD and Joel Paris, MD, Diagnosing borderline personality disorder, CMAJ-JAMC, 2012 Nov 6; 184(16): 1789–1794.
- American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision. Washington, DC: Author, 2007.
- Oldham, MD, John. “Launching DSM-V.” Journal of Psychiatric Practice, 13: 351, November 2007.