Borderline Personality Disorder – DSM-5 and ICD-11 Diagnostic Criteria

This category should ONLY be used in combination with a Personality disorder category (Mild, Moderate, or Severe) or Personality difficulty.

• A personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability.
• The ability to plan ahead may be minimal, and outbursts of intense anger may often lead to violence or “behavioural explosions”; these are easily precipitated when impulsive acts are criticized or thwarted by others.

Borderline pattern qualifier:

The Borderline pattern qualifier may be applied to individuals whose pattern of personality disturbance is characterized by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, as indicated by five (or more) of the following:

• Frantic efforts to avoid real or imagined abandonment.
• A pattern of unstable and intense interpersonal relationships, typically characterized by alternating between extremes of idealization and devaluation.
• Identity disturbance, manifested in markedly and persistently unstable self-image or sense of self.
• Impulsivity manifested in potentially self-damaging behaviours (e.g., risky sexual behaviour, reckless driving, excessive alcohol or substance use, binge eating).
• Recurrent episodes of self-harm (e.g., suicide attempts or gestures, self-mutilation).
• Emotional instability due to marked reactivity of mood. Fluctuations of mood may be triggered either internally (e.g., by one’s own thoughts) or by external events. As a consequence, the individual experiences intense dysphoric mood states, which typically last for a few hours but may last for up to several days.
• Chronic feelings of emptiness.
• Inappropriate, intense anger or difficulty controlling anger manifested in frequent displays of temper (e.g., yelling or screaming, throwing or breaking things, getting into physical fights).
• Transient dissociative symptoms or psychotic-like features (e.g., brief hallucinations, paranoia) in situations of high affective arousal.

Other manifestations of Borderline pattern, not all of which may be present in a given individual at a given time, include the following:

• A view of the self as inadequate, bad, guilty, disgusting, and contemptible.
• An experience of the self as profoundly different and isolated from other people; a painful sense of alienation and pervasive loneliness.
• Proneness to rejection hypersensitivity; problems in establishing and maintaining consistent and appropriate levels of trust in interpersonal relationships; frequent misinterpretation of social signals.

Understanding Narcissistic Personality Disorder: The Concept of Narcissism | DSM-5 Criteria | ICD-11 Conceptualisation

Related learning on The Academy

• To extend the diagnostic discussion of borderline personality disorder into evidence-based management, clinicians may find Dialectical Behaviour Therapy – A Practical Guide for Clinicians on The Academy by Psych Scene particularly valuable. The course explores core DBT principles, including mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness, with practical frameworks for supporting individuals with complex presentations.
• Clinicians interested in diagnostic overlap and differentiation may also find Complex Post-traumatic Stress Disorder (C-PTSD) – A Practical Guide valuable. The course explores adverse childhood experiences, clinical features of C-PTSD, diagnostic challenges, overlap and differentiation between PTSD, C-PTSD and BPD, and phase-oriented approaches to managing complex trauma.
• Clinicians seeking a broader formulation-based approach to personality disorder assessment may find Advanced Psychiatric Formulation and Strategic Management – A 2 Part Series valuable. The series supports diagnostic reasoning alongside DSM and ICD criteria, integrating phenomenology, neurobiology, psychodynamics and clinical formulation to guide personalised management in complex psychiatric presentations.

1. How does DSM-5 describe borderline personality disorder?
DSM-5 describes borderline personality disorder through significant impairments in personality functioning and the presence of pathological personality traits. The key areas of impairment include identity, self-direction, empathy and intimacy.

2. What self-functioning impairments are included in DSM-5 criteria?
DSM-5 self-functioning impairments include unstable or poorly developed self-image, excessive self-criticism, chronic feelings of emptiness, dissociative states under stress and instability in goals, aspirations, values or career plans.

3. What interpersonal impairments are included in DSM-5 criteria?
DSM-5 interpersonal impairments include compromised empathy, interpersonal hypersensitivity, mistrust, neediness, anxious preoccupation with real or imagined abandonment and intense, unstable relationships marked by idealisation and devaluation.

4. Which DSM-5 trait domains are associated with borderline personality disorder?
The DSM-5 trait domains associated with borderline personality disorder are negative affectivity, disinhibition and antagonism.

5. How does negative affectivity present in DSM-5 borderline personality disorder criteria?
Negative affectivity may present as emotional lability, anxiousness, separation insecurity and depressivity. This can include intense emotional reactions, fear of rejection or separation, chronic shame, hopelessness, low self-worth and suicidal thoughts or behaviour.

6. How do disinhibition and antagonism present in DSM-5 criteria?
Disinhibition may present as impulsivity and risk-taking, including acting without considering consequences, difficulty following plans and self-harming behaviour under emotional distress. Antagonism may present as hostility, persistent anger or irritability in response to perceived slights.

7. How does ICD-11 conceptualise the borderline pattern?
ICD-11 uses a borderline pattern qualifier. This qualifier should only be used in combination with a personality disorder category, such as mild, moderate or severe personality disorder, or with personality difficulty.

8. What features are included in the ICD-11 borderline pattern qualifier?
The ICD-11 borderline pattern includes instability in interpersonal relationships, self-image and affect, together with marked impulsivity. Features may include fear of abandonment, unstable relationships, identity disturbance, self-damaging impulsivity, self-harm, emotional instability, chronic emptiness, intense anger and transient dissociative or psychotic-like symptoms during high affective arousal.

9. Is borderline personality disorder a standalone diagnosis in ICD-11?
The ICD-11 borderline pattern is not used as a standalone diagnosis in the same way as traditional categorical personality disorder diagnoses. It is applied alongside a personality disorder severity category or personality difficulty when the borderline pattern is clinically present.

10. What is the difference between DSM-5 and ICD-11 in this article?
DSM-5 describes borderline personality disorder through impairments in personality functioning and pathological personality traits. ICD-11 uses a dimensional structure in which the borderline pattern qualifier is applied alongside a personality disorder severity category or personality difficulty.

11. Why is stability across time and context important in DSM-5 criteria?
DSM-5 specifies that impairments in personality functioning and pathological trait expression should be relatively stable across time and consistent across situations. They should not be better explained by developmental stage, socio-cultural context, substances or a general medical condition.

12. Why is comparing DSM-5 and ICD-11 criteria useful for clinicians?
Comparing DSM-5 and ICD-11 helps clinicians distinguish between personality functioning, pathological trait domains, personality disorder severity and the borderline pattern qualifier. This supports more precise use of diagnostic criteria across both classification systems.

• Borderline personality disorder is defined by impairments in personality functioning, particularly self-functioning and interpersonal functioning, together with pathological personality traits.

• In DSM-5, impairments in self-functioning include unstable identity, excessive self-criticism, chronic emptiness, stress-related dissociative states and instability in goals, values, aspirations or career plans.
• DSM-5 interpersonal impairments include compromised empathy, interpersonal hypersensitivity, mistrust, neediness, anxious preoccupation with abandonment and intense relationships marked by idealisation and devaluation.
• The DSM-5 pathological trait domains associated with borderline personality disorder include negative affectivity, disinhibition and antagonism, expressed through emotional lability, anxiousness, separation insecurity, depressivity, impulsivity, risk-taking and hostility.
• ICD-11 does not use the borderline pattern as a standalone diagnosis; it is applied in combination with a personality disorder severity category or personality difficulty.
• The ICD-11 borderline pattern qualifier describes instability of interpersonal relationships, self-image and affect, together with marked impulsivity, self-harm risk, chronic emptiness, intense anger and transient dissociative or psychotic-like symptoms under high affective arousal.