Borderline Personality Disorder – DSM-5 and ICD-11 Diagnostic Criteria
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits.
According to the DSM- 5, to diagnose a borderline personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
Impairments in self-functioning (a or b):
- Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.
- Instability in goals, aspirations, values, or career plans.
Impairments in interpersonal functioning (a or b):
- Compromised ability to recognise 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.
- 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:
a. Emotional liability:
- Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
- 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.
c. Separation insecurity:
- Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.
- 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 behaviour.
2. Disinhibition, characterized by:
- 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 behaviour under emotional distress.
- 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:
- 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).
ICD-11 DIAGNOSTIC CRITERIA FOR BORDERLINE PATTERN OF PERSONALITY DISORDER OR PERSONALITY DIFFICULTY
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.
Two variants of this personality disorder are specified, and both share this general theme of impulsiveness and lack of self-control.
- The predominant characteristics are emotional instability and lack of impulse control.
- Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others. Includes: explosive and aggressive personality (disorder) Excludes: dissocial personality disorder
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.
American Psychiatric Association, & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA.
Bach, B., & First, M. B. (2018). Application of the ICD-11 classification of personality disorders. BMC psychiatry, 18(1), 1-14.