DSM-5: Borderline Personality Disorder Signs And Symptoms

According to the American Psychiatric Association, borderline personality disorder (BPD) is typically characterized by a pattern of instability in various facets of life. This may include an unstable or poorly developed self-image, rapidly changing personal goals, intense but unstable relationships characterized by efforts to avoid abandonment, and an impaired ability to recognize the needs and feelings of others. Individuals living with borderline personality disorder can experience a range of other symptoms that can vary in their intensity. Additionally, they may live with comorbid mental health conditions, like post-traumatic stress disorder, eating disorders, or depression. 

While borderline personality disorder is a challenging psychiatric condition, it’s also treatable. Understanding how mental health professionals use the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to assess the signs of borderline personality disorder may help you determine whether you could benefit from a medical assessment for borderline personality disorder or other types of mental health conditions. Below, we’ll look at the diagnostic criteria for borderline personality disorder and ways to get support for your symptoms.

Borderline personality disorder: Prevalence and diagnosis

Main diagnostic criteria

Borderline personality disorder (BPD) is classified as a cluster B personality disorder in the Diagnostic and Statistical Manual of Mental Disorder (DSM-5). Cluster B personality disorders are characterized by emotional volatility, unstable relationships, and unpredictable behaviors. According to the DSM-5, a diagnosis of borderline personality disorder can be made if an individual exhibits a “pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood”. This “pervasive pattern of instability” and “marked impulsivity” can be evidenced by five or more symptoms, present in different environments or contexts, which are quoted as follows:

• 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 2 areas that are potentially self-damaging, for example, spending, substance abuse, reckless driving, sex, or binge eating

• Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior   

• Affective instability due to a marked reactivity of mood, for example, intense episodic dysphoria, anxiety, or irritability, usually lasting a few hours and rarely more than a few days    

• Chronic feelings of emptiness

• Inappropriate, intense anger or difficulty controlling anger, for example, frequent displays of temper, constant anger, or recurrent physical fights     

• Transient, stress-related paranoid ideation or severe dissociative symptoms    

Alternative diagnostic criteria

The American Psychiatric Association (APA) found that the traditional set of diagnostic criteria for personality disorders had some shortcomings. For example, several people were diagnosed with more than one personality disorder, and some people even met the criteria for four personality disorders. To address the shortcomings in the traditional approach to diagnosing personality disorders, the APA put forward an alternative method for the diagnosis of personality disorders. This approach, called the Alternative Model for Personality Disorders (AMPD), was included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Elements of personality functioning

According to the alternative criteria, for borderline personality disorder to be diagnosed, there should be moderate or great impairment in personality functioning. Per the Diagnostic and Statistical Manual of Mental Disorders, this impairment can be evidenced by difficulties in two or more of the following elements of personality traits.

1. Identity: Individuals living with borderline personality disorder may have a poorly developed and unstable self-image. This is often evidenced by symptoms such as persistent feelings of emptiness and brief episodes of delusions, especially under stress (e.g., a sensation that a person has left their body). Such feelings of identity disturbance could be alarming and distressing to the individual.

2. Self-direction: People with borderline personality disorder may demonstrate instability when it comes to their plans. They may change goals and aspirations often. Sometimes, changing their plans may result in switching careers, courses of study, or areas of specialization.

3. Empathy: People living with borderline personality disorder may find it challenging to recognize the feelings and needs of others. They may believe that other people will act negatively toward them, which can lead them to feel insulted or hurt easily.

4. Intimacy: People with borderline personality disorder often have intense and unstable relationships. They may go from periods of extreme idealization of their partner to periods of extreme devaluation of the same partner, depending on their perception of their partner leaving them.

Pathological personality traits

In addition to impairments in two of the elements of personality functioning, a person must have at least four of the following personality traits. According to the Diagnostic and Statistical Manual of Mental Disorders, at least one of the four must be impulsivity, risk-taking, or hostility for the individual to be diagnosed with bipolar personality disorder:

1. Emotional lability: People with borderline personality disorder may have emotional responses that are intense and out of proportion to the events to which they are reacting. This affective instability can make it hard for an individual to identify their feelings. It can also contribute to a pattern of unstable relationships.

2. Anxiousness: People with borderline personality disorder may experience intense feelings of nervousness, tension, and panic. They may experience this in response to stressful situations between them and those they are close to. 

3. Separation insecurity: People with borderline personality disorder are often scared of being abandoned by those close to them. This fear of rejection is often out of proportion. 

4. Depression: People with borderline personality disorder sometimes feel down and like nothing is right with the world. When they feel like this, they may also become pessimistic about the future. Depression can be associated with chronic feelings of emptiness. 

5. Impulsivity: People with borderline personality disorder may act without much planning or thought. They tend to act in response to whatever happens around them. When they are exposed to high levels of stress, they may resort to self-harm.

6. Risk-taking: People with borderline personality disorder may sometimes engage in potentially dangerous and risky activities without thought of the consequences for themselves. This can happen in different areas of life and in various environments. 

7. Hostility: People with borderline personality disorder may experience inappropriate, intense anger in response to perceived insults. This is often seen in several social contexts. 

Features associated with borderline personality disorder

The following features tend to be associated with borderline personality disorder but not necessarily diagnostic of it:

• Patterns of undermining oneself when a goal is about to be accomplished, such as leaving therapy just when therapy is working

• Psychotic-like symptoms, such as hallucinations

• Suicidal ideation

Borderline personality disorder can also be associated with other mental health disorders, such as bipolar disorder, depression, substance use disorder, eating disorders (especially bulimia nervosa), post-traumatic stress disorder, attention-deficit hyperactivity disorder, and other personality disorders.

Development and course of borderline personality disorder

Borderline personality disorder (BPD) tends to be more common among first-degree relatives of those with the disorder and often begins in early adulthood. According to the Substance Abuse and Mental Health Services Administration, borderline personality disorder is also more common in women and patients in psychiatric hospital care. Its symptoms are typically greatest in the young adult years and tend to decrease with age. Symptoms like self-harm and suicidal behavior also tend to decrease with age, while other symptoms like intense emotions, impulsiveness, and intense relationships may continue for the long term.

People with borderline personality disorder who receive treatment often show significant improvement within the first year. Studies suggest that after about 10 years of treatment, about half of individuals diagnosed with BPD may no longer meet the criteria for borderline personality disorder.

Differentials of borderline personality disorder

Borderline personality disorder (BPD) sometimes co-occurs with depressive or bipolar disorder. In situations like this, an individual must show clear symptoms of borderline personality disorder outside of episodes of depressive or bipolar disorder. Borderline personality disorder often has similar symptoms to those of some other personality disorders, but it’s usually differentiated in the following ways:

• Histrionic personality disorder (HPD) and borderline personality disorder tend to both be characterized by attention-seeking behavior. However, people with borderline personality disorder may harm themselves and have intense emotional outbursts when they feel abandoned, while people with HPD may act dramatically to get attention.

• People with borderline personality disorder and schizotypal disorder may have paranoid ideas. These ideas tend to occur transiently in people with BPD and are often in response to stress, while these ideas tend to be more constant in people with schizotypal personality disorder.

• Borderline personality disorder, paranoid personality disorder, and narcissistic personality disorder all tend to be characterized by disproportionate anger. However, both paranoid personality disorder and narcissistic personality disorder tend to lack the self-harm that can be common in those with BPD.

• Both people with borderline personality disorder and people with antisocial personality disorder may demonstrate manipulative behavior. People with antisocial personality disorder may be manipulative to gain power, profit, or pleasure. In contrast, people with BPD may manipulate to gain more concern from their loved ones and caregivers.

• People with dependent personality disorder and people with borderline personality disorder may be excessively afraid of abandonment. People with BPD often respond to this fear with outbursts of anger, while people with dependent personality disorder may respond with more submissiveness or the immediate seeking of replacement relationships.

Counseling for borderline personality disorder

If you think you may have symptoms of borderline personality disorder, know that you are not alone. It may help to speak with a licensed therapist about what you’re experiencing. If you feel hesitant about traditional in-office therapy, you might consider online therapy. 

With online counseling, you can connect with a licensed therapist from the comfort of your home via phone, live chat, or videoconferencing. You can also contact your therapist at any time via in-app messaging, and they’ll respond as soon as they can. This may prove to be useful if you experience emotional challenges in between sessions.

The efficacy of online counseling

Numerous studies have demonstrated online therapy to be just as effective as in-office therapy. One study published in the journal Borderline Personality Disorder and Emotion Dysregulation found that participants in an online peer-led art therapy program experienced increased well-being. Participants had an “improved capacity to control emotions and tolerate distress, improved connection with others, enhanced understanding of the self, and higher hope for living well.”