dsm 5 Borderline Personality Disorder

Borderline Personality Disorder

Diagnostic Criteria 301.83 (F60.3)

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 behavior covered in Criterion 5.)

2. A pattern of unstable and intense interpersonal relationships characterized by alternat-

ing 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 behavior covered in Criterion 5.)

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

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.

_____

Diagnostic Features

The essential feature of borderline personality disorder is a pervasive pattern of instability 

of interpersonal relationships, self-image, and affects, and marked impulsivity that begins 

by early adulthood and is present in a variety of contexts.

Individuals with borderline personality disorder make frantic efforts to avoid real or 

imagined abandonment (Criterion 1). The perception of impending separation or rejection, 

or the loss of external structure, can lead to profound changes in self-image, affect, cognition, 

and behavior. These individuals are very sensitive to environmental circumstances. They ex-

perience intense abandonment fears and inappropriate anger even when faced with a real-

istic time-limited separation or when there are unavoidable changes in plans (e.g., sudden 

despair in reaction to a clinician's announcing the end of the hour; panic or fury when some-

one important to them is just a few minutes late or must cancel an appointment). They may 

believe that this "abandonment" implies they are "bad." These abandonment fears are related to an intolerance of being alone and a need to have other people with them. efforts to avoid abandonment may include impulsive actions such as self-mutilating or sui-

cidal behaviors, which are described separately in Criterion 5.

Individuals with borderline personality disorder have a pattern of unstable and intense 

relationships (Criterion 2). They may idealize potential caregivers or lovers at the first or 

second meeting, demand to spend a lot of time together, and share the most intimate details 

early in a relationship. However, they may switch quickly from idealizing other people to 

devaluing them, feeling that the other person does not care enough, does not give enough, 

or is not "there" enough. These individuals can empathize with and nurture other people, 

but only with the expectation that the other person will "be there" in return to meet their 

own needs on demand. These individuals are prone to sudden and dramatic shifts in their 

view of others, who may alternatively be seen as beneficent supports or as cruelly punitive. 

Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had 

been idealized or whose rejection or abandonment is expected.

There may be an identity disturbance characterized by markedly and persistently un-

stable self-image or sense of self (Criterion 3). There are sudden and dramatic shifts in self-

image, characterized by shifting goals, values, and vocational aspirations. There may be 

sudden changes in opinions and plans about career, sexual identity, values, and types of 

friends. These individuals may suddenly change from the role of a needy supplicant for 

help to that of a righteous avenger of past mistreatment. Although they usually have a self-

image that is based on being bad or evil, individuals with this disorder may at times have 

feelings that they do not exist at all. Such experiences usually occur in situations in which 

the individual feels a lack of a meaningful relationship, nurturing, and support. These in-

dividuals may show worse performance in unstructured work or school situations.

Individuals with borderline personality disorder display impulsivity in at least two areas 

that are potentially self-damaging (Criterion 4). They may gamble, spend money irrespon-

sibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly. Individuals 

with this disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilat-

ing behavior (Criterion 5). Completed suicide occurs in 8%-10% of such individuals, and 

self-mutilative acts (e.g., cutting or burning) and suicide threats and attempts are very 

common. Recurrent suicidality is often the reason that these individuals present for help. 

These self-destructive acts are usually precipitated by threats of separation or rejection or 

by expectations that the individual assumes increased responsibility. Self-mutilation may 

occur during dissociative experiences and often brings relief by reaffirming the ability to 

feel or by expiating the individual's sense of being evil.

Individuals with borderline personality disorder may display affective instability that 

is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anx-

iety usually lasting a few hours and only rarely more than a few days) (Criterion 6). The 

basic dysphoric mood of those with borderline personality disorder is often disrupted by 

periods of anger, panic, or despair and is rarely relieved by periods of well-being or satis-

faction. These episodes may reflect the individual's extreme reactivity to interpersonal 

stresses. Individuals with borderline personality disorder may be troubled by chronic feel-

ings of emptiness (Criterion 7). Easily bored, they may constantly seek something to do. 

Individuals with this disorder frequently express inappropriate, intense anger or have dif-

ficulty controlling their anger (Criterion 8). They may display extreme sarcasm, enduring 

bitterness, or verbal outbursts. The anger is often elicited when a caregiver or lover is seen 

as neglectful, withholding, uncaring, or abandoning. Such expressions of anger are often 

followed by shame and guilt and contribute to the feeling they have of being evil. During 

periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., de-

personalization) may occur (Criterion 9), but these are generally of insufficient severity or 

duration to warrant an additional diagnosis. These episodes occur most frequently in re-

sponse to a real or imagined abandonment. Symptoms tend to be transient, lasting min-

utes or hours. The real or perceived return of the caregiver's nurturance may result in a 

remission of symptoms.

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Separation Anxiety Disorder

Diagnostic Criteria 309.21 (F93.0)

A. Developmentally inappropriate and excessive fear or anxiety concerning separation from

those to whom the individual is attached, as evidenced by at least three of the following:

1. Recurrent excessive distress when anticipating or experiencing separation from

home or from major attachment figures.

. Persistent and excessive worry about losing major attachment figures or about pos-

sible harm to them, such as illness, injury, disasters, or death.

3. Persistent and excessive worry about experiencing an untoward event (e.g., getting

lost, being kidnapped, having an accident, becoming ill) that causes separation

from a major attachment figure.

4. Persistent reluctance or refusal to go out, away from home, to school, to work, or

elsewhere because of fear of separation.

5. Persistent and excessive fear of or reluctance about being alone or without major

attachment figures at home or in other settings.

6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.

7. Repeated nightmares involving the theme of separation.

8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nau-

sea, vomiting) when separation from major attachment figures occurs or is antici-

pated.

B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and

adolescents and typically 6 months or more in adults.

C. The disturbance causes clinically significant distress or impairment in social, aca-

demic, occupational, or other important areas of functioning.

D. The disturbance is not better explained by another mental disorder, such as refusing

to leave home because of excessive resistance to change in autism spectrum disorder;

delusions or hallucinations concerning separation in psychotic disorders; refusal to go

outside without a trusted companion in agoraphobia; worries about ill health or other

harm befalling significant others in generalized anxiety disorder; or concerns about

having an illness in illness anxiety disorder.

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Borderline Personality Disorder is also mentioned in the following:

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166, 167, 168

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Bipolar Disorder 

    Personality disorders. Personality disorders such as borderline personality disorder 

may have substantial symptomatic overlap with bipolar disorders, since mood lability 

and impulsivity are common in both conditions. Symptoms must represent a distinct ep-

isode, and the noticeable increase over baseline required for the diagnosis of bipolar dis-

order must be present. A diagnosis of a personality disorder should not be made during an 

untreated mood episode.

 

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SchiZOphreniâ spectrum and other psychotic disorders include schizophrenia, 

other psychotic disorders, and schizotypal (personality) disorder. They are defined by ab-

normalities in one or more of the following five domains: delusions, hallucinations, disor-

ganized thinking (speech), grossly disorganized or abnormal motor behavior (including 

catatonia), and negative symptoms.

Key Features That Define the Psychotic Disorders 

Delusions

Delusions are fixed beliefs that are not amenable to change in light of conflicting evidence. 

Their content may include a variety of themes (e.g., persecutory, referential, somatic, reli-

gious, grandiose). Persecutory delusions (i.e., belief that one is going to be harmed, harassed, 

and so forth by an individual, organization, or other group) are most common. Referential

delusions (i.e., belief that certain gestures, comments, environmental cues, and so forth are 

directed at oneself) are also common. Grandiose delusions (i.e., when an individual believes 

that he or she has exceptional abilities, wealth, or fame) and érotomanie delusions (i.e., when 

an individual believes falsely that another person is in love with him or her) are also seen. 

Nihilistic delusions involve the conviction that a major catastrophe will occur, and somatic

delusions focus on preoccupations regarding health and organ function.

Delusions are deemed bizarre if they are clearly implausible and not understandable to 

same-culture peers and do not derive from ordinary life experiences. An example of a bi-

zarre delusion is the belief that an outside force has removed his or her internal organs and 

replaced them with someone else's organs without leaving any wounds or scars. An ex-

ample of a nonbizarre delusion is the belief that one is under surveillance by the police, de-

spite a lack of convincing evidence. Delusions that express a loss of control over mind or 

body are generally considered to be bizarre; these include the belief that one's thoughts 

have been "removed" by some outside force {thought withdrawal), that alien thoughts have 

been put into one's mind (thought insertion), or that one's body or actions are being acted on 

or manipulated by some outside force (delusions of control). The distinction between a de-

lusion and a strongly held idea is sometimes difficult to make and depends in part on the 

degree of conviction with which the belief is held despite clear or reasonable contradictory 

evidence regarding its veracity.

Hallucinations

Hallucinations are perception-like experiences that occur without an external stimulus. 

They are vivid and clear, with the full force and impact of normal perceptions, and not 

under voluntary control. They may occur in any sensory modality, but auditory halluci-

nations are the most common in schizophrenia and related disorders. Auditory hallucina-

tions are usually experienced as voices, whether familiar or unfamiliar, that are perceived 

as distinct from the individual's own thoughts. The hallucinations must occur in the con-

text of a clear sensorium; those that occur while falling asleep (hypnagogic) or waking up (hypnopompic) are considered to be within the range of normal experience. Hallucinations 

may be a normal part of religious experience in certain cultural contexts.

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Delusional Disorder

Diagnostic Criteria 297.1 (F22)

A. The presence of one (or more) delusions with a duration of 1 month or longer.

B. Criterion A for schizophrenia has never been met.

Note: Hallucinations, if present, are not prominent and are related to the delusional

theme (e.g., the sensation of being infested with insects associated with delusions of

infestation).

C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly

impaired, and behavior is not obviously bizarre or odd.

D. If manic or major depressive episodes have occurred, these have been brief relative

to the duration of the delusional periods.

E. The disturbance is not attributable to the physiological effects of a substance or an-

other medical condition and is not better explained by another mental disorder, such

as body dysmorphic disorder or obsessive-compulsive disorder.

Specify whether:

Erotomanie type: This subtype applies when the central theme of the delusion is that

another person is in love with the individual.

Grandiose type: This subtype applies when the central theme of the delusion is the

conviction of having some great (but unrecognized) talent or insight or having made

some important discovery.

Jeaious type: This subtype applies when the central theme of the individual’s delusion

is that his or her spouse or lover is unfaithful.

Persecutory type: This subtype applies when the central theme of the delusion in-

volves the individual’s belief that he or she is being conspired against, cheated, spiedon, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals.

Somatic type: This subtype applies when the central theme of the delusion involves

bodily functions or sensations.

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Mixed type: This subtype applies when no one delusional theme predominates.

Unspecified type: This subtype applies when the dominant delusional belief cannot

be clearly determined or is not described in the specific types (e.g., referential delu-

sions without a prominent persecutory or grandiose component).

Specify if:

With bizarre content: Delusions are deemed bizarre if they are clearly implausible, not

understandable, and not derived from ordinary life experiences (e.g., an individual’s be-

lief that a stranger has removed his or her internal organs and replaced them with some-

one else’s organs without leaving any wounds or scars).

Specify if:

The following course specifiers are only to be used after a 1 -year duration of the disorder:

First episode, currently in acute episode: First manifestation of the disorder meet-

ing the defining diagnostic symptom and time criteria. An acute episode is a time pe-

riod in which the symptom criteria are fulfilled.

First episode, currently in partial remission: Partial remission is a time period dur-

ing which an improvement after a previous episode is maintained and in which the de-

fining criteria of the disorder are only partially fulfilled.

First episode, currently in full remission: Full remission is a period of time after a

previous episode during which no disorder-specific symptoms are present.

lUlultiple episodes, currently in acute episode

Multiple episodes, currently in partial remission

Multiple episodes, currently in full remission

Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are

remaining for the majority of the illness course, with subthreshold symptom periods be-

ing very brief relative to the overall course.

Unspecified

Specify current severity:

Severity is rated by a quantitative assessment of the primary symptoms of psychosis,

including delusions, hallucinations, disorganized speech, abnormal psychomotor be-

havior, and negative symptoms. Each of these symptoms may be rated for its current

severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present)

to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom

Severity in the chapter “Assessment Measures.”)

Note: Diagnosis of delusional disorder can be made without using this severity specifier.

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