The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) defines Borderline Personality Disorder (BPD) as a pervasive pattern of instability in interpersonal relationships, self-image, and affects, along with marked impulsivity. These symptoms typically begin in early adulthood and occur across various contexts.

DSM-5 Diagnostic Criteria for Borderline Personality Disorder (BPD)

A diagnosis of Borderline Personality Disorder requires meeting five (or more) of the following nine criteria:

1. Frantic efforts to avoid real or imagined abandonment:
   • The individual may go to extreme lengths to prevent someone they care about from leaving them, even when there is no immediate threat of abandonment. This does not include suicidal or self-mutilating behavior covered by Criterion 5.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation (also known as “splitting”):
   • Relationships tend to be highly volatile, swinging between intense admiration (idealization) and complete dismissal or disdain (devaluation).
3. Identity disturbance: Markedly and persistently unstable self-image or sense of self:
   • The individual may have an unclear or unstable sense of who they are, with frequent changes in their values, goals, and identity, often experiencing feelings of emptiness or a lack of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating):
   • These impulsive behaviors occur without much thought to potential long-term consequences and can often put the individual in harm’s way.
5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior:
   • This can include repeated threats or attempts of suicide, as well as self-harming actions such as cutting or burning.
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):
   • Individuals with BPD experience rapid mood swings, often triggered by stress or interpersonal conflicts, resulting in intense, short-lived emotional reactions.
7. Chronic feelings of emptiness:
   • The person may frequently feel hollow or void of meaning and struggle to find satisfaction or purpose in life.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights):
   • Individuals may experience intense and disproportionate anger, often having difficulty managing or regulating it, which can lead to destructive behaviors or conflicts in relationships.
9. Transient, stress-related paranoid ideation or severe dissociative symptoms:
   • Under extreme stress, individuals may experience paranoid thoughts or dissociative symptoms, such as feeling detached from reality, themselves, or their emotions.

Additional Criteria

• Pervasive pattern: These behaviors must be present in a variety of contexts (e.g., at work, in relationships, in personal life) and not limited to a single setting.
• Onset and Duration: Symptoms typically begin by early adulthood and persist over time, though their intensity may vary.

Differential Diagnosis

It is important to rule out other personality disorders, as well as mood disorders (e.g., bipolar disorder), substance use disorders, and post-traumatic stress disorder (PTSD), which may exhibit overlapping symptoms with BPD. The emotional instability and impulsivity of BPD, for example, can sometimes resemble symptoms of bipolar disorder, though they differ in terms of mood episode duration and the overall pattern of symptoms.

Key Features of Borderline Personality Disorder according to DSM-5 Criteria for Borderline Personality Disorder

• Emotional dysregulation: Rapid, intense emotional shifts.
• Interpersonal difficulties: Often swinging between idealization and devaluation in relationships.
• Fear of abandonment: A profound fear of rejection or being left alone.
• Chronic feelings of emptiness: Persistent sense of meaninglessness.
• Impulsive and self-damaging behaviors: Engaging in risky or harmful behaviors without regard for consequences.

Treatment and Management

• Psychotherapy is the primary treatment for BPD, particularly Dialectical Behavior Therapy (DBT), which is designed specifically for managing intense emotions and improving interpersonal relationships.
• Medication may be used to treat co-occurring conditions, such as depression or anxiety, or to help regulate mood, though no medication is specifically approved for BPD.

BPD can significantly impair an individual’s ability to maintain relationships, hold steady employment, and function in daily life, but early diagnosis and appropriate treatment can lead to substantial improvement.

Reference:

American Psychiatric Association, DSM-5 Task Force. (2013). Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.). American Psychiatric Publishing, Inc.. https://doi.org/10.1176/appi.books.9780890425596

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