Borderline Personality Disorder (F60.3) Diagnostic Criteria

Check out the website and YouTube channel for more in depth information on borderline personality disorder criteria.

The most recent (2022) criteria of borderline personality disorder can be found in the DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision¹). The criteria are nicely organized and concise, BUT even since 1980 when the DSM-III first published borderline personality disorder as a categorical diagnosis, there has been much controversy about putting such a dynamic, moving disorder into a box of criteria. See the psychodynamic view of borderline personality disorder and the DSM’s overview of borderline personality disorder for a deeper dive about the differences. Regardless, let’s take a closer look into the actual criteria of this often misunderstood disorder.

Before we look at the individual criteria, the DSM-5-TR gives a framework about borderline personality disorder disorder. The patterns of borderline personality disorder have to be pervasive, meaning spread across the person, time, and settings. This is further explained by noting the patterns of borderline personality disorder must begin by early adulthood (18 to 25) AND be present in a variety of settings (e.g. home, school, work). Basically, borderline personality disorder doesn’t just show up one day in the work environment when you’re 45 years old. It’s been threaded throughout your life from early on and touches multiple parts of your story.

Then we have the actual pattern of borderline personality disorder. There is instability in relationships, self-image (view of self/sense of self), AND affects (moods). It’s not only one of these areas; it’s all of them. The unstable dynamics of borderline personality disorder are widespread - internal, external, and everywhere in between. PLUS we have marked (aka obvious) impulsivity. But that’s not all, folks! We still have the specific criteria that needs to be checked off, and we need FIVE OR MORE of the following noted in the boxes below.

This is where we overtly see a fear of abandonment most commonly associated with borderline personality disorder. I think it’s super important to understand that a fear of abandonment can exist in anyone, and a person with borderline personality disorder technically doesn’t need to check this box if they check five other ones. The tricky part about this criterion is that the abandonment doesn’t have to be real; it can be imagined or anticipated. Abandonment doesn’t have to be actual abandonment. It can be when a therapist goes on a planned vacation, when a friend is a couple minutes late, or when a spouse takes a walk during/after a conflict. There’s a strong need for others and difficulty being alone. The “frantic” avoidance of this cannot include criterion 5 (“Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior¹” p. 752), but may include impulsive action fueled by anxiety.

For example, someone with borderline personality disorder might bring up intense topics in the last 2 minutes of the therapy session; cancel immediately on the friend running late so they abandon the friend and not the other way around; or consume six shots of liquor while they call their spouse at work 27 times. This can also look like self-sabotage. For example, leaving a relationship because it could be stable, dropping out of school days before graduation, or regressing after being aware of progress. It is also possible that those with borderline personality disorder attach to less threatening objects like pets or possessions to avoid abandonment.

Not only do relationships have to be up and down with pushing and pulling (aka unstable), they have to be intensely rollercoaster-y. How do we know if it’s intense or unstable enough? Well, because there’s idealization and devaluation. Idealization is when a person is viewed as “all good,” as they can basically do no wrong and are the best thing ever. Devaluation is when a person is viewed as “all bad,” because everything they do is wrong and they’re the worst thing ever. It’s hard for a person with borderline personality disorder to handle the (assumingly) flawed but safe nature of an attachment figure, so they protect the self by swinging to extreme views of others. This can lead to patterns of relationship and job ruptures/terminations.

Here we need to have a super noticeable (marked) AND long-lasting (persistent) feeling of personal identity (sense of self) OR self-image that fluctuates and shifts (unstable). I’ve seen this range from just adapting and being a chameleon in social situations to shifting all around the drama triangle (podcast/blog) to having different parts that come out (e.g. child, teacher, bully). A (more extreme) example of this might be someone with borderline personality disorder needing their partner’s help with dinner because they love them so much and they’re so good at cooking… but upon a 0.021 second hesitation from said partner, the individual with borderline personality disorder states they “don’t need anyone’s help ever because people suck and no one loves them.”

Impulsivity is often a big thing in borderline personality disorder, but the impulsivity has to be at a level where it could be harmful, though it excludes any self-harm or suicidal behaviors. Examples of specific impulsive behaviors the DSM-5-TR highlights are spending (i.e. irresponsibility, gambling, excessiveness), sex (i.e. unsafe sexual encounters, risky meetups), substance abuse, reckless driving (i.e. driving too fast, intoxicated, unsafely), and binge eating (which can also lead to restricting and compensatory behaviors). Other impulsive behaviors I’ve seen are hobby-jumping, job-hopping, and partner-swapping. A lot of times, these impulsive, possible harmful behaviors serve a purpose of filling up the empty spot identified in criterion 7. Also, don’t forget this has to show up in at least TWO areas.

This criterion is pretty self-explanatory, but if you want more information on suicidal behavior, suicidal gestures (attempted suicide, parasuicide, passive suicide), suicidal threats, self-harm, or self-mutilation, our Borderline series goes deeper into this topic! The behaviors captured in this criterion are commonly why those with borderline personality disorder seek help. Unfortunately, this contributes to some of the stigma associated with borderline personality disorder, as there is risk associated with this for providers. These behaviors usually happen after an individual with borderline personality disorder faces a threat of abandonment, rejection, or increased responsibility (because dependence ensures attachment). However, self-harm can also happen during dissociation. The self-destructiveness can help them feel something or be self-punishing. Note that borderline personality disorder is the only personality disorder that has suicidal behaviors/self-harm listed as a criterion, but it’s not necessarily the only personality disorder at risk for these behaviors.

Affective instability just means unstable emotions. The rollercoaster-y emotions are due to an obvious (marked) reaction of mood. Often, individuals with borderline personality disorder have a baseline of discontent (dysphoric) that can then be disrupted by short periods of despair, anger, or panic (or another intense emotion). It’s notable that these periods “usually [last] a few hours and only rarely more than a few days¹,” (p. 753) which is NOT sufficient to meet any hypomania or mania criteria found in bipolar disorder. Further, the periods of intense emotion often stem from experiencing stress on the relationship front.

Feelings of emptiness can be hard to explain. It’s like there’s an empty spot or void inside that is painful and distressing. Sometimes it can feel like disconnectedness, numbness, nothingness, meaninglessness, and purposelessness². This might lead to impulsivity or recklessness to avoid the feelings of emptiness or to attempt to fill the void. Also, these feelings need to be felt over a long period of time (chronic).

Anger is stereotypically associated with borderline personality disorder, but I think it’s important to note there are those with borderline personality disorder who turn their anger inward or express hurt instead of anger. When angry, it can feel uncontrollable and intense, and it can be out of proportion to the situation or simply inappropriate. Yet, anger tends to be triggered when an attachment figure doesn’t provide the love, nurturance, care, or security needed. The anger can be passive-aggression like intense sarcasm or bitterness, but it can also be verbal or physical aggression. Because anger can threaten the attachment relationship, any anger outburst is often followed by shame or guilt or anger turned inward.

When experiencing high stress, those with borderline personality disorder can experience paranoid ideation or intense disconnectedness (dissociation). Paranoid ideation can include feeling like others are against you or even after you. It might feel like all your coworkers are talking trash about you or like your boss is actively trying to fire you, but that’s unlikely to be what’s happening. The dissociation can include disconnection from the self (depersonalization) or disconnection from the word/reality (derealization). You might not feel real, or things around you might not feel real. Again, this is usually following the intense emotion spurred by real or imagined abandonment, and if resolved, the symptoms may go away. It is absolutely necessary to understand that these symptoms tend to last minutes or hours (transient) and aren’t usually severe or longlasting enough for an additional diagnosis. However, it is possible that some people with borderline personality disorder experience psychotic-like symptoms (like delusions or hallucinations) during high stress periods (e.g. body-image distortion, hypnagogic state, idea of reference).

While I feel it’s unfortunate that borderline was categorized and put into a checklist of diagnostic criteria, there are definitely some benefits. Having structured criteria can help with identifying the struggles of those with borderline personality disorder, and it can assist in knowing the areas to treat. If you or anyone you know are experiencing any of these symptoms, please seek professional help! You can look on Psychology Today or if you’re in Virginia, check out our private practice, Quest Psychological and Counseling Services for available services.

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