Borderline Personality Disorder

Diagnostic Criteria
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 alternating
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 selfmutilating
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 experience
intense abandonment fears and inappropriate anger even when faced with a realistic
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 someone
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. Their franticefforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal
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 unstable
self-image or sense of self (Criterion 3). There are sudden and dramatic shifts in selfimage,
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 selfimage
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 individuals
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 irresponsibly,
binge eat, abuse substances, engage in unsafe sex, or drive recklessly. Individuals
with this disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilating
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 anxiety
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 satisfaction.
These episodes may reflect the individual’s extreme reactivity to interpersonal
stresses. Individuals with borderline personality disorder may be troubled by chronic feelings
of emptiness (Criterion 7). Easily bored, they may constantly seek something to do.
Individuals with this disorder frequently express inappropriate, intense anger or have difficulty
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., depersonalization)
may occur (Criterion 9), but these are generally of insufficient severity or
duration to warrant an additional diagnosis. These episodes occur most frequently in response
to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes
or hours. The real or perceived return of the caregiver’s nurturance may result in a
remission of symptoms.

Associated Features
Individuals with borderline personality disorder may have a pattern of undermining
themselves at the moment a goal is about to be realized (e.g., dropping out of school just
before graduation; regressing severely after a discussion of how well therapy is going; destroying
a good relationship just when it is clear that the relationship could last). Some individuals
develop psychotic-like symptoms (e.g., hallucinations, body-image distortions,
ideas of reference, hypnagogic phenomena) during times of stress. Individuals with this
disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession)
than in interpersonal relationships. Premature death from suicide may occur in individuals
with this disorder, especially in those with co-occurring depressive disorders or substance
use disorders. Physical handicaps may result from self-inflicted abuse behaviors or
failed suicide attempts. Recurrent job losses, interrupted education, and separation or divorce
are common. Physical and sexual abuse, neglect, hostile conflict, and early parental
loss are more common in the childhood histories of those with borderline personality disorder.
Common co-occurring disorders include depressive and bipolar disorders, substance
use disorders, eating disorders (notably bulimia nervosa), posttraumatic stress
disorder, and attention-deficit/hyperactivity disorder. Borderline personality disorder
also frequently co-occurs with the other personality disorders.