Borderline Personality Disorder (Part II

Diagnosis

Diagnosis of borderline personality disorder is based on a clinical assessment by a mental health professional. The best method is to present the criteria of the disorder to a person and to ask them if they feel that these characteristics accurately describe them.  Actively involving people with BPD in determining their diagnosis can help them become more willing to accept it.  Although some clinicians prefer not to tell people with BPD what their diagnosis is, either from concern about the stigma attached to this condition or because BPD used to be considered untreatable, it is usually helpful for the person with BPD to know their diagnosis.  This helps them know that others have had similar experiences and can point them toward effective treatments.

In general, the psychological evaluation includes asking the patient about the beginning and severity of symptoms, as well as other questions about how symptoms impact the patient's quality of life. Issues of particular note are suicidal ideations, experiences with self-harm, and thoughts about harming others.  Diagnosis is based both on the person's report of their symptoms and on the clinician's own observations.  Additional tests for BPD can include a physical exam and laboratory tests to rule out other possible triggers for symptoms, such as thyroid conditions or substance abuse.  The ICD-10 manual refers to the disorder as emotionally unstable personality disorder and has similar diagnostic criteria. In the DSM-5, the name of the disorder remains the same as in the previous editions. 

Diagnostic and Statistical Manual

The Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) has removed the multiaxial system. Consequently, all disorders, including personality disorders, are listed in Section II of the manual. A person must meet 5 of 9 criteria to receive a diagnosis of borderline personality disorder.  The DSM-5 defines the main features of BPD as a pervasive pattern of instability in interpersonal relationships, self-image, and affect, as well as markedly impulsive behavior.  In addition, the DSM-5 proposes alternative diagnostic criteria for BPD in section III, "Alternative DSM-5 Model for Personality Disorders". These alternative criteria are based on trait research and include specifying at least four of seven maladaptive traits.  According to Marsha Linehan, many mental health professionals find it challenging to diagnose BPD using the DSM criteria, since these criteria describe such a wide variety of behaviors. To address this issue, Linehan has grouped the symptoms of BPD under five main areas of dysregulation: emotions, behavior, interpersonal relationships, sense of self, and cognition. 

International Classification of Disease

The World Health Organization's ICD-10 defines a disorder that is conceptually similar to BPD, called (F60.30) Emotionally unstable personality disorder. Its two subtypes are described below.

F60.30 Impulsive type

At least three of the following must be present, one of which must be (2):

1. marked tendency to act unexpectedly and without consideration of the consequences;
2. marked tendency to engage in quarrelsome behavior and to have conflicts with others, especially when impulsive acts are thwarted or criticized;
3. liability to outbursts of anger or violence, with inability to control the resulting behavioral explosions;
4. difficulty in maintaining any course of action that offers no immediate reward;
5. unstable and capricious (impulsive, whimsical) mood.

F60.31 Borderline type

At least three of the symptoms mentioned in F60.30 Impulsive type must be present [see above], with at least two of the following in addition:

1. disturbances in and uncertainty about self-image, aims, and internal preferences;
2. liability to become involved in intense and unstable relationships, often leading to emotional crisis;
3. excessive efforts to avoid abandonment;
4. recurrent threats or acts of self-harm;
5. chronic feelings of emptiness;
6. demonstrates impulsive behavior, e.g., speeding in a car or substance abuse.

The ICD-10 also describes some general criteria that define what is considered a personality disorder.

Millon's subtypes

Theodore Millon has proposed four subtypes of BPD. He suggests that an individual diagnosed with BPD may exhibit none, one, or more of the following: 

Subtype	Features
Discouraged borderline (including avoidant, depressive and dependent features)	Pliant, submissive, loyal, humble; feels vulnerable and in constant jeopardy; feels hopeless, depressed, helpless, and powerless.
Petulant borderline (including negativistic features)	Negativistic, impatient, restless, as well as stubborn, defiant, sullen, pessimistic, and resentful; easily feels "slighted" and quickly disillusioned.
Impulsive borderline (including histrionic or antisocial features)	Captivating, capricious, superficial, flighty, distractable, frenetic, and seductive; fearing loss, the individual becomes agitated; gloomy and irritable; and potentially suicidal.
Self-destructive borderline (including depressive or masochistic features)	Inward-turning, intropunitive (self-punishing), angry; conforming, deferential, and ingratiating behaviors have deteriorated; increasingly high-strung and moody; possible suicide.

Misdiagnosis

People with BPD may be misdiagnosed for a variety of reasons. One reason for misdiagnosis is BPD has symptoms that coexist (comorbidity) with other disorders such as depression, post-traumatic stress disorder (PTSD), and bipolar disorder. 

Family members

People with BPD are prone to feeling angry at members of their family and alienated from them. On their part, family members often feel angry and helpless at how their BPD family members relate to them.  Parents of adults with BPD are often both over-involved and under-involved in family interactions.  In romantic relationships, BPD is linked to increased levels of chronic stress and conflict, decreased satisfaction of romantic partners, abuse, and unwanted pregnancy. However, these links may apply to personality disorders in general. 

Adolescence

Onset of symptoms typically occurs during adolescence or young adulthood, although symptoms suggestive of this disorder can sometimes be observed in children.  Symptoms among adolescents that predict the development of BPD in adulthood may include problems with body-image, extreme sensitivity to rejection, behavioral problems, non-suicidal self-injury, attempts to find exclusive relationships, and severe shame.  Many adolescents experience these symptoms without going on to develop BPD, but those who experience them are 9 times as likely as their peers to develop BPD. They are also more likely to develop other forms of long-term social disabilities.  Clinicians are discouraged from diagnosing anyone with BPD before the age of 18, due to the normal ups and downs of adolescence and a still-developing personality. However, BPD can sometimes be diagnosed before age 18, in which case the features must have been present and consistent for at least one year.

A BPD diagnosis in adolescence might predict that the disorder will continue into adulthood.  Among adolescents who warrant a BPD diagnosis, there appears to be one group in which the disorder remains stable over time and another group in which the individuals move in and out of the diagnosis.   Earlier diagnoses may be helpful in creating a more effective treatment plan for the adolescent.  Family therapy is considered a helpful component of treatment for adolescents with BPD.

Differential diagnosis and comorbidity

Lifetime comorbid (co-occurring) conditions are common in BPD. Compared to those diagnosed with other personality disorders, people with BPD showed a higher rate of also meeting criteria for

• mood disorders, including major depression and bipolar disorder
• anxiety disorders, including panic disorder, social anxiety disorder, and post-traumatic stress disorder (PTSD)
• other personality disorders, including schizotypal, antisocial and dependent personality disorder
• substance abuse
• eating disorders, including anorexia nervosa and bulimia
• attention-deficit hyperactivity disorder (ADHD)
• somatic symptom disorders (formerly known as somatoform disorders: a category of mental disorders included in a number of diagnostic schemes of mental illness)
• dissociative disorders

A diagnosis of a personality disorder should not be made during an untreated mood episode/disorder, unless the lifetime history supports the presence of a personality disorder. 

Comorbid Axis I disorders

Gender differences in Axis I lifetime comorbid diagnosis, 2008 and 1998
Axis I diagnosis	Overall (%)	Male (%)	Female (%)
Mood disorders	75.0	68.7	80.2
Major depressive disorders	32.1	27.2	36.1
Dysthymia	9.7	7.1	11.9
Bipolar I disorder	31.8	30.6	32.7
Bipolar II disorder	7.7	6.7	8.5
Anxiety disorders	74.2	66.1	81.1
Panic disorder with agoraphobia	11.5	7.7	14.6
Panic disorder without agoraphobia	18.8	16.2	20.9
Social phobia	29.3	25.2	32.7
Specific phobia	37.5	26.6	46.6
PTSD	39.2	29.5	47.2
Generalized anxiety disorder	35.1	27.3	41.6
Obsessive-compulsive disorder**	15.6	---	---
Substance use disorders	72.9	80.9	66.2
Any alcoholic use disorder	57.3	71.2	45.6
Any drug use disorder	36.2	44.0	29.8
Eating disorders**	53.0	20.5	62.2
Anorexia nervosa**	20.8	7 *	25 *
Bulimia nervosa**	25.6	10 *	30 *
Eating disorder not otherwise diagnosed**	26.1	10.8	30.4
Somatoform disorders**	10.3	10 *	10 *
Somatization disorder**	4.2	---	---
Hypochondriasis**	4.7	---	---
Somatoform pain disorder**	4.2	---	---
Psychotic disorders**	1.3	1 *	1 *
* Approximate values ** Values from 1998 study --- Value not provided by study

A 2008 study found that at some point in their lives, 75 percent of people with BPD meet criteria for mood disorders, especially major depression and bipolar I, and nearly 75 percent meet criteria for an anxiety disorder.  Nearly 73 percent meet criteria for substance abuse or dependency, and about 40 percent for PTSD.  It is noteworthy that less than half of the participants with BPD in this study presented with PTSD, a prevalence similar to that reported in an earlier study.  The finding that less than half of patients with BPD experience PTSD during their lives challenges the theory that BPD and PTSD are the same disorder.

There are marked gender differences in the types of comorbid conditions a person with BPD is likely to have—a higher percentage of males with BPD meet criteria for substance-use disorders, while a higher percentage of females with BPD meet criteria for PTSD and eating disorders.  In one study, 38% of participants with BPD met the criteria for a diagnosis of ADHD.  In another study, 6 of 41 participants (15%) met the criteria for an autism spectrum disorder (a subgroup that had significantly more frequent suicide attempts).

Regardless that it is an infradiagnosed disorder, a few studies have shown that the "lower expressions" of it might lead to wrong diagnoses. The many and shifting Axis I disorders in people with BPD can sometimes cause clinicians to miss the presence of the underlying personality disorder. However, since a complex pattern of Axis I a diagnosis has been found to strongly predict the presence of BPD; clinicians can use the feature of a complex pattern of comorbidity as a clue that BPD might be present.

Mood disorders

Many people with borderline personality disorder also have mood disorders, such as major depressive disorder or a bipolar disorder.  Some characteristics of BPD are similar to those of mood disorders, which can complicate the diagnosis.  It is especially common for people to be misdiagnosed with bipolar disorder when they have borderline personality disorder or vice versa.  For someone with bipolar disorder, behavior suggestive of BPD might appear while the client is experiencing an episode of major depression or mania, only to disappear once the client's mood has stabilized.  For this reason, it is ideal to wait until the client's mood has stabilized before attempting to make a diagnosis.

At face value, the affective lability of BPD and the rapid mood cycling of bipolar disorders can seem very similar.  It can be difficult even for experienced clinicians, if they are unfamiliar with BPD, to differentiate between the mood swings of these two conditions.  However, there are some clear differences.

First, the mood swings of BPD and bipolar disorder tend to have different durations. In some people with bipolar disorder, episodes of depression or mania last for at least two weeks at a time, which is much longer than moods last in people with BPD.  Even among those who experience bipolar disorder with more rapid mood shifts, their moods usually last for days, while the moods of people with BPD can change in minutes or hours.  So while euphoria and impulsivity in someone with BPD might resemble a manic episode, the experience would be too brief to qualify as a manic episode.

Second, the moods of bipolar disorder do not respond to changes in the environment, while the moods of BPD do respond to changes in the environment.  That is, a positive event would not lift the depressed mood caused by bipolar disorder, but a positive event would potentially lift the depressed mood of someone with BPD. Similarly, an undesirable event would not dampen the euphoria caused by bipolar disorder, but an undesirable event would dampen the euphoria of someone with borderline personality disorder.

Third, when people with BPD experience euphoria, it is usually without the racing thoughts and decreased need for sleep that are typical of hypomania though a later 2013 study of data collected in 2004 found that borderline personality disorder diagnosis and symptoms were associated with chronic sleep disturbances, including difficulty initiating sleep, difficulty maintaining sleep, and waking earlier than desired, as well as with the consequences of poor sleep, and noted that "[f]we studies have examined the experience of chronic sleep disturbances in those with borderline personality disorder".

Because the two conditions have a number of similar symptoms, BPD was once considered to be a mild form of bipolar disorder or to exist on the bipolar spectrum. However, this would require that the underlying mechanism causing these symptoms be the same for both conditions. Differences in phenomenology, family history, longitudinal course, and responses to treatment indicate that this is not the case.  Researchers have found "only a modest association" between bipolar disorder and borderline personality disorder, with "a strong spectrum relationship with [BPD and] bipolar disorder extremely unlikely".  Benazzi et al. suggest that the DSM-IV BPD diagnosis combines two unrelated characteristics: an affective instability dimension related to bipolar II and an impulsivity dimension not related to bipolar II. 

Premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) occurs in 3–8 percent of women.  Symptoms begin 5–11 days before menstruation and cease a few days after it begins.  Symptoms may include marked mood swings, irritability, depressed mood, feeling hopeless or suicidal, and a subjective sense of being overwhelmed or out of control, anxiety, binge eating, difficulty concentrating, and substantial impairment of interpersonal relationships.  People with PMDD typically begin to experience symptoms in their early twenties, although many do not seek treatment until their early thirties.

Although some of the symptoms of PMDD and BPD are similar, they are different disorders. They are distinguishable by the timing and duration of symptoms, which are markedly different: the symptoms of PMDD occur only during the luteal phase of the menstrual cycle whereas BPD symptoms occur persistently at all stages of the menstrual cycle. In addition, the symptoms of PMDD do not include impulsivity. 

Comorbid Axis II disorders

Percentage of people with BPD and a lifetime comorbid Axis II diagnosis, 2008
Axis II diagnosis	Overall (%)	Male (%)	Female (%)
Any cluster A	50.4	49.5	51.1
Paranoid	21.3	16.5	25.4
Schizoid	12.4	11.1	13.5
Schizotypal	36.7	38.9	34.9
Any other cluster B	49.2	57.8	42.1
Antisocial	13.7	19.4	9.0
Histrionic	10.3	10.3	10.3
Narcissistic	38.9	47.0	32.2
Any cluster C	29.9	27.0	32.3
Avoidant	13.4	10.8	15.6
Dependent	3.1	2.6	3.5
Obsessive-compulsive	22.7	21.7	23.6

About three-fourths of people diagnosed with BPD also meet the criteria for another Axis II personality disorder at some point in their lives. (In a major 2008 study – see adjacent table – the rate was 73.9 percent.)  The Cluster A disorders, paranoid, schizoid, and schizotypal, is broadly the most common. The Cluster as a whole affects about half, with schizotypal alone affecting one third.

BPD is itself a Cluster B disorder. The other Cluster B disorders, antisocial, histrionic, and narcissistic, similarly affect about half of BPD patients (lifetime incidence), with again narcissistic affecting one third or more.  Cluster C, avoidant, dependent, and obsessive compulsive, showed the least overlap, slightly under one third.