DSM-5 and how it affects the diagnosis of BPD

DSM-5Changes to the DSM – Diagnostic and Statistical Manual, often referred to as the “bible” for psychiatrists and other mental health professionals and the subject of much recent controversy, affect several diagnoses, including that of Borderline Personality Disorder (BPD).” Changes to the BPD diagnosis in the new DSM-5 involve radical changes that fundamentally amend a definition of BPD that has survived with minimal changes since it entered the DSM system 30 years ago. Because a BPD diagnosis is currently greatly underutilized, most clinicians lack the training that is needed to treat patients with BPD, and because of this lack of training they are hesitant to work with this population.

Changes within the DSM-5 may encourage doctors to make a BPD diagnosis more frequently than before. The diagnosis will be more visible and accessible, possibly (and hopefully) leading to the creation of much needed training programs for clinicians. In the DSM-III and IV, placing BPD under the parent class of Personality Disorders may have encouraged excessive use of the residual category, PDNOS (Personality Disorders Not Otherwise Specified).

Hopefully, the changes in the DSM-5, which make the criteria more specific will diminish both BPD’s overlaps and its heterogeneity.  Below are the changes we will see, starting with the current DSM-IV-TR and moving into the DSM-5:

The current DSM-IV-TR (2000) criteria for Borderline Personality Disorder is as follows:

Borderline Personality Disorder

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., excessive spending, substances of abuse, sex, 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 dysohoria, 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 tantrums, constant anger and reoccurring fights).
  9. transient, stress-related paranoid ideation or severe dissociative symptoms

The proposed DSM-5 (2013) diagnostic criteria for Borderline Personality Disorder:

Borderline Personality Disorder

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met:

A) Significant impairments in personality functioning manifest by:

  1. Impairments in self functioning (a or b)

    a) Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.

    b) Self-direction: Instability in goals, aspirations, values, or career plans.AND

  2. Impairments in interpersonal functioning (a or b)

    a) Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e. prone to feeling slighted or insulted) perceptions of others selectively biased toward negative attributes or vulnerabilities.

    b) Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.

APA Rationale for Revised A Criteria for Personality Disorders and the Levels of Personality Functioning

B) Pathological personality traits in the following domains:

    1. Negative Affectivity, characterized by:

      a) Emotional lability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.

      b) Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.

      c) Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.

      d) Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.

    2. Disinhibition, characterized by:

      a) Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.

      b) Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger.

    3. Antagonism, characterized by:

      a) Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

APA Rationale for Criteria B and the Proposed Trait System

C) The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.

D) The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.

E) The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g. substances of abuse or medication) or a general medical condition (e.g. severe brain injury).

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