Sunday, October 7, 2012

Borderline Changes for DSM-5

I am often inspired (sometime it's "stuck") by what I see throughout the week.  I try to "Ride the Wave" as often as possible but there are think about something past it's expiration date in my head.  Case in point the term "Borderline Personality Disorder," which someone on Twitter had issue with.  As I begin writing this blog about the possible DSM-5 revision  and clicked on "personality disorder" I had the same thought- calling it a personality issue makes it sound minimal and like you have a bad personality.  

Back to the topic: What changes might be in the DSM-5?  First off, the DSM is the manual for which people are diagnosed   I had a college professor say it was like ordering lunch of a Chinese food menu; choose 2 of  5 choices of meat; 2 of 4 sides and 1 of 6 beverage choices and viola you have a diagnosis.  It's a little more complicated than that but you get the idea. Currently it's a 5 Axis system, where Personality Disorder is on Axis II (which insurance companies typically only cover Axis I.)

The DSM 5 proposed revision will make ALL diagnosis on one Axis, like it is done in most other countries. So for example Jane Doe's Diagnosis: Major Depressive Disorder Moderate, Borderline Personality Disorder, Disease of the eye, Problems with living environment, GAF 55.  

Currently the criteria for Borderline Personality Disorder is as follows:

A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as 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-injuring 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., promiscuous sex, excessive spending, eating disorders, binge eating, substance abuse, reckless driving). Note: Do not include suicidal or self-injuring behavior covered in Criterion 5
  5. Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars or picking at oneself (excoriation).
  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 anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
  9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms
The proposed DSM-5 revision is as follows:
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.
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 feel 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.
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.

Okay so following all that information, I am really interested in feedback from those currently diagnosed with Borderline Personality Disorder.  Please comment here and join the discussion or tweet #BPDDiagnosis.  As someone without the diagnosis here is my opinion- it's vague.  It is so vague that I am concerned that people will be over diagnosed with it, that insurance will not cover any care for those with the diagnosis. Or will it be diagnosed appropriate, as many people who don't have the diagnosis meet the criteria and more people will get the help they need?

The DSM-5 doesn't come out until May 2013 so don't fret.


  1. I nave been diagnosed with BPD, off and on for 16 years. My new Psychiatrist, of 1 year will only give me that diagnosis.
    My other diagnosis' were Schizo-affective, BiPolar, PTSD, among others.
    I can relate to the New DSM Diagnoses, much better than the old one!

    1. I think you're right, Stephanie, that it's easier to relate to the definition in DSM5 (prposed), compared with the criteria in DSM-IV. There's a lot more explanation, the criteria feel more current, and up-to-date.

      The obvious omission in DSM5 (proposed) is criterion 5 in DSM-IV ("recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour"). In DBT (Dialectical Behaviour Therapy)-speak, they've taken out "Stage 1" targets, and concentrated on 'classic' borderline behaviours.

      The proposed DSM5 includes two disorders: "V 02 Suicidal Behavior Disorder", and "V 01 Non-Suicidal Self-Injury" which, one imagines, psychiatrists would be able to supplement a diagnosis as co-morbid with, for example, depression or, indeed BPD.

  2. Glad to hear you now have the right diagnosis, and I am a little surprised that your psychiatrist is open to a Personality Disorder being the only one (mostly due to insurance issues and that BDP has no medication.)

    The combo you listed sounds like the recipe for BPD; paranoia/delusions/dissociation (Schizo-affective,) Angry outbursts, self harm, mood instability (Bipolar,) Disassociation and Trauma (PTSD.) I often see this combination and/or Depression added to the mix when BPD is all encompassing.

    Getting the right diagnosis is vital to recovery!

  3. I like how the new criteria sounds much better however when they leave out the suicide behavior does that mean another label will be given to those of us who as my psychiatrist put it to me I have chronic suicide ideation? I have made many attempts on my life and have always thought death a beautiful and welcomed thing

    1. It's my understanding that there is no new diagnosis for suicidality. There is a change in the way suicidality is assessed though The final reviews were made this weekend (I was not invited) so it is still a little up in the air until it's printed.

      There was a push (it failed) to put self-harm syndrome in the DSM5 as well as add a Axis for suicidiality risk on a scale.

  4. Thanks for posting this as this is the first I had heard of these DSM changes. I am diagnosed with BPD and I still fit nearly every characteristic. Overall, I think the changes explain things more clearly. Again, thanks for the post! I am currently reading Debbie Corso's Stop Sabotaging book with your intro. :)

    My BPD blog, in case you are interested, can be found here:

    1. Have you read this article, Alicia? There are some really bad changes. Looks like BPD got off easy...

    2. First off thanks for the comment. I also added your blog to my blogroll, really interesting stuff. I read that article last week, and have the same concerns as well as removing Aspergers reducing the number of people who can seek treatment for it. I can't remember the article, but something like currently 1/4 people meet criteria for a mental illness and with the new DSM5 it's 3/4. This raises questions about insurance coverage, stigma and over/misdiagnosis/medicating people. I think I have 2 new DSM5 disorders as of now, one being Binge Eating Disorder.