Borderline Personality Disorder (BPD) is a serious mental illness that disables an individual to manage his or her emotions effectively. Furthermore, BPD occurs in the context of relationships.
In other words, people suffering from BPD behave impulsively in relationships. As a result, at times, all or only one of their relationships are impacted in a negative way.
Also Know: Gaslighting in Relationship
Furthermore, some individuals suffering from BPD may function quite well in certain settings. However, their personal lives are disrupted.
As per NEABPD, BPD affects 5.9% of the adults at some time in their life. Furthermore, BPD diagnosis is frequently missed. Moreover, a BPD misdiagnosis has either prevented recovery or has showcased a delay in recovery.
So, let’s understand what is a Borderline Personality Disorder Test and how to diagnose BPD.
What is Borderline Personality Disorder Test?
Borderline Personality Disorder Test is a questionnaire that allows an individual a deeper understanding of what symptoms the individual has with regards to the disorder.
However, the BPD test does not give the final diagnosis of the Borderline Personality Disorder. It is just one of the steps involved in the comprehensive assessment of the disorder.
In other words, the BPD test is in the form of a quiz that helps you to identify the BPD symptoms and the help you need to seek as a next step. It does not involve the final diagnosis of the Borderline Personality Disorder. But it helps you to recognize the potential symptoms and becoming aware of the treatment that you need to seek as a next step.
Thus, the goal of Borderline Personality Disorder Test is to question the signs and the symptoms of BPD. And this is done through a self-assessment or a quiz-like test.
Now, there is no definitive or single test that helps the clinician in identifying the symptoms of Borderline Personality Disorder. However, the clinician asks the patient to take self-assessment tests comprising mental health questionnaires. Such assessments help the licensed mental health practitioner to know more about you.
Thus, mental health practitioners need data about BPD symptoms, patient’s life experience, and family history. All this information helps the clinician to make accurate diagnosis.
As per American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), an individual must showcase 5 out of 9 criteria to be diagnosed with BPD.
Borderline Personality Disorder Test NHS
As per National Health Services (NHS), the following is the internationally recognized criteria used to diagnose Borderline Personality Disorder.
A BPD diagnosis is usually made if your patient answers ‘Yes’ to 5 or more of the following questions.
Borderline Personality Test (BPD) NHS
|1.||Do you have an intense fear of being left alone, which causes you to act in ways that, on reflection, seem out of the ordinary or extreme, such as constantly phoning somebody (but not including self-harming or suicidal behaviour)?||Yes/No|
|2.||Do you have a pattern of intense and unstable relationships with other people that switch between thinking you love that person and they’re wonderful to hating that person and thinking they’re terrible?||Yes/No|
|3.||Do you ever feel you do not have a strong sense of your own self and are unclear about your self-image?||Yes/No|
|4.||Do you engage in impulsive activities in 2 areas that are potentially damaging, such as unsafe sex, drug misuse or reckless spending (but not including self-harming or suicidal behaviour)?||Yes/No|
|5.||Have you made repeated suicide threats or attempts in your past and engaged in self-harming?||Yes/No|
|6.||Do you have severe mood swings, such as feeling intensely depressed, anxious or irritable, which last from a few hours to a few days?||Yes/No|
|7.||Do you have long-term feelings of emptiness and loneliness?||Yes/No|
|8.||Do you have sudden and intense feelings of anger and aggression, and often find it difficult to control your anger?||Yes/No|
|9.||When you find yourself in stressful situations, do you have feelings of paranoia, or do you feel like you’re disconnected from the world or from your own body, thoughts and behaviour?||Yes/No|
Borderline Personality Disorder Test NZ
There is no specific test for Borderline Personality Disorder. However, a mental health practitioner can diagnose BPD after talking to the person and knowing his experiences.
Furthermore, the clinician can diagnose BPD if his or her patient showcases several of the symptoms of BPD. Remember, that there are many combinations of these symptoms. Thus, people diagnosed with BPD can seem very different from one another.
Accordingly, the psychologist has to carefully ask questions about the patient’s life, experiences, and symptoms before making the final diagnosis.
It can take more time to come to the correct diagnosis. This is because some of the symptoms of BPD are similar to the symptoms of other mental health conditions.
Borderline Personality Disorder Test NZ
|1.||Are you prone to fear that other people might leave you and hence you make frantic efforts to avoid being abandoned by other people, including in situations where other people wouldn’t feel let down or wouldn’t take it personally?||Yes/No|
|2.||Do you have relationships that are unusually intense and unstable like idealising another person, then intensely disliking them?||Yes/No|
|3.||Do you often feel unsure about yourself and do not really know who you are or what to think about yourself?||Yes/No|
|4.||Do you take risks or act impulsively in ways that could be harmful like not thinking before spending money, engaging in risky sexual behaviour, undertaking risky drug or alcohol use, driving recklessly or binge-eating?||Yes/No|
|5.||Do you repeatedly harm yourself, show suicidal behavior, or talk and think about committing suicide?||Yes/No|
|6.||Do you experience short-lived or at times longer but intense emotional ‘lows’ or times of irritability or anxiety?||Yes/No|
|7.||Do you experience a persistent feeling of being ’empty’ inside?||Yes/No|
|8.||Do you experience anger that is unusually intense and out of proportion to whatever triggered the anger, and being unable to control it like having fits of temper or getting into fights?||Yes/No|
|9.||Do you become highly suspicious of others or experience unusual feelings of being detached from their own emotions, body, or surroundings when you are stressed?||Yes/No|
Diagnostic Test For Borderline Personality Disorder
As mentioned above, there is no definitive or single test for diagnosing Borderline Personality Disorder. However, mental health practitioners make use of certain screening tools that help them diagnose BPD.
In addition to this, a licensed mental health practitioner can only make BPD diagnosis after observing several symptoms of BPD in a patient. Further, he will ask questions to his patient regarding the patient’s life, experiences, and symptoms before giving the final diagnosis for BPD.
Thus, licensed mental health practitioners use screening instruments as well as the structured interviews to diagnose BPD. In fact, clinicians rely more on self-reports as these offer a valid assessment of BPD characteristics. This is because a self-report helps in evaluating the experiences symptoms of Borderline Personality Disorder like feeling of emptiness and identity distortions.
As per BMC Psychiatry, the following are the widely-used screening tools to diagnose BPD:
- McLean Screening Instrument for BPD (MSI-BPD)
- Borderline Personality Questionnaire (BPQ)
- Personality Diagnostic Questionnaire-4 BPD
- International Personality Disorder Examination (IPDE)
Besides this, the clinicians also use Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD) to assess DSM-5 Personality Disorders.
Thus, the clinicians, licensed mental health practitioners, psychologists, or psychiatrists can follow the following assessment process.
The following is the assessment process that clinians adopt for diagnosing BPD:
- Review the Basis of Evidence
The clinicians or the licensed mental health practitioners can ponder over the following questions to identify an individual with BPD:
- What all can help them in recognizing the symptoms of Borderline Personality Disorder?
- What screening tools or assessments can they use that could help them in the assessment process?
- Recognize the Person With Borderline Personality Disorder
A clinician or a licensed mental health practitioner needs to identify the clinical symptoms that may indicate the need for BPD Assessment. Such symptoms may include:
- Repeated suicidal or self-harming behaviors
- Significant emotional instability
- Various comorbidities
- Increasing intensity of symptoms
- Pending response to establishment treatments for current symptoms
- Increased level of functional impairment
Besides this, the clinicians can also use questionnaire tools for BPD diagnosis. These Questionnaires would indicate the clinician whether there is a need for further assessment or not.
Then, the clinician can also undertake structured clinical interview of the patients. This would help him to carry out the comprehensive assessment. As a result, the clinician ill get a clear understanding of the difficulties that the patients encounter.
Furthermore, only a trained mental health practitioner can undertake the diagnosis of Borderline Personality Disorder. This is because such a practitioner has the skill set to conduct a comprehensive and rigorous assessment.
Additionally, the trained practitioner also takes an account of the developmental family history with the family members of the patient.
Thus, it is important for clinicians to carry out such a detailed and comprehensive assessments. This is especially important when there is an increased likelihood of stigmatization in the diagnosis.
What is Borderline Personality Disorder (BPD)?
Borderline Personality Disorder (BPD) is a mental illness characterized by striking mood fluctuations, unstable self-image, fear of abandonment, and a tendency towards self-harm.
Furthermore, an individual suffering from BPD may also experience temporary psychotic symptoms like brief delusions and hallucinations.
It is a common mental disorder associated with severe functional impairment, high rates of suicide, and comorbid mental disorders.
In 1938, Adolf Stern proposed the term Borderline Personality in the United States. Accordingly, Stern explained that there existed a group of people who are neither psychotic nor psychoneurotic. Thus, he came up with the term ‘Borderline’. In other words, Stern observed that some people bordered on other mental conditions. Hence, he coined the term ‘Borderline’.
Later, in 1975, Otto Kernberg introduced the term ‘Borderline Organization’. Kernberg stated that Borderline Organization refers to a consistent pattern of functioning and behavior. Such a behavior reflects instability and a distorted psychological self-organization.
However, Gunderson and Kolb in 1978 elucidated the characteristics that now explain BPD.
BPD is often diagnostically comorbid with other disorders. In other words, the symptoms of BPD may overlap with other disorders.
These disorders may include:
- Anxiety and depression,
- Eating disorders,
- Post Traumatic Stress Disorder (PTSD),
- Substance misuse disorder,
- Bipolar Disorder.
Furthermore, such comorbidity may exist either due to BPD’s position on the border of other conditions or a conceptual confusion.
Furthermore, certain individuals may experience an extreme overlap of BPD with other psychotic disorders. Hence, such individuals may experience both visual and auditory hallucinations and clear delusions.
However, such psychotic symptoms remain typically for a short period of time. Furthermore, these symptoms may occur in individuals undergoing intense emotional instability. But, BPD symptoms can be differentiated from other disorders in such individuals.
Remember, the intensity of comorbidity is so high that at times it is quite challenging to diagnose an individual having pure BPD. In other words, clinically it becomes quite challenging to establish whether the symptoms are those of BPD or a related comorbid condition.
How To Distinguish Between BPD and Comorbid Disorders?
So how to conclude that an individual is suffering from BPD? Well, the symptoms for BPD greatly fluctuate and vary over a brief period of time. For instance:
- Psychotic and Paranoid symptoms are temporary
- Anxiety and Depressive symptoms exist for a brief period of time
- Self-hurt ideas such as suicide exist quite strongly but for a short-period of time
- Doubts about self-identity may exist, but are short-lived
Whereas, the symptoms of each of the corresponding comorbid disorders are much more consistent.
At What Age Does Borderline Personality Disorder Occur?
There is a lot of variation in the advancement of BPD. Mostly, BPD symptoms are reflected in individuals in their late adolescence or early adulthood. However, some individuals may become aware of BPD and seek psychiatric guidance quite later.
So, there is no debate over the probable age when Borderline Personality Disorder may occur. It is clear that borderline symptoms are often detected at a much earlier age.
Furthermore, some believe that Borderline Personality Disorder cannot be diagnosed in individuals under 18 years of age. However, Diagnostic and Statistical Manual of Disorders, Edition 4 reveals that such diagnosis is possible.
But, the criteria for such a diagnosis is the same as that of adults. Though, there are certain additional caveats used while undertaking such a diagnosis.
Borderline Personality Disorder is the most controversial of all the personality disorders. Furthermore, there exits a lot of research challenging the validity and reliability of its diagnostic criteria. Besides this, a lot of researchers have also questioned the very utility of the construct of BPD’s diagnostic criteria.
Additionally, there exists an uncertainty related to the clinical or research diagnosis. In other words, there exists a lot of confusion whether the clinical or research diagnosis is able to actually secure the experiences of people suffering from personality disorders.
Besides this, a lot of research says that there exists an overlap between Borderline personality Disorder and other categories of personality disorders.
Additionally, research says that the intensity of overlap between BPD and cluster B Personality Disorders is the greatest. Well, Cluster B Personality Disorders include Histrionic Personality Disorder, Narcissistic Personality Disorder, and Antisocial Personality Disorder.
Besides this, research also showcases that there exists an extensive overlap between BPD and mood and anxiety disorders.
Origin of the Diagnostic Criteria for BPD
Thus, John G. Gunderson and his colleagues reviewed the literature and made a note of the various features that help in determining BPD. Later, they developed a diagnostic interview based on these features.
Thus, the Diagnostic and Statistical Manual for Disorders, Edition III (DSM-III) included this diagnosis. However, this diagnosis was marginally improved in the DSM-IV. Besides these marginal changes, the DSM-IV also included a ninth criteria for cognitive symptoms.
Thus, all these changes were made to the DSM-IV based on the clinical research that Gunderson and his colleagues undertook.
So, there were no modifications in the next edition of the manual, the DSM-IV TR. However, significant changes were proposed for DSM-V.
Accordingly, the diagnostic procedure for Personality Disorders would consider both definitive and dimensional systems. Thus, the definitive system of diagnosis would identify BPD based on traits and symptoms. Whereas, the dimensional system would consider the personality traits of an individual.
At present, the diagnostic criteria mentioned in DSM-V is the standard that is practiced.
How is BPD Diagnosed?
The diagnosis of Borderline Personality Disorder is based on the symptoms. As mentioned earlier, these symptoms may occur in adolescence of early adulthood. Furthermore, there are no definitive laboratory or brain imaging tests that help in diagnosing BPD.
However, researchers have introduced standardized interview schedules to diagnostically analyze personality disorders. Furthermore, such structured interviews have helped in improving the diagnosis of personality disorders to a greater extent.
Remember, there is no standalone interview schedule for diagnosing Personality Disorders. This is because each of the schedules has its own set of advantages and disadvantages.
Furthermore, these structured interview schedules are excessively lengthy. Hence, it takes a lot of time for the trained rater to carry out such schedules.
For instance, the Diagnostic Interview for Borderlines – Revised is a tool that clinicians validate as well as use frequently to diagnose BPD. However, it may take 30-60 minutes to carry out this interview.
Besides this, there are several other self-report measures developed in the previous years. But, these self-reports are hardly used clinically.
It is important to note that Borderline Personality Disorder occurs in four domains. These include interpersonal functioning, impulse control, cognitive, and affectivity.
Thus, it is important for a clinician to discover symptoms in all the domains when interviewing his or her patients.
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Diagnostic Criteria of Borderline Personality Disorder As Per DSM-IV-Revised
As per APA’s DSM-IV-Revised, a consistent pattern of instability of self-image and affects, interpersonal relationships, and increased impulsivity. And these symptoms occur in adolescence and early adulthood in a variety of situations.
Furthermore, a person meeting five or more of the following criteria is considered to have Borderline Personality Disorder.
- Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behaviour covered in criterion 5.
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
- Identity disturbance: markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least 2 areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour covered in criterion 5.
- Recurrent suicidal behaviour, gestures or threats, or self-mutilating behaviour.
- 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).
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
The following section describes the Borderline Personality Disorder Symptoms in the above mention four domains.
I. Affective Symptoms
The following are the symptoms of BPD based on the affective criterion:
- Instability due to frequent mood changes
- Persistence of mood changes for a brief period of time
- Increased sensitivity to rejection, abandonment, or failure
- Negative emotions specifically persist for a longer period of time and are more intense
- Continuous emotional variability, increased hostility, and dysphoria
- Inappropriate and extreme anger
- Chronic feeling of emptiness
2. Impulsive Symptoms
The following are the symptoms of BPD based on the impulsive criterion:
- Self-harming ideas like recurrent attempts to suicide or threats
- Alcohol and substance abuse
- Binge eating
- Gambling and spending excessively
- Sexual immorality
3. Interpersonal Symptoms
The following are the symptoms of BPD based on the interpersonal criterion:
- Instability in relationships
- Extremely idealizing and then devaluing relationships
- Avoiding abandonment
- Isolating socially
- Identity disturbance including frequent and sudden changes in goals, beliefs, vocational aspirations, and sexual identity
- Inability in defining one’s own identity
- Feeling of an inconsistency or a mismatch in one’s identity
4. Cognitive Symptoms
The following are the symptoms of BPD based on the Cognitive criterion:
- Disassociations or Psychotic symptoms like paranoid thoughts and auditory hallucinations for a brief period of time
- Experiencing depersonalization, that is, a sense that one’s body or self is unreal or modified in a weird manner.
- Derealization that the external world is unreal and unusual
Diagnostic Criteria of Borderline Personality Disorder As Per DSM-V
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:
1. Significant impairments in personality functioning manifest by:
A. 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
B. 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.
2. Pathological personality traits in the following domains:
A. Negative Affectivity, characterized by:
- Emotional liability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
- 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.
- Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.
- 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.
B. Disinhibition, characterized by:
- 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.
- 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 the personal danger.
- Antagonism, characterized by:
- Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.
C. 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. 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., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma)
Diagnostic Criteria of Borderline Personality Disorder As Per International Classification of Diseases
As per International Classification of Diseases (ICD), a definitive category of Borderline Personality Disorder does not exist within the ICD -10the Revision. However, there is a corresponding disorder category termed ‘Emotionally Unstable Personality Disorder’
This is a Borderline kind of disorder that involves emotional instability, self-image, and relationships. However, the category Emotionally Unstable Personality Disorder under ICD-10 does not include apparent psychotic characteristics.
As per evidence, there is some sort of an agreement regarding the diagnostic criteria between DSM and ICD systems. Although,certain changes in DSM and ICD are required to bolster concurrence between the two systems.
As mentioned above, the standardized interview schedules have improved the diagnostic evaluation to a great extent. Although, there are some major instruments available for evaluating Borderline Personality Disorder.
However, these instruments primarily involve questions directly picked up from DSM-IV. And, as per clinicians, such direct questions do not hep them much in evaluating the symptoms of personality disorders.
Thus, the clinicians depend more on the interpersonal interactions and the behaviors of their patients suffering from personality disorders. This is because it helps the clinicians to undertake diagnosis of personality disorders more efficiently.
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Screening For BPD
It is extremely important to screen personality disorders using reliable instruments. This is because it will help clinicians to diagnose the personality disorder correctly. Further, it will also help them prevent the patients from misdiagnosis or no diagnosis at all.
Though, a number of clinical symptoms will indicate the clinician to undertake evaluation for Borderline Personality Disorder. However, the questionnaire instruments may indicate that a comprehensive assessment is needed for BPD.
BPD is a complex mental disorder in terms of its diagnosis. As a result, clinicians had to use some standard instruments to complete their assessment for BPD.
However, the screening instruments as well as the structured interviews used to diagnose BPD today are quite time-consuming. Thus, all these instruments are applied in a restricted manner over clinical population.
In fact, clinicians rely more on self-reports as these offer a valid assessment of BPD characteristics. In other words, clinicians find a self-report as a more effective tool over an interview schedule. This is because a self-report helps in evaluating the experiences symptoms of Borderline Personality Disorder like feeling of emptiness and identity distortions.
Thus, a screening instrument like a self-report is easy-to-use in clinical practice, saves time, and decreases defensive responses. Furthermore, it also comprises better psychometric characteristics as there is standardization in large samples.
Therefore, such characteristics as well as conciseness make these instruments a better option for screening BPD. But remember, you can use these tools just as diagnostic instruments.
As per BMC Psychiatry, the following are the widely-used screening tools to diagnose BPD
I. McLean Screening Instrument for BPD (MSI-BPD)
The MSI-BPD is a screening scale for BPD that relies on DSM-IV and DSM-5. This screening instruments was introduced to provide a reliable and an easy-to-implement scale for BPD assessment.
Thus, Mclean Screening Instrument for BPD is a screening questionnaire comprising ten questions. These questions contain items for each one of the first eight criteria of the DSM-IV and DSM-5 for BPD. Plus, the questionnaire also includes items of ninth criterion of paranoia or dissociation. Further, each of the questions are followed by yes or no answers.
Besides the first eight criteria of the DSM-IV and DSM-5 for BPD , the MSI-BPD also assesses the psychometric characteristics in adolescents and adults.
II. Borderline Personality Questionnaire (BPQ)
Borderline Personality Questionnaire is a self-report measure that evaluates the Borderline Personality Traits as defined by DSM-IV criteria. Furthermore, this self-report instrument has separate subscales for each criterion.
Borderline Personality Questionnaire consists of 80 true or false items and these items test symptoms for nine BPQ subscales.
These subscales include: Impulsivity, Affective Instability, Abandonment, Relationships, Self-Image, Suicide or Self-Mutilation, Emtiness, Intense Anger, and Quasi-Psychotic States.
Though, BPQ is a reliable and valid instrument in a range of clinical and research contexts. However, this test significantly overlap with the Schizotypal Personality features.
In other words, the BPQ instrument reflects comorbidity of other personality disorders. However, the questionnaire demonstrates high internal consistency for the full scale. Furthermore, it also showcases reasonable to strong reliability for most subscales.
III. Personality Diagnostic Questionnaire-4 BPD
Personality Diagnostic Questionnaire-4+ (PDQ-4+) is a self-report designed especially for the assessment of Personality Disorders based on the DSM-IV criteria.
Furthermore, the PDQ-4+ comprises of 99 items distributed along with 12 subscales. Ot of these 12 subscales, 10 subscales refer to the Personality Disorder diagnostic categories included in Axis II. Whereas, the two (passive aggressive and depressive) categories assessed Personality Disorder categories included in Appendix B of the DSM-IV.
In addition to this, each item reflects a single DSM-IV diagnostic criterion. Accordingly, the various dimensions of PDQ-4 BPD are as follows:
Thus, a score of 5 or higher is highly suggestive of the diagnosis of BPD.
Also Read: Avoidant Personality Disorder
IV. International Personality Disorder Examination (IPDE)
The International Personality Disorder Examination (IPDE) is a semistructured clinical interview. Furthermore, such an interview is consistent with the International Classification of Diseases, Tenth Revision (ICDE-10), and the DMS-IV classification systems.
Thus, the InternationalPersonality Disorder Examination (IPDE) is an outgrowth of the Personality Disorder Examination (PDE). Accordingly, the PDE was modified for international use and compatibility with the International Classification of Diseases, Tenth Revision (ICDE-10) and the DSM-IV classification systems.
Thus, the IPDE surveys the behavior and life experiences relevant to 157 criteria. This criteria is used in making personality disorder diagnoses according to DSM-IV and ICD-10. Thus, the IPDE items are arranged under the following heads: work, self, interpersonal relationships, affects, reality-testing, and impulse control.
Furthermore, open-ended inquiries introduce the items. Thus, this gives an opportunity to the individual to discuss the topic and supplement the answers with examples or anecdotes.
The IPDE Manual contains interview questions to evaluate either the 11 DSM-IV or the 10 ICD-10 personality disorders. Further, the IPDE Screening Questionnaire is a self-screening form consisting of 77 DSM-IV or 59 ICD-10 items. And these questions are True or False items.
According to IPDE, an individual must have a specific trait for at least 5 years to consider it as a part of his personality. Such a conservative convention is considered to reflect the enduring nature of personality traits.
Furthermore, it is also considered to avoid confusing it with other temporary phenomena and episodic abnormalities of mental state and behavior.
Besides this, the IPDE also requires that an individual must fulfill at least one of the criteria of a disorder before 25 years of age. Then only that particular disorder can be diagnosed.
V. Structured Clinical Interview for DSM-V
As per APPI, Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD) is a semistructured diagnostic interview for clinicians and researchers. It helps in assessing the 10 DSM-5 Personality Disorders across Clusters A, B, and C, as well as Other Specified Personality Disorder.
Furthermore, the SCID-5-PD is an updated version of the former Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). As the name suggests, it does not include the multiaxial system in DSM-5.
Furthermore, you can use the SCID-5-PD to make Personality Disorder diagnoses, either categorically or dimensionally.
Besides this, the SCID-5-PD includes the Structured Clinical Interview for DSM-5 Screening Personality Questionnaire (SCID-5-SPQ). It is nothing but a self-report screening questionnaire for patients or subjects.
Now, the basic structure of the SCID-5-PD covers non-personality DSM-5 disorders. Further, the SCID-5-PD questions evaluate the DSM-5 criteria for each of the 10 Personality Disorders.
Additionally, the SCID-5-SPQ is an optional self-report screening tool. It comprises of 106 questions that correspond to each first question in the full SCID-5-PD. Furthermore, this screening tool requires an eight grade readability level and just takes 20 minutes to finish. Hence, this tool can help you to decrease the time of the SCID-5-PDclinical interview.
Treating Borderline Personality Disorder
1. Medications of Pharmacological Treatment
A host of international studies showcase diverging viewpoints regarding the pharmacotherapeutic management in BPD.
The German and Dutch studies showcased evidence supporting use of medications in the management of BPD symptoms.
These studies examined various classes of antipsychotics, antidepressants and mood stabilizers. Furthermore, they also studied the effects of various medications on the cognitive behavioral symptoms, impulsive behavioral control, and affective dysregulation.
However, another German Study concluded that the evidence for the use of medications for BPD is limited. In other words, there is no evidence supporting polypharmacy. Accordingly, no specific medication led to a reduction in the severity of BPD.
a. Mood Stabilizers
According to some German and Dutch studies, mood stabilizers have a great impact on the impulsive behavioral control and anger.
Furthermore, these studies revealed that the medications had a larger effect on the global functioning than antipsychotics.
Besides this, Mood Stabilizers also showcased a large decrease in anxiety and moderate improvement in depressed mood.
However, other German studies revealed that the Mood Stabilizers and the antipsychotic, aripiprazole, were the most effective pharmacologic treatment for impulsive behavioral dyscontrol.
Some of the German and Dutch studies showcased that the antipsychotics resulted in a moderate impact on the cognitive perceptual symptoms.
Furthermore, these studies also revealed that antipsychotics had a moderate to large impact on reducing anger.
Whereas, other German Studies revealed that Antipsychotics like flupenthixol and Omega-3 Fatty acids like fish oil best treated suicidal behavior.
Besides this, Antipsychotics like Aripiprazole or Mood Stabilizers like valproate and topiramate treated interpersonal problems most effectively.
The studies revealed that the Antidepressants has a small impact on anxiety and anger. Furthermore, it did not have any significant impact on any other domains.
However, another German study revealed that antidepressants are not widely supported for BPD treatment. Although, the studies showcased that the anti-depressants are beneficial in treating comorbid depression.
However, other German studies revealed that antidepressants best treated the symptom of affective dysregulation.
the National Collaborating Centre for Mental Health for the national health system of Great Britain charted out the NICE guidelines.
As per these guidelines, psychotherapeutic and systems-based interventions are used for managing care in a structured manner. These guidelines do not identify enough evidence to justify recommending a medication treatment strategy.
However, these guidelines do mention the short-term use of sedating antihistamines in the case of crisis.
Furthermore, some studies have showcased favorable results for a combination of education and psychotherapy to treat BPD.
For instance, a study was conducted on 24 women with BPD and high levels of irritability and anger. Thus, these women were assigned to 6 months of Dialectical Behavior Therapy (DBT) alone or DBT and olanzapine.
Both the groups showcased a significant improvement in irritability, depression, aggression and self-injury. However, the group treated with DBT and olanzapine experienced more rapid decrease in irritability and aggression.
In addition to this, evidence suggests that certain medications like benzodiazepines should be avoided in BPD. This is because such medications can inhibit learning. Furthermore, such medications may also interfere with acquiring new skills during the psychotherapeutic treatment.
It is suggested that the clinicians should first determine treatment for any comorbid psychiatric illness. Then, they should identify the prominent symptom domain a patient with BPD may experience.
This is because there can be a possibility of an overdose of medications leading to high risk of toxicity.
Thus, clinicians should focus on specific symptom domains such as cognitive-perceptual symptoms, impulsive-behavioral dyscontrol and affective dysregulation. This approach will help them in guiding treatment choices.
Furthermore, it will also facilitate psychotherapeutic effect and promote the reduction of polypharmacy.
There exist four psychotherapies to address the complexities in treating Borderline Personality Disorder. These include: Dialectical Behavioral Therapy (DBT), Schema Therapy, Mentalization-Based Therapy (MBT), and Transference-Focused Therapy (TFP).
Besides this, systems training for Emotional Predictability and Problem-Solving (STEPPS) are also on the rise.
1. Dialectical Behavioral Therapy (DBT)
Dialectical Behavioral Therapy (DBT) is a psychological intervention. It was initially designed to treat chronically suicidal, multiproblem patients.
This treatment is principle-based and involves manual protocols. Furthermore, it also includes components of individual therapy, skills training groups, phone coaching, and a consultation team for clinicians.
In addition to this, the skills training groups involves approaches like mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.
In other words, DBT emphasizes on skills training and strategies to generalize skill application.
Additionally, the DBT Ways of Coping Checklist helps to identify whether group members use skillful or ineffective strategies to solve problems.
Further, as per data, patients undertaking DBT use skills three times more than those in a control condition. Also, such use of skills helped in reducing suicide attempts, depression, and control over anger in patients.
However, to undertake DBT, patients have to invest time in attending weekly skills group as well as individual sessions for a year.
2. Schema Therapy
An individual suffering from BPD adopts differing coping styles that often lead to destructive behavior. And to capture these self-destructive coping styles, the concept of modes was developed.
Thus, the modes represent the BPD patient as child, parent, and healthy adult. Accordingly, these modes include abandoned or abused child, angry or impulsive child, detached protector, punitive parent and healthy adult modes.
Therefore, Schema Therapy involves four implied mechanisms of change. These include limited reparenting, experiential techniques, education and cognitive restructuring, and behavioral pattern breaking.
a. Limited Reparenting
As a therapist, you first need to provide a supportive environment to your patient during the initial phase of the treatment.
Such an environment makes up for the the ways in which the patient’s parents failed to meet his needs throughout development.
b. Experiential Techniques
Next, you need to utilize various experiential techniques. These techniques will give your patient gets an opportunity to communicate his experiences as a child.
Thus, imagery is the first experiential technique you can use to facilitate discussion and processing of challenging episodes from childhood.
Besides this, you can also use the ‘Empty Chair’ technique to facilitate communication between the fearful and critical facets of the patient.
In addition to this, you can also use the Letter Writing technique. In this technique, you can ask your patient to write letters to those people whose behavior was harmful.
Remember, these letters are not written with an intent to send it across to the person in question. Thus, through Letter Writing, your patient gets an opportunity to communicate his feelings and needs.
c. Education and Cognitive Restructuring
The next thing that you need to do as a therapist is to educate your patient regarding his adaptive needs and emotional experiencing.
Besides this, you also need to change the thought process of your patient through cognitive restructuring. Cognitive restructuring aims to help an individual develop moderate interpretations about his own behavior as well as those of others.
d. Behavioral Pattern Breaking
Finally, the individual learns to apply whatever they have learnt over the sessions in the last phase of the treatment.
They implement their learnings in the real life that is outside the sessions. And they do this through generalization.
It is important to note that new research in the field of Schema-Focused Therapy (SFT) supports development of group work. Furthermore, it revealed that patients assigned to Treatment as Usual (TAU) plus SFT showcased a high retention rate. Besides this, such patients also exhibited reducted BPD symptoms, improved functioning, and a greater change in no longer meeting BPD criteria.
Also Read: What is Cognitive Behavioral Therapy (CBT)?
3. Mentalization-Based Therapy (MBT)
Mentalization is a process in which an individual tries to understand his or her mental state as well as those of others.
Accordingly, individuals with BPD find it quite challenging to undertake this process when they emotionally unstable.
As a result, the goal of the Mentalization-Based Therapy is to help an individual with BPD develop this process and maintain it. And this is done when a BPD individual’s attachment system is active.
In addition to this, the MBT theory states that the core symptoms of BPD are linked with one another. This is because an individual with BPD lacks the ability to understand his or her own mental states as well as those of others. Thus, the core features of BPD may include impulsivity, affect dysregulation, and unstable relationships.
For instance, a randomized controlled study compared the results of MBT with partial hospitalization and Treatment as Usual (TAU).
Such a study demonstrated that patients undergoing MBT showcased significant improvement relative to TAU in terms of:
- Diagnostic status,
- Service use,
- Medication use,
- Global functioning, and
- Vocational status
Another randomized controlled trial compared MBT with Structured Clinical Management. Thus, patients under both the groups showcased improvement across measures like:
- Suicidal and severe self-injurious behaviors,
- Self-reported symptoms,
- Social and interpersonal functioning
However, patients under the MBT group showcased a great improvement in self-report symptoms and crisis situations.
4. Transference-Focused Psychotherapy (TFP)
Transference-Focused Psychotherapy is a process in which the psychological interventions of therapist help an individual to bring about a change in the individual’s representations of the self and others.
Thus, TFP observes the complexities in an individual’s psychological structure as the base for the particular symptoms that he or she experiences.
In other words, the TFP views an individual’s psychological structure as formed around images of oneself and other important people. The individual internalizes such images during the course of his development.
Furthermore, these images are not fully conscious within the individual and may be distorted. Thus, such images of oneself as well as others play a critical role in the manner in which the patient adjusts to life.
This is because these images become the patient’s lenses via which he or she interprets his or her experiences.
Thus, distorted, unrealistic, and exaggerated images may lead to problems in mood, self-esteem, and relations with others.
So, psychotherapy can help in resolving these challenges. Thus, TFP depends on the ideology that a patient experiences and lives based on the internal images. These images are the base of the patient’s psychological structure. And this psychological structure defines or influences the patient’s relationship with his or her therapist.
This is called transference. Thus, a psychologist can help the patient in becoming aware of the existence of such internal images. As a result, it will help the patient to adjust these images to the world around him or her. Besides this, it will also lead to decrease in depressive and anxious feelings.
Quiet Borderline Personality Disorder Test
As mentioned above, Borderline Personality Disorder is a mental condition that involves frequent fluctuations in an individual’s mood and behaviors. Furthermore, individuals with BPD also experience instability in relationships and are doubtful of their self-image.
However, Borderline Personality Disorder manifests in different forms. These include:
- Discouraged or Quiet Borderline
- Self-Destructive Borderline
- Impulsive Borderline
- Petulant Borderline
Quiet Borderline Personality Disorder refers to a state when an individual internalizes all the emotions that he or she feels. Just like BPD, these emotions may include:
- Fear of abandonment,
- Mood swings,
- Self-injurious behaviours,
- Suicidal tendencies and
- Black and white thinking (splitting)
Thus, unlike classic BPD, individuals with Quiet BPD tend to direct their emotions inwards. In other words, instead of acting outward, an individual with Quiet BPD acts inward.
Furthermore, Quiet Borderline Personality Disorder may involve less hostility and relatively lesser aggressive outbursts.
However, an individual suffering fro Quiet BPD may feel isolated and attempt self-harming behaviors.
Thus, the following are the eight specific symptoms of Quiet BPD.
Symptoms of Quiet Borderline Personality Disorder
- Internalizing emotions
- Appearing normally but crumbling on the inside
- Socially withdrawn
- Mental dissociation
- Avoiding anger and conflicts
- Fearing abandonment and intimacy
- Self-Sabotaging abd Self-Doubting
- No clarity of self-image
Take Quiet Borderline Personality Test
The following test was published by Imi Lo is a Psychotherapist, Art Therapist, and Consultant for emotionally intense and highly sensitive people on her website.
|1.||Do you experience an intense emotional roller coaster ride often?||Yes/No|
|2.||When you are upset, is all the shame, hate, or anger directed towards yourself?||Yes/No|
|3.||Do you often find yourself thinking, ‘I must have said or done something wrong,’ or ‘I must have been at fault’?||Yes/No|
|4.||Do you stay awake at night with paranoia because someone you care for did not return a mobile text?||Yes/No|
|5.||Do you distance yourself from friends or colleagues without having first tried to speak to them about what’s upsetting you?||Yes/No|
|6.||Do you find yourself thinking that your very existence is a burden on others?||Yes/No|
|7.||Do you live in denial of the anger you feel?||Yes/No|
|8.||Do you spiral into crushing depression or tend to isolate yourself at the slightest mistakes you make in your interactions with people?||Yes/No|
|9.||Are there incidences where you have cried for days, stayed in bed and remain unmotivated towards life without anyone knowing?||Yes/No|
What Causes Borderline Personality Disorder?
The causes of Borderline Personality Disorder are quite complex. Currently, there exists any definitive model that captures all the available evidence.
However, the following factors may contribute towards Borderline Personality Disorder in an individual.
As per a study, heritability is one of the factors that may contribute towards BPD in an individual.
However, the study states that there is an increased likelihood of traits related to impulsive aggression and mood dysregulation passing in families. In other words, the study suggests that the probability of Borderline Personality traits itself getting transmitted is relatively less.
Also, there is evidence suggesting that genetics have an influence on personality disorders. This means it does not specifically influence Borderline Personality Disorder.
Furthermore, the genetics influences an individual both independently as well as in combination with unusual environmental factors.
More recent studies of heritability reveal that genetics as a factor influences 27% to 35% of Cluster C disorders. Thus, these studies conclude that genetics have a much lesser role to play in contributing towards Borderline Personality Disorder.
There are certain areas in the human brain that play a central role for regulation, attention, self-control, and executive function.
Now, there exists evidence that there exists structural and functional deficits in such ares of the brain if a person is diagnosed with BPD.
Thus, these brain structures include amygdala, hippocampus, and orbitofrontal areas. Furthermore, there exist studies showcasing emotional stimulation in the brain structures of a BPD patient.
Accordingly, individuals with Borderline Personality Disorder showcase increased activity in the dorsolateral prefrontal cortex and in the Cuneus.
However, such individuals show a reduced amount of activity in the right anterior cingulate part of the brain.
In addition to this, an increased activity is observed in the amygdala of an individual whenever he views emotionally aversive images.
The main challenge with Borderline Personality Disorder is that there is an increased regulation of emotional states. Thus, this regulation of impulses, aggression, and affect is due to neurotransmitters.
Out of all the neurotransmitters, Serotonin is the neurotransmitter that has been studies quite extensively.
As a result of such study, it is revealed that there exists an inverse relationship between levels of serotonin and intensity of aggression.
Accordingly, reduced levels of Serotonin in an individual may slow down his ability to control destructive urges. However, there exists some sort of unclarity in the casual pathway of such an activity.
Furthermore, there is evidence of a decrease in the 5-HT 1A receptor responses in women with BPD and those having experienced child abuse for a long period.
Thus, there is a possibility that the environmental factors might be an explanation for the link between 5-HT and aggression.
5-HT 1A receptor is a subtype of Serotonin. Studies suggest that the activity of anxiolytic, antidepressant, and antipsychotic medications take place due to the stimulation of this receptor.
Accordingly, the selective serotonin reuptake inhibitors (SSRIs) and other serotonergic agents are the drugs that increase 5-HT levels and facilitate 5-HT neurotransmission.
There is little evidence suggesting the role of catecholamines including norepinephrine and dopamine in the dysregulation of affect. It is observed that the individuals with BPD have lower levels of plasma-free methoxyhydroxyphenylglycol.
The plasma-free methoxyhydroxyphenylglycol is a metabolite of noradrenaline. However, individuals that do not have BPD have relatively high levels of this metabolite of noradrenaline.
But, this difference does not exist at all when the aggression scores are controlled.
Amphetamine is a powerful stimulator of the central nervous system used to treat some medical conditions.
Furthermore, Amphetamine activates receptors in the brain and increases the activity of a number of neurotransmitters. Norepinephrine and Dopamine are the two neurotransmitters that Amphetamine stimulates
Thus, Amphetamine is used to treat health problems such as obesity, narcolepsy, or attention deficit hyperactivity disorder (ADHD).
Now, evidence suggests that people suffering from BPD and taking amphetamines are sensitive. Furthermore, such individuals showcase more sensitivity relative to those who belong to the control group.
d. Other Neurotransmitters
Acetylcholine , vasopressin, cholesterol, and fatty acids are some of the other neurotransmitters and neuromodulators are suspected in the phenomenology of BPD.
4. Psychosocial Factors
Certain studies conducted on families suggest that there exist various factors that play a key role in the development of Borderline Personality Disorder.
a. Family History and Substance Misuse
One of the factors may be the history of mood disorders and substance misuse in other family members.
b. Less Emotional Involvement of Parents
In addition to this, recent studies also suggest that the caregiver’s neglect as well as lesser emotional involvement with the child also contribute towards BPD.
Therefore, parents involving lesser emotionally with their child makes it challenging for the child to socialize. Such a behavior in children increases the risk of suicide attempts.
c. Biparental Challenges
Besides this, studies also reveal that individuals having Borderline Personality Disorder see their mothers as distant and overprotective. As a result, such individuals often are at conflicting end with their mothers.
However, individuals with BPD view their father as less involved and more distant. Thus, it reveals that problems with both the parents has a greater chance of contributing towards the disorder in individuals diagnosed with BPD.
In other words, there is little evidence suggesting that problems with individual parent alone have pathogenic influence on people with BPD.
Furthermore, the studies of abuse support the view that biparental challenges play a an important role in giving birth to Borderline Personality Disorder.
d. Child Abuse
It is not an unknown fact that physical, sexual, and emotional abuse take place in family setups. Furthermore, studies reveal that the cases reporting abuse are higher in people suffering from Borderline Personality Disorder.
As per a study, 84% of people suffering from BPD revealed that biparental neglect and emotional abuse before the age of 18 as reasons for giving rise to the mental disorder. The emotional abuse reported also included caregivers denying the emotional experiences of people with Borderline Personality Disorder.
Thus, all of this suggests that parents of the individuals suffering from BPD did not consider their child’s experience when undertaking family interactions.
e. Caregiver’s Response to Abuse
Furthermore, abuse alone is neither essential nor enough for BPD to develop in individuals. In other words, contextual as well as predisposing factors of the parent-child relationship are likely to be agreeable factors in the development of BPD.
So, the most important thing with respect to the long-term outcomes in BPD individuals is the caregiver’s response to the abuse. And not the abuse itself.
Thus, there are children brought up in a family environment that discourages to understand or consider their child’s perspective on the world. Such a family environment fails to facilitate successful adjustment of the child following trauma.
Thus, there are certain studies that have examined the family condition of childhood trauma in individuals with Borderline Personality Disorder.
It is revealed that non-nurturing family environment is the most critical factor contributing towards the link between abuse and personality dysfunction.
Besides this, there are certain other studies showcasing that individuals with Borderline Personality Disorder lack social cognition. This is due to the disrupted attachment of the individual with family members.
5. Attachment Process
There are numerous studies showcasing link between attachment processes and occurrence of Borderline Personality Disorder.
Accordingly, certain studies suggest that individuals are vulnerable to immensely stressful psychosocial experiences due to disrupted attachment.
In other words, the disrupted attachment in people with BPD occurs due to family:
- Excessive Control
- Unsupportive Relationships
It is important to note that there is no apparent relationship of Borderline Personality Disorder diagnosis with any particular attachment category. However, there are studies that showcase strong association between BPD and insecure attachment.
Besides this, the interviews and the questionnaire studies indicated disorganization, and fearful, avoidant, and preoccupied attachment.
Thus, an individual who develops attachment insecurity at an early age continues to have insecure attachment with regards to negative life events. There are studies that showcase associations between insecure attachment in early childhood and BPD symptoms.
Thus, childhood attachment may be a critical factor in the development of Borderline Personality Disorder.
As per a study, attachment may have been disrupted due to many reasons. Furthermore, the consequences occurring due to insecure attachment relationships get mediated through a lack of development of social cognitive capacity.
The social cognitive capacity refers to the ability to understand one’s own actions as well as those of others. It also refers to interpreting one’s own actions and those of others as meaningful.
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