DSM-5 in pictures
Written byMegan Anna Neff
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in Images
I'm back with week 4 of my DSM-5 series in pictures (you canTake a look at autism here, zADHD here).
Disclaimers, FAQs, and General Information about the DSM-5
Why am I creating this series?I'm creating this series to improve the accessibility and transparency of DSM-5 and the clinical tools that people like me use when diagnosing you (or anyone else). I believe that the world of mental health can be too mysterious and can increase anxiety and stress for many. I believe that this process should be as understandable and transparent as possible. I use visual aids to decipher the DSM-5 because, like many neurodivergent people, I have a hard time understanding it unless something is visual!
Disclaimer:This is for educational purposes only and is not intended to replace medical advice or be used as a primary diagnostic tool.
A word about language:I'm usingdirect language of the DSM.That's allfor educational purposes. Much of the language used is deficit-based and pathological in nature. That doesn't mean I agree with every word (in fact, I disagree!). I made this decision to increase the transparency of what is actually in the DSM.
What about international people?The Diagnostic and Statistical Manual is based in the United States (it is published by the American Psychiatric Association). However, the criteria are very similar to those of the ICD, which is used worldwide and widely in medical institutions.
DSM in PDF images
Ok, now that we have discussed the purpose, intent, and limitations of this post. let's dive!
What is Borderline Personality Disorder?
Borderline Personality Disorder (BPD) is a personality disorder characterized by a general pattern of instability. More specifically, borderline personality disorder is characterized by instability in relationships, self-image, emotions, and behavior (impulsivity).
Borderline personality disorder has a prevalence rate of 5.9% and is diagnosed more frequently in women.
Borderline Personality Disorder is characterized by:
Intense difficulties in interpersonal relationships.
an unstable self-concept
Impulsivity, disinhibition and risk behavior
Difficulty dealing with painful emotions.
To receive a diagnosis of borderline personality disorder, these symptoms must:
1) Being present in different contexts (home and school or home and work)
2) lead to significant stress or cause significant functional impairment.
What causes borderline personality disorder?
Although no specific "cause" has been identified, several risk factors for BPD have been identified. Mainstream theories about BPD suggest that it occurs when a person with an innate (genetic) vulnerability interacts with a "chronically disabling environment" (Vanwoerden and others, 2019).
DSM-5 criteria for borderline personality disorder
To meet the criteria for borderline personality disorder, five of the nine symptoms must be present. They must be present in multiple contexts and cause significant stress or impairment in relationships and general functioning. The nine criteria for borderline personality disorder include:
1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between the extremes of idealization and devaluation.
3. Identity Disorder: Strong and persistently unstable self-image or sense of self.
4. Impulsiveness in at least two potentially self-destructive areas (eg, spending, sex, substance abuse, reckless driving, binge eating).
5. Repetitive suicidal behavior, gestures or threats, or self-mutilating behavior.
6. Affective instability due to marked mood reactivity (eg, severe episodes of dysphoria, irritability, or anxiety, usually lasting a few hours and rarely more than a few days).
7. Chronic feelings of emptiness.
8. Intense and inappropriate anger or difficulty controlling anger (eg, showing anger frequently, being constantly angry, repetitive physical fights).
9. Transient stress-related paranoid ideas or severe dissociative symptoms.
A brief conceptualization of borderline personality disorder
Before I look at BPD symptoms in more detail, I want to give you some context.why these symptoms make sense.BPD is a heavily stigmatized condition. If we only talk about symptoms and don't think about why they make sense, we perpetuate the stigma associated with BPD.
At the core of BPD is a highly anxious and preoccupied attachment style (in the context of BPD, this is often a traumatic response to early attachment injury). People with this attachment structure tend to believe"I am bad and the others are good."As such, they often feel insecure and anxious in their relationships. You have a strong need to belong, to belong and to feel accepted. When an attachment (relationship) goes wrong (or is perceived to be wrong), it tends to reassure the person that they are worthless and bad. A break in a relationship can trigger an intense grief/shame/anger response.
A person with an anxious and busy attachment structure cannot be okay if the relationship is not okay. When there is tension or distance in the relationship, the person struggles to calm down (fixing the relationship is what calms them down). This can lead to frantic efforts to repair the relationship or to protest the breakup (attack). This can overwhelm the other person and lead to further disconnection.
A person with an anxious attachment style is also primed to look for attachment disorders. Your mind constantly scans your surroundings for signs of rejection. When our mind does this, we tend to overinterpret events as a rejection signal, which can lead the person to interpret something neutral as a rejection signal. This is the brain's attempt to be hyper-alert, trying to protect the person by being hyper-aware of rejection signals. It ends up causing more suffering to the person.
Attachment injuries evoke feelings of shame, meanness, and rejection so intense that they tend to overwhelm the person. These feelings are so intense and painful to process that they can often be channeled out into the world through a process known as projection.
When some emotions are unbearable, we tend to push them away and project them onto others. In projection, we act in such a way that the other person feels what we are afraid of. For example, if a child feels helpless, they may throw a significant tantrum and not respond to the redirection, leaving parents feeling helpless. The child has no words for this, but through an unconscious process, he invites the parent to metabolize emotions that are too big to metabolize.
In the case of BPD, the experience of being rejected is an emotion that is often too overwhelming to process. Therefore, the person may project this onto the other, making the other person feel rejected (through belittling, angry outbursts, or more). This is not a conscious process and often feels out of control. However, learning DBT skills and healing attachment wounds can lead to much more conscious actions and actions.
Now that we have some context for why these symptoms make sense, let's move on to the specific symptom of borderline personality disorder.
First criterion: Intense fear of abandonment
People with BPD often experience an intense fear of abandonment. This can lead to frantic efforts to avoid real or imagined abandonment.
Common triggers are:
next break
Rejection (or even the perception of rejection)
perception of being neglected
A loss of external structure.
These situations can cause profound changes in a person's self-image, emotional stability, thoughts, and behavior. This hypersensitivity to changes in relationships can lead to violent reactions, often accompanied by inappropriate anger. The person's reactions seem out of proportion to the situation.
Planned or unavoidable separation situations will still create a strong sense of hopelessness for the person and can lead to extreme protest behaviors and actions. Perceived abandonment often reinforces the belief that the person is "bad" and invokes their general fear of being alone.
Criterion 2: Unstable relationships
People with borderline personality disorder often experience instability in interpersonal relationships. Interpersonal challenges are often characterized by unstable and intense relationships that oscillate between idealization and devaluation. There is often heightened interpersonal sensitivity with extreme efforts (often interpreted as manipulation) to avoid abandonment (Weiner and have. 2019).
A person with borderline personality disorder often idealizes potential partners, lovers, and caregivers early in the relationship. This can lead to quick and fast attachments (spending a lot of time together and sharing intimate details quickly in the relationship).
The relationship can change quickly (especially when it comes to rejection or abandonment). They may feel (and blame) the other person for not really caring or being there for them.
There are often sudden and dramatic changes in relationships. Someone who was once perceived as caring, kind and wonderful, the next moment may be seen as cruel and punitive.
This change usually occurs when the idealized image is broken. One way to think about this dynamic is external despair. Despair is too painful to metabolize, so it is channeled through devaluation and anger.
Criterion three: unstable self-image
A person with BPD often experiences a confused sense of self that is prone to sudden and dramatic identity changes.
These changes are often characterized by
change goals and future plans
sexual and gender identities
Values
political ideologies
opinions about friendships
professional decisions
An extreme form is when the person transitions from the role of 'needy supplicant' to 'simple avenger of past abuse' (DSM-5). This can lead to false accusations by former caregivers and partners.(Note: It will not appear to the person that they are making a false accusation, as the accusation is consistent with their perceived experience of what happened.)
At other times, this instability can manifest as a general feeling of non-existence. These experiences usually occur when the person feels a lack of connection and meaningful, nurturing, and supportive relationships. Because of the need for structure and meaning, people with BPD generally do better in structured work and school settings.
Fourth criterion: impulsivity (self-destruction)
People with borderline personality disorder "often exhibit impulsivity in at least two areas that are potentially self-defeating."
This may include:
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game
spending money irresponsibly
Binge
substance abuse
have unprotected sex
reckless driving.
Self-destructive impulsivity usually occurs in response to perceived rejection or abandonment and is typically a response to emotional dysregulation.
(Note: While this may sound similar to ADHD impulsivity, it is different and has different causes. To learn more about the similarities and differences between ADHD and BPD, seeCheck out the ebook here).
Criterion 5: Repeated suicidal behavior and self-harm
People with borderline personality disorder often experience recurrent suicidal behavior, suicidal gestures, threats, or self-harm.
These behaviors are usually triggered by abandonment fears and abandonment reactions. These behaviors may also be in response to emotional dysregulation and the dissociative experience.
Although the prevalence rates of self-harm have been estimated at approximately 17% in adolescents and 6% in adult general population samples, the prevalence rates in people with BPD are 95% (adolescents) and 90% ( Adults).Reichl & Kaess, 2021 Show more).
Self-injury can serve many purposes (it can be in response to emotional dysregulation or dissociative experiences). Self-injury in BPD is most commonly associated with attachment injury and relationship conflict.Duda, 2017).
While there are many reasons why a person self-harms, the most common reason in people with BPD is related to emotion regulation. More than 95% of women with BPD reported self-injury for emotional relief (Cole et al., 2020).
Criterion 6: Affective instability
People with BPD tend to experience intense and rapid changes in their emotions. They often experienced heightened emotional sensitivity. Something that may seem small to another person can generate big emotions (deep sadness, irritability, fear, anger).
People with borderline personality disorder are more likely to experience emotional distress and affective instability related to perceived abandonment and relationship distress. Strains in the relationship can lead to feelings of hopelessness and frantic panic (Littmann, E., 2021).
The person's mood tends to be "dysphoric" (sad, depressed), with limited access to the positive emotions of joy, happiness, and hope. The person's underlying depressed mood is often interrupted by periods of anger, panic, or despair.
Criterion 7: Chronic feelings of emptiness
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People with borderline personality disorder are often plagued by chronic feelings of emptiness.
This may seem like mild boredom and they may be constantly looking for something to do to distract themselves from their emptiness.
(*Note that this may seem similar to ADHD's need for stimulation and difficulty resting or a blurred sense of self that often accompanies highly masked autism.)To learn more about the similarities and differences between autism and BPD,You can read about it in my e-book here.
Criterion Eight: Inappropriate Anger
People with BPD often have trouble controlling their anger, which can manifest as intense forms of angry outbursts. This can show up as putting others down through extreme sarcasm or verbal outbursts, and it can also show up as persistent bitterness towards others.
Anger is often triggered when a significant other, significant other, or close friend is perceived to be neglectful, withdrawn, or abandoned. Such expressions of anger are often followed by shame and guilt, leading to a shame-based and negative self-image.
Criterion 9: Imagination and paranoid dissociation
Borderline Personality Disorder (DSM in Pictures)
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Paranoid thinking or dissociative symptoms (eg, depersonalization, derealization) may occur during times of extreme stress. These experiences are mostly triggered by a real or imagined abandonment. These experiences are usually temporary, lasting for minutes or hours.
Borderline personality disorder, ADHD and autism
And since this site is mostly about autism and ADHD. Before I wrap up this article, here are some thoughts on borderline personality disorder, ADHD, and autism.
Co-occurring BPD, ADHD, and Autism
BPD co-occurs more frequently with ADHD and autism (than in the autistic and non-ADHD population). In fact, the prevalence rate of almost all personality disorders is higher among ADHD and the autistic neurotype.
Our neurotype makes us more likely to develop PTSD after acute trauma. It also makes us more prone to developing personality disorders. That makes sense. We have more vulnerable nervous, sensory, and amygdala systems, so our bodies respond more intensely to trauma. We are also seeing more victimization, discrimination, and disability. Having innate neurodivergence means living with many additional vulnerabilities that predispose us to things like PTSD and personality disorders.
misdiagnosis
Due to coexistence, BPD is also commonmisdiagnosisAutistic and ADHD people (especially women and queer people). To the untrained eye, several ADHD traits (impulsivity, hyperactivity, difficulty regulating emotions) can resemble BPD.
To the untrained eye, the common experiences of masked autistics can seem like BPD (a blurred sense of self due to masking, sensory overload can look like angry outbursts, and difficulties with emotions and relationships).
For this reason, I believe it is extremely important in any evaluation of a person for BPD that autism and ADHD are also considered (as coexisting with or instead of BPD). If you want to learn more about how overlapping occurs, features, and more, you can check out mineEbook series on misdiagnosis in which I delve into these topics.
ADHD vs. Borderline personality disorder
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Autism or borderline personality disorder? (ebook)
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Megan Anna Neff
FAQs
What is the DSM-5 criteria for the diagnosis of borderline personality disorder? ›
Diagnostic criteria (DSM-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.
Some other conditions such as schizophrenia, OCD, anti-social personality disorder, borderline personality disorder, dissociative disorder, and bipolar disorder can be classed as a form of neurodivergence too.
What criteria do you have to meet to be diagnosed with BPD? ›- fear of abandonment.
- unstable or changing relationships.
- unstable self-image, including struggles with sense of self and identity.
- stress-related paranoia.
- anger regulation problems, including frequent loss of temper or physical fights.
Symptoms in borderline personality disorder occur in 4 domains: affectivity, interpersonal functioning, impulse control and cognitive. The diagnosis requires that at least 5 of 9 specific criteria be met (Box 2).
What do psychiatrists look for when diagnosing BPD? ›Do you have severe mood swings, such as feeling intensely depressed, anxious or irritable, which last from a few hours to a few days? Do you have long-term feelings of emptiness and loneliness? Do you have sudden and intense feelings of anger and aggression, and often find it difficult to control your anger?
Can autism be misdiagnosed as borderline personality disorder? ›Autism and Borderline Personality can both co-occur, or they can be misdiagnosed as one another. To the untrained eye, undiagnosed autism can easily look like BPD.
What mental health conditions are neurodivergent? ›Some of the conditions that are most common among those who describe themselves as neurodivergent include: Autism spectrum disorder (this includes what was once known as Asperger's syndrome). Attention-deficit hyperactivity disorder (ADHD). Down syndrome.
What disorders are considered neurodivergent? ›Several "recognized" types of Neurodivergence include autism, Asperger's syndrome, dyslexia, dyscalculia, epilepsy, hyperlexia, Dyspraxia, ADHD, obsessive-compulsive disorder (OCD), and Tourette syndrome (TS).
What can BPD be mistaken for? ›- Bipolar disorder.
- Complex post-traumatic stress disorder (C-PTSD)
- Depression.
- Anxiety.
- Psychosis.
- Antisocial personality disorder (ASPD)
People with borderline personality disorders are aware of their behaviors and the consequences of them and often act in increasingly erratic ways as a self-fulfilling prophecy to their abandonment fears.
What questions should I ask borderline personality disorder? ›
Borderline personality disorder
Do you have long-term feelings of sadness? Do you have long-term feelings of anger? Do you find that your relationships usually get very difficult and end abruptly? Have you had thoughts of killing yourself on and off over the years?
By learning to validate the feelings of someone with BPD, you help them and you help yourself. Example: "I can see that you seem very angry. Although I wouldn't be this angry, I recognise how angry you are and I accept that it is how you are feeling. Anger is your emotional response to this situation."
Can a therapist diagnose BPD? ›A licensed mental health professional experienced in diagnosing and treating mental disorders—such as a Psychologist, Licensed Professional Counselor (LPC), Licensed Social Worker (LCSW) or Licensed Marriage and Family Therapist (LMFT)—can diagnose BPD based on a thorough interview and a comprehensive psychological ...
Can my primary doctor diagnose me with BPD? ›Borderline Personality Disorder Diagnosis
Primary healthcare providers, like family doctors and general practitioners, aren't qualified to diagnose BPD but they can refer you to an experienced mental health provider with the expertise you need.
The McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) is a commonly used 10-item measure to screen for borderline personality disorder (BPD).
What is the best medication for borderline personality disorder? ›The authors of a 2020 review state that antidepressants are the most commonly prescribed medications for BPD. A doctor may prescribe : selective serotonin reuptake inhibitors (SSRIs) tricyclic antidepressants.
Why psychiatrists are reluctant to diagnose borderline personality disorder? ›Clinicians can be reluctant to make a diagnosis of borderline personality disorder (BPD). One reason is that BPD is a complex syndrome with symptoms that overlap many Axis I disorders. This paper will examine interfaces between BPD and depression, between BPD and bipolar disorder, and between BPD and psychoses.
What are some rarely known signs for BPD? ›- Have food habits that strongly resemble those found in a person with bulimia or anorexia.
- Experience mood alterations that closely mimic major depression or less severe forms of depression.
- Experience the potentially extreme manic episodes found in people with bipolar disorder.
With borderline personality disorder, you have an intense fear of abandonment or instability, and you may have difficulty tolerating being alone. Yet inappropriate anger, impulsiveness and frequent mood swings may push others away, even though you want to have loving and lasting relationships.
What are the hallmark signs of BPD? ›- Fear of abandonment. People with BPD are often terrified of being abandoned or left alone. ...
- Unstable relationships. ...
- Unclear or shifting self-image. ...
- Impulsive, self-destructive behaviors. ...
- Self-harm. ...
- Extreme emotional swings. ...
- Chronic feelings of emptiness. ...
- Explosive anger.
How can you tell the difference between autism and BPD? ›
Distrust, poor empathy, and intimacy problems are common in BPD patients, often leading to difficulties in friendships and relationships. These symptoms may appear in both disorders, but typically those with autism are less defensive and are unable to read others' emotions.
What is another name for borderline personality disorder? ›Explains borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD). Includes what it feels like, causes, treatment, support and self-care, as well as tips for friends and family.
Why does autism get misdiagnosed as BPD? ›Lack of previous, comprehensive assessment and the patient displaying severe NSSI, in part possibly due to co-occurring depressive disorder and ADD, seemed to have contributed to misdiagnosis of autism as borderline PD.
What is neurodivergent DSM 5? ›Neurodivergence defines cognitive functioning which is not considered 'typical' (such as Autistic, Dyslexic, and ADHD people). Neurodivergent describes people with neurodivergence. The term Neurotypical describes those people with the most common cognitive functioning, noting it's not neuro-normal, just most common.
How do you tell if you are neurodivergent? ›- Struggling with reading and writing.
- Clumsiness.
- Finding it hard to cope with crowds, bright lights, loud, sudden noises, or social situations.
- Difficulty with focusing or keeping still.
- No smiling or social responsiveness.
People who think of themselves as empaths tend to be neurodivergent people with very active mirror neurons. We may easily absorb the emotional feeling state of others, lose touch with our own feelings, and become confused or overwhelmed by the variety of emotional signals in large crowds of people.
Does anxiety count as neurodivergent? ›But the definition has since expanded to include other conditions in advocacy movements and social justice circles. “With this definition, anxiety can be considered a form of neurodivergence, although it may not be as commonly recognized as ADHD, autism, or trauma,” she says.
What is the most misunderstood personality disorder? ›But scientific research suggests that psychopathy is a personality disorder that is widely misunderstood.
What is the most misunderstood mental illness? ›There is perhaps no serious mental illness more maligned and misconstrued than borderline personality disorder.
Do borderlines have empathy? ›People with BPD score low on cognitive empathy but high on emotional empathy. This suggests that they do not easily understand other peoples' perspectives, but their own emotions are very sensitive. This is important because it could align BPD with other neurodiverse conditions.
Do borderlines have insight? ›
Hard to treat disorder such as borderline personality disorder has good insight level. Borderline, schizoprenic and bipolar patients are equal on cognitive insight. Cognitive insight stands as a great predictor for borderline traits importance.
Do borderlines feel remorse? ›Only remorse leads to a real apology and change. One of the hallmarks of people with Borderline Personality Disorder or Narcissistic Personality Disorder (BP/NP) is that they often do not feel truly sorry. Even though a BP/NP may say he or she is sorry, there is often something lacking.
Do borderlines sabotage? ›Medically self-sabotaging behaviors are commonly encountered in psychiatric inpatients with borderline personality disorder.
What does a BPD assessment look like? ›A complete assessment for BPD includes: A thorough interview including a discussion of your symptoms and past and present life. A review of your personal and family medical history. A medical exam to rule out other potential causes of symptoms.
What is the difference between validating and invalidating? ›Validation: The recognition of a person's thoughts, feelings, emotions, and behaviours as valid and understandable. Invalidation, then, is the rejection or dismissal of a person's thoughts, feelings, emotions, and behaviours as being valid and understandable.
What are examples of validating statements? ›- I can see that you are very (upset, sad, frightened, scared).
- Here's what I'm hearing you say. ( ...
- I guess that must have been hard for you.
- I can see you are making an effort.
- I can see how hard you are working.
- Wow, that/she/he must have made you feel really angry/sad.
- SIX LEVELS of VALIDATION.
- Level One: Stay Awake and Pay Attention.
- Level Two: Accurate Reflection.
- Level Three: Stating What Hasn't Been Said Out Loud (“the unarticulated”)
- Level Four: Validating Using Past History or Biology.
- Level Five: Normalizing.
- Level Six: Radical Genuineness.
Additionally, relationship instability is a feature of BPD, and clinicians may be wary of patients with whom establishing a therapeutic bond could be difficult. They may also hold the mistaken belief that treatment is ineffective for BPD patients.
Why do therapists find it difficult to treat BPD? ›Personality disorders are difficult to treat because it's very difficult for someone suffering from one of these disorders to separate their personality (how they interact with others, how they view the world, and how they think about themselves) from the symptoms of their mental illness.
Why do therapists stigmatize people with borderline? ›Because, unlike virtually every other mental disorder in the book, borderline personality disorder is seen as one of the worst of all disorders to try and treat. People with BPD are the most stigmatized amongst a population already burdened with heavy stigma, people with mental health concerns.
What is the best mood stabilizer for borderline personality disorder? ›
- Depakote (valproate)
- Lamictal (lamotrigine)
- Lithobid (lithium)
- Tegretol or Carbatrol (carbamazepine)
To diagnose BPD, mental health clinicians look for patterns of behaviour that last for a long time and have caused distress or problems with relationships or other areas of life, such as work.
Is borderline personality disorder a DSM diagnosis? ›According to the DSM- 5, to diagnose a borderline personality disorder, the following criteria must be met: A. Significant impairments in personality functioning manifest by: Impairments in self-functioning (a or b):
What are the hallmarks of borderline personality disorder? ›A pattern of intense and unstable relationships with family, friends, and loved ones. A distorted and unstable self-image or sense of self. Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating.
Which disorder is BPD most commonly diagnosed as? ›BPD Looks Like So Many Other Mental Health Conditions
In particular, there is evidence that BPD is commonly misdiagnosed as Bipolar Disorder, Type 2.
- Bipolar disorder.
- Complex post-traumatic stress disorder (C-PTSD)
- Depression.
- Anxiety.
- Psychosis.
- Antisocial personality disorder (ASPD)
The prevailing view among many psychiatrists and mental health professionals is that borderline personality disorder (BPD) is a “psychological” condition.
What strain is best for borderline personality disorder? ›The best strain for borderline personality disorder is cannabis sativa since it helps ease anxiety and boost mood. However, it's important to be aware of the health risks and side effects that follow marijuana abuse.
What are the best jobs for someone with BPD? ›Many people with BPD feel emotions deeply and find working in a caring role fulfilling. If you are an empathetic person, consider jobs such as teaching, childcare, nursing and animal care.
How often is BPD misdiagnosed? ›One study cited that almost 40% of people who were diagnosed with BPD were provided with a misdiagnosis of BD at some point in their lifetime in comparison to only 10% of people in the general population receiving a misdiagnosis of BD. The exact reasoning for this high rate of misdiagnosis is debated among researchers.
Can autism be misdiagnosed as BPD? ›
Autism and Borderline Personality can both co-occur, or they can be misdiagnosed as one another. To the untrained eye, undiagnosed autism can easily look like BPD.
What part of the brain is associated with borderline personality disorder? ›BPD has been linked to the amygdala and limbic systems of the brain, the centres that control emotion and, particularly, rage, fear and impulsive automatic reactions.