Symptoms of Borderline Personality Disorder: The 9 DSM-5 Criteria

The symptoms of borderline personality disorder (BPD) are a long-standing pattern of unstable relationships, unstable self-image, intense and fast-shifting emotions, and marked impulsivity, defined in DSM-5 by nine criteria^[3]. A clinician diagnoses BPD when at least five of the nine are present^[2].

The National Institute of Mental Health (NIMH) describes the core experience as intense mood swings and uncertainty about how a person sees themselves, with interests, values and feelings that can change quickly^[1]. How common the disorder is, and how rates differ by group, is covered on the borderline personality disorder statistics page.

The nine criteria group into four areas of instability: emotions, relationships, sense of self and behavior^[3]. People with BPD also tend to view things in extremes, such as all good or all bad, a pattern often called splitting^[1].

Not everyone with BPD has every symptom, and severity, frequency and duration vary from person to person^[1]. The table below lists the nine DSM-5 criteria with plain-language examples.

Five. DSM-5 requires a pervasive pattern that begins by early adulthood, shows up in a variety of contexts, and meets five or more of the nine criteria^[3]. BPD is one of 10 personality disorders in the current DSM-5-TR^[2].

Because any five of nine criteria qualify, there are 256 theoretically possible ways to meet the diagnosis^[3]. The 2024 World Psychiatry review notes this makes BPD a heterogeneous category, and one cluster analysis it cites found three groups: a large core group, an externalizing group with histrionic, narcissistic and antisocial features, and a small group with marked schizotypal and paranoid features^[3].

The threshold has critics. The same review gives the example of a person with intense emptiness, very unstable relationships, severe identity disturbance and self-harm who misses the diagnosis by one criterion despite severe impairment^[3].

The ICD-11 applies a borderline pattern specifier when at least five closely matching features are present, and it adds rejection hypersensitivity and a view of the self as inadequate as possible further features^[3].

Is quiet BPD a separate diagnosis?

No. Neither DSM-5 nor ICD-11 lists a quiet subtype; both use a single set of criteria^[3]. The informal label usually describes people whose symptoms are directed inward, such as emptiness, shame and self-criticism, rather than outward anger, a variation that the 256 possible criteria combinations already allow^[3].

Emotional instability sits at the center of BPD. NIMH describes intense and highly variable moods with episodes lasting from a few hours to a few days^[1]. The DSM-5 wording is affective instability due to marked reactivity of mood, such as episodic dysphoria, irritability or anxiety that only rarely lasts more than a few days^[3].

Chronic emptiness is a separate criterion. The American Psychiatric Association (APA) describes it as often feeling bored or feeling that life has no meaning or purpose^[2].

Anger in BPD is described as intense and out of proportion to the issue, with problems controlling it, such as frequent fights, displays of temper or constant anger^[2].

Dissociation and stress-related paranoia

The ninth criterion covers brief, stress-triggered changes in perception. NIMH lists dissociation as feeling cut off from oneself, observing oneself from outside the body, or feeling disconnected from one's surroundings^[1]. The APA adds fleeting paranoid thoughts, such as suspecting that others have bad motives^[2].

These experiences are transient. DSM-5 limits the criterion to stress-related paranoid ideation or severe dissociative symptoms^[3].

Three criteria describe how people with BPD relate to others and to themselves. The first is frantic effort to avoid real or imagined abandonment^[3]. NIMH gives the example of jumping into or out of relationships quickly, alongside high sensitivity to rejection and feelings of alienation or isolation^[1].

The second is a pattern of unstable, intense relationships that alternate between extremes of idealization and devaluation^[3]. In everyday terms, the APA describes switching between loving someone one moment and hating that person the next^[2].

The third is identity disturbance, a markedly and persistently unstable self-image or sense of self^[3]. The APA describes this as switching between great self-confidence and very poor self-esteem^[2].

These interpersonal symptoms are among the most persistent. In a study that followed 290 patients with BPD, all first assessed during inpatient stays, for 10 years, symptoms tied to abandonment and dependency, such as intolerance of being alone, were among the most stable over time^[4].

DSM-5 requires impulsivity in at least two potentially self-damaging areas, such as spending, sex, substance use, reckless driving or binge eating^[3]. NIMH notes that if these behaviors happen mostly during periods of elevated mood or energy, they may point to a mood disorder rather than BPD^[1].

Recurrent suicidal behavior, gestures or threats, or self-injury form the fifth criterion^[3]. People with BPD have a significantly higher rate of self-harm and suicidal thoughts and behavior than the general population, according to NIMH^[1]. Data on self-injury in the wider population is on the non-suicidal self-injury page.

The 2024 World Psychiatry review reports that suicide attempts occurred in more than 75% of people with BPD in the study it cites^[3]. In one 24-year follow-up study, 5.9% of patients with BPD died by suicide, compared with 1.4% of patients with other personality disorders^[3].

A meta-analysis cited in the same review found suicide rates of 2% to 5% (mean 4%) over follow-up periods of 5 to 14 years^[3]. These figures come from clinical samples, and a separate 10-year study found that self-injury and suicide efforts were among the symptoms that resolved most quickly^[4].

The APA's 2024 practice guideline recommends that the initial assessment of anyone with possible BPD include an assessment of risk of suicide, self-injury and aggressive behavior^[6].

BPD is often compared with bipolar disorder because both involve mood shifts and impulsive behavior. The key difference, according to NIMH, is that BPD symptoms occur without the significantly elevated mood seen in manic or hypomanic episodes^[1]. BPD mood changes also tend to be brief, lasting hours to a few days^[1].

The two can occur together. BPD and bipolar I or II disorder co-occur in about 10% to 20% of patients with either disorder^[3]. The review cautions that a BPD diagnosis should not be added during a depressive or bipolar episode unless the typical BPD pattern persists over time^[3].

How bipolar disorder itself is identified is covered in how bipolar disorder is diagnosed.

Co-occurring conditions are the rule rather than the exception. Lifetime rates among people with BPD reach 83% for mood disorders and 85% for anxiety disorders^[3]. NIMH also lists post-traumatic stress disorder, eating disorders, ADHD, and physical conditions such as diabetes and obesity^[1].

Do symptoms differ in women and men?

The core criteria are the same, but co-occurring conditions differ. Men with BPD more often have substance use problems and antisocial personality disorder, while women more often have mood, anxiety and eating disorders and PTSD^[3]. Among patients with BPD in one psychiatric outpatient sample, women outnumbered men 72% to 28%^[3].

BPD symptoms typically begin in adolescence or early adulthood^[2]. NIMH says the disorder is usually diagnosed in late adolescence or early adulthood, and occasionally before age 18 if symptoms are severe and last at least a year^[1].

Symptoms often ease over time. In a 10-year prospective study, 93% of patients with BPD reached a symptomatic remission lasting two years, 86% a remission lasting four years, and 50% reached full recovery, meaning remission plus good social and vocational functioning^[3]. Relapse was possible: 30% of those in remission lost that status^[3].

Across long-term studies of five years or more, a meta-analysis found a mean remission rate of 60%, with wide variation between studies^[3].

Symptoms do not fade evenly. Of 24 BPD symptoms tracked over 10 years, 12 dropped sharply and were reported by fewer than 15% of the patients who had them at the start^[4]. Impulsive symptoms such as self-injury and suicide efforts resolved fastest, while anger, loneliness and emptiness were the most stable^[4].

In older adults, the picture shifts toward depression, emptiness and physical complaints, while emotional dysregulation, unstable relationships and anger tend to persist and impulsivity and identity disturbance decrease^[3]. Treatment evidence is reviewed in psychotherapy for borderline personality disorder.

BPD is diagnosed through a clinical evaluation. A licensed mental health professional diagnoses it from a thorough discussion of symptoms and personal and family history, and a medical exam can help rule out other causes^[1].

The APA's 2024 practice guideline recommends that the initial assessment cover psychiatric symptoms, including core features of personality disorders and common co-occurring disorders, along with physical health, psychosocial and cultural factors, and risk^[6]. It also suggests using a quantitative measure to identify symptoms and their severity^[6].

One widely studied screening tool is the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), a 10-item self-report questionnaire^[5]. In its 2003 validation study of 200 people with treatment histories, a cutoff of 7 or more identified 81% of people with BPD (sensitivity) and correctly excluded 85% without it (specificity)^[5].

Accuracy was higher in younger people: among the 63 participants aged 25 or younger, sensitivity was 90% and specificity 93%^[5]. A positive screen indicates the need for a full clinical interview; it is not a diagnosis.