Symptoms of Borderline Personality Disorder: DBT versus DSM-5

Marsha Linehan's early work with individuals with chronic suicidal thoughts and behaviors became the solid foundation for applications of dialectical behavior therapy for individuals with borderline personality disorder.


Dr. Linehan's biosocial model with symptoms of Borderline Personality Disorder


Dr. Linehan viewed the symptoms of borderline personality disorder as a biosocial model of pervasive dysregulation.  Her biosocial approach was atypical, as most treatments for personality disorders were grounded in psychoanalytic and psychodynamic theoretical orientations.  Biosocial combines the biological/physiological and social perspectives to describe the extreme dysregulation and an invalidating environment.  To clarify, dysregulation (prefix "dys-" not + regulation); for example, emotional dysregulation refers to intense feelings and reactions based on the feelings that can fluctuate quickly and can come without a behavioral cue or warning.

1. Emotional Dysregulation (emotional ups and downs)
2. Behavioral Dysregulation (impulsivity)
3. Interpersonal Dysregulation (managing relationships)
4. Cognitive Dysregulation (focusing attention)
5. Self Dysregulation (knowing who you are, owning your identity, what you stand for)

The Diagnostic and Statistical Manual of Mental Disorders 5^th Edition (DSM-5)


DSM-5 is a manual that sets symptoms and threshold levels for the diagnosis of a psychiatric disorder or illness (American Psychiatric Association, 2013).  For the diagnosis of borderline personality disorder, five of the nine following symptoms must be present. 


DSM-5 categorical model of symptoms of Borderline Personality Disorder

1. Frantic effort to avoid real or imagined abandonment
2. Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3. Identity disturbance with markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging: spending (money), risky sex, substance abuse, reckless driving (speeding), binge eating
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilation behavior
6. Affective instability due to a marked reactivity of mood (“mood swings,” intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely for more than a few days
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fights)
9. Transient, stress-related paranoid ideation or severe dissociative symptoms

The sticky part of the DSM-5 categories for borderline personality disorder is the presentation.  Two individuals with marked, out-of-control behavior may only share a single criterion, but receive the same diagnosis.  Some clinicians and researchers pushed for a dimensional approach to personality disorders, not a categorical approach.