Understanding How Borderline Personality Disorder Is Diagnosed
Borderline personality disorder (BPD) is a complex condition that can affect both adults and teens and is marked by intense, unstable emotions, relationships, and self-image. The condition usually starts in the teenage years and gradually improves over time.
BPD affects a person’s moods, thinking, behavior, and identity, often leading to impulsive actions and difficulty with self-soothing. People with BPD experience heightened emotional sensitivity, fear of abandonment, and struggle with distress and anger, which can impact relationships.
It’s not unusual for people with BPD to live with other mental health conditions, such as eating disorders, anxiety, depression, and substance use disorder.
Key Diagnostic Criteria for BPD
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the official guide for diagnosing psychiatric disorders, including BPD and other related conditions. It outlines the specific symptoms required for each disorder and details the number and severity of symptoms needed to make an accurate diagnosis.
A BPD diagnosis requires at least five out of the following nine key criteria to be met:
- Intense fear of abandonment
- Unstable, intense relationships alternating between idealization and devaluation
- Persistent instability in self-image or identity
- Impulsive behavior in at least two areas that could cause harm to oneself, such as spending, reckless driving, or substance use
- Recurrent suicidal behaviors or self-harm
- Intense, short-term mood swings triggered by external events
- Chronic feelings of emptiness
- Intense, inappropriate anger or difficulty controlling temper
- Temporary stress-induced paranoia or dissociative symptoms
Expert BPD Care Is Just a Phone Call Away
McLean’s Gunderson BPD programs offer world-class residential and outpatient care. Call us today to get started on the path toward recovery.

Different Types of BPD
BPD is often categorized into four widely accepted types: impulsive, discouraged, self-destructive, and petulant. However, individuals may experience more than one type simultaneously or at different times, and some may not fit neatly into any single category.
Impulsive BPD
People with impulsive BPD often act without thinking about the consequences, which can lead to risky behavior. Common examples include, but are not limited to:
- Binging: Overeating or overspending
- Risk-taking: Unprotected sex, reckless driving, or using drugs and alcohol
- Aggression: Yelling, breaking things, or getting into fights
Discouraged (Quiet) BPD
Discouraged BPD is marked by a strong fear of being abandoned and keeping emotions bottled up. People with this type of BPD often blame themselves instead of others. They may be perfectionists, highly successful, and high functioning, but they often feel alienated and detached in groups. Behaviors often associated with discouraged BPD include, but are not limited to:
- Clinginess, needing constant support, and mood swings when feeling abandoned
- Self-harm or thoughts of suicide
Self-Destructive BPD
Self-destructive BPD involves self-hatred and dangerous actions that harm the person. Examples of these behaviors include, but are not limited to:
- Substance misuse, thrill-seeking behaviors, and self-harm like cutting or burning
- May show signs of high energy, less need for sleep, or feeling extremely happy, which can look similar to mania
Petulant BPD
Petulant BPD involves strong mood swings and feeling unworthy or unloved. People with this type of BPD often feel deeply dissatisfied in their relationships and may resort to manipulative behavior. Examples of associated behaviors include, but are not limited to:
- Easily irritated, stubborn, or passive-aggressive
- Risky or harmful behaviors often stem from relationship problems
Distinguishing BPD From Other Conditions
BPD often occurs alongside other mental health disorders, such as major depression, PTSD, bipolar disorder, anxiety, substance use, or eating disorders. These overlapping conditions can make it harder to diagnose and treat BPD, as they share similar symptoms.
BPD often coexists with depressive or bipolar disorders, and these conditions should be diagnosed if their criteria are met. BPD can often be mistaken for mood disorders like depression or bipolar disorder, especially when symptoms are more severe. However, BPD should only be diagnosed when there are clear, long-term patterns of behavior.
While both BPD and separation anxiety involve a fear of abandonment, BPD also includes challenges with impulsivity, identity, and relationships, making it a distinct diagnosis.
Because many personality disorders share similar traits, it’s important to recognize the unique features of BPD. If someone meets the criteria for more than one personality disorder, the other personality disorder can also be diagnosed.
BPD should also be distinguished from dissociative identity disorder, where there are distinct, lasting personalities. In contrast, BPD involves temporary, unstable, and shifting identity issues.
Finally, persistent substance use and specific traits resulting from medical conditions—like head trauma, strokes, or even infections—can mimic BPD symptoms, so it’s essential to rule out these other possibilities.
Watch Now!
Karen L. Jacob, PhD, provides an overview of BPD diagnosis and treatment.
Challenges in Diagnosing BPD
Diagnosing BPD presents several challenges due to the wide variety of possible symptom combinations—256 different patterns can meet the diagnostic criteria.
This makes it difficult for clinicians to make an accurate diagnosis, especially with limited time to spend with patients. To help with the diagnosis, clinicians should focus on key factors.
One important consideration is whether the symptoms have been present for a long period (at least one year for adolescents). Sudden changes in functioning or the appearance of new symptoms are less likely to indicate BPD.
Additionally, difficulties that span multiple areas of life, such as impulsive behaviors, self-harm, substance misuse, and chronic feelings of emptiness and anger, are more indicative of BPD than isolated symptoms, like suicidality without other mood or relationship problems.
Without a proper diagnosis, patients may end up with several misdiagnosed co-occurring conditions that do not respond to typical treatments. For instance, individuals with both BPD and major depressive disorder often don’t respond well to antidepressants, unlike those with depression alone.
Once BPD is diagnosed, it’s crucial to be informed and discuss treatment options and their implications. Research shows that informing patients about their diagnosis doesn’t cause issues and can help reduce anxiety, particularly since BPD carries a significant stigma.
Who Diagnoses BPD?
Personality disorders, including borderline personality disorder, are diagnosed based on the following:
- Detailed interview with your doctor or a mental health professional
- Mental health evaluation that may include completing a series of questions
- Medical history and exam
- Discussion of your symptoms
A licensed mental health professional—such as a psychiatrist, psychologist, or clinical social worker—can diagnose BPD based on a thorough evaluation of a person’s symptoms, experiences, and family medical history. A careful and thorough medical exam can help rule out other possible causes of symptoms.
BPD is usually diagnosed in late adolescence or early adulthood. It is not unusual for people younger than age 18 to be diagnosed with BPD if their symptoms are significant and last at least one year.
Finding Help and Hope for BPD
If you suspect that you or a loved one may have BPD, learning more about how BPD is diagnosed can be incredibly helpful. Understanding the key criteria for diagnosis can empower you to take the next crucial step: scheduling an assessment with a mental health professional. This knowledge can guide you toward getting the support and treatment needed for a healthier future.
Learning about the available treatments for BPD and the generally good prognosis can help ease concerns. Even just one session of patient education has been shown to reduce symptoms.
It’s important for anyone who has been diagnosed with BPD to understand they are not alone. Many people have BPD and, at times, experience emotional distress from the condition.
However, you don’t have to resort to living a life that’s full of pain and heartbreak. It’s important to take care of yourself, recognize your triggers, and work with your health care team to determine what treatments will work best for you.
By committing to care and learning as much as possible about it, you can make a difference in your quality of life—and the lives of those around you.
Want More Information?
Looking for even more information about borderline personality disorder? You may find these resources helpful.
- Everything You Need To Know About Borderline Personality Disorder
- Video: Decoding Distress – BPD, PTSD, and the Fine Line Between
- Understanding Borderline Personality Disorder in Teens
- Video: Addressing Borderline Personality Disorder in Adolescents
- Video: DBT Skills – The Value of Validation
- Deconstructing Stigma – Jay’s story
- Video: Engaging With Closed-Off Kids & Teens
- Video: The Role of Emotion Regulation and Borderline Personality Disorder
- Everything You Need To Know About Mindfulness
- Find all of McLean’s resources on borderline personality disorder
Find out if the Gunderson BPD programs are right for you or a loved one. Call us today at 617.855.4250.