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How to Diagnose Borderline Personality Disorder

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These 10 questions can identify borderline personality disorder with almost as much precision as a lengthy structured interview. Plus the word of the day: Hysterical Psychosis.

Published On: 6/14/20

Duration: 19 minutes

Article Referenced: A Pragmatic Approach to Borderline Personality Disorder,” The Carlat Psychiatry Report, June 2020

Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

1 in 50 people have borderline personality disorder, but that’s not the number you need to know. You need to know how many are in your practice, and if you’re over- or under-diagnosing it. So here are the benchmarks: In the average outpatient practice, 1 in 10 patients have borderline personality disorder. If you work on an inpatient ward, it’s twice as common: 1 in 5. And if you work in primary care, it’s twice as rare: 1 in 20.

If you’re like me, you’re probably under-diagnosing borderline personality, but why does that even matter? This month we featured an interview with Lois W. Choi-Kain, who directs the Gunderson Personality Disorders Institute at Mass General’s McClean Hospital, and it changed my practice. In her view, it’s not enough to make the diagnosis. We should also tell the patient that they have borderline personality disorder. When people understand their vulnerabilities, and how their symptoms get triggered by key events in relationships, they can start to plan and build a life worth living. It’s not easy to convey all this to a person with borderline personality disorder, and Dr. Choi-Kain has some practical tips online. Here’s a hint ─ one pitfall is being too careful ─ she recommends talking about the diagnosis in a direct and genuine manner.

Whether you’re missing the diagnosis, or over-diagnosing it based on your gut impressions, we’ve we have 10 questions today that will improve your game. It’s the McClean Screening Instrument, and it was developed by Mary Zanarini and colleagues in 2003. Now, there are a lot of screening tests for borderline personality disorder, and most of them are too unwieldy to be useful in everyday practice. This one is not. It’s a paper and pencil test the patient fills out with 10 yes or no questions.

And this simple test performed pretty well in validation study. Its sensitivity and specificity are around 0.8, which is better than what we see with most screening tests. Sensitivity means how sensitive it is at picking up the disorder in someone who has it. So 0.8 means 80% sensitive – so 20% of the time it will miss borderline personality in someone who actually has it. But when a test is very sensitive – above 70% – it usually does so at a cost of specificity – in other words it’s so sensitive that it overdiagnoses everybody. So what impressed me here was that both the sensitivity and specificity landed in the 80% range. Specificity means how well it hones in and gets specific, minimizing false positives and overdiagnosis. With a score of 0.85 or 85% specificity, this test will mis-label someone with borderline personality disorder who doesn’t actually have it 15% of the time.

What’s remarkable about this is that other screening tests for borderline have dozens of questions and are not as accurate. The Personality Diagnostic Questionnaire over-diagnoses borderline, with a specificity of 0.98 and a sensitivity of 0.41. But all these numbers imply that there’s a gold standard – that there’s a pathologist out there who can look under a microscope and really tell if someone has borderline personality. Of course, there’s not. What they used as the gold standard was the Diagnostic Interview for DSM-IV Personality Disorders, and that might explain why the numbers are so good.

The same authors who developed this short screen also developed the one it was compared to – The Diagnostic Interview for DSM-IV Personality Disorders. So the questions are similar, it’s just that the Gold Standard one goes into more detail and is rated by a clinician instead of self rated. So another way of stating these results is that a short version of the long clinical interview is 80% as good as the long interview itself.

Which is still good news for the practicing psychiatrist, because I’m guessing you don’t have the luxury of conducting a lengthy diagnostic interview for borderline personality in every patient. So without further ado, here are the 10 questions. You can find a link to the actual test in the episode notes – it’s online at

1. Have any of your closest relationships been troubled by a lot of arguments or repeated Break-ups?

Borderline symptoms come out more in close, intense relationships. They seek out those relationships, but those same relationship end up triggering the very symptoms they struggle with. As John Gunderson put it, “Patients with borderline personality disorder feel that their lives are not worth living unless they feel connected to someone they believe really cares.” Often that caring person is us ─ their care-giver ─ and our online interview walks you through how to manage your care-giving relationships with these patients. We’ll have excerpts from the interview next Monday.

2. Have you deliberately hurt yourself physically (e.g. punched yourself, cut yourself, burned yourself)? How about made a suicide attempt?

Self harm is more common in women with borderline personality disorder, who make up 70% of those with the disorder. Men are more likely to express that aggression outward, breaking things or getting into fights.

3. Have you had at least two other problems with impulsivity (e.g. eating binges and spending sprees, drinking too much and verbal outbursts)?

4. Have you been extremely moody?

These two cross into the bipolar category, and here’s an interesting statistic. Despite the rivalry between borderline researchers and bipolar researchers, they align in this way. In the mood research, they’ve found that 40% of patients with bipolar II have borderline personality disorder. In borderline research, the number is the same: they’ve found that 40% of borderline patients have bipolar II. So there’s a big overlap here, and the overlap is with bipolar II ─ not so much with bipolar I as those patients are more likely to have stable and healthy personalities when not in a mood episode.  Another pearl in this research is that most of the overlap of bipolar II and borderline personality disorder was due to cyclothymic temperament, and guess what the original word for borderline personality was in the 1970’s when they were first sketching out the disorder for DSM-III? Cycloid Personality Disorder, and the description read almost exactly like cyclothymic disorder. So I wouldn’t pay much mind to the “Is it bipolar or is it borderline” dichotomy. More often than not, it’s both, or ─ more specifically, it’s a complex overlap of cyclothymic temperament, bipolar II moods, and a traumatic or unstable childhood.

5. Have you felt very angry a lot of the time? How about often acted in an angry or sarcastic manner?

6. Have you often been distrustful of other people?

Borderline patients often talk in a caustically sarcastic manner, especially as they enter middle age. When combined with their distrust of us, that sarcasm can elicit intense counter transference reactions, in other words ─ it’s hard to sit with! So if you find yourself the target of a patient’s biting sarcasm, just remember: It’s a symptom of the disorder.

7. Have you frequently felt unreal or as if things around you were unreal?

This one maps with criteria #9 in the DSM “Transient, stress related paranoid ideation or severe dissociative symptoms.” Under extreme stress the patient may have illusions like of shadows or feeling like the walls are shifting; they may feel out of body or develop overly paranoid ideas like that their coworkers are spying on them; but these are brief, rare, and don’t rise to the level of full psychosis.

8. Have you chronically felt empty?

This symptom distinguishes borderline a bit from bipolar disorder, and connects it more with trauma, especially neglect. People who were neglected by their parents often struggle with a life-long emptiness that isn’t changed by psychiatric medications, and these patients may cut themselves just to feel something.

9. Have you often felt that you had no idea of who you are or that you have no identity?

Or as DSM puts it “unstable self image or sense of self.” They seem inconsistent to others, with dramatic shifts in their life goals, values, and religions. This symptom can make patients seek out domineering forces to fill up the identity void, like cults, controlling spouses, or joining the military. Sometimes, though, they strike the right balance in these pursuits, and many a patient with borderline personality disorder will thrive in a rigid and highly structured job like the military that keeps their impulsivity and fractured identity at bay.

Now, it might sound like a symptom that has to do with identity is more on the personality disorder side and less on the bipolar side, but not so much. Remember the main overlap between borderline and bipolar has to do with cyclothymic temperament, and cyclothymic was almost placed in the personality disorder section of DSM-III but was kept with the mood disorders because it bears a genetic relationship to bipolar. But, if you read any descriptive papers on the cyclothymic type you’ll find they mention the same kinds of identity disturbances as we see in borderline ─ an insecure identity with frequent shifts in religions, hobbies, values, jobs, and romantic partners.

10. Have you made desperate efforts to avoid feeling abandoned or being abandoned (e.g., repeatedly called someone to reassure yourself that he or she still cared, begged them not to leave you, clung to them physically)?

In the original DSM-II version, this was listed as “intolerance of being alone”; that morphed to the DSM-5 version which reads “Frantic efforts to avoid real or imagined abandonment.” Check out our online interview with Dr. Choi Kan for tips on how to manage this in practice.

That’s it ─ 10 questions. And you can see they map pretty well with the DSM criteria. The cut off is 7, so patients who answer yes to at least 7 of those have an 80% chance of having borderline personality disorder…. Well, sort of.

There’s one more caveat to this otherwise impressive research. We always need to understand sensitivity and specificity in terms of the population at hand. Suppose you have a great screening question for depression, it’s “Do you feel depressed a lot of the time?”  If you asked people that question in my waiting room, it would prove to be a pretty accurate test, but if you asked it to random people at a rock concert, its accuracy would go down. So let’s look at the people Mary Zanarini recruited for this screening study. She placed an ad that read:

“Are you extremely moody? Do you often feel distrustful of others? Do you frequently feel out of control? Are your relationships painful and difficult?”

So the test is really only 80% accurate if the person has already said yes to those questions. And here’s another interesting fact from the study ─ of the 200 people she recruited who said yes to that question, 70% had borderline personality disorder. So that question alone does a pretty good job of identifying it!

One last thing about this screening test. They excluded people who had active substance abuse, bipolar I, or a psychotic disorder. And they were right to. Those are the disorders that trump borderline personality ─ and in current guidelines, you are supposed to attend to and treat those before trying to treat the borderline part. So in our online version of the rating scale we put those in at the end; it wasn’t in the original scale, but it serves as a useful reminder not to jump into borderline stuff if the basics haven’t been addressed.


And now for the word of the day… Hysterical Psychosis

Hysterical Psychosis refers to transient psychotic symptoms that are thought to arise out of severe stress rather than a genuine psychotic disorder. You’ll also hear it called pseudopsychosis.

The term was widely used and researched in the 19th century, but fell out of favor in the DSM era because of negative connotations around the word “hysteroid.” It was replaced by “Brief reactive psychosis” in DSM-III; DSM-IV removed the word “reactive” ─ preferring not to imply any causation ─ and calls it “Brief Psychotic Disorder,” which is not quite the same as the old conception of Hysterical Psychosis. It also shows up in the 9th criteria for borderline personality disorder.

In psychodynamic terms, Hysterical Psychosis is viewed as a primitive coping mechanism similar to dissociation ─ and like dissociation it might arise out of severe trauma. It’s relevant to borderline personality disorder, and to PTSD, because you’ll often see mild psychotic symptoms at the more severe ends of these disorders. They often have a dream-like quality, with prominent illusions and dissociations. These patients may appear delusional, but a more apt description is that they have trouble separating fantasy from reality. They tell fanciful, dramatic stories that they believe are true, such as having an imaginary boyfriend who’s on the run from the FBI, and there’s a psychiatric term for this as well: pseudologia fantastica

Altered states of consciousness, dissociation, and even multiple personalities are often part of the presentation. It’s not known if this kind of psychosis responds to antipsychotics, but it may respond to psychotherapy. In the 19th century, Pierre Janet treated hysteroid psychosis with hypnosis, and his success there inspired a young neurologist to go on to create the a new type of talking cure: Sigmund Freud.

Join us next week for an interview with Lois Choi-kain: The Do’s and Don’t’s of working with borderline personality disorder.

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