Trait Stages of Diagnosis for Borderline Personality Disorder

October 13, 2017

Peter Fonagy, OBE, FMedSci, FBA, PhD , Chloe Campbell, PhD , Anthony W. Bateman, MA, FRCPsych

The authors describe an alternative model for BPD diagnosis that is dimensional in nature and requires fulfillment of 4 of 7 personality traits.

The authors describe an alternative model for borderline personality disorder (BPD) diagnosis that is dimensional in nature and requires fulfillment of 4 of 7 personality traits.

The criticism of the DSM categorical model is particularly pertinent in the case of personality disorders. To resolve this, Section III of DSM-5 proposes an alternative model for personality disorders that consists of 3 components:

1. Level of personality functioning

2. Specific personality disorder diagnoses are reduced to 6

3. A system of pathological personality traits

DSM-5's system of pathological personality traits are organized into 5 domains: negative affectivity, detachment, antagonism, disinhibition, and psychoticism. Within these domains, there are 25 trait facets. From this perspective, people with BPD are identified by impairment in personality functioning, characterized by difficulties in 2 or more of the following 4 areas:

• Identity: impoverished, poorly developed self-image, often excessive self-criticism; chronic feelings of emptiness; dissociative states under stress

• Self-direction: instability in goals, aspirations, values, career plans

• Empathy: impoverished ability to recognize the feelings and needs of others, especially as a result of hypersensitivity (feeling rejected or insulted; perceptions of others are negatively biased)

• Intimacy: intense, unstable, and conflicted close relationships characterized by mistrust and neediness; close relationships often viewed in extremes of idealization and devaluation, reflected in a pattern of over-involvement or withdrawal

An alternative model is dimensional in nature, which is in keeping with research evidence that indicates that “personality disorders are continuous with normal personality,”[see reference 6 here] and the personality functioning scale accommodates a severity factor, which is a good predictor of outcome. The trait stage of diagnosis for BPD requires fulfillment of 4 or more of the following 7 traits. Of the 4 or more traits fulfilled, at least 1 of these must be impulsivity, risk-taking, or hostility. The first is emotional lability. Also see Sudden Onset of Tics, Tantrums, Hyperactivity, and Emotional Lability: Update on PANS and PANDAS.

Diagnosis for BPD requires fulfillment of 4 or more of the following 7 traits: emotional lability, anxiousness, separation anxiety, depressivity, impulsivity, risk-taking, and hostility (one of the last 3 must be included)

Diagnosis for BPD requires fulfillment of 4 or more of the following 7 traits: emotional lability, anxiousness, separation anxiety, depressivity, impulsivity, risk-taking, and hostility (one of the last 3 must be included)

Diagnosis for BPD requires fulfillment of 4 or more of the following 7 traits: emotional lability, anxiousness, separation anxiety, depressivity, impulsivity, risk-taking, and hostility (one of the last 3 must be included)

Diagnosis for BPD requires fulfillment of 4 or more of the following 7 traits: emotional lability, anxiousness, separation anxiety, depressivity, impulsivity, risk-taking, and hostility (one of the last 3 must be included). 4 or more of the 7 traits must include 1 of the traits in red: impulsivity, risk-taking, or hostility.

The personality functioning scale accommodates a severity factor, which is a good predictor of outcome. The main criticism has been that the new model, with its use of dimensional and trait approaches, is an “unwieldy conglomeration of disparate models that cannot happily coexist and raises the likelihood that many clinicians will not have the patience and persistence to make use of it in their practices” [see reference 7 here]. Clinicians should not be expected to regard their patients in terms of so many subcomponents. However, this may be a way forward for thinking about the conceptualization of personality disorder. For more on this topic and a full discussion, see Update on Diagnostic Issues for Borderline Personality Disorder, on which this slideshow is based.