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New Light on Borderline Personality Disorder (BPD) in DSM-5-TR and ICD-11

Uploaded 7/24/2022, approx. 21 minute read

Psychology is in a period of turmoil right now. It is discombobulated. Look it up.

There have been two releases of the two major diagnostic texts. Now, psychologists and psychiatrists use books. They are known as diagnostic manuals.

In North America, especially in the United States, it is the Diagnostic and Statistical Manual, DSM. And the text revision of the fifth edition has been just released a few weeks ago. It had been just released.

The original fifth edition of the Diagnostic and Statistical Manual had been published in 2013. Now, nine years later, there is a text revision.

At the same time, the World Health Organization is releasing the eleventh edition of the International Classification of Diseases, which is the text the rest of the world uses with variations.

Even in Russia and in China, they have their own diagnostic manuals, but they are largely reflections of the ICD.

So simultaneously, we have new texts, new diagnosis, new definitions, new criteria, and new clinical insights. That is a lot to digest.

In my previous video, I surveyed, I reviewed the new approach to narcissistic personality disorder in the Diagnostic and Statistical Manual, Edition 5 text revision.

Long before that, I've made a video about the changes in the ICD, the International Classification of Diseases, and down, down, like not up, not up, but down in the description. You're going to find a link to this video about ICD versus DSM.

And just not to keep you in suspense, the ICD wins big time, hands down.


Today, I'm going to review the new approach to borderline personality disorder.

There are important developments, critical developments in the way we see this disorder, in the way we conceptualize it.

I mentioned in earlier videos that the distinction between complex trauma, CPTSD, and borderline personality disorder is blurry, is vague.

And many, many very important scholars like Judith Herman, and lesser scholars like myself, we've been advocating for decades to merge the two, to consider various personality disorders, including narcissistic and borderline as post-traumatic conditions.

And so there's a lot of this going on in the background.

And there is the question of whether borderline personality disorder is a personality disorder at all, or whether it has merely to do with the inability to regulate emotions.

The ICD has a lot to say about it.

So strap yourselves for the ride, this roller coaster of clashing concepts, the clash of the titans.

And we are going to emerge from this joint journey with totally new way of looking at borderline personality disorder.

My name, just to remind those of you who haven't been traumatized enough, my name is Sam Vaknin, and I am the only sole exclusive author of Malignant Self-Love: Narcissism Revisited. I'm also, for reasons unknown, professor of psychology to generations of long suffering post-traumatic students.

Okay, enough, enough kidding, Vaknin, get to the point, will you? That's something you're not very good at.

Right, right. I heard you loud and clear. I love these American idioms.

Borderline personality disorder, the Diagnostic and Statistical Manual, edition five text revision, as is the habit, incorporates the diagnostic criteria from the fourth edition, 22 years ago.

So the nine diagnostic criteria of borderline personality disorder are still there in the latest iteration of the DSM, which is not to its credit, to use a British understatement.

And it is the outcome of co-towing or succumbing to pressure by the insurance industry and the pharmaceutical industry.

These diagnostic criteria are outdated. They absolutely diverge from what we know today about borderline personality disorder.

They are categoric, they are categorical. So they are polythetic. They merge seamlessly into other disorders.

So that creates a lot of comorbidity.

In short, in short, it's a bloody mess.

Had the DSM been written by disinterested professionals, professionals with no axe to grind and no hidden special interests, the DSM would have looked completely different. It would have adopted the alternative model.

Now in the DSM 5 and in the DSM 5 text revision, there is a section of the book at the very end which is dedicated to how the DSM could have looked had it been written ethically and evidence-based scientifically and academically. And this section 3, how the DSM could have looked, is called the alternative model.

Now several personality disorders have alternative models in the DSM 5 text revision. One of them is narcissistic personality disorder, borderline, antisocial, avoidant, and so on. And we're going to review all of them.

And today's review is of borderline personality disorder.

Now rather than talking or discussing the text, I'm going to read to you the text with interspersed commentary, a little like the old Talmudic rabbis when they analyzed the Torah.

So let's delve right in.

Here's what the Diagnostic and Statistical Manual, Edition 5, text revision, has to say about borderline personality disorder when it gets the nerve to discuss current knowledge in the alternative model of borderline personality disorder.

I'm quoting from the text, typical features of borderline personality disorder are instability of self-image, personal goals, interpersonal relationships and effects accompanied by impulsivity, risk-taking, and or hostility.

Two important points here, my commentary.

One, identity disturbance. There is, as the text says, an underlying instability, a lack of stability, a lack of predictability is the core of borderline personality disorder. And it is coupled by behaviors which are very reminiscent of psychopathy, like novelty seeking, impulsivity, reactance and defiance, risk-taking, and as the text says, hostility.

This is one of the main reasons we are reconceiving of borderline personality disorder as potentially facto to psychopathy. This is especially true in women, by the way. I'm continuing from the text.

Characteristic difficulties are apparent in identity, self-direction, empathy, and or intimacy as described below, along with specific maladaptive traits in the domain of negative affectivity and also antagonism, exactly like in narcissistic personality disorder and dissinhibition.


Okay, what are the proposed diagnostic criteria in the alternative model of borderline personality disorder, which is a dimensional model and should have been the only text in the DSM. The DSM should have discarded the text in addition, four, and addition text revision. It should not have incorporated them in the new editions, so this is the real text and the only text in my view.

And so what are the proposed diagnostic criteria?

A, a moderate or greater impairment in personality functioning manifested by characteristic difficulties in two or more of the following four areas.

Number one, identity. Marketly impoverished. The identity is markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism, chronic feelings of emptiness, dissociative states, and distress. You've heard it all before on this channel. Some of these things make it for the first time into the Diagnostic and Statistical Manual. Thank God for that, and I'm an atheist, imagine.

Number two, self-direction. Instability in goals, aspirations, values, or career plans.

Number three, empathy. Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity, prone to feel slighted or insulted.

This is a very crucial paragraph. This is the first time the Diagnostic and Statistical Manual acknowledges the work of Otto Kernberg and others who have insisted that borderline personality disorder is intimately linked to narcissistic personality disorder, and the two are actually facets of the same coin.

Indeed, the DSM admits that borderline personality disorder includes a compromised sense of empathy, impaired empathy, exactly like the narcissist and the psychopath. Another connection between borderline and psychopathy.

Yes, borderlines appear to be empathic. They sense empathy. They claim vociferously that they are empathic, but they are not actually. They are hypersensitive. They're prone to feel slighted and insulted exactly like the narcissist. They're hypervigilant. They have ideas of reference or referential ideation.

Now you understand the movement of empaths online.

Empaths are either covert narcissists or they're borderlines. They confuse their own hypersensitivity and hypervigilance with empathy.

But hypervigilance and hypersensitivity lead people to behave in ways which are callous and ruthless and cruel and aggressive.

Hypervigilance and hypersensitivity are the opposite of empathy. They negate empathy.

So borderlines are very much psychopathic.

When borderlines are under stress, exposed to stress or to abandonment or to rejection or to humiliation, they react even worse than the narcissist. They become aggressive, violent, defiant, reactant. They act out. They consume substances and do crazy things. They're dangerous. They're positively dangerous.

And this has to do with a decline in empathy. This decline in empathy could be extreme, for example, after a stage of decompensation when the borderline switches to secondary psychopathy, or it could be background.

A background lack of empathy, very similar to cold empathy. The borderline's lack of empathy is tempered somehow by the fact that the borderline is capable of experiencing positive emotions. The narcissist's lack of empathy is cold. It's dead. The narcissist is like a dead fish. There are no positive emotions there.

And even when he does have empathy, cold empathy, he doesn't come across because he can't communicate anything effectively when it's emotionless. The borderline has the added benefit of positive emotionality. Emotions which are too strong, emotions which overwhelm the borderline. Coupled with even a reduced amount of empathy, it comes across as much more human than the narcissist.


I continue from the text.

Borderlines have perceptions of others selectively biased toward negative attributes or vulnerabilities. In other words, borderlines are very judgmental. Very judgmental. They catastrophize. They anticipate the worst thing in and from other people. And they would push other people to behave in ways which confirm to them their negative view of other people. And this is known as projective identification.

Again, a major change in the text. I'm going to read it to you again.

Perceptions of others are selectively biased toward negative attributes or vulnerabilities. The text continues.

Problems with intimacy, intense, unstable, and conflicted close relationships marked by specifiers, mistrust, neediness, and anxious preoccupation with real or imagined abandonment. Close relationships, often viewed in extremes of idealization and devaluation, exactly like the narcissist, and alternating between over involvement and withdrawal. This has to do with engulfment anxiety. It is the first time that engulfment anxiety, however indirectly, makes it into the DSM.

The borderline is torn between abandonment anxiety, also known as separation insecurity, and engulfment anxiety. She is terrified of being abandoned, and then she's terrified of intimacy. He is afraid of being rejected and humiliated, and then he's afraid of being smothered and subsumed and consumed by the partner.

So there is approach avoidance. The borderline approaches the partner because she wants the partner to regulate her internal world, to regulate her moods and her emotions, to tell her what to think, to help her with reality testing. So she approaches the partner and hands over her mind to the partner. He sort of assumes control over the borderline's inner state, but having done that, the borderline panics. She realizes that she had ceased to exist, that the intimate partner has merged and fused with her and taken over. It's like a hostile takeover.

So she panics, she approaches, and then she avoids. And this is known as approach avoidance repetition compulsion. It's common in narcissists as well.

The borderlines, as the text correctly observes, idealize and devalue exactly like the narcissist.

The text continues.


Four or more of the following seven pathological personality traits, at least one of which must be five, impulsivity, six risk-taking, or seven hostility.

So the new definition includes seven characteristics.

And to be diagnosed with borderline personality disorder, you must have four of these seven. And out of these four, at least one must be either impulsivity or risk-taking or hostility, which brings borderline personality disorder very close to psychopathy.

Do you realize how close it is to psychopathy? So these are the seven criteria.

Number one, emotional ability. It is an aspect of negative affectivity.

Unstable emotional experiences and frequent mood changes, emotions that are easily aroused, intense, and or out of proportion to events and circumstances.

Criterion number two, anxiousness, an aspect of negative affectivity, by the way, common among psychopaths, contrary to the nonsense spewed online by self-styled experts.

Anxiousness, intense feelings of nervousness, tenseness or panic, often in reaction to interpersonal stresses.

Worry about the negative effects of past unpleasant experiences and future negative possibilities, catastrophizing. Feeling fearful, apprehensive, or threatened by uncertainty. Fears of falling apart or losing control.

Criterion number three, separation insecurity, also known as abandonment, an aspect of negative affectivity.

The borderline fears of rejection by or separation from significant others associated with fears of excessive dependency and complete loss of autonomy.

I'm going to read this criterion again to you because it, for the first time in the history of the DSM, accepts that borderlines are torn between two types of mutually exclusive anxieties, abandonment or anxiety or separation insecurity, on the one hand, an engulfment anxiety, a fear of being consumed, of disappearing, of being taken over, of being controlled by the intimate partner.

So I read to you again this, this is again a massive change, a very important change.

Criterion number three, separation insecurity, an aspect of negative affectivity. Fears of rejection by and or separation from significant others associated with fears of excessive dependency and complete loss of autonomy.

Criterion number four, depressivity, an aspect of negative affectivity. Frequent feelings of being down, miserable and hopeless, difficulty recovering from such moods or pessimism about the future, pervasive, pervasive shame, feelings of inferior self-worth, thoughts of suicide and suicidal behavior.

Now this is again very important. Everything that is described in this criterion is typical also of the narcissist, but the narcissist has defenses, constructed defenses in early childhood against this.

So the narcissist also experiences depression very frequently. The narcissist also is pessimistic about the future. Shame is the foundation of narcissism. The narcissist feels inferior and has a lack of self-worth. His self-worth is fluctuating. He cannot regulate his sense of self-worth. Everything, exactly like the borderline, but the narcissist has the narcissistic defense. He has a facade, the false self, this extraneous entity that takes over and suppresses the true self with its inferiority. And the false self affords the narcissist the ability to deny, repress and ignore his deep pervasive shame and feeling of inadequacy. These defenses are not available to the borderline, which is exactly why Grotstein, the famous psychoanalyst, suggested that borderlines are unfinished narcissists.

The half-baked borderlines are half-baked narcissists.

When the child fails to develop narcissistic defenses effectively, usually because of parental interference, then the child remains stuck at the stage of borderline.

And when we take away from the narcissist, the narcissistic defenses, as I do in cold therapy, the narcissist becomes borderline.

Criterion number five, impulsivity and aspect of disinhibition, very common in factor two psychopathy as well.

Acting on the spur of the moment in response to immediate stimuli, acting on a momentary basis, without a plan or consideration of outcomes, difficulty establishing or following plans, a sense of urgency and self-harming behavior under emotional distress.

Criterion number six, risk-taking, an aspect of disinhibition, again very common with factor one and factor two psychopaths.

The borderline, what does the text have to say about the borderline's risk-taking? Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences, lack of concern for one's limitations, and denial of the reality of personal danger.

Criterion number seven is hostility and aspect of antagonism, and very common in both narcissists and psychopaths.

We are beginning to see that all these distinctions, differential diagnosis, between narcissism, psychopathy, borderline are bullshit. Simply wrong.

Hostility, an aspect of antagonism, persistent or frequent angry feelings, anger or irritability in response to minor slights and insults. This is the borderline. Doesn't it sound like psychopaths and narcissists? It does.

The text continues to describe the borderline. Trait and level of personality functioning specifiers may be used to record additional personality features that may be present in borderline personality disorder, but are not required for the diaphragm that may be present in borderline personality disorder, but are not required for the diagnosis.

For example, traits of psychoticism, cognitive and perceptual dysregulation. They are not diagnostic criteria for borderline personality disorder, but can be specified when appropriate.

Furthermore, although moderate or greater impairment of personality functioning is required for the diagnosis of borderline personality disorder, the level of personality functioning can also be specified. So there are minor variations and the diagnostician is well advised to note down everything he sees.

What's happening with the ICD? The latest edition of the ICD is ICD edition 10-CM, but edition 11 has already been released in effect. It's available. The text is available.

In the 10th edition, the authors depicted, the committee depicted different types of personality disorders, including emotionally unstable personality disorder, EOPD, emotionally unstable personality disorder. But the recent edition, edition 11, the most courageous undertaking in diagnostic literature ever, if you ask me, edition 11 does not identify different types of emotional dysregulation. Edition 11 has realized, they have realized that there's an overlap between personality disorders. So instead, the whole edition is focused on personality traits and severity. There are no demarcated diagnosis, differential diagnosis. It's like there's a single personality disorder with different types of severity or traits or manifestations or emphases and so on.

Some very courageous dimensional approach. Emotionally unstable personality disorder at the time in ICD-10, which is still widely used, don't misunderstand, was one of 10 personality disorders. In the classification system of ICD-10, there were 10 personality disorders. Emotionally unstable personality disorder was described as pervasive instability in interpersonal relationships, affective instability, mood, and impulsive behavior. Very close to the DSM, actually.

The cause of emotionally unstable personality disorder is unknown. There is some research and there's a suggestion that adverse life events, known as adverse childhood events, ACE, and genetic factors are in play. There's neurobiological research and it suggests that abnormalities in the fronto limbic networks somehow have something to do with borderline personality disorder.

We also know that emotionally unstable personality disorder, which is effectively another name for borderline, runs in families. You're much more likely to develop borderline personality disorder if your mother and aunt have it as well.

Emotionally unstable personality disorder causes significantly impaired functioning. Feelings of emptiness. It's exactly borderline. Lack of identity. Unstable mood and relationships. Intense fear of abandonment and dangerous impulsive behavior, including severe episodes of self-harm. There's a pattern of rapid fluctuation from periods of confidence to periods of despair, which is why very often people with borderline personality disorder and narcissistic personality disorder are misdiagnosed as suffering from bipolar disorder. Bipolar disorder is very often misdiagnosed. People with emotionally unstable personality disorder are particularly at risk of suicide.

Transient psychotic symptoms, including brief delusions and hallucinations, may also be present. And not to mention that borderline personality disorder or emotionally unstable personality disorder, there's a dual diagnosis. Usually they go hand in hand, for example, with substance abuse disorder.

So borderline are much more likely to consume alcohol and drugs. There's a substantial impairment of social, psychological, and occupational functioning quality of life. Many people recover from borderline personality disorder or emotionally unstable personality disorder over time.

The spontaneous recovery, which is one of the main reasons we believe that it's a brain abnormality, but they still continue with some behaviors and there are still difficulties socially and interpersonally.

So the most important feature of emotionally unstable personality disorder is, as I said, a pervasive pattern of unstable and intense interpersonal relationships.

Self perceptions and moods, which are also very labile all over the place, fluctuating out of control. Impulses are also out of control. Borderlines or EOPDs, they are very impulsive and sometimes they appear psychotic.

The intensity of the disorder pushes them into persecretary ideation, paranoid delusions, a hypervigilance which borders on literal insanity, confusion of internal and external psychosis.

I mean, borderlines on the verge of psychosis, which is why we call them borderline. They are on the border between neurosis and psychosis.


They are, however, very powerful neurotic features.

For example, borderlines as opposed to narcissists. Borderlines do have many autoplastic defenses. In other words, borderlines do feel shame, regret, guilt, and responsibility for their misconduct. They are likely to apologize and try to make amends, modify their behaviors in the short-term until they are, again, overtaken by their emotions.

Narcissists are incapable of this. This is the neurotic side of the borderline.

At the time in the ICD-10, emotionally unstable personality disorder was divided into two subtypes, the impulsive subtype and the borderline subtype.

And I'll read to you the criteria in the ICD-10. Although I repeat, these criteria have been abolished in the ICD-11. They're no longer valid.

But it's interesting to see how our thinking had evolved until about 10, 15, or 20 years ago. So, EUPD was divided to two parts, two types, the impulsive type, the predominant characteristics are emotional instability and lack of view.

Probability and lack of impulse control. Outbursts of violence or threatening behavior are very common, particularly in response by criticism by others, or I would add rejection, humiliation, and perceived real or perceived abandonment.

And then there's a borderline type. The borderline type was defined in the ICD-10 as including several characteristics of emotional instability. The patient's own self-image, aims, and internal preferences, including sexual preferences, are unclear or disturbed. They're usually chronic feelings of emptiness.

A liability to become involved in intense and unstable relationships may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment in a series of suicidal threats or acts of self-harm, although these may occur without obvious precipitants.

All this has been abolished, demolished, eradicated, erased, and deleted. We don't divide EUPD to two subtypes anymore.

Impulsivity is an integral part of borderline. It's no longer divided from borderline in the ICD thinking.

And exactly like the alternative model of the DSM-5 text revision, the ICD-11 focuses on dimensions like identity, like empathy, like antagonism, which includes negative affectivity. These are dimensions. And because they are dimensions, they lie on a spectrum. They are gradations, they're nuances, they're variants. It's much closer to reality.

And borderline personality disorder intermeasures seamlessly with narcissistic personality disorder, psychopathic personality disorder, even with some mood disorders, paranoid personality disorder, and so on.

Because we are beginning to understand that all of these are a single disorder, a disorder of personality, end of story, the patient's fluctuates and cycle between various manifestations, aspects, and expressions of this single underlying clinical entity.

And I've suggested the mechanism of collapse as an explanation as to why.

But scholars may come with much better mechanisms, I don't know, in the future.

We are beginning to realize the unitary nature of the human condition, that even mental illness expresses ineluctably.

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