# MHApps BPD – Diagnosis – DSM IV Diagnostic Criteria - BPD EUPD GP Health Professional Information On Making A Diagnosis

1 Diagnosis
GP

- 1. Make the diagnosis The main task for the GP is to consider and make the diagnosis. This is sometimes easy and sometimes difficult. In the past many health professionals have been reluctant to make the diagnosis because of the attitudes and responses the label engenders. However, we now know that if a person is diagnosed and treatment commenced by their late teens, the prognosis is much, much better than if this is delayed until their mid twenties.
- DSM IV Diagnostic Criteria (American Psychiatric Association) A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following nine criterion:
  1. Frantic efforts to avoid real or imagined abandonment (often stay in difficult, destructive or violent relationships).
  2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation (especially with health professionals).
  3. Identity disturbance: markedly and persistently unstable self-image or sense of self (they don’t know who they are and it changes with who they are with).
  4. Impulsivity in at least two areas that are potentially self-damaging e.g. spending, sex, substance abuse, reckless driving, binge eating.
  5. Recurrent suicidal behaviour, gestures, threats, or self-mutilating behaviour (pose a particular difficulty for health professionals to deal with).
  6. Affective instability due to a marked reactivity of mood e.g. intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days (can look like depression or rapid cycling bipolar disorder if taken on face value).
  7. Chronic feelings of emptiness.
  8. Inappropriate, intense anger or difficulty controlling anger e.g. frequent displays of temper (can raise child protection concerns), constant anger, recurrent physical fights (usually women living on the edge).
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms (often leads to misdiagnosis of schizophrenia – might be pseudo-psychotic experiences like hearing voices of the devil saying the person is evil – but the character of the symptoms is usually different to those of schizophrenia).
- What you are looking for is a longitudinal pattern of how the individual behaves in emotional situations - whether they can act in a way that is not mood dependent. All of us under extreme pressure may show some of the “borderline” qualities occasionally (eg retail therapy, losing our temper inappropriately) and most adolescents will often show these types of responses in difficult situations (eg the devastation of the loss of their first love) as part of the maturation process - usually they grow out of it. For individuals with BPD / EUPD, apparent competence in living will disintegrate under comparatively minor stress and reveal a fragile, helpless and hopeless shadow.
- Common presentations to the GP can include:
  - Dramatic or unusual expressions of distress (Could be a mismatch between displayed emotion and expected emotion given the circumstances).
  - Emotional extremes with moods that shift rapidly when circumstances change.
  - Suicidal ideation.
  - Self harm, especially cutting, burning and overdosing.
  - Self-destructive behaviours including substance abuse, disordered eating and exacerbation of gambling problems.
  - Abnormal illness behaviour.
- They are prone to regression, with childish behaviours and expectations under stress. They will often use primitive defences such as splitting, where the self and others are viewed as either ‘all good’ or ‘all bad’. Their thought patterns are such that they view the external world as unsafe, others as untrustworthy and themselves as bad and unlovable. They experience major difficulty with separation and abandonment, with patterns of checking for proximity, pleading for attention, clinging behaviours and an intolerance of being alone – which makes night-time particularly problematic for this group.
  Any of these presentations should alert you to look closer at the possibility of an underlying BPD / EUPD and assess against the formal criteria.

1 Diagnosis
GP