Diagnostic accuracy of DSM-5 borderline personality disorder criteria: Toward an optimized criteria set

J. Christopher Fowler, Marianne Carlson, William H. Orme, Jon G. Allen, John M. Oldham, Alok Madan, B. Christopher Frueh

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


OBJECTIVE: The polythetic system used by the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) for diagnosing borderline personality disorders (BPD) is far from optimal; however, accumulated research and clinical data are strong enough to warrant ongoing utilization. This study examined diagnostic efficiency of the nine DSM-IV BPD criteria, then explored the feasibility of an optimized criteria set in classifying BPD.

METHODS: Adults (N=1,623) completed the Structured Clinical Interviews for DSM-IV Axis II Disorders resulting in a BPD group (n=352) and an inpatient psychiatric control group (PC) with no personality disorders (n=1,271). Receiver operator characteristics and diagnostic efficiency statistics were calculated to ascertain the relative diagnostic efficiency of each DSM-5 BPD criterion in classifying BPD cases.

RESULTS: Affective instability (Criterion 6) evidenced the strongest capacity to differentiate the groups (AUC = .84, SE = .01, p < .0001). Abandonment fears (Criterion 1), unstable relationships (Criterion 2), identity disturbance (Criterion 3), impulsivity (Criterion 4), and chronic emptiness (Criterion 7) yielded good-to-moderate discrimination (AUC range = .75-.79). A composite index of these six criteria yielded excellent accuracy (AUC = .98, SE = .002, p < .0001), sensitivity (SN=.99), and specificity (SP=.90).

CONCLUSIONS: The current findings add to evidence that affective instability is a useful gate criterion for screening, and the optimized criteria set evidences equivalent accuracy to the original 9 criteria, with a substantial reduction in estimated heterogeneity (from 256 combinations with the original set to 42 combinations with the optimized set).

Original languageEnglish (US)
Pages (from-to)203-207
Number of pages5
JournalJournal of Affective Disorders
StatePublished - Jan 15 2021


  • Borderline Personality Disorder
  • DSM 5 criteria
  • Diagnostic Accuracy
  • Impulsive Behavior
  • Fear
  • Diagnostic and Statistical Manual of Mental Disorders
  • Mass Screening
  • Humans
  • Adult
  • Borderline Personality Disorder/diagnosis

ASJC Scopus subject areas

  • Psychiatry and Mental health
  • Clinical Psychology


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