Axis II and Borderline Personality Disorder

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The diagnostic system that was typically used to diagnose borderline personality disorder (BPD) and other personality disorders using axes are now obsolete. BPD and other personality disorders were diagnosed as Axis II disorders in the last Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). These axes are no longer used in the current edition of the DSM.

Diagnosis of BPD in DSM-IV as an Axis II Disorder

Borderline personality disorder (BPD) and other personality disorders are typically diagnosed using the official guidebook for the diagnosis of psychiatric disorders, the Diagnostic and Statistical Manual of Mental Disorders (currently in its fifth edition, the DSM-5).

The last DSM, DSM-IV-TR, used a "multi-axial" diagnostic system. This means that when a diagnosis was made, attention was paid to five different areas, or axes, that could affect the individual who was being diagnosed.

Axis I was for the diagnosis of clinical disorders, the conditions that people most often think of when they think of psychiatric disorders. For example, major depressive disorder or post-traumatic stress disorder would have been diagnosed on Axis I.

Axis II was reserved for long-standing conditions of clinical significance, like personality disorders and mental retardation. These disorders typically last for years, are present before adulthood and have a significant impact on functioning.

The Rationale for Putting Personality Disorders on Axis II

In theory, personality disorders were relegated to Axis II because this was a way to make sure that they did not get overlooked. If a person had multiple clinical disorders on Axis I, coding the personality disorders on Axis II helped those disorders to stand out.

Another reason that experts decided to put personality disorders on Axis II in DSM-IV relates to the course of these disorders. Whereas the Axis I disorders tend to be episodic, meaning they are on-again, off-again, personality disorders are thought of as chronic, meaning they occur over years.

Diagnosis of BPD in DSM-5

DSM-5 did away with the axis system, relegating everything to one axis to ostensibly make diagnosing easier. However, diagnosing, assessing and treating personality disorders are basically the same as in DSM-IV, including the symptoms that need to be present in order to diagnose BPD.

Symptoms of Borderline Personality Disorder

The hallmark of BPD is emotional instability and frequent mood swings. To be diagnosed with borderline personality disorder, you must have at least five of the following symptoms:

  • Impulsive choices and behaviors that may result in risky behavior, such as gambling, shopping sprees or engaging in unprotected sex with multiple partners.
  • Powerful, changeable emotions and moods that may last from a few hours to a few days.
  • A pattern of turbulent and unstable relationships with friends and family.
  • Feeling constantly bored and/or empty
  • Anger problems, including difficulty controlling anger, intense anger that may not fit the situation and/or angry outbursts
  • A distorted and insecure concept of yourself that affects everything in your life, from relationships to goals to moods and opinions.
  • Suicidal and/or self-harming behavior, like cutting.
  • Paranoid thoughts or dissociative feelings, as if you are not a part of your own life or you're out of your body. 
  • An irrational fear of being abandoned that causes powerful emotions and going to extremes to make sure you aren't abandoned.
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Article Sources

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  1. Association AP. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR). American Psychiatric Association; 2000.

  2. Substance Abuse and Mental Health Services Administration. DSM-5 Changes: Implications for Child Serious Emotional Disturbance. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. 2, DSM-IV to DSM-5 Changes: Overview.

  3. Biskin RS, Paris J. Diagnosing borderline personality disorder. CMAJ. 2012;184(16):1789-94. doi:10.1503/cmaj.090618

Additional Reading

  • "Borderline Personality Disorder." National Alliance on Mental Illness (2016).
  • "Borderline Personality Disorder." National Institute of Mental Health.
  • "Personality Disorders." American Psychiatric Association (2013).
  • Westen D, Shedler J. Revising and Assessing Axis II, Part II: Toward an Empirically Based and Clinically Useful Classification of Personality Disorders. American Journal of Psychiatry, 156(2):273-285, 1999.

  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Fourth Edition. American Psychiatric Association: 2000.
  • Trestman, R.L. "DSM-5 and Personality Disorders: Where Did Axis II Go?" The Journal of the American Academy of Psychiatry and the Law, 42 (2), 2014.