Borderline Personality Disorder in ICD-11: Diagnosis, Coding, and the Borderline Pattern

Is Borderline Personality Disorder Still a Diagnosis in ICD-11?

Yes, but ICD-11 approaches it differently from ICD-10. Rather than using a list of specific personality disorder types, ICD-11 uses a dimensional model. Clinicians first determine whether a personality disorder is present and then rate its severity. Prominent personality traits can be described using five trait domain specifiers – negative affectivity, detachment, dissociality, disinhibition, and anankastia – while the borderline pattern can be added as a separate specifier.^[1][3]

The borderline pattern was not included in the earliest versions of the ICD-11 model. It was added during the development process after clinicians and researchers argued that the construct has substantial clinical value, particularly because a large body of treatment research is based on it.^[4][6] The ICD-11 guidelines also note that identifying the borderline pattern may help clinicians recognize people who are likely to benefit from certain psychotherapeutic approaches.^[1]

From F60.31 to 6D11.5: What Changed in ICD-11?

ICD-10 classified emotionally unstable personality disorder under F60.3, with two subtypes. The impulsive type (F60.30) was characterized by emotional instability and poor impulse control. The borderline type (F60.31) additionally involved disturbances in self-image, goals and preferences, chronic feelings of emptiness, intense and unstable relationships, and a tendency toward self-destructive behavior.^[2]

Step 1: Establish That a Personality Disorder Is Present

The borderline pattern can only be applied after the general requirements for personality disorder have been met. According to the ICD-11 guidelines, these include:^[1]

• an enduring disturbance in aspects of self-functioning, such as identity, self-worth, accuracy of self-view, or self-direction, and/or persistent interpersonal dysfunction;
• persistence over an extended period, typically two years or more;
• maladaptive patterns of thinking, emotional experience, emotional expression, and behavior;
• difficulties that occur across a range of personal and social situations rather than being limited to specific relationships or roles;
• substantial distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning;
• no better explanation by another mental disorder, medication or substance use, medical condition, developmental stage, or relevant social or cultural factors.

This last point is particularly important in borderline presentations. Emotional instability that occurs only during a depressive or manic episode, during intoxication or withdrawal, or only within a specific abusive relationship does not, by itself, establish a personality disorder.

Step 2: Rate the Severity

Severity reflects the extent of difficulties in self and interpersonal functioning and how strongly associated emotional, cognitive, and behavioral problems affect everyday life. The guidelines also consider how a person responds to intense emotions and stress, including any risk of self-harm or violence.^[1]

The borderline pattern can occur at any level of severity. Severity should be based on overall personality functioning and should not be inferred simply from the presence or absence of the borderline pattern.

Step 3: Identify the Borderline Pattern (6D11.5)

The borderline pattern can be applied when the personality disturbance is characterized by pervasive instability in relationships, self-image, and emotions, together with marked impulsivity. Five or more of the following features are required:^[1]

• frantic efforts to avoid real or imagined abandonment;
• a pattern of unstable and intense relationships that may alternate between idealization and devaluation;
• identity disturbance, with a markedly and persistently unstable self-image or sense of self;
• a tendency to act rashly when experiencing intense negative emotions, resulting in potentially self-damaging behavior such as risky sex, reckless driving, excessive alcohol or substance use, or binge eating;
• recurrent episodes of self-harm;
• emotional instability characterized by marked mood reactivity;
• chronic feelings of emptiness;
• intense or inappropriate anger or difficulty controlling anger;
• transient dissociative symptoms or psychotic-like experiences, such as brief hallucinations or paranoia, during periods of high emotional arousal.

The ICD-11 guidelines also describe additional features that may occur but are not required. These include seeing oneself as inadequate, bad, guilty, or contemptible; feeling profoundly different from or isolated from others; experiencing pervasive loneliness; and being highly sensitive to rejection, with difficulty establishing appropriate levels of trust and a tendency to misread social cues.^[1]

Mood reactivity is particularly important. In the borderline pattern, intense low or dysphoric states typically last for several hours and, at most, a few days. They are usually triggered by thoughts or events, particularly interpersonal events. This pattern can help distinguish borderline presentations from bipolar disorder.^[1]

Borderline Pattern or Trait Domains?

The borderline pattern overlaps substantially with several ICD-11 trait domains, particularly negative affectivity, dissociality, and disinhibition. A person can therefore be described using the borderline pattern, trait domains, or both.^[1]

Adding trait domains can provide a more individualized picture. For example, two people may both meet criteria for the borderline pattern while having very different trait profiles – one may have prominent detachment, while another may show pronounced dissociality.^[3]

In clinical practice, the borderline pattern can be particularly useful when it informs a treatment pathway or service organized around this presentation, while trait domains provide a more detailed description of the individual's personality profile.

For an overview of the full dimensional model, see Personality Disorders in ICD-11.

How Is Borderline Personality Disorder Coded in ICD-11?

Two coding rules are especially important. First, 6D11.5 is never used on its own. It must be combined with a personality disorder severity code or personality difficulty. Second, the borderline pattern does not determine severity – severity is coded separately.^[1]

Descriptions of all Chapter 6 codes are available in our ICD-11 mental disorder codes list.

ICD-11 vs. DSM-5-TR: How Do the Criteria Compare?

The nine features of the ICD-11 borderline pattern closely correspond to the DSM-5-TR criteria for borderline personality disorder. Both systems require five or more of nine features. This close alignment was intentional and allows research based on DSM criteria to remain relevant to the ICD-11 construct.^[3]

The broader structure of the two systems is different. In the main DSM-5-TR model, borderline personality disorder remains a separate categorical diagnosis and does not require a severity rating. In ICD-11, the same general features are represented as a pattern within a personality disorder that is first rated by severity.

DSM-5-TR also includes the Alternative Model for Personality Disorders, which, like ICD-11, combines the assessment of personality functioning with trait domains. For a broader comparison, see ICD-11 vs. DSM-5.

Differential Diagnosis

Emotional instability, impulsivity, self-harm, and interpersonal difficulties can occur in a range of mental disorders. Other possible explanations should therefore be considered before applying the borderline pattern.

Complex PTSD (6B41). Complex PTSD requires exposure to an extreme stressor as well as the core symptoms of PTSD. In complex PTSD, negative self-concept tends to be persistent, while interpersonal difficulties may involve withdrawal or avoidance rather than a pronounced fear of abandonment. The two conditions can co-occur. See Complex PTSD vs. Borderline Personality Disorder.^[7]

Bipolar disorders (6A60, 6A61). Mood episodes typically last days to weeks and involve changes in energy, activity, and sleep. They are not primarily triggered by interpersonal events. In the borderline pattern, mood shifts tend to be more reactive and usually last hours.

ADHD (6A05). Impulsivity and emotional dysregulation can occur in adults with ADHD, but ADHD begins in childhood, occurs across settings, and is also characterized by persistent difficulties with attention. Identity disturbance and fear of abandonment are not core features of ADHD, although the conditions can co-occur. See ADHD in Adults.

Depressive disorders. Chronic emptiness and self-harm can occur in depression as well, but the borderline pattern is characterized by rapid, reactive shifts in emotional state rather than persistent depressed mood occurring most of the day, nearly every day, for at least two weeks.

Disorders due to substance use. Intoxication and withdrawal can cause impulsivity, mood instability, and interpersonal conflict. A personality disorder should be diagnosed only when the pattern is also present outside periods of substance use.

Dissociative disorders. Brief dissociative experiences during periods of intense emotional arousal can occur as part of the borderline pattern. More persistent dissociation that is independent of emotional arousal, significant amnesia, or distinct personality states may point toward a dissociative disorder.

Borderline Features in Adolescents

ICD-11 does not specify a minimum age for diagnosing personality disorder, but it recommends caution when applying the diagnosis to children and adolescents, whose personalities are still developing. Developmentally expected difficulties – such as struggles with establishing an independent identity during adolescence – should not automatically be interpreted as personality disorder.^[1]

At the same time, persistent and pervasive borderline features during adolescence can be clinically significant. Early recognition and developmentally appropriate treatment may be appropriate when the pattern remains stable over time and causes clear impairment, while ensuring that the diagnostic label does not become a barrier to care.

Assessment Tools

No questionnaire can establish a personality disorder diagnosis on its own. Assessment relies primarily on clinical interviews that examine personality functioning over time. When possible, information from someone who knows the person well can also provide useful additional context.^[1]

Several instruments can support ICD-11-based assessment. The Personality Inventory for ICD-11 (PiCD) is a self-report measure of the five trait domains.^[8] Brief measures of personality disorder severity, such as the Standardized Assessment of Severity of Personality Disorder (SASPD), can be used for screening. Borderline features are also commonly assessed using DSM-based structured interviews such as the SCID-5-PD, whose borderline criteria closely correspond to the ICD-11 pattern.

See SCID-5-CV vs. SCID-5-PD for more information. Our clinical assessment tools database provides information on selected instruments without reproducing copyrighted test items.

Course and Treatment

Borderline personality disorder is not necessarily a lifelong, unchanging condition. In the McLean Study of Adult Development, which followed patients for 16 years, most participants achieved symptomatic remission lasting at least two years. Broader recovery – defined as remission together with good social and occupational functioning – was more difficult to achieve and maintain.^[9]

Structured psychotherapies have the strongest evidence base. A Cochrane review found that psychotherapy, particularly dialectical behavior therapy (DBT) and mentalization-based treatment, reduced borderline symptoms, self-harm, and suicide-related outcomes and improved psychosocial functioning compared with usual treatment, although the overall certainty of the evidence was generally low.^[10]

Guidelines such as NICE recommend against using medication specifically to treat borderline personality disorder or its individual symptoms. Medication may still be appropriate for co-occurring conditions.^[11]

The Ongoing Debate Around the Borderline Pattern

The borderline pattern remains one of the more debated elements of ICD-11. Critics, including members of the group that developed the new model, have argued that borderline personality disorder is a heterogeneous construct whose features may be better captured through severity and trait domains. Concerns have also been raised about the stigma associated with the borderline label.^[4][5]

European experts have highlighted both the potential clinical value of the borderline pattern for treatment services and research and the importance of integrating it with the broader dimensional model.^[6]

For clinicians, the practical takeaway is straightforward: when using the borderline pattern, assess severity carefully, consider adding relevant trait domains, and explain the diagnosis in terms of specific, understandable, and treatable difficulties rather than as a fixed description of someone's character.

Summary

ICD-11 retains the borderline construct but places it within a broader dimensional model of personality disorder. The assessment involves three main steps: establish that the general requirements for personality disorder are met, rate severity (6D10.0–6D10.2), and add the borderline pattern (6D11.5) when five or more of its nine features are present.

The borderline pattern corresponds closely to the ICD-10 diagnosis F60.31 and to the DSM-5-TR criteria, meaning that much of the existing research and clinical experience remains relevant.

The diagnosis should be made by a qualified clinician following a comprehensive assessment of long-term personality functioning and appropriate differential diagnosis. If someone is at immediate risk of self-harm or suicide, urgent professional help should be sought.

Frequently asked questions