The Development of the ICD-11 Classification of

The Development of the ICD-11 Classification of Personality Disorders: An Amalgam of Science, Pragmatism and Politics

Psychological MedicineUniversity of Otago, Christchurch

Prof Roger T MulderMBChB, PhD, FRANZCP

Acknowledgements

Peter Tyrer

Roger Blashfield

Youl-Ri Kim

David Ndetei

Dusica Tosevki

Lee Anna Clark

Jeremy Coid

Michael Crawford

Andrea Fossati

Nestor Koldobsky

Michaela Swales

Alrizea Farnam

John Horwood

Bo Bach

Problems with Personality Disorder Classification

• General consensus that DSM-5 and ICD-10 categories are unsatisfactory (Bernstein et al., 2007)

• Still largely based on an uncritical acceptance of Schneider’s historical categorical model.

• Only antisocial (ASPD), borderline (BPD), and personality disorder not otherwise specified (PD NOS) are used widely.

• Rates of clinical diagnosis much less than that reported in structured epidemiological studies (around 10% of the general population and 40-50% of patients with mental illness).

• Consideration and treatment of personality disorders increasingly confined to specialist units.

Bernstein et al. (2007). Opinions of personality disorder experts regarding the DSM-IV personality… Journal of Personality Disorders, 21(5), 536-551

Schneider DSM-5 ICD-10

Emotionally unstable BorderlineEmotionally unstable –

borderline and unstable

Explosive Antisocial Dissocial

Self-seeking Narcissistic Narcissistic

Histrionic Histrionic

Depressive

Asthenic Avoidant Anxious

Weak-willed Dependent Dependent

Affectless Schizoid Schizoid

Fanatical

Hyperthymic

Obsessive-compulsive Anankastic

Paranoid

Schizotypal

DSM-5 Classification

• Originally proposed hybrid model which included assessment of severity, a reduction from ten to six categories and an assessment of 25 trait facets grouped into five broad trait domains.

• APA Board of Trustees felt the model was not yet ready for general use. Relegated to Section 111.

• DSM-5 personality disorder classification is essentially DSM-IV-R.

The categorical approach to personality disorders presented in DSM-5 and ICD-10 is not fit for purpose

We had the following goals:

• Establish the primacy of severity in measuring personality disorders.

• Eliminate the arbitrarily diagnostic thresholds that create the appearance of strict category boundaries.

• Reduce diagnostic co-occurrence among personality categories.

• Reduce heterogeneity of personality categories.

• Eliminate excessive use of personality disorders – not otherwise specified (NOS).

• Try to implement an empirically based model of personality disorder structure that is consistent with the structure of personality in the general population.

Changes in ICD-11

• Conceptually compatible in many ways with the DSM-5 Section 111 alternative model.

• Major differences are its emphasis on the severity of personality disturbance and not attempting to preserve traditional personality categories.

• ICD-11 classification abolishes all type specific categories of personality disorder apart from the general one of personality disorder itself.

• Different levels of severity reflect the following:

– Personality dysfunction is best represented on a continuum or dimension.

– The severity of the personality dysfunction is the best predictor of outcome regardless of type.

– There is abundant evidence that the severity and form of personality disorders fluctuate over time depending on many psychosocial factors.

“Personality disorder is characterised by problems in functioning of aspects of the self (e.g. identity, self-worth, accuracy of self-view, self-direction), and/or interpersonal dysfunction (e.g. ability to develop and maintain close and mutually satisfying relationships, ability to understand others’ perspectives and to manage conflict in relationships) that have persisted over an extended period of time (e.g. 2 years or more)…”

World Health Organisation - 6D10 Personality Disorder

World Health Organisation. (2018). ICD-11, the 11th Revision of the International Classification of Diseases [Online]. https://icd.who.int/

https://icd.who.int/

“… The disturbance is manifest in patterns of cognition, emotional experience, emotional expression, and behaviour that are maladaptive (e.g. inflexible or poorly regulated) and is manifest across a range of personal and social situations (i.e. is not limited to specific relationships or social roles). The patterns of behaviour characterizing the disturbance are not developmentally appropriate and cannot be explained primarily by social or cultural factors, including socio-political conflict…"




“… The disturbance is associated with substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning."




All general diagnostic requirements for Personality Disorder are met. Disturbances affect some areas of personality functioning but not others (e.g. problems with self-direction in the absence of problems with stability and coherence of identity or self-worth), and may not be apparent in some contexts. There are problems in many interpersonal relationships and/or in performance of expected occupational and social roles, but some relationships are maintained and/or some roles carried out. Specific manifestations of personality disturbances are generally of mild severity. Mild Personality Disorder is typically not associated with substantial harm to self or others, but may be associated with substantial distress or with impairment in personal, family, social, educational, occupational or other important areas of functioning that is either limited to circumscribed areas (e.g. romantic relationships; employment) or present in more areas but milder.

Mild Personality Disorder



All general diagnostic requirements for Personality Disorder are met. Disturbances affect multiple areas of personality functioning (e.g. identity or sense of self, ability to form intimate relationships, ability to control impulses and modulate behaviour). However, some areas of personality functioning may be relatively less affected. There are marked problems in most interpersonal relationships and the performance of most expected social and occupational roles are compromised to some degree. Relationships are likely to be characterised by conflict, avoidance, withdrawal, or extreme dependency (e.g. few friendships maintained, persistent conflict in work relationships and consequent occupational problems, romantic relationships characterised by serious disruption or inappropriate submissiveness). Specific manifestations of personality disturbance are generally of moderate severity. Moderate Personality Disorder is sometimes associated with harm to self or others, and is associated with marked impairment in personal, family, social, educational, occupational or other important areas of functioning, although functioning in circumscribed areas may be maintained.

Moderate Personality Disorder



All general diagnostic requirements for Personality Disorder are met. There are severe disturbances in functioning of the self (e.g. sense of self may be so unstable that individuals report not having a sense of who they are or so rigid that they refuse to participate in any but an extremely narrow range of situations; self-view may be characterised by self-contempt or be grandiose or highly eccentric). Problems in interpersonal functioning seriously affect virtually all relationships and the ability and willingness to perform expected social and occupational roles is absent or severely compromised. Specific manifestations of personality disturbance are severe and affect most, if not all, areas of personality functioning. Severe Personality Disorder is often associated with harm to self or others, and is associated with severe impairment in all or nearly all areas of life, including personal, family, social, educational, occupational, and other important areas of functioning.

Severe Personality Disorder



Personality Difficulty

• Not a diagnosis; listed in the section “non-disease entities that constitute factors influencing health status and encounters with health services that may be of clinical importance” called Q factors.

• May be considered an integral part of the personality disorder spectrum and having personality difficulty creates considerable disturbance in functioning and relationships.

Personality Difficulty Personality Disorder

Intermittent presentation Persistent presentation

Confined to certain situations Present in all situations

Does not interfere greatly with normal social

and occupational performance

Impairs social and occupational

performance

Not associated with risk of harm to self or

others

Often associated with risk of harm to self or

others

Differences Between Personality Difficulty and Disorder

Level Main Features

No PD No personality disturbance

Personality Difficulty Some personality problems in certain situations but not universally

Mild PDDefinite well-demarcated personality problems across a range of

situations

Moderate PDDefinite personality problems usually covering several personality

domains and across all situations

Severe PDAs for complex disorder with personality problems leading to

significant risk to self or others

The Five Severity Levels of Personality Disturbance Proposed in ICD-11

New ICD-11 Classification and Likely Population Prevalence

Tyrer et al. (2014). Preliminary studies of the ICD-11 classification of personality disorder…Personality and Mental Health, 8(4), 254–263

• No personality dysfunction45%

• Personality difficulty48%

• Mild personality disorder5.3%

• Moderate personality disorder1.5%

• Severe personality disorder0.2%

ICD-11 Personality Trait Domain Qualifiers

• All personality disturbance incorporated into a single spectrum.

• Traditional categories have no intrinsic validity and should be abandoned.

• Decision was made to separate the two issues of ‘disorder’ and ‘behavioural manifestations’ which is the description of the behavioural disturbance.


• The description of behavioural disturbance constrained by the need for them to be useful in all medical settings in all WHO countries.

• Need it to be reasonably simple, concise and clinically useful.

• Traditional descriptions of personality pathology were designed and used by PD specialists who have time and motivation to undertake comprehensive assessments. In contrast, working clinicians do not.

• We hoped to link PD descriptors with models describing ‘normal’ personality in community samples, but only if supported by evidence.


• Systematic review of all studies which had explored the factor structure of patients with personality pathology.

• Reasonably consistent despite heterogenous samples, methodology and models

• All studies reported a general ‘personality distress’ dimension and an externalizing and internalising dimension

• Most reported a ‘schizoid’ and obsessive-compulsive (or anankastic) dimension.

Mulder et al. (2011). The central domains of personality pathology in psychiatric patients.Journal of Personality Disorders, 25(3), 364-377


• Externalising factors very broad and incorporated symptoms conceptualized within the diagnosis of ASPD and psychopathy which sometimes loaded as a separate factor.

• After much debate, a factor incorporating non-psychopathic externalising behaviours – disinhibition – was introduced for further study.

• Therefore, ICD-11 consisted of five broad descriptions of personality pathology.


• Negative Affectivity

• Detachment

• Dissociality

• Disinhibition

• Anankastia

Prominent Personality Traits or Patterns ICD-11

• Trait domain qualifiers may be applied to personality disorders or personality difficulty to describe the characteristics of the individual’s personality that are most prominent and that contribute to personality disturbance.

• Trait domains are not diagnostic categories, but rather represent a set of dimensions that correspond to the underlying structure of personality.

• As many trait domain qualifiers may be applied as necessary to describe personality functioning. Individuals with more severe personality disturbance tend to have a greater number of prominent trait domains.

ICD-11 Domains & DSM-5 AMPD

Despite independent derivation, the ICD-11 ‘domains’ are similar to the ‘Alternative DSM-5 Model for Personality Disorders’

ICD-11 DSM-5 (alternative)

Negative Affectivity Negative Affectivity

Detached Detachment

Dissocial Antagonism

Disinhibition Disinhibition

(Anankastia) (Psychoticism)

Negative Affectivity

The core feature of the Negative Affectivity trait domain is the tendency to experience a broad range of negative emotions.

Common manifestations (not all of which may be present in a given individual at a given time) include:

• experiencing a broad range of negative emotions with a frequency and intensity out of proportion to the situation

• emotional lability and poor emotion regulation

• negativistic attitudes

• low self-esteem and self-confidence

• mistrustfulness

Detachment

The core feature of the Detachment trait domain is the tendency to maintain interpersonal distance (social detachment) and emotional distance (emotional detachment).


• social detachment (avoidance of social interactions, lack of friendships, and avoidance of intimacy)

• emotional detachment (reserve, aloofness, and limited emotional expression and experience)

Dissociality

The core feature of the Dissociality trait domain is disregard for the rights and feelings of others, encompassing both self-centeredness and lack of empathy.


• self-centeredness(sense of entitlement, expectation of others’ admiration, positive or negative attention-seeking behaviours, concern with one's own needs, desires and comfort and not those of others)

• lack of empathy(indifference to whether one’s actions inconvenience hurt others, which may include being deceptive, manipulative, and exploitative of others, being mean and physically aggressive, callousness in response to others' suffering, and ruthlessness in obtaining one’s goals)

Disinhibition

The core feature of the Disinhibition trait domain is the tendency to act rashly based on immediate external or internal stimuli (i.e. sensations, emotions, thoughts), without consideration of potential negative consequences.


• impulsivity

• distractibility

• irresponsibility

• recklessness

• lack of planning

Anankastia

The core feature of the Anankastia trait domain is a narrow focus on one’s rigid standard of perfection and of right and wrong, and on controlling one’s own and others’ behaviour and controlling situations to ensure conformity to these standards.


• perfectionism (concern with social rules, obligations, and norms of right and wrong, scrupulous attention to detail, rigid, systematic, day-to-day routines, hyper-scheduling and planfulness, emphasis on organisation, orderliness, and neatness)

• emotional and behavioural constraint (rigid control over emotional expression, stubbornness and inflexibility, risk-avoidance, perseveration, and deliberativeness)

Measures

• Oltmanns & Widiger. (2018). A self-report measure for the ICD-11 dimensional trait model proposal: The personality inventory for ICD-11. Psychological Assessment, 30(2), 154-169.

• Olajide et al. (2018). Development and psychometric properties of the Standardized Assessment of Severity of Personality Disorder (SASPD). Journal of Personality Disorders, 32(1), 44-56.

• Oltmanns & Widiger. (2020). The Five-Factor Personality Inventory for ICD-11: A facet-level assessment of the ICD-11 trait model. Psychological Assessment, 32(1), 60-71.

ICD-11 Model Testing

• Is measuring severity clinically useful?

• Do the ICD-11 domains appear to have face validity?

• What are the associations between ICD-11 domains and DSM-5 personality disorder criteria?

• Do the ICD-11 domains link with a normal personality model –the Five Factor Model (FFM)?

Significance: P<0.001 is <0.01 at all times of testing

Note: Primary outcome is change in HAI scores at 1 year (P<0.001)

Change in HAI score over two years of study

All differences from 3 m onwards significant at P<0.006

Screening Baseline 3 months 6 months 12m 24m

17

18

19

20

21

22

23

24

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Me

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HA

I sco

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→ Treatment ←

But we also wanted to know if ICD-11 personality status affected the outcome…

Sanatinia et al. (2016). Impact of personality status on the outcomes and cost of CBT for health anxiety.British Journal of Psychiatry, 209(3), 244–250

Methods

• Used DSM-5 220-item self-report inventory (PID 5) to develop an ICD-11 trait domain algorithm.

• 1541 patients and community participants from Denmark.

• 637 undergraduate students as replication sample from the US.

• Derived 5 factor model with reasonably low inter-correlations.

Structural Hierarchy of ICD-11 Trait Features

• One factor: captures overall ‘personality pathology’.

• Two factors: splits into externalising and internalising.

• Three factors: externalising, Negative Affectivity, and Detachment.

• Four factors: Dissociality, Disinhibition, Negative Affectivity, and Detachment

• Five factors: Dissociality, Disinhibition, Negative Affectivity, Detachment, and Anankastia.

NA DT DL DN AN

Neuroticism .81 .39 .14 .50 -.02

Extraversion -.25 -.52 .25 .01 -.01

Agreeableness -.08 -.23 -.56 -.33 .29

Conscientiousness -.31 -.20 -.21 -.67 .56

Openness and experience .09 -.24 .06 .13 -.10

Adapted from: Oltmanns & Widiger. (2019). Evaluating the assessment of the ICD-11 personality disorder… Psychological Assessment, 31(5), 674–684

ESSPD Response

1. Classification radical and untested.

2. Body of knowledge, particularly with respect to BPD, would be lost.

3. Service funding relies on categorical diagnoses.

4. Clinicians won’t be able to use such a radically different classification.

Change in Paradigm

On what basis should such a change in paradigm be evaluated?

• Should the empirical data be especially strong because the change is so large?

• Given how poorly the ICD-10 personality disorders perform, is the proposed conceptual framework so superior that less data is needed?

Politics and Pragmatism

• Despite little research on the validity of borderline classification, there is no doubt it has helped research – particularly treatment and etiological research.

• Compromise was to add a borderline pattern specifier to the classification.

Borderline Pattern

The borderline pattern descriptor may be applied to individuals whose pattern of personality disturbance is characterised by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, as indicated by many of the following:

• Frantic efforts to avoid real or imagined abandonment

• A pattern of unstable and intense interpersonal relationships

• Identity disturbance, manifested in markedly and persistently unstable self-image or sense of self

• A tendency to act rashly in states of high negative affect, leading to potentially self-damaging behaviours

• Recurrent episodes of self-harm

• Emotional instability due to marked reactivity of mood

• Chronic feelings of emptiness

• Inappropriate intense anger or difficulty controlling anger

• Transient dissociative symptoms or psychotic-like features in situations of high affective arousal

Profile of borderline symptomatology against total personality disorder symptom score

Borderline Pattern Descriptor

• Strongly associated with overall severity of personality pathology.

• Associated with disinhibited, dissocial and negative affective domains, but not detached or anankastic.

• Further study needed to test the clinical utility of the borderline descriptor over ICD-11 severity and domain classification.

Challenges

• Conceptually is a four factor structure with a bipolar Anankastic – Disinhibition domain superior?

• Some Negative Affectivity items may be more relevant to low Detachment or mood/anxiety disorders.

• Attachment to the Borderline specifier may result in less use of domain structure.

• The Personality Difficulty diagnosis and expansion.

Advantages

• Clinicians generally judge the ICD-11 classifications as more useful than the ICD-10 categories to formulate treatment planning (Hansen et al., 2019)

• The domains align as predicted with Five Factor Model of normal personality (Oltmanns & Widiger, 2020; Somma et al., 2020).

Hansen et al. (2019). Mental health professionals’ perceived clinical utility of the ICD‐10 vs. ICD‐11...Personality and Mental Health, 13(2), 84–95

Oltmanns & Widiger. (2020). The Five-Factor Personality Inventory for ICD-11: A facet-level assessment…Psychological Assessment, 32(1), 60-71

Somma et al. (2020). Reliability and construct validity of the Personality Inventory for ICD-11 (PiCD)…Psychological Assessment, 32(1), 29–39

Advantages

• Compatible with DSM-5 Alternative Model of Personality Disorder (Bach et al., 2018; 2020).

• Short 9 item questionnaire – SAPAS – developed (Olajide et al., 2018).

Bach et al. (2018). ICD-11 and DSM-5 personality trait domains capture categorical personality…Australian and New Zealand Journal of Psychiatry, 52(5), 425-434

Bach et al. (2020). International Assessment of DSM-5 and ICD-11 Personality Disorder Traits… Psychopathology, 53(3-4), 179–188

Olajide et al. (2018). Development and psychometric properties of the Standardized Assessment…Journal of Personality Disorders, 32(1), 44-56

Advantages

• Longer questionnaire for patients requiring a more comprehensive assessment (Oltmanns & Widiger, 2018; 2019).

Oltmanns & Widiger. (2018). A self-report measure for the ICD-11 dimensional trait model proposal... Psychological Assessment, 30(2), 154-169.

Oltmanns & Widiger. (2019). Evaluating the assessment of the ICD-11 personality disorder… Psychological Assessment, 31(5), 674–684

Conclusions

• Beginning of a paradigm shift in diagnosis

• Dimensional structure consistent with decades of research on personality traits

• ICD-11 and DSM-5 AMPD are consistent with each other and dimensional models of normal personality such as the 5 factor model

• For system to be successful, clinicians need to use it.

Conclusions

• Personality status can be recorded with relative ease.

• Considering personality in the diagnosis of all patients may help reduce stigma.

• If personality is useful in planning treatment and predicting outcome for mental disorders, then clinicians may realise the advantage of bringing personality disorders to the forefront of their thinking, instead of the afterthought so often in present day practice.

Documents

The Development of the ICD-11 Classification of