Application of the ICD-11 classification of personality disorders

Personality Disorder is important to all health care practitioners because it is a prevalent condition that applies to approximately 12% of the general community [1], 25% of primary care patients [2], and at least 50% of psychiatric outpatients [3]. This potentially complicates the relationship between patients and health care professionals, increases the risk of premature mortality, and results in a huge cost to society [4]. However, research highlights significant problems with the ICD-10 and DSM-IV/DSM-5 categorical approaches to Personality Disorder diagnostics, including arbitrary diagnostic thresholds, extensive overlap among categories, lack of evidence for 10 distinct categories, and insufficient clinical utility [4‐6]. In comparison to the assessment of other mental disorders, assessment of Personality Disorders is more difficult in routine clinical practice. Reviewing the 79 DSM criteria for 10 disorders (plus 15 criteria of conduct disorder) is cumbersome and requires specialized training. In response to these shortcomings, the 11th edition of the International Classification of Diseases (ICD-11) adopts a dimensional approach to the classification of Personality Disorders that focuses on global level of severety and five trait qualifiers [7]. The present article aims to introduce and illustrate how the ICD-11 Personality Disorder classification may be applied in clinical practice using five brief cases with different diagnostic features.

At a basic level, the ICD-11 classification allows the clinician the option of rapid assessment of personality functioning. As such, a practitioner should be able first to identify the presence or absence of Personality Disorder, then its severity, and, if appropriate, one or more prominent trait qualifiers that contribute to the expression of personality dysfunction. Accordingly, the procedure for classification of ICD-11 Personality Disorder is fairly similar to the procedure of diagnosing ICD-10 F32 Depressive episode which has three levels of severity (mild, moderate, and severe), and which may, if appropriate, be further qualified by additional codes for individual features. For example, F32.11 Moderate depressive episode with somatic syndrome or F32.3 Severe depressive episode with psychotic symptoms.

The following five cases demonstrate how the ICD-11 Personality Disorder classification may be applied to individuals with varying severity of personality dysfunction and configuations of trait qualifiers. All five cases meet the general diagnostic requirements for Personality Disorder, except for Case 4 (Fig. 4) whose clinical presentation is only characterized by subthreshold Personality Difficulty.

Case 1 (Fig. 1) is a 29-year-old women, who has a history of numerous serious suicide attempts resulting in repeated hospitalizations, multiple treatment providers, and medication trials typically with little to no benefit. She has been diagnosed with ICD-10 F60.3 Emotionally unstable Personality Disorder, but her clinical presentation is also complicated by substance abuse (i.e., cannabis and amphetamine), eating disorder, panic attacks, aggressive/impulsive behaviors leading to a total loss of reliable friends, and severe self-harm that has endangered her life. During her childhood she was verbally and physically abused by her mother, and sexually abused by two of her mother’s male acquantances; she never knew her dad. Under stress she suffers from trauma-related dissociative states including symptoms of depersonalization and psychotic-like voices telling her to punish herself or vanish from the present reality, though, she is mostly aware that the voices only exist in her mind. When experiencing minor defeats or perceived rejection, she responds with feelings of self-loathing or anger. Due to excessive mistrust of other people, her ability to form intimate relationships and capacity for empathy is severily compromised, and she has no idea what to do with her life or what she has to offer. Apart from experiencing mistrust, emptiness, and anger, she occasionally uses ingratiation and charm in her attempts to have her need for warmth and approval met. As displayed in the figure, Case 1’s (Fig. 1) clinical presentation is classified as Severe Personality Disorder (e.g., serious difficulty with regulation of emotional experience, self-esteem, and impulses with a past history and future expectation of severe harm to self, psychotic-like perceptions, and she lacks reliable friends) with prominent trait qualifiers of Negative Affectivity (e.g., experiences negative emotions that are out of proportion to the situation including shame, mistrustfulness, and anger), Disinhibition (e.g., tendency to act impulsively in response to immediate stimuli in a harmful manner), and Dissociality (e.g., mistrust-related aggression and tendency to manipulate or seduce others). In this case Moderate Personality Disorder does not apply because Case 1 (Fig. 1) is not even able to maintain a few friendships or a regular job, and her self-injuries have caused long-term damage and endangered her life. Additionally, Case 1’s (Fig. 1) diagnosis may be further elucidated using the Borderline Pattern qualifier as indicated by nearly all of the features presented in Table 6.

Case 2 (Fig. 2) is a 36-year-old man with a history of panic attacks and recurrent depressive episodes. He is intelligent and sensitive but has not managed to finish any degree after high school. A psychiatric evaluation at an outpatient psychotherapy unit concluded that his personality features met ICD-10 criteria for F60.6 Avoidant Personality Disorder and F60.7 Dependent Personality Disorder. Case 2 (Fig. 2) grew up in a home with poor resources and a family climate characterized by emotional and physical neglect along with some emotional abuse by both parents. During adolescence, he suffered from loneliness, insecurity, poor self-worth, and self-defeating behaviors such as letting peers take advantage of him. He virtually had no friends in school and he generally felt anxious, shy, and unaccepted among peers. Accordingly, he was prone to act as an underdog or people-pleaser. These features were preserved in adulthood in terms of social withdrawal and intimacy avoidance in order not to feel criticized, ashamed, or rejected. However, today he maintains a permanent job and a couple of relationships beyond his two brothers. As displayed in the figure, Case 2’s (Fig. 2) clinical presentation is classified as Mild Personality Disorder (e.g., some distortions in interpersonal appraisal, difficulty maintaining positive self-esteem, is highly submissive in relationships but at least some healthy relationships and occupational roles are maintained) with prominent features of Negative Affectivity (e.g., anxiety, shame, low self-esteem, vulnerability, and depression depressivity) and Detachment (e.g., avoidance of social interactions). Notably, when Case 2 (Fig. 2) was younger, he would probably have been classified as Moderate Personality Disorder because he virtually had no friends; but he has improved since then as he now maintains a stable job and at least a couple of relationships.

Case 3 (Fig. 3) is a 26-year-old man incarcerated for brutal violence (e.g., purposely injured a shop owner with a blunt instrument just to get his money). Although he claimed to feel no suffering from any symptoms or dysfunction, he sought rehabilitation for his dependency on cocaine which had caused him certain problems while imprisoned including withdrawal symptoms and symptoms of intoxication (e.g., tremor and dry mouth). A psychiatric evaluation concluded that his personality features met ICD-10 criteria for F60.2 Dissocial Personality Disorder including some characteristic psychopathic (e.g., callousness and exploitativeness) and narcissistic (e.g., entitlement) features as well as recklessness without concern for others’ safety. Case 3 (Fig. 3) did not recall much from his childhood and appeared aloof and emotionally detached while mentioning that his father was extremely physically abusive towards him and his mother. He did not experience anything positive from friendships, unless they could provide him with certain favors. Moreover, he was not ashamed of admitting that he did not care about harming others, but was rather proud of it, and he generally never felt any emotional or physical pain nor remorse. Case 3’s (Fig. 3) clinical presentation is classified as Severe Personality Disorder (e.g., past history and future expectation of severe harm to others, friendships have no genuine value to him, and self-view is characterized by entitlement) with prominent features of Dissociality (e.g., callousness, exploitation of others, and entitlement), Disinhibition (e.g., recklessness with no regard for others’ safety), and some Detachment (e.g., aloofness). In this case Moderate Personality Disorder would not apply because Case 3 (Fig. 3) is not even interested in maintaining a single friendship and the risk of dangerous harm to others is not just “sometimes” but “often” taking place.

Case 4 (Fig. 4) is a 19-year-old highschool student, who was referred for treatment of ICD-10 F41.2 mixed anxiety and depressive disorder along with symptoms of anorexia nervosa, which she had previously been treated for in a private adolescent psychiatric clinic. Case 4 (Fig. 4) is from a relatively stable familiy, where the father works as physician and the mother as dentist. She has always been good at school and at finishing her duties in the home. Even though her parents have been busy with their own careers, they have persistently encouraged her to play the piano at different occasions and excel at horse riding competitions because they knew and expected that she was good at that. For that reason, her father never responded positively when she performed very well, whereas he showed disaoppointment if she did not get an A at her exams. While she was 13 her world fell apart as she discovered her father having an affair with another woman from his workplace, and she started overperforming in school and in sport while gradually developing eating disorder symptoms (restricting food leading to abnormally low weight) and even more unrelenting standards. However, she managed to maintain satisfying relationships with her friends as well as her mother and siblings. Case 4’s (Fig. 4) clinical presentation is primarily classified as Anorexia Nervosa in the context of Personality Difficulty (i.e., some long-standing difficulties in her way of thinking about the self and the world, including unrelenting standards, which are insufficiently severe to cause notable disruption in school and most relationships) with prominent features of Negative Affectivity (e.g., depressivity, shame, and anxiety) and Anankastia (e.g., perfectionism, concern with meeting obligations, perseveration, deliberatetiveness, and tight control of own emotional expression). In this case Mild Personality Disorder would not apply because Case 4’s (Fig. 4) habitual personality issues are not leading to any notable psychosocial impairment, whereas her problems are mainly attributable to other current mental problems.

Case 5 (Fig. 5) is a 53-year-old highly skilled and well-groomed accountant who has worked for several companies during his carreer. At his current job, Case 5 (Fig. 5) was referred to a psychologist at the company’s HR department. Overall his personality characteristics were consistent with the ICD-10 Personality Disorder diagnoses F60.5 Anankastic Personality Disorder and F60.8 Other: Narcissistic Personality Disorder. Since adolescence, Case 5 (Fig. 5) has been more or less preoccupied with order, details, rules, and organization, including excessive pedantry and stubbornness. He always knew the “right” solution to most problems, and felt more capable of solving complicated things than nearly anyone else. Furthermore, he felt more important and entitled than most other people, and turned hostile when this was not recognized by others. Therefore, at work he has been reluctant to collaborate with others or to delegate “important” tasks to others, unless they submit to exactly his way of doing it. Colleagues and other people who know him well describes him as officious, supercilious, high-handed, unimaginative, intrusive, petty-minded, meddlesome, and nosy. An ex-wife has called Case 5 (Fig. 5) “a narcissist”, whereas he refers to her as “too vulnerable and unintelligent”. For those reasons he has not been able to maintain his occupational positions due to conflicts with superiors and emotional abuse of co-workers who he perceives as less efficient than himself. According to his account of things, it was his decision to leave the different companies during his career simply because they were not professional enough. According to ICD-11 guidelines, Case 5’s (Fig. 5) clinical presentation may be classified as Moderate Personality Disorder (e.g., a compromized capacity for understanding and appreciating others’ perspectives, work relationships are disrupted, and persistent conflicts result in emotional harm to others) with prominent traits of Anankastia (e.g., stubbornness, orderliness, and perfectionism) and Dissociality (e.g., entitlement, grandiosity, lack of empathy, meanness, and hostility). In this case, Severe Personality Disorder does not apply because while Case 5’s (Fig. 5) intimate and occupational relationships have been disrupted by frequent conflicts, he is still able to maintain work productivity and at least some relationships for a certain period of time. Likewise, Mild Personality Disorder does not apply because he is virtually incapable of or unwilling to sustain employment due to interpersonal issues, and he does not have any positive/healthy relationships not even with family members.

The ICD-11 approach changes the structure and process of diagnosing a Personality Disorder by focusing attention on the universal features of personality dysfunction including a classification of severity. Such a classification system has the advantage of simplifying the process of identifying a Personality Disorder. For example, the practitioner does not have to rule out the presence of a Personality Disorder by determining that none of the nine ICD-10 categories are present. Moreover, the ICD-11 classification is likely to have greater clinical utility because placing severity of personality functioning at the center of the diagnostic process can help service providers to distinguish those patients who have the greatest level of disturbance from those who do not, and thereby help services to target their interventions more effectively [13, 18].

The parsimoniousness of the ICD-11 classification may also frustrate some clinicians who desire a more detailed conceptualization of the patient’s personality stucture. Accordingly, in comparison to the nine categories in ICD-10 or the 25 facets in the DSM-5 AMPD model, the ICD-11’s five trait domains may be viewed as insufficiently detailed for describing all the subtle nuances of the patient’s personality. Yet, when all trait qualifier combinations are taken into account, the number of diagnostic constellations provides information for a more detailed clinical conceptualization. For example, when describing features of the ICD-10 diagnosis Avoidant Personality Disorder, the clinician may use the ICD-11 code Mild Personality Disorder with prominent features of Negative Affectivity (i.e., anxiousness and poor self-esteem) and Detachment (i.e., social withdrawal and intimacy avoidance). However, the ICD-11 classification does not accommodate a coding of the specific subfeatures or facets as in the DSM-5 AMPD model where Avoidant Personality Disorder may be described in terms of anxiousness, withdrawal, and intimacy avoidance. In any case, preliminary research suggests that the five ICD-11 trait domains explain a substantial amount of variance in all Personality Disorder categories [22, 35‐38]. From this empirical perspective, little information (i.e. variance) seems lost in the transition from the 10 familiar Personality Disorder types to 5 trait domain qualifiers. However, this empirical reality may not necessarily be noticed by practitioners when using this new approach for the first time, and communication remains a central purpose of a diagnostic system.

The ICD-11 classification allows the clinician to apply as many trait domain qualifiers as necessary to portray the clinical reality and dynamics of personality functioning, which offers more unique diagnostic profiles in various combinations. For example, the trait domain qualifier of Negative Affectivity applies to both Case 1 and Case 2 (Figs 1 and 2) but with a substantially distinct “flavour” in each case due to the influence of co-occuring trait qualifiers. This is acknowledged in the ICD-11 guidelines, which indicates that the manifestation of one prominent trait is largely dependent on the presence of other traits. Accordingly, Case 1 (Fig. 1) is likely to experience “externalizing” features of Negative Affectivity (e.g., anger and contempt) due to her co-occuring Dissociality, whereas Case 2 (Fig. 2) is likely to experience “internalizing” features of Negative Affectivity (e.g., depression, anxiety, guilt) due to his co-occuring Detachment.

In this article we illustrated the application of the ICD-11 classification using five different cases in which we took all aspects of the diagnostic guidelines into account. The ICD-11 Personality Disorder classification was found applicable to the five clinical cases, which were classified according to Personaity Disorder severity and trait domain qualifiers. We propose that the classification of severity may help inform clinical prognosis and intensity of treatment, whereas the classification of trait qualifiers may help inform the focus and style of treatment. Empirical research is warranted to investigate such important aspects of clinical utility. Moreover, future empirical research should evaluate perceived ease of use, utility for communication with patients and professionals, and inter-rater reliability. Finally, it seems vital to investigate whether practitioners across all WHO member countries can use the classification in a reliable manner despite substantial diversity in culture and professional resources.