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Rationale of the ICD-11 classification of personality disorders
● An enduring disturbance characterized 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).
● The disturbance has persisted over an extended period of time (> 2 years).
● The disturbance is manifest in patterns of cognition, emotional experience, emotional expression, and behaviour that are maladaptive (e.g., inflexible or poorly regulated).
● The disturbance is manifest across a range of personal and social situations (i.e., is not limited to specific relationships or social roles), though it may be consistently evoked by particular types of circumstances but not others.
● 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 symptoms are not due to the direct effects of a medication or substance, including withdrawal effects, and are not better explained by another Mental and Behavioural Disorder, a Disease of the Nervous System, or another health condition.
● The disturbance is associated with substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
Degree and pervasiveness of disturbances in functioning of aspects of the self:
● Stability and coherence of one’s sense of identity (e.g., extent to which identity or sense of self is variable and inconsistent or overly rigid and fixed).
● Ability to maintain an overall positive and stable sense of self-worth.
● Accuracy of one’s view of one’s characteristics, strengths, limitations.
● Capacity for self-direction (ability to plan, choose, and implement appropriate goals).
Degree and pervasiveness of interpersonal dysfunction across various contexts and relationships (e.g., romantic relationships, school/work, parent-child, family, friendships, peer contexts):
● Interest in engaging in relationships with others.
● Ability to understand and appreciate others’ perspectives.
● Ability to develop and maintain close and mutually satisfying relationships.
● Ability to manage conflict in relationships.
Pervasiveness, severity, and chronicity of emotional, cognitive, and behavioral manifestations of the personality dysfunction:
○ Range and appropriateness of emotional experience and expression.
○ Tendency to be emotionally over- or underreactive.
○ Ability to recognize and acknowledge unwanted emotions (e.g., anger, sadness).
○ Accuracy of situational and interpersonal appraisals, especially under stress.
○ Ability to make appropriate decisions in situations of uncertainty.
○ Appropriate stability and flexibility of belief systems.
○ Flexibility in controlling impulses and modulating behaviour based on the situation and consideration of the consequences.
○ Appropriateness of behavioural responses to intense emotions and stressful circumstances (e.g., propensity to self-harm or violence).
The extent to which the dysfunctions in the above areas are associated with distress or impairment in personal, family, social, educational, occupational or other important areas of functioning.
Mild Personality Disorder
Moderate Personality Disorder
Severe Personality Disorder
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; see Table 2), and may not be apparent in some contexts.
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; see Table 2). However, some areas of personality functioning may be relatively less affected.
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 characterized by self-contempt or be grandiose or highly eccentric; see Table 2).
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.
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 characterized by conflict, avoidance, withdrawal, or extreme dependency (e.g., few friendships maintained, persistent conflict in work relationships and consequent occupational problems, romantic relationships characterized by serious disruption or inappropriate submissiveness).
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 disturbances are generally of mild severity (see examples in Table 4).
Specific manifestations of personality disturbance are generally of moderate severity (see examples in Table 4).
Specific manifestations of personality disturbance are severe (see examples in Table 4) and affect most, if not all, areas of personality functioning.
Is typically not associated with substantial harm to self or others.
Is sometimes associated with harm to self or others.
Is often associated with harm to self or others.
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.
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.
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.
Mild Personality Disorder
Moderate Personality Disorder
Severe Personality Disorder
The individual’s sense of self may be somewhat contradictory and inconsistent with how others view them.
The individual’s sense of self may become incoherent in times of crisis.
The individual’s self-view is very unrealistic and typically is highly unstable or internally contradictory.
The individual has difficulty recovering from injuries to self-esteem.
The individual has considerable difficulty maintaining positive self-esteem or, alternatively, has an unrealistically positive self-view that is not modified by evidence to the contrary.
The individual has serious difficulty with regulation of self-esteem, emotional experience and expression, and impulses, as well as other aspects of behaviour (e.g., perseveration, indecision).
The individual’s ability to set appropriate goals and to work towards them is compromised; the individual has difficulty handling even minor setbacks.
The individual exhibits poor emotion regulation in the face of setbacks, often becoming highly upset and giving up easily. Alternatively, the individual may persist unreasonably in pursuit of goals that have no chance of success.
The individual is largely unable to set and pursue realistic goals.
The individual may have conflicts with supervisors and co-workers, but is generally able to sustain employment.
The individual may exhibit little genuine interest in or efforts toward sustained employment.
The individual is unwilling or unable to sustain regular work due to lack of interest or effort, poor performance (e.g., failure to complete assignments or perform expected roles, unreliability), interpersonal difficulties, or inappropriate behaviour (e.g., fits of temper, insubordination).
The individual’s limitations in the ability to understand and appreciate others’ perspectives create difficulties in developing close and mutually satisfying relationships.
Major limitations in the ability to understand and appreciate others’ perspectives hinder developing close and mutually satisfying relationships.
The individual’s interpersonal relationships, if any, lack mutuality; are shallow, extremely one-sided, unstable, and/or highly conflictual, often to the point of violence.
There may be estrangement in some relationships, but relationships are more commonly characterized by intermittent or frequent, minor conflicts that are not so severe that they cause serious and long-standing disruption. Alternatively, relationships may be characterized by dependence and avoidance of conflict by giving in to others, even at some cost to themselves.
Problems in those relationships that do exist are common and persistent; may involve frequent, serious, and volatile conflict; and typically are quite one-sided (e.g., very strongly dominant or highly submissive).
Family relationships are absent (despite having living relatives) or marred by significant conflict.
The individual has extreme difficulty acknowledging unwanted emotions (e.g., does not recognize or acknowledge experiencing anger, sadness, or other emotion).
Under stress, there may be some distortions in the individual’s situational and interpersonal appraisals but reality testing remains intact.
Under stress there are marked distortions in the individual’s situational and interpersonal appraisals. There may be mild dissociative states or psychotic-like beliefs or perceptions (e.g., paranoid ideas).
Under stress, there are extreme distortions in the individual’s situational and interpersonal appraisals. There are often dissociative states or psychotic-like beliefs or perceptions (e.g., extreme paranoid reactions).
A tendency to experience a broad range of negative emotions with a frequency and intensity out of proportion to the situation.
Anxiety, anger, worry, fear, vulnerability, hostility, shame, depression, pessimism, guilt, low self-esteem, and mistrustfulness.
For example, once upset, such individuals have difficulty regaining their composure and must rely on others or on leaving the situation to calm down.
A tendency to maintain interpersonal distance (social detachment) and emotional distance (emotional detachment)
Social detachment including avoidance of social interactions, lack of friendships, and avoidance of intimacy. Emotional detachment including being reserved, aloofness, and limited emotional expression and experience.
For example, such individuals seek out employment that does not involve interactions with others.
Disregard for the rights and feelings of others, encompassing both self-centeredness and lack of empathy.
Self-centeredness including entitlement, grandiosity, expectation of others’ admiration, and attention-seeking. Lack of empathy including being deceptive, manipulative, exploiting, ruthless, mean, callous, and physically aggressive, while sometimes taking pleasure in others’ suffering.
For example, such individuals respond with anger or denigration of others when they are not granted admiration.
A 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, and lack of planning.
For example, such individuals may be engaged in reckless driving, dangerous sports, substance use, gambling, and unplanned sexual activity.
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 including concern with rules, norms of right and wrong, details, hyper-scheduling, orderliness, and neatness. Emotional and behavioral constraint including rigid control over emotional expression, stubbornness, risk-avoidance, perseveration, and deliberativeness.
For example, such individuals may stubbornly redo the work of others because it does not meet their standards.
The Borderline pattern qualifier may be applied to individuals whose pattern of personality disturbance is characterized by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, as indicated by five (or more) of the following:
● Frantic efforts to avoid real or imagined abandonment.
● A pattern of unstable and intense interpersonal relationships, typically characterized by alternating between extremes of idealization and devaluation.
● Identity disturbance, manifested in markedly and persistently unstable self-image or sense of self.
● Impulsivity manifested in potentially self-damaging behaviours (e.g., risky sexual behaviour, reckless driving, excessive alcohol or substance use, binge eating).
● Recurrent episodes of self-harm (e.g., suicide attempts or gestures, self-mutilation).
● Emotional instability due to marked reactivity of mood. Fluctuations of mood may be triggered either internally (e.g., by one’s own thoughts) or by external events. As a consequence, the individual experiences intense dysphoric mood states, which typically last for a few hours but may last for up to several days.
● Chronic feelings of emptiness.
● Inappropriate intense anger or difficulty controlling anger manifested in frequent displays of temper (e.g., yelling or screaming, throwing or breaking things, getting into physical fights).
● Transient dissociative symptoms or psychotic-like features (e.g., brief hallucinations, paranoia) in situations of high affective arousal.
Other manifestations of Borderline pattern, not all of which may be present in a given individual at a given time, include the following:
● A view of the self as inadequate, bad, guilty, disgusting, and contemptible.
● An experience of the self as profoundly different and isolated from other people; a painful sense of alienation and pervasive loneliness.
● Proneness to rejection hypersensitivity; problems in establishing and maintaining consistent and appropriate levels of trust in interpersonal relationships; frequent misinterpretation of social signals.
Application of the ICD-11 model in clinical practice
Classification of personality disorder severity replaces comorbidity
The option of coding subthreshold personality difficulty
Personality trait qualifiers
Borderline pattern qualifier
Onset and stability of personality disorder
Features of psychoticism and level of severity
How to operationalize the ICD-11 personality disorder diagnosis?
ICD-11 Severity of Personality Dysfunction
DSM-5 Criterion A: Level of Personality Functioning
0) No impairment (Healthy Functioning)
1) Some impairment
Mild Personality Disorder
2) Moderate impairment
Moderate Personality Disorder
3) Severe impairment
Severe Personality Disorder
4) Extreme impairment
ICD-11 Trait Domain Qualifiers
DSM-5 Criterion B: Trait Domains
[Rigid Perfectionism and Perseveration]a
Specific ICD-11 Trait Features
Mistrustfulness, anger, bitterness, tendency to hold grudges; may become overwrought over real or perceived slights or insults from others.
Emotional and interpersonal distance; avoidance of close friendships.
Do not enjoy intimacy or social interactions and are not particularly interested in sexual relations; aloofness, emotional unexpressiveness, non-reactive to negative and positive events, with a limited capacity for enjoyment.
low Negative Affectivity
Absence of emotional intensity and sensitivity.
Lack of empathy including callous, deceptive, manipulative, exploiting, mean, ruthless, and physically aggressive behavior, and may sometimes take pleasure in inflicting pain or harm.
Impulsivity, irresponsibility, recklessness, and lack of planning without regard for risks or consequences.
low Negative Affectivity
Absence of vulnerability, shame, and anxiety.
F60.3 Emotionally unstable
Poor emotion regulation including being overreactive to criticism, problems, and setbacks; low frustration tolerance; often experiencing and displaying multiple emotions simultaneously or vacillate among a range of emotions in a short period of time. Once upset, it is difficult to regain composure.
Impulsivity associated with e.g., substance use, unplanned sexual activity, and sometimes deliberate self-harm; lack of planning.
Sometimes being mean and physically aggressive.
Expectation of others’ admiration and attention-seeking behaviours to ensure being the center of others’ focus.
Easily distracted by extraneous stimuli, such as others’ conversations and tend to scan the environment for more enjoyable options. Acts rashly based on whatever is attractive at the moment. Focus on immediate feelings and sensations.
Emotional lability including being overreactive to external events; often experiences and displays multiple emotions simultaneously.
Reversed emotional and social detachment including avoidance of social interactions, limited emotional expression and experience.
Perfectionism including hyper-scheduling, planfulness, orderliness, and neatness. Behavioral constraint including control over emotional expression, stubbornness, risk-avoidance, perseveration, and deliberativeness.
Reversed irresponsibility, lack of Planning, and impulsivity.
Worry, anxiety, and negativistic attitudes involving rejection of other’s suggestions or advice.
F60.6 Anxious (avoidant)
Anxiety, vulnerability, fear, shame, and low self-esteem/confidence including avoidance of situations and activities that are judged too difficult.
Avoidance of social interactions and intimacy, seek out employment that does not involve interactions with others, and even refuse promotions if it would entail more interaction with others.
Reversed self-centeredness: attention-seeking behaviours to ensure being the center of others’ focus; believing that one has have many admirable qualities, that one’s accomplishments are outstanding, that one will achieve greatness, and that others should admire one.
Anxiety, vulnerability, and low self-confidence including dependency, which may be manifested in frequent reliance on others for advice, direction, and other kinds of help.
Excessive prosocial behavior and absence of self-centeredness: lack of concern about own needs, desires, and comfort, while those of others are overly considered.
F60.8 Other: Narcissistic
Grandiosity, a sense of entitlement, believing that they have many admirable qualities, that they have or will achieve greatness, and that others should admire them.
Dysregulated self-esteem, which may involve envy of others’ abilities and indicators of success; the individual can become overwrought over real or perceived slights or insults.