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The WHO’s ICD-11 “Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders“, the latest revision, building on ICD-10, has introduced rigorous requirements for personality disorder diagnosis.

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The clinical aims of ICD-11 are conspicuously about improving diagnostic accuracy, enhancing clinical utility, facilitating research, and distinguishing from other mental disorders. Though not explicity stated in ICD-11 the significantly different approach, seems to recognise the reality that receiving a personality disorder diagnosis can have significant negative consequences for an individual such as serious stigma, additional social disadvantages and the potential for such a diagnosis to last a lifetime. See also Fathoming personality disorder.

1. Stigma: Society often associates personality disorders with negative stereotypes, such as being manipulative, difficult, or untreatable. This stigma can lead to discrimination, social exclusion, and reduced opportunities in various areas of life, including employment, housing, and relationships.
2. Self-stigma: Individuals diagnosed with a personality disorder may internalise the negative stereotypes, leading to feelings of shame, hopelessness, and a negative self-image. This self-stigma can hinder their recovery and make it harder to seek help.
3. Lifelong label: Personality disorders are often viewed as enduring and stable patterns of behaviour, which can lead to the assumption that they are unchangeable. This perception may cause individuals to feel trapped by their diagnosis and can discourage them from seeking treatment or believing in their ability to change.
4. Limited access to treatment: The stigma surrounding personality disorders may lead to limited resources and funding for specialised treatment programs. This can make it difficult for individuals to access the care they need to manage their symptoms and improve their quality of life.
5. Misunderstanding among professionals: Some mental health professionals may hold negative views about personality disorders, which can impact the quality of care provided. This can lead to a lack of empathy, patience, and understanding in the therapeutic relationship.
6. Overshadowing other mental health concerns: The presence of a personality disorder diagnosis may overshadow other mental health issues, leading to inadequate treatment of co-occurring conditions such as depression, or neurodevelopmental disorders.

While ICD-11 has made efforts to improve the diagnostic process and reduce stigma, it is essential to acknowledge the ongoing challenges faced by individuals with personality disorders. Addressing these issues will require continued efforts to educate the public, challenge stereotypes, and promote compassionate, evidence-based treatment approaches. It is also vital to empower individuals with personality disorders by providing support, resources, and hope for recovery. See: Fundamentals of psychiatric diagnosis.

Different and similar approaches

Based on the comparison between the ICD-10 and ICD-11 diagnostic criteria for personality disorders, there are a few significant departures in the ICD-11 approach:

In summary, the ICD-11 adopts a more dimensional approach emphasising severity and core personality disturbances, with less focus on specific personality disorder types compared to the more categorical approach of the ICD-10. However, many of the essential features of personality disorders are retained across both systems.

Personality difficulty

The inclusion of “Personality Difficulty” in ICD-11 is a unique addition that sets it apart from ICD-10 and other diagnostic systems. This concept recognises that individuals may have significant personality-related issues that do not meet the full diagnostic criteria for a personality disorder but still cause distress or impairment in certain areas of life.

Key aspects of Personality Difficulty in ICD-11:

1. Not considered a mental disorder, but rather a problem associated with interpersonal interactions
2. Characterised by longstanding difficulties (at least 2 years) in experiencing and thinking about the self, others, and the world
3. Manifested intermittently or at low intensity, unlike the pervasive nature of personality disorders
4. Associated with some problems in functioning, but not severe enough to cause notable disruption across multiple domains
5. May be limited to specific relationships or situations

The inclusion of this category acknowledges the dimensional nature of personality characteristics and provides a way to recognise and address personality-related issues that fall below the threshold for a disorder. This approach may help in identifying individuals who could benefit from interventions or support without unnecessarily pathologising their experiences.

Moreover, by placing Personality Difficulty in the chapter on factors influencing health status or contact with health services, ICD-11 emphasises the potential impact of these characteristics on treatment outcomes and healthcare utilisation, even if they don’t constitute a formal psychiatric diagnosis.

Aspect	ICD-10	ICD-11
Core Features	Focuses more on specific behavioural patterns and traits	Emphasises disturbances in self-functioning (identity, self-worth, self-direction) and interpersonal dysfunction (empathy, intimacy, cooperativeness)
General Approach	More categorical, focusing on specific disorder types	More dimensional, emphasising severity and core personality disturbances. The inclusion of Personality Difficulty – not as a diagnosis – is unique.
Severity Levels	No severity levels specified	Introduces mild, moderate, and severe levels based on the extent of disturbances in self and interpersonal functioning
Temporal Stability and Pervasiveness	Not explicitly required	Requires personality disturbance to be “relatively stable across time and consistent across situations”
Specific Personality Disorder Types	Treats specific types (e.g., paranoid, schizoid, dissocial) as separate disorders	Retains specific types as optional specifiers that can be applied to the overall personality disorder diagnosis
Borderline Pattern Qualifier	Not present	Includes a borderline pattern qualifier that can be applied to personality disorder
“Other Specific Personality Disorders” Category	Includes examples like eccentric, “haltlose” type, immature, etc.	Does not include these subtypes
Diagnostic Threshold	Presence of specific behavioural patterns and traits	Presence of disturbances in self and interpersonal functioning, along with other criteria
Exclusion Criteria	Specifies that the disorder should not be attributable to another mental disorder, substance use, or general medical condition	Similar exclusion criteria, with the addition of requiring that the disturbance is not better accounted for by developmental stage or socio-cultural environment

General diagnostic requirements

ICD-11 maintains a similar approach to ICD-10, where the general criteria must be met before subtyping. This means that psychatric practice where ‘EUPD’ was plucked out of a hat without clinically addressing evidence for the general criteria being satisfied, is frankly slipshod.

Here are the general requirements – important words are in bold type.

1. An enduring disturbance 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) is required for diagnosis.
2. The disturbance has persisted over an extended period of time (e.g. lasting 2 years or more).
3. The disturbance is manifested in patterns of cognition, emotional experience, emotional expression and behaviour that are maladaptive (e.g. inflexible or poorly regulated).
4. The disturbance is manifested across a range of personal and social situations (i.e. is not limited to specific relationships or social roles), although it may be consistently evoked by particular types of circumstances and not others.
5. The symptoms are not due to the direct effects of a medication or substance, including withdrawal effects, and are not better accounted for by another mental disorder, a disease of the nervous system or another medical condition.
6. The disturbance is associated with substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
7. Personality disorder should not be diagnosed if the patterns of behaviour characterising the personality disturbance are developmentally appropriate (e.g. problems related to establishing an independent self-identity during adolescence) or can be explained primarily by social or cultural factors, including sociopolitical conflict.

Subtypes

ICD-11 is not occupied with subtyping people into EUPD, paranoid and other subtypes. The approach is significantly different in subtyping by severity first.

Comparison by theme

Theme	Mild	Moderate	Severe
Extent of disturbances in self-functioning	Affect some areas of self-functioning, but not others, or are of mild severity	Affect multiple areas of self-functioning and are of moderate severity	Severe disturbances in multiple areas of self-functioning (e.g., unstable sense of self, rigid behaviour, grandiose self-view)
Interpersonal functioning	Problems in many interpersonal relationships, but some relationships are maintained	Marked problems in most interpersonal relationships (conflict, avoidance, withdrawal, or extreme dependency)	Problems seriously affect virtually all relationships; ability and willingness to perform social roles severely compromised
Severity of specific manifestations	Generally of mild severity	Generally of moderate severity	Severe and affect most, if not all, areas of personality functioning
Harm to self or others	Typically not associated with substantial harm	Sometimes associated with harm	Often associated with harm
Extent of impairment in functioning	May be substantial distress or impairment, but limited to circumscribed areas or milder severity	Associated with marked impairment, although functioning in circumscribed areas may be maintained	Associated with severe impairment in all or nearly all areas of life

This table clearly illustrates how the severity of personality disorders progresses across the common themes, making it easier to differentiate between mild, moderate, and severe subtypes based on the extent, severity, and impact of the disturbances in various areas of functioning.

Specifiers: A conceptual transition from ICD-10 to ICD-11

ICD-10 goes from general criteria more quickly into specific subtypes (paranoid, narcissistic etc), with no categorisation into mild, moderate and severe like in ICD-11. In order to understand how the specifiers approximate categories in ICD-10, it is important to distinguish between the specifiers in ICD-11.

The table below allows for a quick but probably imperfect comparison of the key features associated with each of the ICD-11 personality disorder specifiers across various domains of functioning. By highlighting these themes, newcomers can better grasp the core characteristics of each specifier and how they might manifest in an individual’s emotional experiences, interpersonal relationships, self-concept, cognitive patterns, and behavioural tendencies.

Themes	Negative Affectivity	Detachment	Dissociality	Disinhibition	Anankastia
Emotional Experience	Intense, unstable emotions; anxiety, depression, worry	Emotional coldness, limited capacity for pleasure	Lack of empathy, callousness	Impulsivity, recklessness	Emotional restraint, perfectionism
Interpersonal Style	Dependency, avoidance of abandonment	Social withdrawal, limited desire for close relationships	Exploitation, manipulation, aggression	Irresponsibility, disregard for consequences	Rigid control, stubborn, inflexible
Self-Concept	Fragile self-esteem, self-criticism	Detached from self and others	Grandiosity, entitlement	Lack of self-reflection, blaming others	Perfectionism, fear of failure
Cognitive Patterns	Ruminative, catastrophic thinking	Constricted, limited fantasy life	Suspicious, paranoid ideation	Lack of planning, distractible	Preoccupied with order, details, rules
Behavioural Patterns	Reactive, self-damaging behaviours	Withdrawn, isolated	Violates norms, antisocial behaviours	Impulsive, risky behaviours	Rigid adherence to routines, compulsions
Related ICD-10 Subtypes	Borderline, Avoidant, Dependent	Schizoid, Avoidant	Antisocial, Narcissistic	Borderline, Histrionic	Obsessive-Compulsive

The bottom row of the table links each specifier to related ICD-10 subtypes, the table helps bridge the gap between the two diagnostic systems and provides a frame of reference for those more familiar with the ICD-10 categories.

It is important to note that this table is a simplified representation and may not capture the full complexity and heterogeneity of personality disturbances. However, it can serve as a useful starting point for understanding the ICD-11 specifiers and guiding further exploration and discussion of these dimensions of personality functioning.

As mentioned in the ICD-11 guidelines: “As many trait domain specifiers may be applied as necessary to describe the characteristics of the individual’s personality that are most prominent and that contribute to personality disturbance. Individuals with more severe personality disturbance tend to have a greater number of prominent trait domains. However, a person may have a severe personality disorder and manifest only one prominent trait domain (e.g., detachment).”

For example, an individual could be diagnosed with:

• Mild personality disorder with negative affectivity and anankastia
• Moderate personality disorder with dissociality and disinhibition
• Severe personality disorder with detachment, negative affectivity, and disinhibition

The ability to combine multiple specifiers helps capture the unique profile of an individual’s personality disturbance and provides a more nuanced understanding of their specific challenges and treatment needs. This is in contrast to the ICD-10 approach, which focused on single, distinct subtypes of personality disorders.

However, it is essential for clinicians to exercise caution and clinical judgment when applying multiple specifiers to ensure that the diagnosis remains clear, concise, and clinically meaningful. The use of multiple specifiers should be based on a thorough assessment of the individual’s personality functioning and should not result in an overly complex or cumbersome diagnosis that loses its practical utility.

Closing summary

ICD-11 makes some significant departures from ICD-10. In doing so it recognises that personality disorder is not a diagnosis to be taken lightly. At the outset it was recognised that receiving a personality disorder diagnosis can have significant negative consequences for an individual: serious stigma, additional social disadvantages and the potential for such a diagnosis to last a lifetime.

This exploration focused on the key differences and similarities between the ICD-10 and ICD-11 diagnostic guidelines for personality disorders. The ICD-11 introduces a more dimensional approach, emphasising the severity of disturbances in self and interpersonal functioning, while the ICD-10 primarily focuses on specific behavioural patterns and traits. The ICD-11 also includes severity levels (mild, moderate, severe) and requires the personality disturbance to be relatively stable across time and situations, which are not explicitly mentioned in the ICD-10.

Another significant difference is that the ICD-11 treats specific personality disorder types as optional specifiers rather than separate disorders, and introduces a borderline pattern qualifier. The ICD-10, on the other hand, includes a category for “Other Specific Personality Disorders” with examples like eccentric, “haltlose” type, and immature, which are not present in the ICD-11.

Despite these differences, both systems share similar exclusion criteria, requiring that the disturbance is not attributable to another mental disorder, substance use, or general medical condition. However, the ICD-11 adds that the disturbance should not be better accounted for by developmental stage or socio-cultural environment.

A unique aspect of the ICD-11 is the inclusion of “Personality Difficulty,” which refers to pronounced personality characteristics that may affect treatment or health services but do not meet the threshold for a personality disorder. This concept acknowledges the dimensional nature of personality and provides a way to address personality-related issues that cause distress or impairment in specific areas of life without necessarily labelling them as disorders.