Practical Implications of ICD-11 Personality Disorder Classifications PDF

Pan and Wang BMC Psychiatry (2024) 24:191 BMC Psychiatry https://doi.org/10.1186/s12888-024-05640-3 REVIEW...

Pan and Wang BMC Psychiatry (2024) 24:191 BMC Psychiatry https://doi.org/10.1186/s12888-024-05640-3 REVIEW Open Access Practical implications of ICD-11 personality disorder classifications Bing Pan1 and Wei Wang2* Abstract Personality disorders (PDs) are associated with an inferior quality of life, poor health, and premature mortality, leading to heavy clinical, familial, and societal burdens. The International Classification of Diseases-11 (ICD-11) makes a thorough, dramatic paradigm shift from the categorical to dimensional diagnosis of PD and expands the application into adolescence. We have reviewed the recent literature on practical implications, and severity and trait measures of ICD-11 defined PDs, by comparing with the alternative model of personality disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), by mentioning the relevance in forensic and social concerns, and by referencing the developmental implication of life span, especially in adolescence. Study results strongly support the dimensional utility of ICD-11 PD diagnosis and application in adolescence which warrants early detection and intervention. More evidence-based research is needed along the ICD-11 PD application, such as its social relevance, measurement simplification, and longitudinal design of lifespan observation and treatment. Keywords Dimensional diagnosis, DSM-5, ICD-11, Personality disorder assessment, Personality disorder in adolescence Introduction and 1.6 years shorter for women as compared to patients Personality disorders (PDs) are associated with sev- with depression only. eral areas of human daily functioning, such as affectiv- In general population, PDs are prevalent as high as ity, impulse control, perception, thinking patterns, and 12.16% in Western countries and 4.1% in Asia. reaction to stress factors. These disorders impose The borderline PD itself affects approximately 0.7–2.7% noticeable clinical, familial, and societal burdens [2, 3]. of the American adults. In clinics, the overall rate Moreover, PDs have high comorbidity with other mental of PDs in psychiatric patients was reported to be about disorders, influencing outcomes [4, 5], and they increase 46–58% , and the estimated meta-analytic PD preva- the treatment difficulties of chronic psychosomatic dis- lence rates of suicide attempts and self-harm were 35% orders. The life expectancy for patients with PDs and and 22% respectively in hospital emergency departments comorbid depression is at least 1.5 years shorter for men. On the other hand, the missed diagnosis of PDs has serious consequences, such as suicide risk, impairment in social functioning, burden of health-related suffering, *Correspondence: and loss of productivity. Wei Wang [email protected]; [email protected] Additional challenges in addressing PDs involve tack- 1 Department of Psychiatry, Second Affiliated Hospital, Zhejiang University ling stigma and promoting early detection. The diagnosis School of Medicine, Zhejiang University, Hangzhou, China of PDs is associated with a particular stigma, even among 2 Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway clinical staff. These negative attitudes towards PD © The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Pan and Wang BMC Psychiatry (2024) 24:191 Page 2 of 11 have adversely impacted the provision of healthcare ser- planning, comprehensive assessment, effective commu- vices. Therefore, there is a reluctance to diagnose nication with patients, and simplified applicability. PDs in younger age groups in the categorical classifica- tion systems. These systems have been criticized Major concerns in ICD-11-based diagnoses for the lack of continuity between normal and abnormal Regarding the diagnostic considerations, both ICD- personalities, high heterogeneity within PD categories, 11 and the Diagnostic and Statistical Manual of Mental high PD comorbidity, high prevalence of PDs not other- Disorders-the 5th edition (DSM-5) section III (the alter- wise specified, and restricted clinical ability to predict the native model, DSM-5-AMPD) are dimensional. The treatment outcomes. More seriously, the reluctance ICD-11 has eliminated all traditional PDs except border- of PD diagnosis in younger age groups increases the risk line, a departure from the International Classification of of fatal outcomes. Diseases-10 (ICD-10) and has aligned more closely with Therefore, the precise diagnosis and early detection of the personality disorders in DSM-5-AMPD. PDs warrant more logical, practical systems. The dimen- In the ICD-11, clinicians are initially advised to deter- sional systems are primarily rooted in a global sever- mine whether individuals meet the general diagnos- ity dimension, partially encompassing personality traits tic requirements of PDs, followed by evaluating the PD inherent in PDs. These normal and disordered traits severity (mild, moderate, or severe) based on the impair- form a continuum across the lifespan. Maladap- ment of self and interpersonal functions. Furthermore, a tive PD traits, such as neuroticism and psychopathy, distinct delineation of five stylistic traits, namely Nega- may contribute to enhanced survival, successful mating, tive Affectivity, Detachment, Disinhibition, Dissociality or reproduction in humankind. Although these traits and Anankastia, needs to be identified. The ICD-11 may undermine essential biological objectives, they can trait descriptors can be applied to characterize the per- concurrently support others, potentially reducing the sonality features of individuals presenting with PD or competition for finite resources. The International personality difficulty, thereby aiding in maintaining diag- Classification of Diseases-11 (ICD-11) has undergone a nostic continuity. Moreover, the retention of the border- significant paradigm shift, moving away from traditional line pattern aims to facilitate a smoother transition from categorical descriptions of PDs to embrace dimensional ICD-10 to ICD-11 and to assist in identifying individuals perspectives. Moreover, the adoption of a life-span who may be responsive to psychotherapy. perspective on mental disorders aims to facilitate the Preceding the introduction of ICD-11, the DSM-5- diagnosis of PDs in young individuals. This shift not AMPD incorporated the assessment of impairment in only improves the clinical utility and global applicability self and interpersonal functioning, along with a distinct of diagnostic criteria, but also aids in better treatment characterization of 25 stylistic traits organized under five domains (Negative Affectivity, Detachment, Antagonism, Table 1 Comparisons of DSM-5 and ICD-11 models regarding Disinhibition and Psychoticism). Versus the ICD-11 personality disorder functioning type and impairment severity* purely dimensional model, the DSM-5-AMPD is a hybrid Items DSM-5 alternative model ICD-11 model dimensional-categorical model. In contrast to previous Personality 0 No impairment None DSM versions (e.g., DSM-IV, texted revision, etc.), the dysfunction 1 Some impairment Personality difficulty DSM-5-AMPD incorporates the six individual PD types 2 Moderate impairment Mild personality (antisocial, avoidant, borderline, narcissistic, obsessive- disorder 3 Severe impairment Moderate personal- compulsive, and schizotypal PD), and eliminates the ity disorder subclassification of “personality disorders not otherwise 4 Extreme impairment Severe personality specified” Table 1. disorder Both ICD-11 and DSM-5-AMPD dimensional models Trait domain Negative affectivity Negative affectivity are primarily derived from psychodynamic frameworks Detachment Detachment such as Kernberg’s model and the object relational Disinhibition Disinhibition models. Each of 10 categorical PD types (DSM-5 Antagonism Dissociality domains, criterion count and binary diagnoses) can be (rigid perfectionism) Anankastia generally predicted by the ICD-11 and DSM-5-AMPD Psychoticism (Schizotypal Table 2. Prior research has presented evidence of disorder) scale loadings on five personality traits. Both ICD- Specific type Six (Antisocial, Avoidant, Borderline pattern 11 and DSM-5-AMPD are connected to the big five per- Borderline, Narcissistic, specifier Obsessive-Compulsive, sonality traits, and in ICD-11, there exists a bipolar factor Schizotypal) personality disor- encompassing anankastia-disinhibition along the consci- der of Trait-Specified. entiousness dimension [29, 30] (Fig. 1). Note *, after Mulder, 2021 Pan and Wang BMC Psychiatry (2024) 24:191 Page 3 of 11 Table 2 Categorical to dimensional cross-walk with personality conceptualization of the fifth dimension: anankastia in disorder domains in DSM-5 and ICD-11 models* ICD-11 versus psychoticism in DSM-5. ICD-11 has elim- Personality disorder DSM-5 domain ICD-11 domain inated the psychoticism trait due to its features different type from PDs. It fails to map the normal traits under the Cluster A five-factor personality model, while it is incorporated Paranoid Detachment Detachment with the antisocial PD. Anankastia, as conceptual- Negative Affectivity Negative Affectivity ized in ICD-11, is closely associated with perfectionism. Antagonism Dissociality Schizoid Detachment Detachment This trait manifests as a rigid adherence to norms and Low Negative Low Negative obligations, featuring emotional and behavioral con- Affectivity Affectivity straints, such as inflexible control and perseveration. The Schizotypal Psychoticism [Schizotypal DSM-5 trait facets corresponding to anankastia include Disorder] rigid perfectionism and preservation, originating from Detachment Detachment the low Disinhibition and Negative Affective domains - (Anankastia) respectively. Anankastia encompasses essential fea- Cluster B tures of obsessive-compulsive PD and certain aspects of Antisocial Antagonism Dissociality narcissistic (e.g., narcissistic perfectionism) and avoidant Disinhibition Disinhibition (e.g., risk aversion and overconcern) PDs. However, the Low Negative Low Negative negative associations with Disinhibition (e.g., reversed Affectivity Affectivity Disinhibition) do not account for these features. Borderline Negative Affectivity Negative Affectivity Nevertheless, ICD-11’s anankastia exhibited satisfactory Disinhibition Disinhibition discrimination and validity across various cultures. Psychoticism -# However, both ICD-11 and DSM-5-AMPD possess Histrionic Disinhibition Disinhibition their own advantages when referring to anankastia and Negative Affectivity Negative Affectivity psychoticism. The ICD-11 provides a more comprehen- Low Detachment Low Detachment sive coverage of personality pathology compared with Antagonism Dissociality DSM-5-AMPD, notably due to the specificity and cohe- Narcissistic Antagonism Dissociality sive placement of anankastia within the overall personal- Cluster C Avoidant Negative Affectivity Negative Affectivity ity structure in contrast to psychoticism. While the Detachment Detachment ICD-11’s Anankastia considerably overlaps with DSM-5 Low Antagonism Low Dissociality obsessive-compulsive PD , its rigidity falls short of Dependent Negative Affectivity Negative Affectivity fully capturing the obsessive-compulsive PD construct Low Antagonism Low Dissociality. Bach et al. have found a similar superiority in cap- Obsessive-compulsive - Anankastia turing obsessive-compulsive PD using ICD-11, while Low Disinhibition Low Disinhibition DSM-5-AMPD excels in capturing schizotypal PD. Negative Affectivity Negative Affectivity Additionally, some case reports concentrated on the dis- Note *, after Bach et al., 2018 ; #, may potentially be elucidated using the tinction advocated by the ICD-11 in the disinhibition/ ICD-11 diagnosis of complex post-traumatic stress disorder including feature of anankastia personality domain, whereas the psychoticism dissociation personality domain is a DSM-5-AMPD conceptualized trait. The two diagnostic models are advantageous in differ- entiating PDs from other mental disorders. They can Severity of personality dysfunction also be utilized to detect the association between person- The ICD-11 categorizes PDs into five severity levels: “No ality features and patients’ readmission and mortality risk impairment, Personality Difficulty, Mild Personality Dis- [32, 33], and they are applicable to old people and order, Moderate Personality Disorder, and Severe Person- adolescents. In addition, both ICD-11 and DSM-5- ality Disorder.” The last three severity levels specifically AMPD possess advantages over the categorical system pertain to clinical disorders, while the first two do not. In in PD treatment, which is largely compatible with the contrast, DSM-5-AMPD proposes five levels of impair- Schema Therapy model. ment in personality functioning: None/ Little (0), Some (1), Moderate (2), Severe (3), and Extreme (4) Table 1. Anankastia vs. psychoticism Notably, the ICD-11 not only encompasses the self and The components of ICD-11 and DSM-5-AMPD exhibit interpersonal functioning, but also includes emotional, interrelations and align closely with specific normal per- cognitive, and behavioral manifestations. For instance, sonality traits. However, differences exist between this encompasses self-harm and psychotic-like percep- the two diagnostic systems, with a distinct arising in the tions, such as disturbances in reality testing. Pan and Wang BMC Psychiatry (2024) 24:191 Page 4 of 11 Fig. 1 Juxtaposition of ICD-11 and DSM-5 models of personality disorder domains and the five-factor model of normal personality traits (after Strus et al., 2021 ) ICD-11-related diagnostic measures strongly associated with negative affectivity compared There is no structured clinical interview for the ICD- with antagonism and anankastia. Further validation 11 model, while several self-report and clinician-rating of PDS-ICD-11 in a community mental health sample scales are existed to assess PD severity and the normal has exhibited moderate-to-large associations with all cli- and disordered personality traits. nician ratings, as well as more variable associations with self-report and informant-report measures. Mean Measures of severity scores of PDS-ICD-11 were significantly different across At present, a structured clinical interview for the ICD- all levels of ICD-11 PD clinician-rated diagnostic levels. 11 model is unavailable. However, various self-report In a Danish general population, practical thresholds of and clinician-rating scales exist for evaluating disorder 12, 16, and 19 indicated mild, moderate, and severe PD severity, and for both normal and disordered personality. An additional study of the Clinician-Rating Form traits. Long-term studies have underscored the perspec- of PDS-ICD-11 demonstrated that item-response theory tive that personality pathology is not solely a criterion- and confirmatory factor analyses support both item func- defined disorder, while is also categorized by severity. tioning and uni-dimensionality. Notably, the severity of PDs strongly determines impair- The Scales of Self and Interpersonal Dysfunction (65 ment and outcome. The Personality Disorder Sever- items) are based on the ICD-11, including six domains of ity ICD-11 (PDS-ICD-11, 14 items) has been developed self- and interpersonal dysfunctions, identity problems, to evaluate self and interpersonal dysfunctions as well as relationship difficulties, and dysfunctional engagements, emotional, cognitive, and behavioral symptoms, and psy- as well as five personality domains. The psychomet- chosocial impairments. This measure uniquely captures ric properties of the Scales are excellent, as indicated by all features of PD severity as defined in the ICD-11 model the domains and their components’ convergent and dis-. Across diverse samples, including a US commu- criminant validities. However, the Scales do not cover nity, a New Zealand mental health sample, and a Span- the emotional, cognitive, and behavioral manifestations, ish mixed sample, the PDS-ICD-11 has demonstrated nor the global psychosocial impairments. The scales are noticeable criterion validity and incremental validity in only preliminary and do not take the full ICD-11 severity predicting PD impairments. In a Spanish mixed sam- models into account. ple, the PDS-ICD-11 properties are as adequate as those Other measures originally developed for the DSM-5- original instruments. Its German version is accept- AMPD criterion A have recently been utilized to assess able in the general population, and its total score is more PD severity based on the ICD-11. For example, the Level Pan and Wang BMC Psychiatry (2024) 24:191 Page 5 of 11 Table 3 Scales based ICD-11 and DSM-5 models and Kernberg’s Table 4 Scales based on ICD-11 and DSM-5 models to measure theory of personality organization to measure personality personality disorder trait domain* disorder dysfunctional severity Measures Number of Domains Facets/items Measurement Item Components/ subscales ICD-11 numbers Personality Inven- 5 scales (Negative 60 items, 12 items per ICD-11 tory (PiCD) Affectivity, Dissociailty, domain Personality Disorder 14 Identify, self-worth, self-perception, Disinhibition, Detach- Severity ICD-11 goals, interest in relationships, ment, Anankastia) (PDS-ICD-11) disagreement management, Informant Person- 5 scales (Negative 60 items, 12 items per emotional control and expression, ality Inventory for Affectivity, Dissociailty, domain behavioral control, experience ICD-11 (IPiC) Disinhibition, Detach- of reality during stress, harm to ment, Anankastia) self, harm to others, psychosocial Five-factor Person- 5 scales (Negative 20 facets scales, 47 nu- impairments. ality Inventory for Affectivity, Dissociality, ance scales; 121 items, Scales of Self and 65 Low self-worth, low self-accuracy, ICD-11 (FFiCD) Disinhibition, Detach- 40 items for Negative Interpersonal Dys- low self-directedness, relationship ment, Anankastia) Affectivity, 22 items for function (of Clark and difficulties, and dysfunctional, Dissociality, 24 items for Colleagues) engagement Disinhibition, 13 items DSM-5 for Detachment and 22 Level of Personality 80 Identify, self- direction, empathy, items for Anankastia; Functioning Scale intimacy 2–4 nuance scales for (LPFS) each facet (except Dis- trust), Unassertiveness, Level of Personality 12 Self-functioning, interpersonal and Thrill-Seeking). 2–3 Functioning Scale - functioning, six items for each items per nuance. Brief Form (LPFS-BF) Personality Assess- 5 scales (Negative 17 items, 3–4 items per Level of Personality 80 Identity (21 items), Self-Direction ment Question- Affectivity, Dissociailty, domain Functioning Scale- (16 items), Empathy (23 items), naire for ICD-11 Disinhibition, Detach- self-report (LPFS-SR) Intimacy (20 items) (PAQ-11) ment, Anankastia) Self and Interpersonal 24 Identity, Self-Direction, Empathy, DSM-5 Functioning Scale Intimacy (SIFS) Personality Inven- 5 scales (Negative Af- 25 facets, 220 items; tory for DSM-5 fectivity, Detachment, 4–14 items per facet Semi-structured 28 Identity, Self-Direction, Empathy, (PID-5) Antagonism, Disinhibi- Interview for DSM-5 Intimacy; 12 facets (Experience tion, Psychoticism) Personality Function- of oneself as unique, self-esteem, ing (STiP5.1) emotions, goals, self-reflection, Note *, after Oltmanns, 2021 understanding others, perspectives impact, connection, closeness, mutuality) it has been utilized effectively in different cultural con- Level of Personal- 97 Identity, self-direction, empathy, texts, such as the Czech , Estonian , and German ity Functioning and intimacy versions. As a specific tool for assessing personal- Questionnaire for ity functioning in adolescence, the Levels of Personality adolescents (LoPF-Q Functioning Questionnaire 12–18 (LoPF-Q 12–18) is 12–18) available and recommended. In addition, the Inven- Kernberg’s theory of personality organization tory of Personality Organization is a self-report measure Inventory of Person- 57 Primitive Defenses (16 items), ality Organization Reality Testing (20 items), Identity which can be employed to assess three domains of per- (IPO) Diffusion (21 items) sonality organization. Table 3 of Personality Functioning Scale , the Level of Person- Measures of traits ality Functioning Scale - Brief Form , and the Level Numerous self-report instruments Table 4 have been of Personality Functioning Scale-self-report are the developed to measure the ICD-11 domains and subjected reliable measures. The Self and Interpersonal Function- to the examination of their factor structure, multimethod ing Scale is a time-efficient support for clinical decision usage, convergent and discriminant validities with other and treatment planning under the ICD-11 framework prominent, dimensional personality models (e.g., the. Other measures, such as the Semi-Structured Inter- five-factor model of normal traits), and criterion validity view for DSM-5 Personality Functioning (STiP5.1), may for important life outcomes. describe most information needed for determining PD The Personality Inventory for ICD-11 (PiCD) was severity based on the ICD-11. The STiP5.1 has been designed to assess five maladaptive traits (Negative Affec- translated into several versions and proven to be valuable tivity, Detachment, Dissocial, Disinhibition and Anankas- to evaluate personality functioning dimensions. Notably, tia) of ICD-11, involving 60 items (12 items each domain) Pan and Wang BMC Psychiatry (2024) 24:191 Page 6 of 11. Preliminary results have shown its adequate inter- reliable and valid to capture the pathological personality nal reliability, and convergent and discriminant validities traits. In Chinese and Brazilian clinical-PD sam-. PiCD has been tested in Spanish community and ples, the PID-5 has exhibited substantial deviations from clinical samples and in Italian adult samples. normative data, suggesting its potential as an instrument Results supported the single-dimensionality for the PiCD for measuring pathological personality traits in psychiat- Negative Affectivity, Detachment, and Dissocial scale ric patients. Additionally, traditional assessments, such items, as well as the bifactor model (confirmatory factor as the Minnesota Multiphasic Personality Inventory, may analysis) of PiCD Disinhibition and Anankastic items in aid clinicians in evaluating ICD-11 personality trait dys- Italian samples. All PiCD scales are significantly associ- functions. ated with the impairment in personality functioning. An informant-report version of PiCD is the Informant- Measurement of borderline pattern Personality Inventory for ICD-11 (IPiC), which facilitates A specific assessment, particularly for borderline PD, reporting from other perspectives of a target person. In the Borderline Pattern Scale, comprises 12 items and older adults, IPiC and PiCD have exhibited a moderate has demonstrated commendable internal consistency self-other agreement, which is associated with several and convergent validity. This scale evaluates the important life functioning areas, and they have structural four components characterizing the borderline pattern: validity at the item level. Affective Instability, Maladaptive Self-Functioning, Mal- The Personality Assessment Questionnaire for ICD- adaptive Interpersonal-Functioning, and Maladaptive 11 personality trait domains (PAQ-11) was developed Regulation Strategies. Moreover, it exhibits satisfactory in South Korea for a rapid measurement by clinicians internal consistency and convergent validity, as evidenced and researchers, exhibiting adequate convergent and by its correlation with four established measures: the discriminant validities with the five-factor model, the borderline scales from the Schedule for Nonadaptive and DSM-5 trait model and emotional difficulties. When Adaptive Personality , the Coolidge Axis II Inventory PAQ-11 is applied to a sample from a U.S. community, , the Wisconsin Personality Disorders Inventory , the findings encompass 4 out of 5 ICD-11 trait domains, and the Five Factor Borderline Inventory. namely Negative Affectivity, Detachment, Disinhibition and Anankastia. Additionally, the results prompt inqui- Diverse applications of ICD-11 ries regarding the structural reliability of the Dissociality An investigation conducted on a Kurdistan community scale and the discriminant validity of the Disinhibition and clinical sample (N = 3196) has revealed that and Anankastia scales. the ICD-11 PD trait model exhibited a better fit for the A recently proposed alternative measure to PiCD, aim- Kurdish population compared to the DSM-5-AMPD ing to provide a more detailed and clinically relevant trait model. In this study, the trait domains were opera- depiction of personality traits, is the Five-Factor Person- tionalized using empirically supported algorithms for ality Inventory for ICD-11 (FFiCD). Comprising 121 PID-5, and Structural validity was determined through items and 20 facets, the FFiCD functions as a self-report Exploratory Factor Analysis. The findings from Kurd- tool, concentrating ICD-11 maladaptive traits at the facet istan demonstrated that the model fit and the expected level, with 47 short scales situated under the facets, pro- factor structure were deemed appropriate for the ICD-11 viding a nuanced perspective. In a Spanish community trait model, whereas they were less adequate for DSM-5 sample, the FFiCD has demonstrated strong internal con- (specifically, disinhibition did not emerge as a sepa- structs and exhibited high correlations with other scales rate factor). Significant differences were observed in all measuring personality functioning. Other scholars domain and facet scores between clinical and commu- have proposed that the Revised NEO Personality Inven- nity subsamples, with notable variations for disinhibition tory and the Short-form of the Zuckerman-Kuhlman- and dissociality/ antagonism, and comparatively less for Aluja Personality Questionnaire may be complementary anankastia. Hemmati et al. thus suggest that the ICD- to PD measures or FFiCD [70, 71]. 11 trait model is more cross-culturally fitting than the The self-report Personality Inventory for DSM-5 DSM-5 AMPD trait model. Moreover, clinical and com- (PID-5), involving 220 items, 25 traits facets, and five munity samples from Brazil, Canada, China, Denmark, higher traits, can also be utilized to capture ICD-11 Korea, Spain, and the USA generally support the ICD-11 trait domains. To compute the ICD-11 domains, an trait domains [38, 83]. algorithm based on the 16 PID-5 facet scales has been Furthermore, ICD-11 has demonstrated its high developed. Both the 16 PID-5 facets in an Iranian acceptability and practicability in some cultures, between community sample and the expanded 18 PID-5 fac- clinicians and patients or within patients’ families. The ets (including Suspiciousness and Attention Seeking) in rationale lies in the ICD-11 approach, emphasizing a Canadian psychiatric sample have proven to be traits and severity over diagnostic labels. For example, Pan and Wang BMC Psychiatry (2024) 24:191 Page 7 of 11 discussing a patient’s capacity to maintain a consistently and other seriously destabilizing behaviors, thus they positive and stable sense of self-worth, and unraveling may apply the comprehensive DBT including the individ- this in terms of traits, such as self-centeredness and self- ual therapy, skills class, phone coaching, and consultation esteem, proves more straightforward than assigning a team action. potentially stigmatizing label-like “notorious” narcissism Psychotherapies can also be tailored based on the to that patient. Furthermore, findings from a survey prominent trait domains. For patients exhibiting nega- involving 163 mental health professionals in the Zealand tive affectivity, therapies may aim to regulate anxiety, region of Denmark indicated that the ICD-11 PD frame- sadness, and other emotional variations. This involves work is generally acceptable in terms of utility. Clini- helping patients to develop tolerance to distress, fos- cians perceive it as comprehensive and user-friendly for tering self-compassion, enhancing mentalization, pro- describing global personality traits, irrespective of their moting acceptance of negative emotions, and acquiring educational background and professional experience, stress management skills. Furthermore, research suggests especially compared with the ICD-10 framework. In that for individuals with PDs featuring blends of trait a further clinical comparative study conducted in New domains, treatment targeting prominent facets proves to Zealand (Aotearoa) regarding clinicians’ perspectives on be beneficial. the utility of the ICD-11 PD diagnosis, the ICD-11 sys- tem received higher ratings than the DSM-5 PD types Forensic and other settings across all six clinical metrics. These metrics include Ease Individuals exhibiting high psychopathic traits tend to of use, Communication with professionals, and Commu- engage in more criminal activities and report a higher nication with patient, Describing all personality prob- frequency of arrests. Moreover, severe PDs are nota- lems, Formulation of treatment planning, and Describing bly prevalent among those involved in homicides. global personality. The ICD-11 framework facilitates the early identification of individuals at risk of developing severe PDs, enabling Treatment and social issues the implantation of timely and appropriate preventive Treatment decision-making interventions. A significant legal development in the According to the ICD-11, scholars have developed a state of Victoria, Australia, underscores the consideration series of patient-centered measures for PD, exhibiting of PDs during sentencing for convicted offenders, high- the potential to improve making clinical decisions and lighting the greater utility of the dimensional approach treatment and enhance the healthcare standard for PD over the categorical one in forensic mental health. patients worldwide. Moreover, a community team, However, challenges in forensic practice arise from The Boston (UK) Personality Project, has suggested that potential reliability issues in assessing personality pathol- an increased awareness of personality functioning may ogy, particularly when relying on self-report question- lead to superior clinical outcomes and satisfaction for naires. Additionally, the ICD-11 diagnosis of “severe treating PDs. personality disorder, borderline pattern” may influence The overall severity of PDs serves as a valuable deci- juror attitudes by introducing considerations of dimin- sion-making tool for tailoring personalized medicine ished responsibility. and determining appropriate treatment approaches and In alternative settings, such as during the assessment intensity. This severity level is intricately linked to vari- before bariatric surgery, applying the dimensional ICD- ous aspects, including long-term prognosis, treatment 11 trait models are suitable procedures for defining per- outcomes, risk of dropout, therapeutic alliance, readi- sonality psychopathology and overall impairments of ness for treatment, risk of self-harm and violence, and patients with obesity, which often help tailor interven- susceptibility to dissociation and psychotic-like breaks. tions and improve surgical treatment outcomes. Additionally, it plays a role in the coherence of narra- tive identity, reflective functioning, and epistemic trust Developmental perspectives and implications. For example, the dialectical behavior therapy (DBT) Mounting evidence suggests that personality under- is one of the psychotherapies for personality disorders. goes changes throughout the lifespan. A meta-analysis For mild personality disorder, therapists focus mainly on study indicates that people increase in measures of social interpersonal problems and other quality-of-life issues, dominance (a facet of extraversion), conscientiousness, or the less comprehensive DBT may be considered (e.g., and emotional stability, especially in young people aged skills class and consultation team) with the possibility around 30 (20 to 40 years old); and the decline in trait of more comprehensive treatment if problems do not measures of openness to experience and agreeableness improve. While for moderate and severe personality dis- are in old age. In a comprehensive 30-year cohort orders, therapists focus primarily on reducing suicidal study employing category and severity descriptions and self-harm behaviors, therapy interfering behaviors for personality diagnosis, findings revealed that 47% of Pan and Wang BMC Psychiatry (2024) 24:191 Page 8 of 11 patients (especially those without personality distur- facilitates the early intervention and improves both bances at baseline) maintained their personality statuses, mental and physical health consequences. Notably, the 16.8% showed improvement, and 20.4% experienced a structured psychological interventions have consistently worsening to a more severe level. Notably, in patients demonstrated a significant improvement among young diagnosed with DSM-III, the frequencies of Clusters A people with borderline pattern specifiers, including the and C PDs increased from 14 to 40% over the follow- reduced self-harm and suicidal ideation [103, 104]. How- up period, underscoring the dynamic nature of PDs and ever, the available high-quality studies regarding the their varied expressions across the lifespan. Ado- effect of specialized treatments for borderline pattern lescence emerges as a sensitive period for the develop- in adolescence is limited, and efforts to translate adult ment of PDs , with clinical onset and peak prevalence borderline pattern psychotherapies to adolescents have occurring during adolescence and young adulthood. exhibited minimal success [98, 105]. An empirically epidemiological study has shown that the cumulative prevalence of PDs is about 25.7% in ages Future perspectives and conclusions around 22. The cultural feasibility, communication convenience, and Despite this, PDs in young individuals are often under- treatment implications of ICD-11 have been evident in its diagnosed or face delayed diagnosis. Only 1% of young application. However, there are several areas for poten- people attending a national primary care youth mental tial exploration with the use of ICD-11. These include health service network receive a primary diagnosis of investigating the social, family, and personal relevance of borderline PD or “borderline traits”. This contrasts reducing stigma associated with PDs, understanding the with estimates of 11–22% among outpatients and as high longitudinal significance of lifespan development related as 33–49% among inpatients. Failing to diagnose to PDs and their treatments, and exploring the easy PDs in their early stages deprives adolescents of effective applicability of PD diagnostic tools, such as the simplic- treatments and increases their risk of adverse outcomes ity of reliable questionnaires. ICD-11 underscores that later in life. PDs may change over the lifespan, emphasizing that early Nevertheless, diagnosing PDs during adolescence intervention during adolescence can enhance overall remains a subject of controversy. One crucial factor is treatment outcomes. the substantial variation in the trajectories of adoles- At present, there is no structured clinical interview cents with different personality traits as they mature specifically designed for the ICD-11 model. However,. Another contributing factor is the stigma associated alternatives include using structured clinical interviews with mental health conditions. A survey examining the for DSM-5-AMPD to map personality pathology accord- 10-year stability of PDs from adolescence to young adult- ing to the ICD-11 and considering instruments, such hood in a high-risk sample revealed a prevalence of any as the STiP-5.1. While existing instruments assessing PD at 20.0% during baseline and 30.4% at follow-up. Sig- PDs according to the ICD-11 are valuable aiding diag- nificantly increased prevalence rates were observed for noses, but they are not enough to assess the personality most PDs except for the histrionic PD. For a clinical pathology, meanwhile there is a gap in measuring treat- benefit, the earlier detection, diagnosing, and treatment ment outcomes aligned with the ICD-11 classification. of PDs is essential. Recognizing the potential for growth Addressing this gap may involve developing clinician- and temporary stability, ICD-11 permits the diagnosis rating forms, diagnostic interviews, and treatment proto- of PDs at any age if a special trait persists over two years cols and trials. These assessments or clinical control. By incorporating a continuum of severity, ranging practices hold promise for PD patients by enhancing from none to difficulty and from mild to severe, ICD-11 their diagnosis, distinguishing them from other mental moves away from specific disorders, which may contrib- disorders and comorbidities, and guiding personalized ute to a reduction of stigma associated with PDs. treatment effectively. A recent comprehensive overview has been conducted In conclusion, regarding the diagnostic and treatment on instruments designed for assessing personality func- applications, the dimensional PD approaches in ICD-11 tioning in adolescents. This review and other show promise in diagnostic and treatment applications. attempts to measure the DSM-5-AMPD styles in ado- Continuous research is essential, especially regarding lescence might provide the assessment safety and the ICD-11 implementation into clinical practice across decrease the related controversy. For example, the Cri- diverse cultures, the efficacy of personalized treatment, terion A (i.e., identity, self-direction, empathy, and inti- particularly in adolescence, the development of simplified macy) helps to assess the PD onset in adolescence, and instruments supporting diagnosis, and the design of lon- the Criterion B provides a valuable description of con- gitudinal clinical spanning different age groups (Table 5). tinuous aspects of personality function functioning over time. 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