Moderate Personality Disorder

The ICD-11 classification of personality disorders is a diagnostic framework for personality disorders (PD), introduced in the 11th revision of the ''International Classification of Diseases'' (ICD-11). This system of classification is an implementation of a dimensional model of personality disorders, meaning that individuals are assessed along continuous trait dimensions, with personality disorders reflecting extreme or maladaptive variants of traits that are continuous with normal personality functioning, and classified according to both severity of dysfunction and prominent trait domain specifiers. The ICD-11 classification of personality disorders differs substantially from the one in the previous edition, ICD-10; all distinct PDs have been merged into one: ''personality disorder'', which can be coded as ''mild'', ''moderate'', ''severe'', or ''severity unspecified''.

Severity is determined by the level of distress experienced and degree of impairment in day to day activities as a result of difficulties in aspects of self-functioning, (e.g., identity, self-worth and agency) and interpersonal relationships (e.g., desire and ability for close relationships and ability to handle conflicts), as well as behavioral, cognitive, and emotional dysfunctions. There is also an additional category called ''personality difficulty'', which can be used to describe personality traits that are problematic, but do not meet the diagnostic criteria for a PD. A personality disorder or difficulty can be specified by one or more of the following ''prominent personality traits or patterns'': Negative affectivity, Detachment, Dissociality, Disinhibition, and Anankastia. In addition to the traits, a ''Borderline pattern –'' similar in nature to borderline personality disorder – may be specified.

Background

Described as a clinical equivalent to the Big Five model, the five-trait system addresses several problems of the old category-based system. Of the ten PDs in the ICD-10, two were used with a disproportionate high frequency: emotionally unstable personality disorder, borderline type () and dissocial (antisocial) personality disorder (). Many categories overlapped, and individuals with severe disorders often met the requirements for multiple PDs, which Reed ''et al.'' described as "artificial comorbidity". PD was therefore reconceptualized in terms of a general dimension of severity, focusing on five negative personality traits which a person can have to various degrees.

There was considerable debate regarding this new dimensional model, with many believing that categorical diagnosing should not be abandoned. In particular, there was disagreement about the status of borderline personality disorder. Geoffrey Reed wrote: "Some research suggests that borderline PD is not an independently valid category, but rather a heterogeneous marker for PD severity. Other researchers view borderline PD as a valid and distinct clinical entity, and claim that 50 years of research support the validity of the category. Many – though by no means all – clinicians appear to be aligned with the latter position. In the absence of more definitive data, there seemed to be little hope of accommodating these opposing views. However, the WHO took seriously the concerns being expressed that access to services for patients with borderline PD, which has increasingly been achieved in some countries based on arguments of treatment efficacy, might be seriously undermined." Thus, the WHO believed the inclusion of a borderline pattern category to be a "pragmatic compromise".

The Alternative DSM-5 Model for Personality Disorders (AMPD) included near the end of the DSM-5 is similar to the PD-system of the ICD-11. It was considered for inclusion in the ICD-11, but the WHO decided against it because it was considered "too complicated for implementation in most clinical settings around the world", since an explicit aim of the WHO was to develop a simple and efficient method that could also be used in low-resource settings.

Diagnoses

Personality disorder

Personality disorder () can be coded as mild, moderate, severe, or severity unspecified (). There is also an additional category called personality difficulty, which can be used to describe personality traits that are problematic, but do not rise to the level of a PD.

Mild personality disorder

In ''mild personality disorder'' (), only some areas of personality function are affected. For example, a person might have difficulty making decisions or deciding on the direction of their career yet have a strong sense of self-worth and identity. Problems in many interpersonal relationships or in the performance of social and occupational roles are evident but some relationships are maintained or social roles carried out. The manifestations of a person’s difficulties are generally mild and not typically associated with harm to the self or others. For example, they may struggle to recover from minor setbacks or criticisms when stressed or they may distort how they perceive situations or other people’s motives without losing total contact with reality. Whilst the personality disturbance may be mild, the person may still experience substantial distress and impairment. The distress and impairment are limited to a narrower range of functioning or, if the difficulties are across many areas, the difficulties are less intense.

Moderate personality disorder

For ''moderate personality disorder'' (), disturbance affects multiple areas of personality functioning such as identity, sense of self, formation and maintenance of intimate relationships, capacity to control and moderate behaviour. Despite these difficulties, some areas of functioning may be relatively less affected. Occasionally moderate personality disorder will be associated with harm to self or others. When this is present, typically, it will be of moderate severity.

Severe personality disorder

People with ''severe personality disorder'' () have major disturbances in their sense of self functioning. For example, they may have no sense of who they are, experience intense numbness or report that what they believe and think changes dramatically from one context to another. Some individuals may have a very rigid view of themselves and the world and have very regimented routines and approaches to situations. A person’s sense of self may be grandiose or highly eccentric or characterized by disgust and self-contempt.

Virtually all relationships in all contexts are adversely affected. Often relationships are very one-sided, unstable or highly conflictual. There may even be a degree of physical violence. Family relationships are likely to be severely limited or highly conflictual. The person’s ability, and sometimes willingness, to fulfil social and occupational roles is severely impaired. So, for example, a person may be unwilling or unable to sustain regular work as a result of lack of interest, or effort, or poor performance. Alternatively, the poor work performance may derive from interpersonal difficulties or inappropriate behaviour such as angry outbursts or insubordination. Severe personality disorder is often associated with harm to the person or other people. Severe impairment is evident in all areas of the person’s life.

Personality difficulty

In addition to the PD diagnosis (at least “Mild Personality Disorder”), there is an option to assign a sub-diagnostic code for the presence of ''Personality Difficulty'' (). Personality Difficulty is not a disorder per se, but is available as a code to inform treatment and preventive care, and is located in the section of the ICD-11 classification for non-disease entities that constitute factors influencing health status and encounters with health services. Thus, Personality Difficulty can be compared to the ICD-10 non-disorder codes for “accentuation of personality traits” () or “borderline intellectual functioning” ().

This code may typically be used in cases where there is an issue with personality that must be addressed (e.g., perfectionism or anxiousness) or to recognize that a patient, who has undergone successful treatment of a PD, still has some residual features of the personality disturbance, which other health professionals should pay attention to. In contrast to a Personality Disorder diagnosis, Personality Difficulty is typically less complex and only limited to specific situations or relationships. Problems typically occur with less intensity or are only expressed intermittently (e.g., during times of stress and pressure).

Prominent personality traits or patterns

The ICD-11 uses five trait domains – listed as ''Prominent personality traits or patterns'' () – for specification of pathological traits within the clinical picture of a ''personality disorder'' or ''personality difficulty'' diagnosis:
# Negative affectivity () – including inappropriate anger, crying, anxiety, remorse, dependent attachment styles, negativistic attitudes, suicidal ideation, mistrustfulness, worthlessness, low self-esteem, and emotional instability
# Detachment () – including social detachment and emotional coldness
# Dissociality () – including superior grandiosity, egocentricity, callousness, deception, exploitativeness and aggression
# Disinhibition () – including risk-taking, substance misuse, gambling, reckless driving, impulsivity, irresponsibility and distractibility
# Anankastia () – including rigid obsessive compulsions, intransigent control over behaviour and affect, and rigid perfectionism

Borderline pattern

In addition to the classification of PD severity and the most prominent trait domains, the ICD-11 also provides a ''borderline pattern'' specifier (), which essentially relies on DSM-IV/5’s definition of borderline personality disorder. Thus, in contrast to the ICD-10 operationalization of Emotionally unstable PD (i.e., impulsive subtype and borderline subtype), the ICD-11 Borderline Pattern specifier is defined by the nine familiar DSM-IV/5 features including “dissociative symptoms or psychotic-like features (e.g., brief hallucinations, paranoia in situations of high affective arousal)”. In supplement to these nine features, the user may also take three additional manifestations of the Borderline Pattern into consideration, which may be of help for both diagnostic pattern recognition, more fine-grained clinical description, and treatment planning: 1) a view of self as bad, inadequate, guilty, and contemptible; 2) a sense of alienation or loneliness; and 3) rejection sensitivity, problems with trust, and misinterpretation of social signals.

References

{{Personality disorder classification