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 Table of Contents  
DEBATE/PERSPECTIVE/VIEWPOINT
Year : 2018  |  Volume : 34  |  Issue : 5  |  Page : 49-53

Personality disorders: The reformed classification in international classification of Diseases-11 (ICD-11)


1 Research Center of Psychiatry and Behavioral Sciences, Tabriz, Iran
2 Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran

Date of Web Publication20-Nov-2018

Correspondence Address:
Dr. Masumeh Zamanlu
Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_26_18

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  Abstract 


It is of the plain conclusions of education in psychiatry that no psychiatric evaluation is complete, until an understanding of the patient's personality together with its life-long challenges, development, and growth is acquired. However, guides of evaluating personality and diagnosing personality disorders are still on the way to become more and more practical. The current approach for personality disorders is based on syndrome-based classifications, mainly the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases and Related Health Problems (ICD). The previous classification for personality disorders posed certain gaps and inconveniences; therefore, a reclassification of personality disorders was performed in the 11th revision of ICD. The current perspective article discusses the trend of personality disorders since its first introduction in psychiatry until its recent reclassification in ICD-11.

Keywords: International Classification of Diseases, mental nosology, personality disorder


How to cite this article:
Farnam A, Zamanlu M. Personality disorders: The reformed classification in international classification of Diseases-11 (ICD-11). Indian J Soc Psychiatry 2018;34, Suppl S1:49-53

How to cite this URL:
Farnam A, Zamanlu M. Personality disorders: The reformed classification in international classification of Diseases-11 (ICD-11). Indian J Soc Psychiatry [serial online] 2018 [cited 2018 Dec 11];34, Suppl S1:49-53. Available from: http://www.indjsp.org/text.asp?2018/34/5/49/245827




  Introduction Top


Comprehension of personality and personality disorders is an important consideration for psychiatrists; in fact, it is a discernment of psychiatry among other medical specialties. It could be claimed that no psychiatric evaluation is complete, until an understanding of the patient's personality together with its life-long challenges, development, and growth is acquired. Understanding the personality is in fact an understanding of the psychobiologic background of behaviors. Personality could be considered as the difference of human beings and machines, the mental fundament by which the self-aware psyche of a human being functions and develops.[1] Any deep and precise realization of psychiatric disorders necessitates understanding personality; in fact, personality is the soil which conceives and grows mental illnesses as well as mental creativity and transcendence. Compared with normal personality, personality disorders are associated with higher mortality and morbidity.[2],[3] Definitions and conceptualizations (and hence the clinical utility) of personality disorders have gone through dynamic reformulations, especially during the recent decades. The classification of personality disorders in International Classification of Diseases (ICD-11) is actually a complete reform in this regard. The current article discusses the trends related to personality disorders since its first introduction in psychiatry until its recent reclassification in ICD-11.


  History of Personality Disorders Top


Personality disorders were not considered a medical and psychiatric diagnosis until the 19th century. The first physician, who formed a category for personality disorders, was James Cowles Prichard. He innovated the term “moral insanity” defined as a “gross disturbance of behavior with no apparent psychiatric illness.” Prichard believed that moral insanity is a mental derangement in which mental principles and moralities are depraved or perverted, and self-government is lost or greatly impaired.[4] Similarly, Galen (129 AD) related the four humors to personality, introducing the four types of sanguine, phlegmatic, choleric, and melancholic tempers. Among these four types, the sanguine type was not related with mental pathologies, but each of the remaining three could be related with specific personality pathologies.[5]

However, discussions on personality date as far back as Heraclitus who stated that human beings were a combination of water and fire,[6] and even farther in the ancient Iranian culture, which believed humane psych as a prudent combination of darkness and light.[7] Moreover, there are mentions about the quintessence of psych and personality in the Indian Upanishads, which are among the most ancient Indo-European writings and include, in common, points with the ancient Iranian culture.[8]


  Current Classifications of Personality Disorders Top


The current diagnosis and approach toward psychiatric practice, including the practice related to personality pathologies, are based on syndrome-based classifications, mainly the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Diseases and Related Health Problems (ICD).[1] The backbone of these modern classifications was built by the ideas of Kurt Schneider. He defined abnormal personality as a statistical deviation from the norm, and psychopathic personality types as those who suffered from their abnormal personality or caused suffering to the society because of it. He saw abnormal personalities as distinct from mental illnesses but not as categorically distinct from normal personality. His central classic work, the book of “Psychopathic Personalities,” published in 1923, described nine types of personality which were entered into the ICD-6 after slight modifications and are currently in use since then.[9],[10] Schneider states this key description about individuals with personality pathologies as follows: “Those with personality disorders suffer because of their disorders and also cause society to suffer.”[11] This notion suggests that, at the core of personality disorders, it is an inability to develop and maintain significant interpersonal relationships. Thus, Schneider considered the interpersonal domain as the basic element of the personality disorders and did not think these disorders to be mere intrapsychic issues.[12] Schneider focused on the specific properties of each personality disorder rather than on the general features that are common to most or all personality disorders. For each disorder, he described a prototype, collating all properties of a specific disorder he believed as essential. Two resultant concepts could be concluded from Schneider's classification: first, personality disorders could be evidently discriminated from health state and that social and cultural variations do not impact its symptoms. Second, the types of personality disorders as introduced by Schneider are valid and homogeneous categories which exist recognizably, originally, and obviously.[13]


  Challenges of the Current Classifications of Personality Disorders Top


Since 1968, Schneider's concept is the dominant view in different revisions of the ICD as well as the DSM, until quite recently that revisions of DSM-IV and ICD-11 encountered some challenges. Six prominent challenges are discussed in this article, for which the revision of ICD-11 proposes beneficial solutions.

First, there was not an evident distance between health and disorder, no sharp boundary where health ends and personality disorder begins. Dividing individuals into “healthy” and “having a personality disorder” could be considered similar to dividing the weather into “hot” and “cold,” merely according to the temperature! Obviously, psychiatrists need some sort of cut points and scaling in order to make clinical decisions for initiating treatment, estimating pharmacologic doses, and suggesting hospital admission, as in the disorder of “hypertension” where clear-cut points have been determined. A related issue is the extant focus on the forms of personality disorders rather than on intermediate disturbances which cause apparent dysfunctions and interfere with the flow of the individual's life. There have been endeavors for designing dimensional classifications in which the diagnosis could be based on the current functioning.[14] Studies worldwide indicate that personality disorders are compatible with dimensional models.[15],[16],[17],[18] The dimensional approach to personality disorders conceptualizes these disorders as not qualitatively but rather quantitatively different from normal personality. According to these models, personality disorders consist of extreme, maladaptive levels of certain personality characteristics, the so-called “dimensions” described as trait domains in the ICD-11. These dimensions or domains refer to a continuum on which an individual can have various levels of manifestation. Hence, the dimensional model is in contrast to the dichotomous categorical approach in which an individual does or does not possess a characteristic, which is the dominant approach in the previous ICD revisions. Accordingly, in dimensional models, personality disorders are classified based on the level of manifestation of traits.[19]

The second challenge to be noted is the vast comorbidities among the different types of personality disorders. In fact, a pure case of prototypical personality disorder diagnosis is rare; most real cases have a combination of the traits of several personality disorders. Studies demonstrate that such cases may show a combination of traits of 3–10 personality disorders at the same time.[20] Investigations also indicate that patients with severe personality disorders have multiple comorbidities among personality disorders as well as other mental disorders.[21],[22] In fact, the most frequently diagnosed personality disorder, based on the DSM-IV criteria, has been reported to be the “personality disorder not otherwise specified.”[23] Except for the antisocial personality disorder and the borderline personality disorder, which have considerable general usage among psychiatric diagnoses, clinical use of most of the remaining personality disorder diagnoses is less significant in psychiatry.

The third challenge in the current classifications of personality disorders is that they are inconveniently detailed. There are 11 categories of personality disorders in DSM-IV and each category contains about 10 criteria, so there are overall 110 criteria of personality disorders to be assessed. Even if a psychiatrist were to check each criterion in 10 s, it will take nearly 20 min to check the full panel of criteria for personality disorders. This is usually not possible in busy psychiatric practices; therefore, most psychiatrists rely on their intuition rather than a systematic review of criteria, in diagnosing personality disorders. Understandably, this approach is utterly longsome for nonpsychiatrist medical workers.[24]

The fourth challenge is that personality disorders are very stigmatizing diagnoses as they are assumed to be untreatable and to be associated with social aberrance; hence, psychiatrists are less willing to use these diagnoses. A solution is substituting the names of the diagnoses, but the substituted names would soon gain the same repugnant notability; therefore, the stigmatization would also occur for the new names.[13]

The fifth challenge is that the classifications of personality disorders and the related categories were not very successful at guiding psychiatric practice, regarding pharmacologic or psychosocial treatments. And ultimately, the sixth challenge is that the Schneiderian classification is prominently based on the Western cultures and described deviations from the life norms of the Western world. These descriptions sometimes come in contrast with the principles of other societies, especially the Eastern societies which possess a frame of collectivistic and modest traditions.[13],[25]


  The Solution of Reclassification of Personality Disorders in the 11th Revision of International Statistical Classification Top


The challenges mentioned above, about the current classifications of personality disorders, motivated the working group for revision of the personality disorders section in the ICD-11, to replace the Schneiderian system with a new classification which is based on severity spectrum and dimensional models. Tyrer and Johnson's classification system formed the foundation of the new classifications for personality disorders in ICD-11.[26] The classification based on severity brings in dimensional elements.[13] Responsibilities of the clinicians in the suggested classification of personality disorders in ICD-11 are introduced around three main pivots: (1) whether or not personality disorder exists in the given case, (2) determining the severity of the existing personality disorder, and finally [Table 1] (3) determining configurations of the personality disorder based on the involved domains.
Table 1: The five severity levels of personality disturbance proposed in ICD-11

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The aim of the reformed classification of personality disorders in ICD-11 was to provide an assessment which is more concise and rapid and, at the same time, more precise. The dimensional model proposed by ICD-11 is not only comprehensive but also clinically useful. When determination of high and low levels on the five dimensions is made, individuals as well as pre- and post-treatment state can be compared, and goals for therapy could be defined. Previous categorical approaches yielded diagnosis that did not help with clinical decision-making. The dimensional model proposed by ICD-11 is treatment oriented and personalized.

For the first pivot, diagnosing whether or not personality disorder exists in a given case, the following definition of personality disorder is used in the ICD-11: “Personality disorder is characterized by a relatively enduring and pervasive disturbance in how individuals experience and interpret themselves, others, and the world that results in maladaptive patterns of cognition, emotional experience, emotional expression, and behavior. These maladaptive patterns lead to significant problems in psychosocial functioning that are particularly evident in interpersonal relationships, manifested across a range of personal and social situations (i.e., not limited to specific relationships or situations).” Key points in this definition are “pervasive disturbance,” inflexible “maladaptive patterns associated with significant problems in psychosocial functioning,” universality of the disturbance, “stability over time, long duration, and clear evidence in adolescence.” In addition, “boundaries with other disorders and normality” provide guidance on how to differentiate personality disorder from other disorders and sociocultural behavioral patterns.

Two terms are defined in the ICD-11 to aid clinical practice in relation to intermediate conditions. “Late-onset personality disorder” indicates the disturbance originated in adulthood, that is after 25 years of age, and “personality difficulty” refers to pronounced personality characteristics that may affect treatment or health services' contact but are not severe enough to merit a diagnosis of personality disorder.[13] The boundary of normality determined in ICD-11 is a solution for the cultural problem of previous formulations. Since Schneider's pioneering approach until quite recently, personality disorders were defined against a Western cultural context. The Western culture directs the concept of normality toward more individuality and an independent- and achievement-oriented lifestyle, at a price of less modesty and less fulfillment in relations and social interactions, together with relative inattention to the inner world and spiritual transcendence. These ignored concepts are dominant in Eastern cultures including cultures of Asian countries and regions such as India and the Middle East. The ICD-11 is considering interpersonal issues, social functions and successes, as well as cultural differences more seriously.

For the second pivot, the severity of the personality disorder (e.g. mild, moderate, or severe) needs to be specified, according to the frequency, intensity, and pervasiveness of its manifestations. Based on personality functioning, five severity levels have been defined: healthy state; personality difficulty; and mild, moderate, or severe personality disorders.[13]

The main needs of clinical practice in terms of diagnosis and treatment of personality disorders are met by the above-mentioned two pivots. For the third pivot, five trait domains have been described as follows: (1) “prominent features of negative affectivity” are characterized by the tendency to manifest a broad range of distressing emotions, for example, anxiety, anger, self-loathing, irritability, and depression, often in response to even relatively minor actual or perceived stressors; (2) “prominent dissocial features” are characterized by disregard for social obligations and conventions and the rights and feelings of others or unwillingness to maintain prosocial behavior – it includes traits such as callousness, lack of empathy, and hostility; (3) “prominent features of disinhibition” are characterized by a persistent tendency to act impulsively in response to immediate internal or environmental stimuli without consideration of long-term consequences – including traits such as irresponsibility, impulsivity, and distractibility; (4) “prominent anankastic features” are characterized by a narrow focus on the control and regulation of one's own and others' behavior in order to ensure that things conform to the individual's particularistic ideal – including traits such as perfectionism, emotional and behavioral constraints, stubbornness, and deliberativeness; and (5) “prominent features of detachment” characterized by emotional and interpersonal distance, manifested in marked social withdrawal and/or indifference to people, isolation with very few or no attachment figures, avoidance of not only intimate relationships but also close friendships – including traits such as aloofness or coldness in relation to other people, reserve, passivity, and lack of assertiveness” (WHO ICD-11, unpublished material).

There were parallel attempts to reform the classification of Personality Disorders in DSM-5. These attempts recruited a hybrid approach, combining the definition of several common prototypes including antisocial and borderline personality disorders, together with the dimensional and configurational model of personality disorders. The resultant approach of DSM-5 failed to fulfill the practical psychiatric needs for personality disorders and dropped, with a return to previous DSM approaches. Since the interim approach was not successful, ICD-11 adopted a pure dimensional model of personality disorders, since it is more promising in terms of clinical utility.


  Conclusion Top


The classification of personality disorders is reformulated in the ICD-11 toward more utility in clinical practice worldwide. Most of the identified challenges of previous classifications of personality disorder have been resolved in ICD-11.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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