Personality disorder classification can generally be broken down into acategorical approach and adimensional approach. The categorical approach views personality disorders as discrete entities that are distinct from each other as well as from normalpersonality. In contrast, the dimensional approach suggests that personality disorders exist on acontinuum, with traits varying in degree rather than kind.[5] There has been a sustained movement toward replacing categorical models of personality disorder classification with dimensional approaches.[6][7] This dimensional perspective may allow for more nuanced understanding and flexible diagnostic practices.
Classical views of personality disorder as discrete categories have had benefits for understanding and communicatingpsychopathology throughout history, such as for: a contained organization of symptoms to facilitate standardized research, organizing public awareness and stigma reduction campaigns, allocating public health funding and appropriate treatment intensities, and normalizing clear labels for communicating patient formulations (a description of symptoms and their inter-relationships) to professionals and families.[5]
Since its inception, the categorical system has steadily accumulated criticism. Attempts to reproduce the factor structure of theDSM-IV-TR's categorical model have been unsuccessful, suggesting that the categorical structure cannot robustly describe the architecture of personality psychopathology.[5] Such issues are exacerbated by the substantial symptom overlap between disorders that facilitates their excessive and unwarrantedcomorbidity,[5][6][7] with the majority of people with a PD being eligible for another PD diagnosis.[8] As a result, individuals are substantially more likely to be diagnosed with several PDs than a singular one, contradicting the notion that categories provide neatconstellations of inter-related symptoms.[5]
Equally, this approach appears unable to accurately capture the full range of personality psychopathology. Estimates of patients who do not fit neatly into current categories range from 21 to 49%, accordingly given the general diagnosis ofPersonality Disorder – Not Otherwise Specified (PD-NOS). PD-NOS also appears to be in regular usage to describe mixed or complex presentations given the difficulties in classifying individuals within the current framework.[5] It has been found that "many patients in clinical practice misleadingly receive multiple PD diagnoses, a 'not otherwise specified' PD diagnosis, or no PD diagnosis at all, even if a PD diagnosis is relevant to the presentation".[9] Another issue is theheterogeneity within categories.[7]
Setting standardized diagnostic thresholds (based uponpolythetic symptoms) is difficult particularly when each symptom is given equal weighting. This means that individuals with the same number of symptoms can have substantially different levels of distress. Between each PD, diagnostic thresholds occur at different levels of pathology. Due to these issues, it is likely that many clinicians use their clinical judgment based upon an internalized representation of the disorder when making diagnoses. The current categorical approach falls short of fully representing personality psychopathology and providing a scientifically robust understanding of what personality is and what disorders of personality are.[5]
In response to observed deficiencies in the categorical approach, dimensional models, which suggest that humans differ in degree not in kind,[5] have been developed, assessing personality disorders in terms of severity of impairment and maladaptivepersonality traits.[6] Within this perspective, PD occurs atmaladaptive extremes of the standard personality traits all humans share and as specific combinations of these trait extremes. The degree of life impairment forms the basis for a PD diagnosis. This approach has gained substantial support, with broad calls and movements toward mainstream adoption.[5]
The shift towards dimensional models is reflected in the inclusion of theAMPD in Section III of the DSM-5, and in theICD-11's adoption of a dimensional system. These are believed to ameliorate several shortcomings of the categorical model,[7] as well as improve clinical utility[5] and potentially reduce stigma,[6][5] although no research has so far specifically examined the effect on stigma.[5] Emerging research indicates that dimensional models may also facilitate the personalization ofpsychotherapy by aligning treatment strategies with underlying trait dimensions rather than diagnostic categories.[10] Despite some important differences in the prevailing approaches, dimensional models of PD typically consider two key criteria:severity andstyle.[5]
Mapping of ICD-11 PD classification to the AMPD[1][11]
Severity captures the core distress that is common to all PDs, its impact on the individual's self-direction andidentity (intrapersonal functioning), as well as their ability to formclose relationships andempathize with others (interpersonal functioning). Indices of global severity are robust predictors of both the presence of a personality disorder andprognosis, and track with fluctuations in clinical functioning. According to the ICD-11, severity is the key and sole requirement for making a diagnosis of PD. The central placement of impairment is grounded in research that global severity ratings are sensitive and specific predictors of PD, and provide better estimates of clinician-ratedpsychosocial impairment than specific categorical diagnoses do. The severity of personality disorder (i.e., mild, moderate, severe) may be more indicative of dysfunction and outcomes than the specific typology of the disorder.[5]
The second criterion describes the stylistic features of the presentation, largely in relation to some derivation of theFive-Factor Model (FFM) of personality. The DSM-5's Alternative Model of Personality Disorders (AMPD) Criterion B comprises the traits ofnegative affectivity (continua from emotional stability toneuroticism), detachment (introversion to extroversion), antagonism (agreeableness to antagonism),disinhibition (conscientiousness toimpulsivity), and psychoticism (closed to experience toopen to experience). The DSM-5's approach to diagnosing PD in the AMPD differs from the ICD-11 as it requires the presence of one or more elevated traits. Nevertheless, there is a growing interest in using only Criterion A for understanding, diagnosing, and managing PD. The FFM has the ability to explain all personality variation, with current dimensional PD models capturing dysfunctional versions or extremes of these traits.[5]
In thefifth edition of theDiagnostic and Statistical Manual of Mental Disorders, a categorical classification was retained for personality disorders. Located in Section II (Diagnostic Criteria and Codes; where official diagnoses are listed),[12] it contains ten specific personality disorders grouped into threeclusters (A, B, and C), as well as three other diagnoses. Thus, it lists personality disorders in the same way as other mental disorders, rather than on a separate 'axis', as previously.[13] The clusters are based on descriptive similarity between the disorders they encompass, and it is not proven that they possess clinical utility.[14]
The clusters, as well as definition of personality disorders being done through specific sets of criteria, have been part of the DSM since the DSM-III (1980).[15] The classification system was retained from theDSM-IV (1994) due to theBoard of Trustees of theAmerican Psychiatric Association having decided to reject the AMPD.[16][17] This system was carried forward in the more recentDSM-5-TR.
The DSM-5 and the more recent DSM-5-TR provide a definition and six criteria forgeneral personality disorder. Any of its ten personality disorder diagnoses[18] is subject to this definition, which requires that a differential diagnosis is performed in order to verify that the disturbance is not the result of other mental disorders, medical conditions or substances, and that the disturbance is stable over time and "inflexible and pervasive across a broad range of personal and social situations", having evident continuity since "at least to adolescence or early adulthood". Additionally, disturbance must be evident in regards to at least two of four specified aspects of functioning, namely: cognition, affectivity, interpersonal functioning and impulse control.[18][19]
People with these disorders can be paranoid and have difficulty being understood by others, as they often have odd or eccentric modes of speaking and an unwillingness and inability to form and maintain close relationships.[20] Significant evidence suggests a small proportion of people with Cluster A personality disorders, especially schizotypal personality disorder, have the potential to develop schizophrenia and other psychotic disorders. These disorders also have a higher probability of occurring among individuals whose first-degree relatives have either schizophrenia or a Cluster A personality disorder.[21]
Paranoid personality disorder (PPD) is apersonality disorder characterized byparanoia, and a pervasive, long-standing suspiciousness and generalizedmistrust of others. People with this disorder may be hypersensitive, easilyinsulted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions that may validate their fears or biases. They are eager observers and they often think they are in danger and look for signs and threats of that danger, potentially not appreciating other interpretations or evidence.[22]
Cluster B personality disorders are characterized by dramatic, impulsive, self-destructive, emotional behavior and sometimes incomprehensible interactions with others.[20]
Antisocial personality disorder (ASPD) is apersonality disorder defined by a chronic pattern of behavior that disregards the rights and well-being of others. People with ASPD often exhibit behavior that conflicts with social norms, leading to issues with interpersonal relationships, employment, and legal matters. The condition generally manifests inchildhood or early adolescence, with a high rate of associated conduct problems and a tendency for symptoms to peak in late adolescence andearly adulthood.
Narcissistic personality disorder (NPD) is a complex andheterogeneouspersonality disorder characterized by patterns ofgrandiosity,entitlement, low empathy, and interpersonal difficulties, which can manifest as either grandiose (“thick-skinned”) or vulnerable (“thin-skinned”) forms.[37][38] Grandiose individuals displayarrogance,social dominance, and exploitative behaviors, while vulnerable individuals show shame, inferiority,hypersensitivity, and extreme reactions to criticism. NPD often involves impaired emotional empathy, superficial relationships, and difficulty tolerating disagreement. It is often comorbid with other mental disorders and associated with significant functional impairment andpsychosocial disability.[37]
Dependent personality disorder (DPD) is apersonality disorder characterized by a pervasive dependence on other people and subsequentsubmissiveness[41][42] and clinginess.[42] This personality disorder is a long-term condition[43] in which people depend on others to meet their emotional and physical needs. Individuals with DPD often struggle to make independent decisions and seek constant reassurance from others.[42] This dependence can result in a tendency to prioritize the needs and opinions of others over their own.[44]
Obsessive–compulsive personality disorder (OCPD) is acluster Cpersonality disorder marked by a spectrum of obsessions with rules, lists, schedules, and order, among other things. Symptoms are usually present by the time a person reaches adulthood, and are visible in a variety of situations.[45] The cause of OCPD is thought to involve a combination of genetic and environmental factors, namely problems withattachment.[46]
The DSM-5 chapter on personality disorders also contains three diagnoses for conditions not matching these ten disorders,[47] which nevertheless exhibit characteristics of a personality disorder:
Other specified personality disorder – used when recording the presence of personality disorder along with the reasons for the condition not being classified as one of the specific personality disorders.[47]
Unspecified personality disorder – used when a patient presents with personality disorder symptoms that cause distress or impairment, but the clinician either chooses not to indicate the specific reason these criteria are not met for any one disorder, or there isn't enough information available to make a more precise diagnosis.[47]
Overview diagram showing the steps of assessing a personality disorder using the AMPD
Located in section III of the DSM-5, theAlternative DSM-5 Model for Personality Disorders (AMPD) is a dimensional–categorical hybrid,[49] yielding diagnoses based on combinations of ratings of impairment in personality functioning (criterion A) and pathological personality traits (criterion B).[9][50] Created with the aim of ameliorating issues such as arbitrary thresholds and excessive comorbidity,[49] it was intended to replace the categorical model in the at the time upcoming DSM-5; however, upon its rejection, it was instead placed in Section III (Emerging Measures and Models).[16]
Assessed across self and interpersonal domains, the level of personality functioning (criterion A) consists of four elements, namely: identity, self-direction, empathy and intimacy; the first two of these constitute self functioning, while the other two comprise interpersonal functioning.[12] Supposed to capture fundamental problems specific and common to personality disorders,[50] the level of functioning is rated on the Level of Personality Functioning Scale (LPFS), which ranges from 0 (little or no impairment) to 4 (extreme impairment).[51] Describing the manner in which the disorder is manifested, criterion B encompasses the assessment of pathological personality traits; these are grouped into the following five domains:Negative Affectivity,Detachment,Antagonism,Disinhibition, andPsychoticism.[49] These domains consist of twenty-five specific trait facets, such asirresponsibility andrisk taking within the domain of disinhibition.[9]
Defined by combinations of criteria A and B, available in the AMPD are both sixspecific personality disorders and atrait specified diagnosis.[9][12] The six specific ones – based on diagnoses from the categorical system in theDSM-IV – are: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal; whilepersonality disorder–trait specified is available for presentations differing a lot from the predefined categories.[52] This applies to mixed presentations and categorical diagnoses which were not specifically included in the alternative model.[12] Additional requirements for diagnosis are defined in criteria C–G, which require that the disturbance has affected the individual broadly and continuously since they were young, and that it is not better explained by substances, medical conditions or othermental disorders; nor may it be considered normal for the individual'ssocial environment ordevelopmental stage.[51]
Once the presence of personality disorder is established, its severity may be determined; classified as mild, moderate, or severe, it is based on how pervasive and disabling the disturbances are. The evaluation considers impairments in several areas of functioning, such asidentity and self-direction,interpersonal relationships,emotional andbehavioural problems, the extent of psychosocial dysfunction or distress, and risk of harm to self or others. These indicators serve as guidelines for global clinical judgment rather than as fixed diagnostic criteria.[53] Severity may also be coded as unspecified (6D10.Z).[1]
Mild Personality Disorder (6D10.0): Disturbance is limited to certain aspects of personality functioning. The person may struggle with decisions, relationships, or handling criticism while retaining a coherent identity and overall reality testing. Distress and impairment are present but circumscribed, and harm to self or others is uncommon.[54]
Moderate Personality Disorder (6D10.1): Disturbance extends across multiple domains, such as self-concept, relationships, and moderation of behaviour, yet some capacities remain intact. Harm to self or others may occur but is typically moderate.[54]
Severe Personality Disorder (6D10.2): There are profound disturbances in identity and interpersonal functioning. The person may lack a stable sense of self, display rigid or chaotic self-concepts, and experience pervasive conflict or exploitation in relationships. Social and occupational functioning is severely compromised, and significant risk of self-injury or violence is common.[54]
In addition to coding severity, clinicians may use trait and pattern qualifiers to describe the specific stylistic dimensions and configurations of personality disturbance.[53] These qualifiers indicate prominent traits contributing to the overall dysfunction but do not represent distinct categories or syndromes. Although the traits exist dimensionally, for coding purposes they are recorded as either present or absent.[1] The combination and number of trait qualifiers typically reflect the individual's global severity, with more complex or numerous traits often accompanying greater impairment.[1][53]
Negative Affectivity (6D11.0): Involves a tendency to experience frequent and intense negative emotions, such as anxiety, anger, guilt, or shame, accompanied by impairedemotional self-regulation. Common problems are excessive dependency on others, suicidal ideation and hopelessness.[54]
Dissociality (6D11.2): Characterized byself-centeredness, lack ofempathy, and disregard for the rights and feelings of others. Individuals often displaygrandiosity,entitlement, andmanipulativeness, pursuing their own needs and comfort without concern for others, or expecting attention oradmiration from them. Lack of empathy may be manifested in callousness,aggression, and exploitation, and sometimes in taking pleasure in others' suffering.[1][54]
Disinhibition (6D11.3): Involves impulsivity, recklessness, and poor self-control, with actions driven by immediate desires without regard for long-term consequences.[54]
Anankastia (6D11.4): Marked by perfectionism, rigidity, and excessive orderliness, accompanied by a preoccupation with rules, control, and moral standards.[54]
Borderline Pattern (6D11.5): A pattern qualifier corresponding closely to the DSM-5borderline personality disorder diagnosis.[53]
^Department of Psychiatry and Psychotherapy, Medical Faculty, LVR-Klinikum Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany; Gaebel, Wolfgang; WHO Collaborating Centre on Quality Assurance and Empowerment in Mental Health, Düsseldorf, Germany; Kerst, Ariane; Department of Psychiatry and Psychotherapy, Medical Faculty, LVR-Klinikum Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany; WHO Collaborating Centre on Quality Assurance and Empowerment in Mental Health, Düsseldorf, Germany; Stricker, Johannes; Department of Psychiatry and Psychotherapy, Medical Faculty, LVR-Klinikum Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany; WHO Collaborating Centre on Quality Assurance and Empowerment in Mental Health, Düsseldorf, Germany (2020-12-24)."Classification and Diagnosis of Schizophrenia or Other Primary Psychotic Disorders: Changes from Icd-10 to Icd-11 and Implementation in Clinical Practice"(PDF).Psychiatria Danubina.32 (3–4):320–324.doi:10.24869/psyd.2020.320.PMID33370728.Schizotypal disorder is defined as an enduring pattern of unusual speech, perceptions, beliefs, and behaviours of insufficient intensity to meet requirements for another psychotic disorder in ICD-10 and in ICD11. Yet, schizotypal disorder may be a possible predecessor of schizophrenia (Jablensky 2011, Stein et al. 2020) and is therefore kept in the ICD-11 chapter of primary psychotic disorders, contrary to DSM-5 which classifies schizotypal disorder as a personality disorder.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^Zimmermann, J., Kerber, A., Rek, K., Hopwood, C. J., & Krueger, R. F. (2019). Integrating clinical and personality assessment: Toward the development of a shared framework.Journal of Personality Assessment, 101(3), 292–304. doi:10.1080/00223891.2018.1483373.
^abAmerican Psychiatric Association; American Psychiatric Association, eds. (2013). "Personality Disorders".Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington, D.C: American Psychiatric Association. pp. 645–649.ISBN978-0-89042-554-1.This chapter begins with a general definition of personality disorder that applies to each of the 10 specific personality disorders.
^Sartorius N, Henderson A, Strotzka H, Lipowski Z, Yu-cun S, You-xin X, Strömgren E, Glatzel J, Kühne G, Misès R, Soldatos C, Pull C, Giel R, Jegede R, Malt U, Nadzharov R, Smulevitch A, Hagberg B, Perris C, Scharfetter C, Clare A, Cooper J, Corbett J, Griffith Edwards J, Gelder M, Goldberg D, Gossop M, Graham P, Kendell R, Marks I, Russell G, Rutter M, Shepherd M, West D, Wing J, Wing L, Neki J, Benson F, Cantwell D, Guze S, Helzer J, Holzman P, Kleinman A, Kupfer D, Mezzich J, Spitzer R, Lokar J."The ICD-10 Classification of Mental and Behavioural Disorders Clinical descriptions and diagnostic guidelines"(PDF).www.who.int.World Health Organization. bluebook.doc. pp. 77,83–4. Retrieved23 June 2021.
^Cattane N, Rossi R, Lanfredi M, Cattaneo A (June 2017)."Borderline personality disorder and childhood trauma: exploring the affected biological systems and mechanisms".BMC Psychiatry.17 (1) 221.doi:10.1186/s12888-017-1383-2.PMC5472954.PMID28619017.[BPD] is a pervasive pattern of emotional dysregulation, impulsiveness, unstable sense of identity and difficult interpersonal relationships. [Prevalence is 0.2–1.8% for general community, 15–25% among] psychiatric inpatients and 10% of all psychiatric outpatients. [Linehan (1993) proposed BPD to] be the result of [...] biologically based temperamental vulnerabilities and [adverse/traumatic childhood experiences]. Several studies have shown that a diagnosis of BPD is associated with child abuse and neglect more than any other personality disorders, with a range between 30 and 90% in BPD patients.
^"Borderline Personality Disorder". The National Institute of Mental Health. December 2017.Archived from the original on 29 March 2023. Retrieved25 February 2021.Other signs or symptoms may include: [...] Impulsive and often dangerous behaviors [...] Self-harming behavior [...]. Borderline personality disorder is also associated with a significantly higher rate of self-harm and suicidal behavior than the general public.
^abCaligor E, Levy KN, Yeomans FE (May 2015). "Narcissistic personality disorder: diagnostic and clinical challenges".The American Journal of Psychiatry.172 (5):415–422.doi:10.1176/appi.ajp.2014.14060723.PMID25930131.
^Sperry, Len (2016).Handbook of the diagnosis and treatment of DSM-5 personality disorders: assessment, case conceptualization, and treatment (Third ed.). New York London: Routledge.ISBN978-0-415-84191-7.
^abcDiagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington, D.C: American Psychiatric Association. 2013. pp. 675–678.ISBN978-0-89042-554-1.
^Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (5th ed.). United States: American Psychiatric Association. May 18, 2013. pp. 678–81.ISBN978-0-89042-554-1.
^Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington, D.C: American Psychiatric Association. 2013. p. 683.ISBN978-0-89042-554-1.The essential feature of a personality change due to another medical condition is a persistent personality disturbance that is judged to be due to the direct pathophysiological effects of a medical condition.
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