To facilitate some continuity with established clinical practice, it seems important to understand the new ICD-11 approach with reference to the traditional ICD-10 PD types. We are entering a transition phase in which both systems might be used side by side in order to gain the necessary knowledge about this question. It is important to underscore that such transition should be limited to a certain period of time as we eventually must leave the ICD-10 PD categories behind and entirely commit to the official ICD-11 system as a standalone approach.
Some of the familiar PD types described in ICD-10 seem fairly recognizable in the ICD-11 trait domain specifiers. For example, it appears straightforward that the trait domain of Anankastia resembles the Anankastic or Obsessive-Compulsive PD. Likewise, the trait domain of Dissociality resembles the Dissocial PD, while the trait domain of Detachment resembles the Schizoid PD. However, the very common and frequently discussed types of Avoidant PD (ICD-10 F60.6 Anxious personality disorder) and Narcissistic PD (ICD-10 F60.8 Other specific personality disorder) seem less straightforward to characterize using trait domain specifiers. This might be critical as Avoidant PD is highly prevalent and associated with poor psychosocial functioning but often goes unrecognized. At the same time there are empirically supported treatment approaches available [34, 35]. In clinical contexts, Narcissistic PD often poses a challenge for treatment [36]. In the following, we therefore seek to portray these two familiar types using specific ICD-11 PD definitions.
Characterizing avoidant personality disorder within the new system
It is assumed that individuals with Avoidant PD may virtually be characterized by features ranging from mild to severe PD. They are characterized by marked difficulty in self-esteem along with intense fear of criticism and rejection. Their ability to work towards goals is often compromised due to lack of self-confidence and anxiousness. Likewise, their relationships are characterized by avoidance, which compromises social and occupational roles. Individuals with this pattern typically do not cause substantial harm to others, but may cause harm to themselves.
According to meta-analytic evidence, Avoidant PD is generally characterized by a combination of Negative Affectivity and Detachment [37, 38]. With respect to Negative Affectivity, this pattern particularly involves anxiousness, shame, low self-esteem, and a tendency to be over-reactive to external events (e.g., perceived threats of criticism or potential future problems). These patients’ low self-esteem and lack in self-confidence manifest in terms of avoidance of situations and activities that are perceived as too difficult (e.g., intellectually, physically, socially, interpersonally, emotionally, etc.), even despite evidence to the contrary.
With respect to Detachment, the Avoidant PD pattern involves social Detachment characterized by avoidance of social interactions, lack of friendships, and avoidance of intimacy. Due to anxiousness and low self-esteem, they either avoid social interactions completely or endure them with extreme discomfort. These patients tend to engage in little to no ‘small talk’ even if initiated by others (e.g., at store check-out counters), seek out employment that does not involve interactions with others, and even refuse promotions if it would entail more interaction with others. The complete Avoidant PD pattern of Negative Affectivity and Detachment is overall consistent with the description of Avoidant PD patients as being both fearful and emotionally inhibited [39,40,41,42]. In addition, Avoidant PD features may also be illuminated by scales developed to capture ICD-11 trait facets and nuances such as evaluation apprehension, social isolation, shame, interpersonal inadequacy, unassertiveness, risk aversiveness, ineptitude, and fragility (see Table 4) [10, 22, 31].
Characterizing narcissistic personality disorder within the new system
Individuals with a Narcissistic PD may be characterized by features ranging from mild to severe PD [2]. Their self-view can vacillate between overly positive and omnipotent, and extraordinarily negative and devastating. Depending on the specific nature of the narcissistic disorder (i.e., grandiose or vulnerable), such individuals may have difficulty recovering from injuries to their grandiose and vulnerable self-image. They may exhibit poor emotion regulation in the face of setbacks. Their self-focus and callousness may compromise the quality of their relationships, in particular by ignoring other’s opinions or exploiting others, which may contribute to their difficulties in developing close and mutually satisfying relationships. Their existing relationships may often be characterized by volatile and one-sided conflicts, where they may appear as strongly dominant. For the same reason, a sub-group of these patients may be unable to sustain regular work conditions or collaboration.
Narcissistic features are essentially characterized by the trait domain of Dissociality with emphasis on self-centeredness [18]. This pattern involves a sense of exploitativeness of others, believing and acting as if they deserve whatever they want which, in their eyes, should be obvious to others. Such features of narcissism can be manifested as an expectation of others’ admiration, attention-seeking behaviours to ensure being the center of others’ focus, and anger or denigration of others when the admiration and attention that the individual expects are not granted. Typically, such individuals believe that their accomplishments are outstanding, that they have many admirable qualities, that they have or will achieve greatness, and that others should admire them.
As an anticipated challenge for clinicians, the Dissociality trait domain specifier may not appear very specific for narcissism because it would also characterize dissocial PD and psychopathy. Nevertheless, many individuals with the diagnosis of a Narcissistic PD, in order to keep up with a subjective sense of superiority, are also characterized by the trait domain of Anankastia in terms of perfectionism and vanity, which serves to enhance competitiveness, self-esteem, and grandiose self-presentations [43]. Accordingly, the combination of Dissociality and Anankastia may often indicate distinct features of narcissism, including perfectionistic overcompensation and rule-bound narcissistic dominance. Likewise, additional features of Negative Affectivity in terms of vulnerability, depression, anger, hostility, and shame may also capture vulnerable manifestations of narcissism. Thus, the combination of Dissociality and Negative Affectivity may characterize some individuals with vulnerable narcissism who are ruminating over perceived slights or insults from others, are overreactive to criticism, and have a low frustration tolerance that easily makes them become overtly or covertly upset over even minor issues. Their low self-esteem may manifest as envy of others’ abilities and success, and it may also be driven by shameful experiences of repeated failures and procrastinations in their lives. Taken together, individual manifestations of narcissism may be captured by distinctive combinations of trait domains where Dissociality serves as the main ingredient. In addition, narcissistic features may also be illuminated by scales developed to capture ICD-11 trait facets and nuances such as grandiosity, need for admiration, vanity, arrogance, selfishness, reactive anger, shame, self-centeredness, lack of empathy, and entitled superiority (see Table 4) [10, 22, 31].
Where do we go from here?
The advent of the ICD-11 classification of PDs will be a significant change for health care workers, psychotherapists, researchers, insurance companies, administrators, and service providers, as well as patients and families concerned. When discussing how to proceed from here, we must first and foremost acknowledge that much is still unknown. Accordingly, in the following we aim to share with the readers a number of unanswered questions related to the perceived challenges and opportunities. We expect these questions to be further discussed and studied in the coming years, and that such endeavor will also help identify yet unknown obstacles, problems and opportunities.
Diagnostic reliability
Even though development of specific semi-structured interview instruments are underway, there are no default instruments for the ICD-11 PD classification. This is consistent with WHO’s rationale that the diagnostic guidelines per se should be sufficient to make a diagnosis in clinical practice. While this may be an advantage for worldwide clinical utility and feasibility, it may prove to be a disadvantage for diagnostic reliability (e.g., inter-rater reliability) and research. For example, what we gain in validity, we may lose in diagnostic precision or reliability? For example, some clinicians may find it challenging to determine the overall severity-level when the patient may be characterized by features of more than one level of PD severity. We therefore propose that rigorous field trials should be conducted to determine the reliability of the diagnostic guidelines, with reference to the reliability of other established and well-validated instruments (e.g., SCID-5-PD). Table 4 provides an overview of instruments and measures, which are officially being recommended to be used for empirical investigations and clinical operationalization of the ICD-11 classification in the years to come.
User preference investigations
Apart from the somewhat promising results of initial user preference studies [44, 45], it still remains inconclusive whether the ICD-11 PD classification truly fulfills the criteria for clinical utility. We therefore recommend that more studies are conducted with practitioners who are allowed to express what they think about this new system with respect to its perceived usefulness in routine clinical practice, and how it might be further improved in future revisions. Moreover, it would be valuable to include patients and their families in such surveys in order to get a service user perspective on the changes [45, 46]. Finally, it seems particular relevant to further investigate whether practitioners find the severity classification and the trait domain specifiers helpful for case formulation, treatment planning, and intervention as suggested by initial research [47, 48].
Future relevance of the borderline pattern specifier
We welcome the inclusion of a borderline pattern specifier as a pragmatic solution to divergent positions and even more important to ensure access for patients to evidence-based treatments. Large-scale studies in different countries evaluating the utility of this specifier with reference to the established instruments for this construct are needed. Preliminary research suggests that global severity of personality dysfunction accounts for substantial parts of the variance described by Borderline PD [49,50,51]. Certain clinical research and meta-analytic evidence suggest that the heterogeneity of Borderline PD features may be captured by trait domains of Negative Affectivity and Disinhibition, along with some features of Dissociality [18, 37], although it seems clear that these three trait domains alone do not capture all possible borderline symptoms in a clinically relevant manner. For example, Borderline-related disturbances of identity and reality testing are only globally captured in the ICD-11 classification of PD severity, but not by any trait domain.
While the aforementioned findings do not question the clinical relevance of the borderline pattern specifier as a specific “pattern”, more research is needed on the relationships between the severity levels and trait domains on the one hand and the borderline pattern on the other [52]. Given the substantial burden of disease associated with Borderline PD, such research may become important in order to elucidate severity and trait patterns of Borderline PD, and help allocate resources effectively according to different treatment options that have already proven to be effective for Borderline PD. On the one hand, because of the demonstrated responsiveness to evidence-based treatments, the ICD-11 borderline pattern may in some cases become a frontrunner specifier and thereby encapsulating some of the challenges and opportunities with respect to established treatment programs [16]. On the other hand, ICD-11’s global PD severity classification and trait domain specifiers may appeal to the increased use of transdiagnostic and personalized treatments cutting across traditional categorical PD diagnoses [53].
Is negative affectivity just a “One Size Fits All” trait specifier?
Some evidence suggests that the trait domain of Negative Affectivity explains a large amount of personality pathology observed in mental health services [18, 54]. However, it must be combined with other relevant trait domain specifiers in order to be more informative from a clinical viewpoint [18]. Metaphorically, Negative Affectivity may be compared to the juice that serves as base ingredient in many different cocktails. However, while such “cocktails” of trait domains may be clinically relevant, it remains questionable whether they actually capture the content of the familiar PD types that we usually treat.
From a critical perspective, the base ingredient of Negative Affectivity may potentially become a reductionistic “one size fits all” conceptualization of most PD cases. We therefore welcome exploratory work on how trait domains interact with one another at different levels of severity, and in particular how they are related to familiar ICD-10 PD types. The descriptions in the ICD-11 classification already convey a more complex understanding of Negative Affectivity. For example, it is highlighted that a combination with Detachment may cause self-blaming, whereas a combination with Dissociality may involve blaming of others.
The ICD-11 guidelines explicitly recognize that individuals with Negative Affectivity may exhibit poor self-esteem in a number of ways depending on context and other dynamics: a) avoidance of situations that are judged too difficult; b) dependency on others for advice, direction, and help; c) envy of others’ abilities and indicators of success; and d) suicidal ideations due to believing themselves to be useless. All four manifestations may even apply to the same individual across time and situation, all depending on context, complexity, and PD severity. The key message here is that the aforementioned patterns comprise different situational expressions of Negative Affectivity resulting in different implications for treatment. Taken together, Negative Affectivity per se may be understood as a “one size fits all” domain that applies to all emotional disorders, and when combined with other information, it may also reveal more clinically informative material. To further uncover such trait- and severity dynamics, it seems worthwhile to operationalize, portray, and investigate more fine-grained features (i.e., facets) of Negative Affectivity. Accordingly, facet-level scales have been developed to capture Negative Affectivity features such as emotional lability, negativistic attitudes, low self-esteem, and mistrustfulness (see Table 4) [10, 22, 31].
It remains an open question whether the concept of Negative Affectivity – alone or in combination with other domains – informs an explanatory formulation of the problems observed in a particular patient. Thus, disorder-specific case formulation methods may assist the clinician in this task, moving into the idiosyncratic details of each case. Problems associated with Negative Affectivity may be best explained by case formulation methodologies according to Dialectical-Behavior Therapy, the Unified Protocol, or Emotion-Focused Therapy [55, 56].
Utility of severity classification for treatment decisions
The introduction of the ICD-11 classification of PD severity may help in clinical decision making and allocation of treatment resources (e.g., type, length, and intensity of treatment) [47]. More research is also needed to determine empirically-informed thresholds and the prognostic value of grouping patients into categories of severity.
However, some practitioners may also be concerned that certain severity levels can fall under insurance companies’ and service providers’ criteria for support due to financial constraints in many European countries. For example, insurance companies or service providers may decide only to cover treatment for those with a severe PD while neglecting those with milder forms. At worst, a simple ordinal scale intended for transparent use by clinicians may well turn into a political instrument of resource allocation in health systems or hospitals. At best, such approach to allocation of resources may actually help ensure treatment for those who need it the most rather than exclusively basing such decisions on individual practitioners’ private opinions and observations. In any case, it would be helpful if such a PD severity classification could improve early detection, prognostic evaluation, and targeted treatment of mild, moderate, and severe PDs.