The Development of The ICD-11 Personality Disorders by Petery Tyrer

CP15CH19_Tyrer ARjats.
cls April 17, 2019 12:41
Annual Review of Clinical Psychology

The Development of the
ICD-11 Classification of
Personality Disorders: An
Access provided by 2806:2f0:1141:983d:44b2:b9b5:4d06:a303 on 12/02/23. For personal use only.
Annu. Rev. Clin. Psychol. 2019.15:481-502. Downloaded from www.annualreviews.org
Amalgam of Science,
Pragmatism, and Politics
Peter Tyrer,1 Roger Mulder,2 Youl-Ri Kim,3
and Mike J. Crawford1
1
Centre for Psychiatry, Department of Medicine, Imperial College London, London W12 0NN,
United Kingdom; email: p.tyrer@imperial.ac.uk, m.crawford@imperial.ac.uk
2
Department of Psychological Medicine, University of Otago, Christchurch 8140,
New Zealand; email: roger.mulder@otago.ac.nz
3
Department of Psychiatry, Seoul Paik Hospital, Inje University, Seoul 100-032, South Korea;
email: youlri.kim@paik.ac.kr
Annu. Rev. Clin. Psychol. 2019. 15:481–502 Keywords

First published as a Review in Advance on
classification, personality disorders, borderline, dimensions, severity
January 2, 2019
The Annual Review of Clinical Psychology is online at Abstract

clinpsy.annualreviews.org
The nomenclature of personality disorders in the 11th revision of the In-
https://doi.org/10.1146/annurev-clinpsy-050718-
ternational Classification of Diseases and Related Health Problems represents the
095736
most radical change in the classification history of personality disorders. A
Copyright © 2019 by Annual Reviews.
dimensional structure now replaces categorical description. It was argued
All rights reserved
by the Working Group that only a dimensional system was consistent with
the empirical evidence and, in the spirit of clinical utility, the new system is
based on two steps. The first step is to assign one of five levels of severity,
and the second step is to assign up to five prominent domain traits. There
was resistance to this structure from those who feel that categorical diagno-
sis, particularly of borderline personality disorder, should be retained. After
lengthy discussion, described in detail here, there is now an option for a bor-
derline pattern descriptor to be selected as a diagnostic option after severity
has been determined.
481
CP15CH19_Tyrer ARjats.cls April 17, 2019 12:41
Contents
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 482
DEVELOPMENT OF THE CLASSIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
Initial Work of the ICD-11 Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484
Domain Traits and Severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484
Initial Reaction to the Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486
Developments from 2015 Onward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
DERIVATION OF ICD-11 DOMAINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Analysis of Domain Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Subsequent Reactions to the Proposal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
THE BORDERLINE CONTROVERSY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494

Bridging the Gap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494
Solution to the Borderline Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495

FUTURE DIRECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
BACKGROUND
The classification of personality disorder is one of the more contentious subjects in nosology. Al-
though all classifications are defective, that for personality dysfunction has never been embraced
by more than a few, and there has been a constant clamor for reform that has increased in inten-
sity during the past decade. This was recognized by the Work Group for Personality and Person-
ality Disorders for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5; Am. Psychiatr. Assoc. 2013), which worked intensively for 4 years to effect radical
changes. The history of the DSM-5 personality disorder controversy and subsequent develop-
ment is well documented (Krueger & Markon 2014, Zachar et al. 2016) and will not be re-
peated here, except to say that the proposals generated by the group were initially rejected by the
American Psychiatric Association and placed in Section III of DSM-5, indicating they represent
an alternative model. Many explanations have been given for the original decision, but the fun-
damental reason was that the proposed classification, involving a hybrid model of categorical and
dimensional classification, was too complex to have clinical utility.
What was clear from the discussions by both the DSM-5 Work Group and the ICD-11 (In-
ternational Statistical Classification of Diseases and Related Health Problems, 11th revision) Work-
ing Group was that any revised classification had to incorporate dimensions, and our view in
the ICD-11 group was that if categories were to be used, they had to be part of a dimension,
not independent elements. This can be argued for all psychiatric disorders, but for personality
DSM-5: 5th revision disorders, the case for dimensions was overwhelming. The science of personality, with its well-
of the Diagnostic and
developed hypotheses founded on trait-based theory, unequivocally requires dimensional classifi-
Statistical Manual of
Mental Disorders cation, and even more importantly, abhors adherence to independent and unvalidated categories.
In summary, and as more fully explained below, the ICD-11 Working Group avoided the hy-
ICD-11: The 11th
brid model by having a single dimension of severity for all personality dysfunction, ranging from
revision of the
International Statistical normal (nondisordered) personality at one extreme to severe personality disorder at the other.
Classification of Diseases As personality disorder includes different types of pathology, trait domains were introduced to
and Related Health qualify severity levels without replacing them. The five traits identified were negative affectivity,
Problems anankastia (equivalent to obsessive compulsiveness), detachment, dissociality, and disinhibition,
similar to those identified by the DSM-5 Work Group, but not including schizotypy, which is
482 Tyrer et al.

considered to be part of the schizophrenia spectrum in the ICD classification. The date of onset
of personality disorder was also made more flexible, allowing the diagnosis of personality dis-
order to be made at any age. A new subsyndromal condition of personality difficulty was also
ICD classification:
identified. the World Health
Organization’s official
classification of all
DEVELOPMENT OF THE CLASSIFICATION diseases; the
International Statistical
The ICD-11 Working Group for the revision of the classification of personality disorders was
Classification of Diseases
set up in 2010 before the DSM-5 proposal was finalized. The group was chaired by Peter Tyrer, and Related Health
and its membership, with representation from all of the World Health Organization’s (WHO) Problems
regions, was selected to include expertise in the nosology of personality disorder; research on
Personality difficulty:
classification; clinical experience across the spectrum of clinical practice, from adolescence to old a subsyndromal
age; and understanding of personality traits in both normal and clinical populations. It was also felt condition, not a
necessary to have some understanding of the DSM-5 discussions, and it was agreed that Lee Anna personality disorder
Clark, a member of the Work Group for Personality and Personality Disorders, would join also. WHO: World Health
The groundwork for a new classification had been begun by the Section of Personality Disor- Organization
ders of the World Psychiatric Association, and it already hinted at a simpler dimensional classifi-
ICD-10: the 10th
cation based on severity levels and qualifying domains that could be applied across all countries revision of the
(Tyrer et al. 2010). International Statistical
The review of the classification was carried out at a time of great dissatisfaction with the Classification of Diseases
DSM-IV (Am. Psychiatr. Assoc. 1994) and ICD-10 (WHO 1992) classifications. The basic defi- and Related Health
Problems
nition of personality disorder was all but ignored by clinicians, and when personality disorder was
recorded, almost all were coded into one of three groups—borderline (emotionally unstable in PD-NOS: personality
ICD-10), antisocial (dissocial in ICD-10), or mixed or personality disorder: not otherwise specified disorder: not
otherwise specified
(PD-NOS). Something was seriously wrong with the classification system when, for example, an
official diagnosis of personality disorder in the United Kingdom was given for only 8% of psychi-
atric inpatients (Health Soc. Care Inf. Cent. 2010) and yet data showed it was present in 40–90%
of psychiatric inpatients and outpatients (Beckwith et al. 2014, Ranger et al. 2004, Tyrer et al.
2014).
The reluctance to ascribe personality disorder as a diagnosis was related to the former def-
initions, particularly in the early versions of ICD, which implied the condition was immutable,
pervasive, and untreatable, and so it became a reason for not treating patients rather than a di-
agnosis to embrace for positive reasons. This has persisted even more strongly in recent years,
with the growth of interest in trauma, so that many clinicians, and even more patients, prefer to
use the diagnosis of complex posttraumatic stress disorder (Brewin et al. 2017), a condition that is
similar to that of the former borderline personality disorder in terms of presentation, but which,
of course, requires a history of trauma before it can be used.
What was clear from the discussions in both the DSM Work Group and ICD-11 Working
Group was that there were strong arguments for making any revised classification of personality
disorder a completely dimensional one (Widiger et al. 2009). This can be argued for all psychiatric
disorders, but for personality disorders, the case for dimensions was overwhelming, and, more
particularly, there were few barriers to implementing this compared with other conditions for
which specific treatments, often psychopharmacological, depended on, or were at least linked to,
categorical classification.
We were also aware that many clinicians in the field of personality disorders liked the relative
simplicity of categorical classification and continued to believe that detailed operational criteria
were helpful in diagnosis, despite the evidence that they were incompatible with research evidence
(Livesley et al. 1992). To ensure this aspect was addressed, most of the experts we invited to join
www.annualreviews.org • Development of the ICD-11 Classification 483

the group were active clinicians as well as researchers (Mike Crawford, Alireza Farnam, Andrea
Fossati, Michaela Swales, Dušica Lečić-Toševski, Roger T. Mulder, and Nestor Koldobsky).
Domain traits:
enduring and
Initial Work of the ICD-11 Group
consistent personality
characteristics At the first meeting of the group in Geneva in April 2010, the essentials of the revised classifica-
Severity: tion were agreed. It was decided to reject the hybrid model proposed by the DSM-5 Work Group
a dimensional system at that time and instead have a single dimension of severity for all personality dysfunction, rang-
extending from normal ing from normal (nondisordered) personality at one extreme to severe personality disorder at the
personality to severe other. The main determinants of severity were the degree of interpersonal dysfunction, the im-
personality disorder
pact on social and occupational roles, cognitive and emotional experiences, and the risks of harm
Comorbidity: the to self or others. Self-pathology was addressed later. Differences in the expression of personality
simultaneous presence dysfunction were addressed by introducing domain traits, higher order traits of personality recog-
of two or more
nized in all personality systems, that qualified, but did not replace, the severity level of diagnosis.
disorders
Initially, four traits were identified, but their names changed frequently during the next few years.
PAS: Personality The original four traits were (a) negative affectivity or emotional instability, (b) anankastia or ob-
Assessment Schedule
sessive compulsiveness, (c) detachment or schizoid features, and (d) dissociality or antagonism.
Disinhibition was considered also but not added until later. These five domain traits were similar
to the DSM-5 personality trait model (Krueger & Markon 2014, Zachar et al. 2016), but did not
include schizotypy, which is considered to be a variant of schizophrenia in the ICD classification
(Handest & Parnas 2005). The date of onset of personality disorder was also felt to have been
inappropriately set at late adolescence or early adult life. Therefore, the time of onset was made
more flexible, allowing for the diagnosis of personality disorder to be made at any age. There
were discussions about the option of stating a limit to the age of onset. Perhaps understandably,
despite evidence that personality structure is formed at a young age (Elliott et al. 2011, Newton-
Howes et al. 2015), this was not pursued. It was also agreed that a new subsyndromal condition of
personality difficulty should be proposed.
Domain Traits and Severity

The driving forces behind the single spectrum of severity as the main classification of personality
dysfunction were the need to avoid the current spurious comorbidity (better called consanguinity;
Tyrer 1996) of personality disorder, and the continuing abundant evidence that when personality
disorder increased in severity it was accompanied by an increase in the domains (or categories) of
personality disorder (Blasco-Fontecilla et al. 2009, Oldham et al. 1992, Palomares et al. 2016). This
also was a partial explanation of the use of the diagnosis PD-NOS in practice: Patients who had
this disorder as well as a formal diagnosis of personality disorder had more severe symptoms than
others (Verheul et al. 2007). So clinicians, in an attempt to avoid listing many different personality
disorders when seeing complex patients, opted for PD-NOS as a compromise.
The history of the new classification began long before the first meeting of the WHO ICD-
11 Working Group. In an early phase of a long-term cohort study (the Nottingham Study of
Neurotic Disorder; Tyrer et al. 1988) involving anxious and depressed patients, a different system
of personality classification was developed that was independent of the ICD and DSM. This was
derived from the Personality Assessment Schedule (PAS; Tyrer et al. 1979), a 24-item interview
schedule that scored each trait on a nine-point scale of severity. An algorithm was then used to
classify four main clusters and nine subclusters of personality groups (Tyrer et al. 1988). In the
Nottingham study, categorical clusters from the PAS and severity classifications of personality
disorders were measured at baseline, and their impact on outcome was assessed after 10 weeks
484 Tyrer et al.

(Tyrer et al. 1990) and then regularly for up to 12 years. The first severity classification divided the
population into six groups (Tyrer & Johnson 1996): no personality disorder, personality difficulty,
simple personality disorder (patients with scores above the threshold for personality disorder but
in only one cluster), combined personality disorder (as for simple disorder, but with high scores
in more than one cluster), severe personality disorder (patients with high severity scores in only
one cluster), and gross personality disorder (high severity scores in more than one cluster). The
assumption made in creating this classification system was that those in the combined group would
have less pathology than those with a single cluster in the severe personality disorder group and
less than those in the gross personality disorder group (this last group had only seven patients, or
3.5% of the total; Tyrer et al. 1990).
The results after 2 years disproved this hypothesis. In general, there was a worse outcome in
those with personality disorder than in those without the disorder, but those in the combined
disorder group had a worse outcome than those in the severe group (Tyrer & Johnson 1996;
Figure 1). Thus, the number of pathological domains was a better measure of severity than the
individual scores in any one cluster. When the classification was changed to accommodate this,
there was better consistency of outcome (Figure 1).
This study was critical in determining the need to abandon the categorical system in revising
ICD-11. Some might argue that the operational guidelines for each category could be altered to
30 30
Comprehensive psychopathological rating scale
25 25
(back-transformed scores)
20 20
15 15
10 10
5 5
0 0
0 1 2 0 1 2
Time (years) Time (years)
Personality assessment schedule Suggested new classification system
No personality disorder (N = 74) No personality disorder (N = 74)
Personality difficulty (N = 32) Personality difficulty (N = 32)
Personality disorder (N = 29) Simple personality disorder (N = 40)
Combined personality disorder (N = 13) Diffuse personality disorder (N = 17)
Severe and gross personality disorder (N = 15)
Figure 1
Evidence from the Nottingham Study of Neurotic Disorder (Tyrer et al. 1988) that the outcome at 2 years
was worse in those with disorders that were less severe but included more pathological domains. Note: The
Comprehensive Psychopathological Rating Scale covers all psychopathology, and a score of 15 is considered
abnormal. Adapted with permission from Tyrer & Johnson (1996).

avoid overlap, but because there was a consistent increase in the number of categories into which
patients were placed when personality disorder became more severe, it was clear that the value of
individual categories of disorders was severely curtailed or nullified.
A related problem arose in discussions about the definition of different levels of personality
disorder. However one viewed personality abnormality—whether in terms of traits, characteristics,
or categorical diagnosis—there was consistent evidence that greater severity was associated with
more pathological domains. But the general principle of the classification of all mental disorders in
ICD-11, articulated most clearly by Michael First at our meetings, was that the parent disorders
(the higher ranks) should not include characteristics from a lower rank (the children) in their
definition. So we were encouraged to exclude any mention of domains in defining severity. But
time after time we came across data in our own pilot studies that contradicted this. In the end it
was agreed that the children could join the parents covertly, without being mentioned specifically
in the language of the domains, and this was stated in the approved online version of ICD-11. For
example, the definition of severe personality disorder in the classification (WHO 2018, section
titled Severe Personality Disorder) includes the sentence, “Specific manifestations of personality
disturbance are severe and affect most, if not all, areas of personality functioning.”
At the first meeting of the ICD-11 Working Group, there was universal approval of the revised
system, and it is relevant to add that this level of agreement was maintained throughout all meet-
ings of the group; in this respect, there was much less controversy than in the similar discussions
that emanated from the DSM-5 Work Group (Zachar et al. 2016). The severity classification, with
its acknowledged primacy in the classification system, was embraced unequivocally, and the only
debate in the group was about the trait domains. In particular, the position of disinhibition was
disputed, although argued for strongly by Lee Anna Clark. Some members felt disinhibition was
more a measure of the severity of personality disturbance than a separate trait. This was a subject
that was hoped to be resolved by field trials, and vignettes were prepared for these, but they have
not yet been tested. Analyses of other data sets using the new classification, discussed in more de-
tail in the section Derivation of ICD-11 Domains, gave strong support for the separateness of the
domains of anankastia and detachment, with adequate, but slightly less, support for dissociality.
The domain of negative affectivity was not well separated, and this might have been predicted
because it includes anxiety and dependence as well as the other moods of anger, frustration, and
irritability. When an assessment was made of borderline features, the domain structure seemed to
disintegrate, and examining the full implications of this involved a great deal of the group’s time
and early studies.
Initial Reaction to the Classification

The first explanation of the rationale behind the proposed classification was published in 2011
(Tyrer et al. 2011c). The criticisms accompanying its publication in Personality and Mental Health
were not as strong as expected. The major concerns were that the proposal was too radical and
represented too great a change in an established system, and our group was expecting this crit-
icism. At the same time, the group felt strongly that there could not be a place for categories
that were rarely used in practice and had no evidence base or scientific status apart from group
consensus. But categories had existed for personality disorder ever since they were first proposed
by Kurt Schneider (1950), and most clinically oriented research had been linked to them. Thus,
it was not surprising that Kate Davidson (2011, p. 244) commented that the proposal appeared
to “undermine the significant research and clinical advances that have been gained over the last
30 years.” John Gunderson and Mary Zanarini (Gunderson & Zanarini 2011, p. 260) were more
pointed, stating that the classification followed the “still unproved idea that normal personality
486 Tyrer et al.

offers a valid bridge to the structure of abnormal personality.” They were also skeptical that any
committee could increase the usage or clinical utility of the classification of personality disorder
without much more clinical testing. Anthony Bateman (2011) and Andrew Chanen (2011) recog-
nized advantages in focusing on severity, but were particularly concerned about the fate (i.e., the
absence) of borderline personality disorder in the classification and the implications this would
have for therapy.
Two other commentators favored the new approach while still expressing reservations.
Antonia New (2011) thought the main severity dimension, extending from normal personality
through to personality difficulty and on to personality disorder, entirely succeeded because it im-
proved clinical utility and removed comorbidity. John Livesley (2011), always a constructive but
exacting commentator, felt that the proposal was moving in the right direction, but there was a
need to decide on the key differences between interpersonal and general social dysfunction, to
pay attention to self-pathology in personality disorder, and to decide to what extent personality
disorder was a relationship disorder. John was also concerned about the option for practitioners
to allow the classification of personality disorder to end at the severity level of classification with-
out adding the domain qualifiers. Although we understood his concerns, we were also aware, and
were reminded of this by our working group representatives from low-income countries, that most
practitioners around the world who come across patients with personality disorders will have had
very little in training in the subject. These practitioners include most general practitioners, the se-
nior nurses who substitute for doctors when none are available (Mendenhall et al. 2014), and a host
of other health practitioners, ranging from n’angas in Africa to shamans in India and curanderos
in South America, who carry out treatments based on various forms of diagnostic procedures.
These are not practitioners who will ever sit down and study psychiatric classification manuals
but who, nonetheless, have some understanding of the major groupings of mental disorder that
determine the particular interventions that they use (Tyrer 2013). The ICD-11 gives practition-
ers the relatively easy option of recording personality status on the severity dimension without
further qualification. This can be both useful and important: If someone is diagnosed with severe
personality disorder, it can lead to appropriate action to protect the public as well as the person.
Some criticism was hardly surprising given that the existing classification, despite its many
imperfections, had been used more or less unchanged for more than 40 years, and a major change
was bound to be a wrench for those who were steeped in familiarity. What was also clear from the
commentaries and the literature at that time, was the complete absence of any real alternative that
would gain wide acceptance. In responding to the criticisms, the Working Group maintained with
some force that the new proposal was evidence based to a much greater extent than the existing
categorical system and that what purported to be clinical evidence in favor of categories had not
proved to be so (Tyrer et al. 2011b).
After the publication of the rationale behind the classification, there was little further published
comment during the next 5 years. But the working party appreciated the need to carry out studies
to test the suitability and feasibility of both the severity levels and domain structure. It is not widely
known that WHO does not have external funding to support such studies and those mounted were
all internally funded.
The classification for the severity of personality disorder was tested retrospectively and
prospectively. The retrospective aspect derived from the previous randomized trial (the Notting-
ham study), begun in 1983 and with its personality data first published in 1990 (Tyrer et al. 1990).
In this study, the short-term outcomes of five treatments for anxiety and depressive disorders
were tested, as were the effect of personality status on symptomatic and functional outcomes in
the medium- (Tyrer et al. 1992, 1993, 2016a) and long term (Seivewright et al. 1998, 2004; Tyrer
et al. 2016b). Personality status at baseline was assessed using the PAS (Tyrer et al. 1979, 2004b).

Although this instrument is independent of the ICD and DSM classifications, it was used to deter-
mine whether good agreement could be reached between an ICD-11 diagnosis and the baseline
data obtained by the PAS because the PAS records the severity of personality disturbance in a way
that is similar to the ICD-11 proposal (Tyrer et al. 1990). Two independent investigators were
given the PAS data and a range of baseline data from the Nottingham study and asked to reclas-
sify personality status using the proposed ICD-11 severity guidelines available at that time (Tyrer
et al. 2011c). Agreement between these two investigators was high (κ = 0.93; Tyrer et al. 2014).
Once full agreement was successfully achieved with the help of two additional investigators, who
helped to achieve consensus, the algorithm for the personality assessments was adjusted to the
ICD-11 system. In the 2014 study, personality assessments were reported at baseline, 2 years, and
12 years, and their influence on outcome was assessed at 12 years.
An earlier analysis had shown that the domains of personality had changed for participants
during the 12-year period, with the schizoid domain (detached in the new nomenclature) becom-
ing more prominent as people aged (Seivewright et al. 2002). Further analysis showed that those
who had moderate or severe ICD-11 personality disorder at baseline had significantly worse out-
comes at both 2 and 12 years than others, particularly with regard to social functioning (Tyrer et al.
2016b). Their personality disturbance during the 12-year period was also significantly more per-
sistent than it was in those with mild personality disorder at baseline (Tyrer et al. 2016b). Together,
these findings showed that a spectrum of personality disturbance, from mild to severe pathology,
was accompanied by a similar grading in terms of long-term functioning, symptomatology, and
also in health service use and cost (Knerer et al. 2005, Yang et al. 2010).
Further prospective studies of the clinical and public health value of the severity dimension.
The advantages of classifying personality disturbance by severity have been shown in other studies.
People with more severe personality disturbance are more likely to self-harm and to do so at
greater frequency (Blasco-Fontecilla et al. 2009; Tyrer et al. 2004c), to have mood episodes in
bipolar disorder (Ng et al. 2017), to have a greater frequency of disorganized attachment (Beeney
et al. 2017), to respond less well to treatment unless it is highly attuned to specific pathology
(Bateman & Fonagy 2013, Kvarstein et al. 2019), and to have a greater degree of comorbid mental
pathology and social dysfunction (Conway et al. 2016).
Personality difficulty. Personality difficulty is also defined in the formal ICD-11 classification
even though it is not a personality disorder. The definition emphasizes that the personality dis-
turbance is intermittent and often confined to limited situations.
Personality difficulty refers to pronounced personality characteristics that may affect treatment or
health services but do not rise to the level of severity to merit a diagnosis of personality disorder.
Personality difficulty is characterized by long-standing difficulties (e.g., at least 2 years) in the individ-
ual’s way of experiencing and thinking about the self, others and the world. In contrast to personality
disorders, these difficulties are manifested in cognitive and emotional experience and expression only
intermittently (e.g., during times of stress) or at low intensity. The difficulties are associated with some
problems in functioning, but these are insufficiently severe to cause notable disruption in social, oc-
cupational, and interpersonal relationships and may be limited to specific relationships or situations
(WHO 2018, section titled Personality Difficulty).
There have been several studies illustrating the importance of personality difficulty in psy-
chiatry and public health. It seems to be highly prevalent (Yang et al. 2010), and although more
studies are needed it seems likely that, when the full range of personality disturbance is taken into
488 Tyrer et al.

account, a majority of the population will have some personality disturbance. This should come
as no surprise. The high prevalence of PD-NOS in the United States, a condition that includes
subsyndromal as well as puzzling comorbid disorders (Verheul & Widiger 2004), is in keeping
with this finding. Although there are obvious concerns about attributing pathology to normal hu-
man variation, there are good data from several studies showing that personality difficulty creates
significant distress, increases health service use, and impairs social functioning among those with
personality difficulty compared with those who have no personality disorder (Karukivi et al. 2017,
Sanatinia et al. 2016, Yang et al. 2010). Personality difficulty also may be important in detect-
ing early personality pathology in adolescents with self-harming behavior (Ramleth et al. 2017).
There is also an increased cost associated with this greater dysfunction, with longitudinal studies
showing a 7–10% increase in total costs among those with personality difficulty compared with
those with no personality disorder (Knerer et al. 2005, Sanatinia et al. 2016).
Value of the severity classification in therapeutic research. A classification of mental disor-

ders should not be specifically tailored to treatment, but it can be a useful measure of clinical
utility. Therefore, personality status was recorded in a large, randomized controlled trial of the
effectiveness of an adapted form of cognitive behavioral therapy (CBT) for patients with health
anxiety who were attending medical clinics (Tyrer et al. 2011a, 2017). This study was particularly
relevant because preliminary work suggested that those with different levels of personality distur-
bance might have different outcomes (Tyrer et al. 1999, 2013). There was also a growing literature
suggesting that, despite some early doubt (Kool et al. 2005, Mulder 2002), in common disorders,
such as depression and anxiety, personality disorder of any severity hindered a positive outcome
(Newton-Howes et al. 2006, 2014; Skodol et al. 2014).
The study assessed personality status using a precursor of the ICD-11 proposal, the Quick
Personality Assessment Schedule (Tyrer 2000, Appendix 3), which includes verbal responses to
the main questions as well as numerical scores determined by the clinician. During the course
of the study, these scores were converted to the ICD-11 severity classification by independent
assessors (Sanatinia et al. 2016) who were ignorant of the scores up to that point.
Both the short-term and long-term results of the trial were in complete contrast to previ-
ous studies. We had expected those with personality disorder to fare poorly compared with those
with no personality disturbance and for CBT to be less effective for people with personality dis-
order. But in the first 6 months, those with no personality disorder who had CBT had a worse
outcome than all other groups, and after 2 years, those with personality difficulty and mild per-
sonality disorder had the best outcome with CBT compared with standard treatment (Sanatinia
et al. 2016). These differences between CBT and standard treatment in the two intermediate per-
sonality groups were more than maintained at 5-year follow-up, with those assessed as having
mild personality disorder at baseline having the best outcome (Tyrer et al. 2017; Figure 2). De-
pendence was also identified as an important personality trait in the study and was assessed using
the Dependent Personality Questionnaire (Tyrer et al. 2004a). Similar results were obtained, with
increasing levels of dependence being associated with the best outcomes in the CBT group (Tyrer
et al. 2016c). Subsequent analysis showed that people in the high-dependence groups were less
likely to drop out and had more treatment sessions than people in the other groups (Tyrer et al.
2016c).
The results showed the advantage of recording the outcome of treatment by level of disorder
severity not just by the overall absence or presence of personality disorder. If the old dichotomous
classification had been used, it is likely that no difference between the groups would have been
detected because the poorer results of those with no personality disorder or moderate or severe

Personality severity score = 0 Personality severity score = 1

0
Mean change in HAI score

–2.5
–5.0
–7.5
CBT-HA CBT-HA
Standard Standard
–10
Personality severity score = 2 Personality severity score = 3–4

0
Mean change in HAI score
–2.5
–5.0
–7.5
CBT-HA CBT-HA
Standard Standard
–10
0 6 12 18 24 0 6 12 18 24
Months Months
Figure 2
Mean change in scores on the short version of the Health Anxiety Inventory (HAI) after randomization to
cognitive behavioral therapy adapted for health anxiety (CBT-HA) or standard treatment, by personality
disorder status: no personality dysfunction (personality severity score = 0; n = 63), personality difficulty
(personality severity score = 1; n = 197), mild personality disorder (personality severity score = 2; n = 142),
and moderate or severe personality disorder (personality severity score = 3–4; n = 42). The mean scores of
this population were 25; a reduction of 7 points or more indicates that a person no longer meets the level of
pathology.
personality disorder would have obscured the differences. This is an important finding in favor of
the classification, but it needs replicating in other populations.
Other studies followed the initial 2010 meeting. In South Korea, two studies were carried out
to examine the reliability and utility of the severity levels and domain structure (Kim et al. 2014,
2015). Kim et al.’s (2014) first study, based on an algorithm for severity levels developed in the
initial proposal (Tyrer et al. 1990), suggested that the severity classification had good construct
validity, with higher levels of social dysfunction associated with greater severity of personality
disorder. Test–retest reliability was also good. The second study (Kim et al. 2015) examined the
domain structure using discriminant function analysis and comparison with other personality sys-
tems, including the five-factor model. The results showed that the anankastic domain had the best
discrimination and the emotionally unstable the least. Some changes were made to the wording of
the domains, and negative affectivity replaced the descriptors emotionally unstable, anxious, and
dependent.
It was also decided to develop a brief screening tool for assessing personality disorder according
to the initial ICD-11 criteria (Tyrer et al. 2011b). This provided another opportunity to examine
the reliability of the proposed levels of severity for personality disorder.
490 Tyrer et al.

Developing this tool involved asking two independent raters to judge the level of sever-
ity of personality disorder in 110 patients attending outpatient psychiatric services in London
(England) and Wellington (New Zealand). Raters were presented with information on each pa-
tient regarding their personality, social functioning, and history of harm to self and others, and
asked to use ICD-11 criteria to assign each to no PD, or mild, moderate, or severe PD. Each pairing
of raters was selected from a pool of nine clinicians from four countries. Agreement between the
two independent raters was moderate (weighted κ = 0.50; 95% confidence interval, 0.36 to 0.64;
p < 0.001; Olajide et al. 2018).
Developments from 2015 Onward

A series of papers on personality disorder was commissioned by the Lancet in 2014, and this in-
cluded one describing further revisions of the classification (Tyrer et al. 2015). Again, there was
little reaction to this publication, although it generated more interest generally, and the new clas-
sification was given prominence in a United Kingdom television adaptation of a novel, Apple Tree
Yard (Doughty 2013), wherein the dimensional nature of personality disorder is critical in deciding
the level of responsibility of a murder suspect.
In 2016, Personality and Mental Health published a series of studies that used the ICD-11 cri-
teria. These supported the utility of the severity spectrum (Kim et al. 2016, Tyrer et al. 2016b)
and showed how an assessment of personality status from written information could be made with
reasonable accuracy and be consistent with ICD-11 criteria (Kim et al. 2016), with one also illus-
trating how a single trait, such as dependence, could be assessed using a similar severity spectrum
(Tyrer et al. 2016c). Two commentaries accompanying this publication were supportive. Krueger
(2016, p. 119) not only praised the new dimensional approach in ICD-11 but also mentioned its
clinical value, “Ultimately, thinking about new dimensional ways of conceptualizing personality
pathology is likely to lead to new insights into case conceptualization and, in this way, to new
ways of helping our patients.” Widiger & Oltmanns (2016, p. 121) added, choosing their words
cautiously, that the ICD-11 proposal was “close to approving a paradigm shift in the classification
of personality disorder.”
DERIVATION OF ICD-11 DOMAINS

Analysis of Domain Structure
Although there was already a considerable literature on the main higher order domains of per-
sonality in a dimensional system (Krueger & Markon 2014, Widiger & Trull 2007), illustrated
in particular by the work of Lee Anna Clark (2007), a member of our group, we also wanted
to examine a range of data from clinical populations to assess the proposed domains. Initially, a
systematic review was undertaken of studies that had performed analyses to identify pathologi-
cal personality domains in samples of patients (Mulder et al. 2011). This review concluded that
despite differences among the samples of patients, in the assessment of personality, and the statis-
tical methods used, there were reasonably (some might say remarkably) consistent findings. There
appeared to be between three and five higher order dimensions. All studies reported an external-
izing and internalizing dimension. Nearly all noted a schizoid or detached dimension, consisting
of social indifference, restricted expression of affect, and, often, odd behaviors. Most reported a
domain encompassing obsessive–compulsive or anankastic personality traits, which split from the
internalizing dimension as a coherent and reasonably independent domain. Finally, a fifth domain
associated with disinhibition or impulsivity was reported in some studies, but not all.

Interestingly, and despite its independent derivation, these ICD-11 domains are similar to the
DSM-5 alternative model for personality disorders. The DSM-5 Section III model proposes 25
trait facets organized as five trait domains that are called negative affectivity, detachment, antago-
ESSPD: European
Society for the Study nism, disinhibition, and psychoticism, and these link well to the five-factor model (Gore & Widiger
of Personality 2013). The only significant difference in ICD-11 is that psychoticism is replaced by anankastia.
Disorders This reflects the fact that WHO considers psychoticism to be part of the schizophrenia spectrum
(i.e., schizophrenia spectrum disorders) rather than personality disorder phenomena.
The radical change in describing personality pathology proposed by the ICD-11 Working
Group made it important to test the five domains expeditiously. A large sample of depressed out-
patients (n = 606) with data obtained using the Structured Clinical Interview for DSM-IV Axis II
Personality Disorders interview (First et al. 1997) was used to test the domains (Mulder et al. 2016).
DSM personality disorder symptoms were independently assigned to the ICD-11 domains, and a
confirmatory factor analysis in an exploratory framework was used. The best-fitting model pro-
duced five domains. The anankastic and detached domains closely matched the ICD-11 proposal.
A separate dissocial domain was also identified. The negative affective and disinhibited domains
were less distinctly represented.
A study by Bach et al. (2017) used the DSM-5 alternative model personality disorder traits to
describe the proposed ICD-11 domains. They reported that the ICD-11 trait domains and the
DSM-5 Section III trait domains were largely commensurate. The proposed ICD-11 traits were
organized in a hierarchical meta-structure, with internalizing and externalizing psychopathology
at the top and the five domains at the lower level. As the authors and others (Gore & Widiger
2013) noted, these domains may in part be interpreted as pathological extremes of the five-factor
model’s dimensions. Negative affectivity is linked with high neuroticism, detachment with low
extraversion, disinhibition with low conscientiousness, dissociality with low agreeableness, and
anankastia with high conscientiousness.
Further studies evaluating the domains have been conducted in Korea and Iran, allowing
for cross-cultural comparisons. The Korean study showed good discrimination for detachment,
anankastia, and dissociality, but it was less good for negative affectivity and disinhibition (Kim
et al. 2015); and the Iranian study replicated the findings of Bach et al. (2017), reporting a sound
five-factor structure for the ICD-11 domains (Lotfi et al. 2018). Both studies suggest that the pro-
posed domains are valid across different cultural groups. These consistent data can be regarded as
a major improvement over the 10 categories currently used in ICD-10.
In summary, the proposed ICD-11 domains capture most of the essential information of the
established categorical personality disorders. The domains are also compatible with the trait do-
mains in the DSM-5 Section III personality disorders model. The ICD domains are superior in
capturing obsessive–compulsive personality disorder, whereas the DSM-5 domains are superior in
representing schizotypal personality disorders, but the domains of the two systems are potentially
in harmony. In addition, the ICD domains are able to be related to normal personality traits via
the five-factor model and appear to be cross-culturally represented.
Subsequent Reactions to the Proposal

In December 2016, a letter was sent to Geoffrey Reed, the key person involved in revising the
ICD-11 classification of mental and behavioral disorders, asking for the revised classification to
be rejected. This letter was sent by the chair, vice-chair, and secretary of the European Society
for the Study of Personality Disorders (ESSPD). The key criticisms made in the letter were that
(a) the new classification was too radical and had not been tested; (b) the body of knowledge that
had been developed during recent years, particularly in respect to borderline personality disorder,
492 Tyrer et al.

was in danger of being lost or distorted by a new description; and (c) previous criticisms of the
classification had not been addressed.
This last point is important because between 2011 and 2016 we were unaware of any published
ISSPD: International
criticisms of the classification. The details of the classification had been presented at international Society for the Study
meetings across the world, and some disquiet had been expressed about the loss of borderline of Personality
personality disorder, especially with regard to funding for this diagnosis, but there was no analysis Disorders
or rebuttal of the proposal from any recognized authority.
Although the ESSPD letter was widely circulated, it was not published despite requests for it
to be placed in the public domain along with a response. Subsequent to the criticisms in the letter,
another version was published with a more considered tone (Herpertz et al. 2017). In addition
to the previous comments made by the ESSPD, and supported by some members of the Interna-
tional Society for the Study of Personality Disorders (ISSPD), Sabine Herpertz and her colleagues
added a fuller description of the worries that had been expressed. In summary, these were that no
description of a well-functioning personality had been described, that the general categorization
of personality disorder had not been tested adequately, that suffering as opposed to functioning
was not in the definitions, that it was the trait domains that would ultimately decide clinical man-
agement, that relationship dynamics were ignored, and that clinicians in the field much preferred
prototype models of personality disorder.
Much of the criticism had in fact been answered by the ICD-11 proposal. The spectrum of
severity was to be paramount in the classification to reduce the impact of a dichotomous no per-
sonality disorder/personality disorder system, and with five options to classify, including personal-
ity difficulty, improvement in personality function could be measured more effectively. Although
suffering is an important clinical feature, it is not normally given any form of personal accen-
tuation in classification, but the domain of negative affectivity incorporates this. We agree that
the specific interventions used to treat personality disorder will rely on the trait domains, but the
decisions of when to treat and how can be decided by the severity level. If more than 1% of the
population has a condition currently described as borderline personality disorder, it might not be
appropriate for all of them to have an intensive intervention, such as dialectical behavior therapy,
but until treatment is tested at different levels, we will not know. While relationship dynamics are
clearly important, they are part of the interaction between therapist and patient, not part of the
process of classification.
The evidence from the factor analytic studies, demonstrating that what is called borderline
covers several domain traits, shows that we have a heterogeneous diagnosis that needs a properly
planned enquiry; the domain structure allows this enquiry to take place. It will allow testing of the
hypothesis that the borderline features are themselves indicative of greater severity because they
involve several domains. Indeed, there are already suggestions that this might be the case (Clark
et al. 2018). As borderline personality disorder is not only heterogeneous with respect to other
personality disorders but also overlaps with mood, stress, and dissociative disorders, trait domain
studies can also help us decide to what extent the condition should remain within or be separate
from the personality grouping.
We also surmised that the domain structure would help to better assess the high current co-
morbidity of borderline, antisocial, and impulse control disorders. There are already good data
showing that when antisocial (dissocial) and mood features are prominent in patients who other-
wise satisfy the categorical diagnosis of borderline personality disorder, the nature of the disorder
becomes fundamentally different, as does its prevalence in different settings and its management
(Coid 1993, Freestone et al. 2013, González et al. 2016). There are insufficient data in most of
the literature to evaluate this fully; far too many studies require only that participants satisfy the
requirements for borderline personality disorder without considering other personality pathology.

The criticisms of the ESSPD and ISSPD groups also stimulated others to defend the dimen-
sional classification of personality disorder, including a powerful group, those involved in the Hi-
erarchical Taxonomy of Psychopathology (known as HiTOP), of whom 49 signatories argued
strongly that a dimensional framework for personality disorder was clearly preferable as it was
unequivocally evidence based (Hopwood et al. 2018).
THE BORDERLINE CONTROVERSY

Bridging the Gap
A degree of consensus subsequently emerged. It was felt that a smaller group of the ICD-11 Work-
ing Group should meet with a similar grouping from ESSPD and ISSPD. Peter Tyrer voluntarily
excluded himself as he had previously expressed doubts about the status of borderline personal-
ity disorder (Tyrer 1999, 2009). Despite admitting this concern, he had been chosen to chair the
guideline development committee on this subject for the United Kingdom’s National Institute for
Health and Care Excellence (NICE 2009).
In deciding where to compromise, the main sticking point was clear. When the long list of
concerns expressed about the ICD-11 classification was distilled to the core elements, it was the
loss of borderline personality disorder that was the most disturbing. When the ICD-11 proposal
was criticized as too radical, lacking clinical utility, or abandoning the advances in treatment that
have happened during the past 30 years, it was almost always with borderline personality disorder
as a subcontext.
Whatever one’s views about the usefulness of this diagnosis, and there are few who feel neu-
trally about the subject, there is no doubt that it has helped research in the area enormously.
Research studies into borderline personality disorder have far outnumbered those for other cat-
egorical diagnoses (Blashfield & Intoccia 2000). They have also led to greater optimism about
treatment. Research into the disorder has also stimulated much work on etiology, particularly re-
lated to trauma and abuse, and led to advances in neuropsychology (Luyten & Fonagy 2015). In
many countries, borderline was the only personality disorder diagnosis that attracted reimburse-
ment for treatment from insurance providers.
The major problem with borderline personality disorder is the limited research on its classi-
fication. This has been true since its inception, and, despite the wide use of the nine operational
criteria in the DSM classifications, there has been no independent verification of these or, indeed,
of the diagnosis itself. It is also fair to add that despite all the support for borderline personality
disorder as a concept or as a clinically useful diagnosis, there has been a notable absence of sound
scientific evidence that it is a unified syndrome.
During the original ICD-10 discussions in the 1980s, there was a strong wish to omit the bor-
derline concept entirely (Charles Pull, personal communication), but eventually it was included
under the main title of emotionally unstable personality disorder, where it shared a subdiagno-
sis with impulsive personality disorder (a separation of diagnostic groups that has not received
any support) (Whewell et al. 2000). Despite this lack of evidence—the diagnosis was created
only by an expert committee—the concept of borderline personality disorder has a strong clin-
ical attraction. Although borderline is clearly a heterogeneous diagnosis, there are attractions in
having a diagnosis for all seasons. It can be used to explain behaviors such as self-harm, to ex-
clude patients from the standard treatments for other diagnoses, to offer treatments for the con-
dition itself, and to recruit patients to research trials or services because it is so prevalent, and
it has a sufficiently robust intervention base to allow insurance companies to issue contracts for
treatment.
494 Tyrer et al.

The counter-argument used by the ICD-11 Working Group in defending the new classification
was that the borderline concept could be embraced readily within the proposed domain structure
and that would also enable researchers to decide its relationship to other disorders. Borderline
personality disorder has genetic links to bipolar disorder (Witt et al. 2014), can be regarded as a
syndrome of emotional dysregulation linked to other mood disorders (Glenn & Klonksy 2009),
and has strong links to antisocial behavior, predominantly in forensic samples (Tyrer & Mulder
2018).
A recent study in adolescents supported the concept that borderline personality disorder can
be separated into externalizing and internalizing subtypes by executive function (Kalpakci et al.
2018). Because externalizing and internalizing characteristics are opposing central domains of per-
sonality, it is difficult to reconcile these findings with the concept of a distinct personality entity or
domain. The ICD-11 domain structure suggests that the characteristics associated with border-
line personality disorder are distributed across three domains—negative affectivity, disinhibition,
and dissociality—and there is no specific borderline domain. Our expectation, which needs test-
ing in further trials, is that individuals with mild personality disorder will display largely negative
affective symptoms, whereas those with more severe disturbance will also have disinhibited and
dissocial behaviors. There is already some indication that most patients with borderline personal-
ity disorder who are formally diagnosed and in psychiatric care have greater severity and pathology
across several domains (Crawford et al. 2018, McMurran et al. 2017).
Originally, it had been hoped that the use of the severity levels and domain structure in the
ICD-11 revision might be sufficient to satisfy the critics, but these were quickly rejected without
much discussion. The ICD-11 Working Group had powerful arguments to put forward. Although
the classification was alleged to be radically simple, it is multifaceted. The combination of mild,
moderate, and severe personality disorder together with personality difficulty and the five domain
traits can create nearly 500 different diagnostic outcomes. The classification has particular rele-
vance to forensic psychiatrists, as they deal with the most severe personality disorders. In meetings
of the ICD-11 Working Group forensic psychiatrists also took part. Despite a continuing interest
in the notion of psychopathy (which is not embraced by any formal classifications), the combina-
tion of the dissocial with other domains was felt to offer sufficient scope to include the essentials
of psychopathy, which itself is felt to be on a spectrum of antisocial personality (Coid & Ullrich
2010).
Solution to the Borderline Question

The need to achieve an amicable resolution to the problem of the borderline question was taken
seriously by the ICD-11 Working Group and the ESSPD. Nobody wished to preserve the old
ICD-10 classification, but some felt the cost of losing the borderline diagnosis was worse than
retaining the status quo. The subsequent discussions with the ESSPD group over the fate of bor-
derline in the classification were led by Geoffrey Reed, Lee Anna Clark, Roger Mulder, Michaela
Swales, and Mike Crawford. Eventually, it became clear that no agreement could be reached with-
out an acknowledgment of the essential substance of borderline personality disorder.
It was also agreed that the essentials of the ICD-11 classification would remain intact and that
even if the borderline description was included as a diagnosis, it would not replace the main sever-
ity definitions. Despite accepting the introduction of borderline to the classification, all agreed
that this was an exception that could not be extended to any other personality disorder grouping.
By making this exception, we recognized it was important to maintain the impetus of research
and the clinical development utility of the borderline concept and, particularly, to facilitate the
identification of individuals who may respond to certain psychotherapeutic treatments. We also

recognized that having the original ICD-11 and borderline option side by side in the classification
structure would be a useful paradigm for researchers, allowing these options to be compared in
future studies.
The wording of the borderline terminology may look clumsy, but it was carefully constructed.
A practitioner who feels that the severity–domain structure is inadequate has the option of using a
borderline pattern descriptor, which is essentially an updated rewording of the ICD-10 description
of emotionally unstable personality disorder.
The borderline pattern descriptor may be applied to individuals whose pattern of personality distur-
bance is characterized by a pervasive pattern of instability of interpersonal relationships, self-image,
and affects, and marked impulsivity, as indicated by many of the following: Frantic efforts to avoid
real or imagined abandonment; A pattern of unstable and intense interpersonal relationships; Identity
disturbance, manifested in markedly and persistently unstable self-image or sense of self; A tendency
to act rashly in states of high negative affect, leading to potentially self-damaging behaviors; Recur-
rent episodes of self-harm; Emotional instability due to marked reactivity of mood; Chronic feelings of
emptiness; Inappropriate intense anger or difficulty controlling anger; Transient dissociative symptoms
or psychotic-like features in situations of high affective arousal (WHO 2018, section titled Borderline
Pattern).
FUTURE DIRECTIONS
Any classification that departs from accepted norms has to be tested critically and thoroughly
in the years after its introduction. Until the evidence supports its use, every such classification
should be regarded as being on probation only. The watchwords of the ICD-11 classification are
clinical utility, and while this is an elastic term having several different interpretations (as can
be seen from comments in this article), the extent to which the classification system fits with
clinicians’ thinking is a key factor (Reed et al. 2013). If there is congruence here, the ICD-11
classification of personality disorders will be used much more widely than the ICD-10 equivalent
and its use will not be confined to only one or two areas. There is going to be a problem with formal
classification now that Axis II has disappeared from the DSM system and there is no equivalent in
ICD-11 (Newton-Howes et al. 2015). There is concern that clinicians will not record personality
status even when they recognize there is personality disturbance present because the main mental
disorder will take precedence. Our suspicion is that only moderate or severe levels of personality
disorder will be recorded, and in some countries only the severe level will be. This is unfortunate
because personality status may be the main driver in persistent or recurring disorders, such as
depression and anxiety (Berk et al. 2018, Tyrer 2015).
Another area that will need to be addressed is to answer the question that is asked repeatedly by
practitioners who want to take shortcuts, “Is there a questionnaire or scale we can use to diagnose
personality disorder?” This is not the place to go into detail about the difficulties of devising such
instruments, but already we have the Standardized Assessment of Severity of Personality Disorder
(Olajide et al. 2018) for assessing severity and the Personality Inventory for ICD-11 for assessing
the domains (Oltmanns & Widiger 2018). One of the authors (Y.-R.K.) has just completed a study
with nearly 650 psychiatric patients in which a new instrument for recording personality status
(the Personality Assessment Schedule: ICD-11 Version) has been used to examine the ICD-11’s
factor structure, its relationship to the Big Five Model, and its internal consistency.
The most difficult area is the one that has aroused the most controversy: the position of bor-
derline personality disorder. The ICD-11 Working Group feels this is an excellent opportunity
to compare diagnostic assessments using the approved severity–domain model and the border-
line pattern descriptor. Our hope, and it may be an unrealistically optimistic one, is that once
496 Tyrer et al.

practitioners realize that all relevant borderline pathology can be recorded equally well using the
standard classification, then the borderline pattern descriptor will become less needed. But bor-
derline has a long pedigree, and doubtless it will survive until we have more powerful evidence to
validate the classification.
CONCLUSIONS
The ICD-11 Working Group for the revision of the classification of personality disorders was a
harmonious one that had a common purpose: to provide a classification that was easily understood,
could be readily used by practitioners of all disciplines, and that allowed all people with person-
ality disturbance to be recognized. Its two-stage elements—with severity level as the primary and
domain traits as the secondary—represent a dimensional classification that also has clinical and re-
search utility. Despite concern about its radical nature, it has been generally accepted in principle,
and the main concern has been expressed by supporters of the borderline concept. As a conse-
quence, a borderline pattern descriptor has been introduced to the classification as an option that
can be used once severity levels have been determined. By having the option of using trait domains
to describe the pathology of borderline as well as a pattern descriptor, the classification offers the
opportunity for comparisons to be made in clinical and research practice, and this should enhance
knowledge in a complex area of mental pathology.
SUMMARY POINTS
1. There are multiple reasons for opting for a fully dimensional classification of personality
disorders, including empirical support and clinical utility.
2. Comorbidity in personality disorders is a measure of increased severity.
3. Severity provides the most useful dimension for clinicians to consider and the revision
includes a subsyndromal condition of personality difficulty.
4. Five personality trait domains serve as qualifiers of severity, with links to the five-factor
model of general personality and the DSM-5 Section III dimensional trait model.
5. Multiple field trials support the classification system.
6. The arguments against the ICD-11 classification mainly reflect a desire to retain bor-
derline personality disorder.
7. Resolution of the borderline debate has been achieved by introducing the option of a
borderline pattern descriptor but only after severity levels have been determined.
FUTURE ISSUES
1. It will be important to ensure that the classification is understood by all health profes-
sionals in all countries in view of the high prevalence of personality disorders.
2. Personality status should be part of an assessment and recorded, even if it is not consid-
ered to be the main pathology.
3. Further field studies are needed to help determine severity thresholds and domain
structures.

4. Comparisons of the two methods of recording borderline pathology—the standard ICD-

11 severity–domain model and the borderline pattern descriptor—may help practition-
ers recognize the advantage of the new approach so that the old terminology will no
longer be needed.
DISCLOSURE STATEMENT
P.T., R.M., Y.-R.K., and M.J.C. are all members of the ICD-11 Working Group.
ACKNOWLEDGMENTS
We thank the other members of the ICD-11 revision group, Roger Blashfield, Lee Anna Clark,
Alireza Farnam, Andrea Fossati, Nestor Koldobsky, Dušica Lečić-Toševski, David Ndetei, and
Michaela Swales, for all their help in revising the ICD-11 classification of personality disorders
and, in particular, Geoffrey Reed, who in his role as the WHO convenor, played a major part in
achieving final agreement for the classification. We also thank the DSM-5 Work Group for their
cooperation in allowing Lee Anna Clark to join the ICD-11 revision group, and we thank her for
her insightful and thoughtful contributions to all aspects of our discussions, and admire her great
ability to self-scrutinize.
LITERATURE CITED
Am. Psychiatr. Assoc. 1994. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: Am. Psy-
chiatr. Publ. 4th ed.
Am. Psychiatr. Assoc. 2013. Diagnostic and Statistical Manual of Mental Disorders. Arlington, VA: Am. Psychiatr.
Publ. 5th ed.
Bach B, Sellbom M, Kongerslev M, Simonsen E, Krueger RF, Mulder R. 2017. Deriving ICD-11 personality
disorder domains from DSM-5 traits: initial attempt to harmonize two diagnostic systems. Acta Psychiatr.
Scand. 136:108–17
Bateman AW. 2011. Throwing the baby out with the bathwater? Personal. Mental Health 5:274–80
Bateman A, Fonagy P. 2013. Impact of clinical severity on outcomes of mentalisation-based treatment for
borderline personality disorder. Br. J. Psychiatry 203:221–27
Beckwith H, Moran PF, Reilly J. 2014. Personality disorder prevalence in psychiatric outpatients: a systematic
literature review. Personal. Mental Health 8:91–101
Beeney JE, Wright AGC, Stepp SD, Hallquist MN, Lazarus SA, et al. 2017. Disorganized attachment and
personality functioning in adults: a latent class analysis. Personal. Disord. 8:206–16
Berk M, Boyce P, Hamilton A, Morris G, Outhred T, et al. 2018. Personality: distraction or driver in the
diagnosis of depression. Personal. Mental Health 12:126–30
Blasco-Fontecilla H, Baca-Garcia E, Dervic K, Perez-Rodriguez MM, Saiz-Gonsalez MD, et al. 2009. Severity
of personality disorder and suicide attempt. Acta Psychiatr. Scand. 119:149–155
Blashfield RK, Intoccia V. 2000. Growth of the literature on the topic of personality disorders. Am. J. Psychiatry
157:472–73
Brewin CR, Cloitre M, Hyland P, Shevlin M, Maercker A, et al. 2017. A review of current evidence regarding
the ICD-11 proposals for diagnosing PTSD and complex PTSD. Clin. Psychol. Rev. 58:1–15
Chanen AM. 2011. New era or false dawn? Personal. Mental Health 5:281–85
Clark LA. 2007. Assessment and diagnosis of personality disorder: perennial issues and an emerging recon-
ceptualization. Annu. Rev. Psychol. 58:227–57
498 Tyrer et al.

Clark LA, Nuzum H, Ro E. 2018. Manifestations of personality impairment severity: comorbidity,

course/prognosis, psychosocial dysfunction, and ‘borderline’ personality. Curr. Opin. Psychol. 21:117–
21
Coid JW. 1993. An affective syndrome in psychopaths with borderline personality disorder? Br. J. Psychiatry
162:641–50
Coid JW, Ullrich S. 2010. Antisocial personality disorder is on a continuum with psychopathy. Compr. Psychi-
atry 51:426–33
Conway CC, Hammen C, Brennan PA. 2016. Optimizing prediction of psychosocial and clinical outcomes
with a transdiagnostic model of personality disorder. J. Personal. Disord. 30:545–66
Crawford MJ, Sanatinia R, Barrett B, Cunningham G, Dale O, et al. 2018. The clinical effectiveness and cost-
effectiveness of lamotrigine in borderline personality disorder: a randomized placebo-controlled trial.
Am. J. Psychiatry 175:756–64
Davidson K. 2011. Changing the classification of personality disorder—an ICD-11 proposal that goes too far?
Personal. Mental Health. 5:243–45
Doughty L. 2013. Apple Tree Yard. London: Faber

Elliott T, Tyrer P, Horwood J, Fergusson D. 2011. Assessment of abnormal personality in childhood: a Delphi
survey of questionnaire data. J Personal. Disord. 25:89–100
First MB, Gibbon M, Spitzer R, Williams JBW, Benjamin LS. 1997. Structured Clinical Interview for DSM-IV
Axis II Personality Disorders (SCID-II): User’s Guide. Washington, DC: Am. Psychiatr. Press
Freestone M, Howard R, Coid JW, Ullrich S. 2013. Adult antisocial syndrome co-morbid with borderline
personality disorder is associated with severe conduct disorder, substance dependence and violent anti-
sociality. Personal. Mental Health 7:11–21
Glenn CR, Klonsky ED. 2009. Emotional dysregulation as a core feature of borderline personality disorder.
J. Personal. Disord. 23:20–28
González RA, Igoumenou A, Kallis C, Coid JW. 2016. Borderline personality disorder and violence in the UK
population: categorical and dimensional trait assessment. BMC Psychiatry 16:180
Gore WL, Widiger TA. 2013. The DSM-5 dimensional trait model and five-factor models of general person-
ality. J. Abnorm. Psychol. 122:816–21
Gunderson JG, Zanarini MC. 2011. Deceptively simple—or radical shift? Personal. Mental Health 5:260–62
Handest P, Parnas J. 2005. Clinical characteristics of first-admitted patients with ICD-10 schizotypal disorder.
Br. J. Psychiatry 48(Suppl. 48):S49–54
Health Soc. Care Inf. Cent. 2010. Hospital episode statistics, admitted patient care—England, 2009–10. Health
Soc. Care Inf. Cent. https://digital.nhs.uk/data-and-information/publications/statistical/hospital- An elucidation of the
admitted-patient-care-activity/hospital-episode-statistics-admitted-patient-care-england- alternative view that the
2009-10#summary ICD-11 classification is
Herpertz SC, Huprich SK, Bohus M, Chanen A, Goodman M, et al. 2017. The challenge of transform- too radical and should
ing the diagnostic system of personality disorders. J. Personal. Disord. 31:577–89 be changed.
Hopwood CJ, Kotov R, Krueger RF, Watson D, Widiger TA, et al. 2018. The time has come for dimensional
personality disorder diagnosis. Personal. Mental Health 12:82–86 An important paper
Kalpakci A, Ha C, Sharp C. 2018. Differential relations of executive functioning to borderline personality illustrating the
disorder presentations in adolescents. Personal. Mental Health 12:93–106 significant pathology
Karukivi M, Vahlberg T, Horjamo K, Nevalainen M, Korkeila J. 2017. Clinical importance of person- created by personality
ality difficulties: diagnostically sub-threshold personality disorders. BMC Psychiatry 17:16 difficulty.
Kim YR, Blashfield R, Tyrer P, Hwang ST, Lee HS. 2014. Field trial of a putative research algorithm for
diagnosing ICD-11 personality disorders in psychiatric patients: 1. Severity of personality disturbance. Demonstration of the
Personal. Mental Health 8:67–78 potential value of using
Kim YR, Tyrer P, Lee H-S, Kim S-G, Connan F, et al. 2016. Schedule for personality assessment from the ICD-11
notes and documents (SPAN-DOC): preliminary validation, links to the ICD-11 classification of classification to enable
personality disorder, and use in eating disorders. Personal. Mental Health 10:106–17 personality assessments
Kim YR, Tyrer P, Lee H-S, Kim S-G, Hwang S-T, et al. 2015. Preliminary field trial of a putative research to be made from notes
algorithm for diagnosing ICD-11 personality disorders in psychiatric patients: 2. Proposed trait domains. and documents without
face-to-face assessment.
Personal. Mental Health 9:298–307

Knerer G, Byford S, Johnson T, Seivewright H, Tyrer P. 2005. The Nottingham Study Of Neurotic Disorder:
predictors of 12 year costs. Acta Psychiatr. Scand. 112:224–32
Kool S, Schoevers R, de Maat S, Van R, Molenaar P, et al. 2005. Efficacy of pharmacotherapy in depressed
patients with and without personality disorders: a systematic review and meta-analysis. J. Affect. Disord.
88:269–78
Krueger RF. 2016. The future is now: personality disorder and the ICD-11. Personal. Mental Health 10:118–
19
Krueger RF, Markon KE. 2014. The role of the DSM-5 personality trait model in moving toward a quan-
titative and empirically based approach to classifying personality and psychopathology. Annu. Rev. Clin.
Psychol. 10:477–501
Kvarstein EH, Pedersen G, Folmo E, Urnes Ø, Johansen MS, et al. 2019. Mentalization-based treatment or
psychodynamic treatment programmes for patients with borderline personality disorder - the impact of
clinical severity. Psychol. Psychother. 92:91–111

Livesley WJ. 2011. Tentative steps in the right direction. Personal. Mental Health 5:263–70
Livesley WJ, Jackson DN, Schroeder ML. 1992. Factorial structure of traits delineating personality disorders
in clinical and general population samples. J. Abnorm. Psychol. 101:432–40
Lotfi M, Bach B, Sellbom M, Kongerslev M, Simonsen E, et al. 2018. Structure of DSM-5 and ICD-11 per-
sonality domains in an Iranian community sample. Personal. Mental Health 12:155–69
Luyten P, Fonagy P. 2015. The neurobiology of mentalizing. Personal. Disord. 6:366–79
McMurran M, Day F, Reilly J, Delport J, McCrone P, et al. 2017. Psychoeducation and problem solving
(PEPS) therapy for adults with personality disorder: a pragmatic randomized-controlled trial. J. Personal.
Disord. 31:810–26
Mendenhall E, De Silva MJ, Hanlon C, Petersen I, Shidhaye R, Jordans M, et al. 2014. Acceptability and
feasibility of using non-specialist health workers to deliver mental health care: stakeholder perceptions
from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Soc. Sci. Med. 118:33–
42
Mulder RT. 2002. Personality pathology and treatment outcome in major depression: a review. Am. J. Psychiatry
159:359–71
A detailed account of
Mulder RT, Horwood J, Tyrer P, Carter J, Joyce PR. 2016. Validating the proposed ICD-11 domains.
the domain structure
Personal. Mental Health 10:84–95
of ICD-11 and the
Mulder RT, Newton-Howes G, Crawford MJ, Tyrer PJ. 2011. The central domains of personality pathology
difficulty of fitting
borderline pathology in psychiatric patients. J. Personal. Disord. 25:364–77
to it. New AS. 2011. Partial success? Personal. Mental Health. 5:301–3
Newton-Howes G, Horwood J, Mulder R. 2015. Personality characteristics in childhood and outcomes in
adulthood: findings from a 30 year longitudinal study. Aust. N. Z. J. Psychiatry 49:377–86
Newton-Howes G, Tyrer P, Johnson T. 2006. Personality disorder and the outcome of depression: a meta-
analysis of published studies. Br. J. Psychiatry 188:13–20
Newton-Howes G, Tyrer P, Johnson T, Mulder R, Kool S, Dekker J, et al. 2014. Influence of personality on
the outcome of treatment in depression: systematic review and meta-analysis. J. Personal. Disord. 28:577–
93
Ng TH, Burke TA, Stange JP, Walshaw PD, Weiss RB, et al. 2017. Personality disorder symptom severity
predicts onset of mood episodes and conversion to bipolar I disorder in individuals with bipolar spectrum
disorder. J. Abnorm. Psychol. 126:271–84
NICE (Natl. Inst. Health Care Excell.). 2009. Borderline Personality Disorder: Recognition and Management. Clin-
ical Guideline [CG78]. London: NICE
Olajide K, Munjiza J, Moran P, O’Connell L, Newton-Howes G, et al. 2018. Development and psychomet-
ric properties of the Standardized Assessment of Severity of Personality Disorder (SASPD). J. Personal.
Disord. 32:44–56
Oldham JM, Skodol AE, Kellman HD, Hyler SE, Rosnick L, Davies M. 1992. Diagnosis of DSM-III-R per-
sonality disorders by two structured interviews: patterns of comorbidity. Am. J. Psychiatry 149:213–20
Oltmanns JR, Widiger TA. 2018. A self-report measure for the ICD-11 dimensional trait model proposal: the
personality inventory for ICD-11. Psychol. Assess. 30:154–69
500 Tyrer et al.

Palomares N, McMaster A, Díaz-Marsá M, de la Vega I, Montes A, Carrasco JL. 2016. Multiple cluster axis
II comorbidity and functional outcome in severe patients with borderline personality disorder. Actas Esp.
Psiquiatr. 44:212–21
Ramleth RK, Groholt B, Diep LM, Walby FA, Mehlum L. 2017. The impact of borderline personality disor-
der and sub-threshold borderline personality disorder on the course of self-reported and clinician-rated
depression in self-harming adolescents. Borderline Personal. Disord. Emot. Dysregulation 4:22
Ranger M, Methuen C, Rutter D, Rao B, Tyrer P. 2004. Prevalence of personality disorder in the case-load of
an inner-city assertive outreach team. Psychiatr. Bull. 28:441–43
Reed GM, Roberts MC, Keeley J, Hooppell C, Matsumoto C, et al. 2013. Mental health professionals’ A study showing that
natural taxonomies of mental disorders: implications for the clinical utility of the ICD-11 and the expectations of
the DSM-5. J. Clin. Psychol. 69:1191–212 health professionals
Sanatinia R, Wang D, Tyrer P, Tyrer H, Cooper S, et al. 2016. The impact of personality status on the cost with regard to
classification are
and outcomes of cognitive behaviour therapy for health anxiety. Br. J. Psychiatry 209:244–50
consistent and should
Schneider K. 1950 (1923). Die Psychopathischen Persönlichkeiten. Vienna: Deutike
be acknowledged by
Seivewright H, Tyrer P, Johnson T. 1998. Prediction of outcome in neurotic disorder: a 5-year prospective
nosologists.
study. Psychol. Med. 28:1149–57
Seivewright H, Tyrer P, Johnson T. 2002. Changes in personality status in neurotic disorder. Lancet 359:2253–
54
Seivewright H, Tyrer P, Johnson T. 2004. Persistent social dysfunction in anxious and depressed patients with
personality disorder. Acta Psychiatr. Scand. 109:104–9
Skodol AE, Geier T, Grant BF, Hasin DS. 2014. Personality disorders and the persistence of anxiety disorders
in a nationally representative sample. Depress. Anxiety 31:721–28
Tyrer P. 1996. Comorbidity or consanguinity. Br. J. Psychiatry 168:669–71
Tyrer P. 1999. Borderline personality disorder: a motley diagnosis in need of reform. Lancet 354:2095–
96
Tyrer P. 2000. Personality Disorders: Diagnosis, Management and Course. London: Arnold. 2nd ed.
Tyrer P. 2009. Why borderline personality disorder is neither borderline nor a personality disorder. Personal.
Mental Health 3:86–95
Tyrer P. 2013. Models for Mental Disorder. Chichester, UK: Wiley. 5th ed.
Tyrer P. 2015. Personality dysfunction is the cause of recurrent non-cognitive mental disorder: a testable
hypothesis. Personal. Mental Health 9:1–7
Tyrer P, Alexander MS, Cicchetti D, Cohen MS, Remington M. 1979. Reliability of a schedule for rating
personality disorders. Br. J. Psychiatry 135:168–74
Tyrer P, Alexander J, Ferguson B. 1988. Personality Assessment Schedule. In Personality Disorders: Diagnosis, The first full description
Management and Course, ed. P Tyrer, pp. 140–67. London: Wright. 1st ed. of the rationale behind
Tyrer P, Cooper S, Tyrer H, Salkovskis P, Crawford M, et al. 2011a. CHAMP: cognitive behaviour therapy the initial phase of the
for health anxiety in medical patients, a randomised controlled trial. BMC Psychiatry 11:99 ICD-11 classification.
Tyrer P, Crawford M, Mulder R, Blashfield R, Farnam A, et al. 2011b. A classification based on evidence is the
first step to clinical utility. Personal. Mental Health 5:304–307 A comparison of
Tyrer P, Crawford M, Mulder R, Blashfield R, Farnam A, et al. 2011c. The rationale for the reclassi- ICD-11 and ICD-10
fication of personality disorder in the 11th Revision of the International Classification of Diseases personality disorder
(ICD-11). Personal. Mental Health 5:246–59 classifications in three
Tyrer P, Crawford M, Sanatinia R, Tyrer H, Cooper S, et al. 2014. Preliminary studies of the ICD-11 different populations,
classification of personality disorder in practice. Personal. Mental Health 8:254–63 showing an increase in
Tyrer P, Johnson T. 1996. Establishing the severity of personality disorder. Am. J. Psychiatry 153:1593– prevalence with
97 ICD-11.
Tyrer P, Morgan J, Cicchetti D. 2004a. The Dependent Personality Questionnaire (DPQ): a screening in-
strument for dependent personality. Int. J. Soc. Psychiatry 50:10–17 This paper explains why
Tyrer P, Mulder R. 2018. Dissecting the elements of borderline personality disorder. Personal. Mental Health more domains of
12:91–92 personality pathology
Tyrer P, Mulder R, Crawford MJ, Newton-Howes G, Simonsen E, et al. 2010. Personality disorder: a new are associated with
global perspective. World Psychiatry 9:56–60 greater severity.

Tyrer P, Reed GM, Crawford MJ. 2015. Classification, assessment, prevalence and effect of personality
An extended version of
disorder. Lancet 385:717–26
the 2011 ICD-11 paper
Tyrer P, Salkovskis P, Tyrer H, Wang D, Crawford MJ, et al. 2017. Cognitive behaviour therapy for
that gives a history of
health anxiety in medical patients (CHAMP): randomised controlled trial with outcomes to five
the classification of
personality disorders. years. Health Technol. Assess. 21:1–58
Tyrer P, Seivewright N, Ferguson B, Murphy S, Darling C, et al. 1990. The Nottingham Study Of Neurotic
Disorder: relationship between personality status and symptoms. Psychol. Med. 20:423–31
An easy-to-download
Tyrer P, Seivewright N, Ferguson B, Murphy S, Johnson AL. 1993. The Nottingham Study of Neurotic
monograph illustrating
Disorder: impact of personality status on response to drug treatment, cognitive therapy and self-help
the extent to which
over two years. Br. J. Psychiatry 162:219–26
personality pathology
influences the outcome Tyrer P, Seivewright N, Ferguson B, Tyrer J. 1992. The general neurotic syndrome: a coaxial diagnosis of
of psychological anxiety, depression and personality disorder. Acta Psychiatr. Scand. 85:201–6
treatment. Tyrer P, Seivewright H, Johnson T. 2004b. The Nottingham Study of Neurotic Disorder: predictors of 12-
year outcome of dysthymic, panic and generalised anxiety disorder. Psychol. Med. 34:1385–94
Tyrer P, Seivewright N, Seivewright H. 1999. Long-term outcome of hypochondriacal personality disorder.

J. Psychosom. Res. 46:177–85
Tyrer P, Tom B, Byford S, Schmidt U, Jones V, et al. 2004c. Differential effects of manual assisted cognitive
behavior therapy in the treatment of recurrent deliberate self-harm and personality disturbance: the
POPMACT study. J. Personal. Disord. 18:82–96
Tyrer H, Tyrer P, Barrett B. 2013. Influence of dependent personality on the outcome and service costs of
health anxiety. Int. J. Soc. Psychiatry 59:274–80
Tyrer P, Tyrer H, Guo B. 2016a. The general neurotic syndrome: a re-evaluation. Psychother. Psychosom. 85:193–
197
Tyrer P, Tyrer H, Yang M, Guo B. 2016b. Long-term impact of temporary and persistent personality disorder
on anxiety and depressive disorders. Personal. Mental Health 10:76–83
Tyrer P, Wang D, Tyrer H, Crawford M, Cooper S. 2016c. Dependent personality and its influence on the
short- and long-term outcomes of cognitive behaviour therapy for health anxiety: randomised controlled
trial. Personal. Mental Health 10:96–105
Verheul R, Bartak A, Widiger T. 2007. Prevalence and construct validity of Personality Disorder Not Other-
A useful paper that wise Specified (PDNOS). J. Personal. Disord. 21:359–70
illustrates how the old
Verheul R, Widiger TA. 2004. A meta-analysis of the prevalence and usage of the personality disorder
categorical systems of
not otherwise specified (PDNOS) diagnosis. J. Personal. Disord. 18:309–19
classification fall down
Whewell P, Ryman A, Bonanno D, Heather N. 2000. Does the ICD 10 classification accurately describe
and use PD-NOS as a
dustbin diagnosis. subtypes of borderline personality disorder? Br. J. Med. Psychol. 73:483–94
WHO (World Health Organ.). 1992. International Statistical Classification of Diseases and Related Health Problems.
Geneva: WHO. 10th rev.
The full classification of WHO (World Health Organ.). 2018. International Statistical Classification of Diseases and Related Health
ICD-11 in an online Problems. Geneva: WHO. 11th rev. https://icd.who.int/
version. The individual
Widiger TA, Livesley WJ, Clark LA. 2009. An integrative dimensional classification of personality disorder.
disorders can be
Psychol. Assess. 21:243–55
searched using the
Widiger TA, Oltmanns JR. 2016. The ICD-11 proposals and field trials. Personal. Mental Health 10:120–22
browser. The paper
version is likely to be Widiger TA, Trull TJ. 2007. Plate tectonics in the classification of personality disorder: shifting to a dimen-
available in 2021. sional model. Am. Psychol. 62:71–83
Witt SH, Kleindienst N, Frank J, Treutlein J, Muhleisen T et al. 2014. Analysis of genome-wide significant
bipolar disorder genes in borderline personality disorder. Psychiatr. Genet. 24:262–65
Yang M, Coid J, Tyrer P. 2010. A national survey of personality pathology recorded by severity. Br. J. Psychiatry
197:193–99
Zachar P, Krueger RF, Kendler KS. 2016. Personality disorder in DSM-5: an oral history. Psychol. Med. 46:1–
10
502 Tyrer et al.

CP15_TOC ARI 12 April 2019 11:12
Annual Review of
Clinical Psychology
Volume 15, 2019
Contents
Positive Psychology: A Personal History

Martin E.P. Seligman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
History of Psychopharmacology
Joel T. Braslow and Stephen R. Marder p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p25
Bifactor and Hierarchical Models: Specification, Inference,
and Interpretation
Kristian E. Markon p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p51
The Utility of Event-Related Potentials in Clinical Psychology
Greg Hajcak, Julia Klawohn, and Alexandria Meyer p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p71
An Active Inference Approach to Interoceptive Psychopathology
Martin P. Paulus, Justin S. Feinstein, and Sahib S. Khalsa p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p97
Implicit Cognition and Psychopathology: Looking Back and Looking
Forward
Bethany A. Teachman, Elise M. Clerkin, William A. Cunningham,
Sarah Dreyer-Oren, and Alexandra Werntz p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 123
The MMPI-2-Restructured Form (MMPI-2-RF): Assessment of
Personality and Psychopathology in the Twenty-First Century
Martin Sellbom p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 149
Normal Versus Pathological Mood: Implications for Diagnosis
Ayelet Meron Ruscio p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 179
The Role of Common Factors in Psychotherapy Outcomes
Pim Cuijpers, Mirjam Reijnders, and Marcus J.H. Huibers p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 207
One-Session Treatment of Specific Phobias in Children: Recent
Developments and a Systematic Review
Thompson E. Davis III, Thomas H. Ollendick, and Lars-Göran Öst p p p p p p p p p p p p p p p p p p p p 233
Augmentation of Extinction and Inhibitory Learning in Anxiety and
Trauma-Related Disorders
Lauren A.M. Lebois, Antonia V. Seligowski, Jonathan D. Wolff, Sarah B. Hill,
and Kerry J. Ressler p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 257
CP15_TOC ARI 12 April 2019 11:12
Mindfulness Meditation and Psychopathology

Joseph Wielgosz, Simon B. Goldberg, Tammi R.A. Kral, John D. Dunne,
and Richard J. Davidson p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 285
Prenatal Developmental Origins of Future Psychopathology:
Mechanisms and Pathways
Catherine Monk, Claudia Lugo-Candelas, and Caroline Trumpff p p p p p p p p p p p p p p p p p p p p p p p 317
Using a Developmental Ecology Framework to Align Fear
Neurobiology Across Species
Bridget Callaghan, Heidi Meyer, Maya Opendak, Michelle Van Tieghem,
Chelsea Harmon, Anfei Li, Francis S. Lee, Regina M. Sullivan,

and Nim Tottenham p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 345
Man and the Microbiome: A New Theory of Everything?

Mary I. Butler, John F. Cryan, and Timothy G. Dinan p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 371
Estrogen, Stress, and Depression: Cognitive and Biological
Interactions
Kimberly M. Albert and Paul A. Newhouse p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 399
Adolescent Suicide as a Failure of Acute Stress-Response Systems
Adam Bryant Miller and Mitchell J. Prinstein p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 425
Abnormal Sleep Spindles, Memory Consolidation, and Schizophrenia
Dara S. Manoach and Robert Stickgold p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 451
The Development of the ICD-11 Classification of Personality
Disorders: An Amalgam of Science, Pragmatism, and Politics
Peter Tyrer, Roger Mulder, Youl-Ri Kim, and Mike J. Crawford p p p p p p p p p p p p p p p p p p p p p p p 481
A Reciprocal Model of Pain and Substance Use: Transdiagnostic
Considerations, Clinical Implications, and Future Directions
Joseph W. Ditre, Emily L. Zale, and Lisa R. LaRowe p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 503
Anxiety-Linked Attentional Bias: Is It Reliable?
Colin MacLeod, Ben Grafton, and Lies Notebaert p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 529
Biomedical Explanations of Psychopathology and Their Implications
for Attitudes and Beliefs About Mental Disorders
Matthew S. Lebowitz and Paul S. Appelbaum p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 555
Psychology’s Replication Crisis and Clinical Psychological Science
Jennifer L. Tackett, Cassandra M. Brandes, Kevin M. King,
and Kristian E. Markon p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 579
Errata
An online log of corrections to Annual Review of Clinical Psychology articles may be
found at http://www.annualreviews.org/errata/clinpsy

The Development of The ICD-11 Personality Disorders by Petery Tyrer

Uploaded by

Copyright:

Available Formats

You might also like

The Development of The ICD-11 Personality Disorders by Petery Tyrer

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

The Development of The ICD-11 Personality Disorders by Petery Tyrer

Uploaded by

Copyright:

Available Formats

CP15CH19_Tyrer ARjats.

cls April 17, 2019 12:41

Annual Review of Clinical Psychology

Annu. Rev. Clin. Psychol. 2019. 15:481–502 Keywords

The Annual Review of Clinical Psychology is online at Abstract

THE BORDERLINE CONTROVERSY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494

Solution to the Borderline Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495

482 Tyrer et al.

www.annualreviews.org • Development of the ICD-11 Classification 483

Domain Traits and Severity

484 Tyrer et al.

www.annualreviews.org • Development of the ICD-11 Classification 485

Initial Reaction to the Classification

486 Tyrer et al.

www.annualreviews.org • Development of the ICD-11 Classification 487

488 Tyrer et al.

Value of the severity classification in therapeutic research. A classification of mental disor-

www.annualreviews.org • Development of the ICD-11 Classification 489

Personality severity score = 0 Personality severity score = 1

Mean change in HAI score

Personality severity score = 2 Personality severity score = 3–4

490 Tyrer et al.

Developments from 2015 Onward

DERIVATION OF ICD-11 DOMAINS

www.annualreviews.org • Development of the ICD-11 Classification 491

Subsequent Reactions to the Proposal

492 Tyrer et al.

www.annualreviews.org • Development of the ICD-11 Classification 493

THE BORDERLINE CONTROVERSY

494 Tyrer et al.

Solution to the Borderline Question

www.annualreviews.org • Development of the ICD-11 Classification 495

496 Tyrer et al.

www.annualreviews.org • Development of the ICD-11 Classification 497

4. Comparisons of the two methods of recording borderline pathology—the standard ICD-

498 Tyrer et al.

Clark LA, Nuzum H, Ro E. 2018. Manifestations of personality impairment severity: comorbidity,

Doughty L. 2013. Apple Tree Yard. London: Faber

www.annualreviews.org • Development of the ICD-11 Classification 499

clinical severity. Psychol. Psychother. 92:91–111

500 Tyrer et al.

www.annualreviews.org • Development of the ICD-11 Classification 501

Tyrer P, Seivewright N, Seivewright H. 1999. Long-term outcome of hypochondriacal personality disorder.

502 Tyrer et al.

Volume 15, 2019

Positive Psychology: A Personal History

Mindfulness Meditation and Psychopathology

Chelsea Harmon, Anfei Li, Francis S. Lee, Regina M. Sullivan,

Man and the Microbiome: A New Theory of Everything?

You might also like