Diagnostic Criteria for Personality Disorders
The ICD-11 has fundamentally restructured personality disorder diagnosis by replacing discrete categorical diagnoses with a single dimensional diagnosis based on severity (mild, moderate, severe) and optional specification of maladaptive personality traits. 1, 2
Core Diagnostic Framework
The diagnosis centers on two fundamental elements 1, 2:
- Problems in functioning of aspects of the self (identity, self-worth, self-direction) and/or interpersonal dysfunction (capacity for intimacy, empathy, cooperation) 1, 2
- Severity grading (mild, moderate, severe) that reflects the degree of impairment in personality functioning 1, 2
Optional Trait Specification
After establishing severity, clinicians may specify one or more maladaptive personality traits 1, 2:
- Negative affectivity (emotional lability, anxiousness, hostility)
- Detachment (social withdrawal, anhedonia, intimacy avoidance)
- Dissociality (manipulativeness, callousness, deceitfulness)
- Disinhibition (impulsivity, distractibility, irresponsibility)
- Anankastia (perfectionism, rigidity, orderliness)
- Borderline pattern (emotional dysregulation, identity disturbance, relationship instability, self-harm)
Why This Change Matters
The old ICD-10 categorical system lacked empirical support and created artificial boundaries—most patients met criteria for multiple personality disorders simultaneously, rendering the categories clinically meaningless 1. Field studies demonstrate that mental health professionals rate the ICD-11 approach as significantly more useful for treatment planning, patient communication, comprehensiveness, and ease of use compared to ICD-10 1.
DSM-5 Alternative Model
The American Psychiatric Association's alternative model parallels ICD-11 by using a dimensional-categorical hybrid 1, 2:
- Assessment of impairments in personality functioning (self and interpersonal)
- Evaluation of pathological personality traits across five domains: Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism 2
Critical Assessment Principles
Lack of Insight Is Expected, Not Exclusionary
A common pitfall is expecting patients with personality disorders to have insight into their condition—lack of insight is a core feature that distinguishes personality disorders from other psychiatric conditions. 1, 3
- Self-report psychiatric scales have minimal usefulness in personality disorders specifically because of impaired insight 1, 3
- Behavioral observation and collateral information trump self-report 1, 3
Multi-Informant Assessment Is Mandatory
Use structured interviews rather than self-report questionnaires for diagnosis. 1, 3
- Gather information from multiple sources using developmentally sensitive techniques 1, 3
- Expect and systematically evaluate informant discrepancies—they provide diagnostic information rather than invalidating the diagnosis 1, 3
Process Variables Reveal Pathology
Observe clinical process independent of patient self-report 1, 3:
- Who initiated the consultation? (Patients with personality disorders, especially narcissistic traits, rarely self-refer and often present under external pressure) 3
- Is the patient over- or under-emphasizing disability? (This pattern reveals defensive operations) 3
Etiology
Personality disorders arise from complex interactions 1:
- Genetic predisposition
- Environmental factors, particularly adverse childhood experiences
- Family psychopathology (history of suicidal behavior, bipolar illness, physical/sexual abuse, substance abuse)
Treatment Options for Personality Disorders
Evidence-based psychotherapy is the primary treatment for personality disorders; pharmacotherapy serves only as adjunctive treatment targeting specific symptoms, not the personality disorder itself. 1, 4
First-Line: Evidence-Based Psychotherapies
The following psychotherapeutic approaches have demonstrated efficacy 1:
- Dialectical Behavior Therapy (DBT)
- Cognitive Behavioral Therapy (CBT)
- Mentalization-Based Treatment
- Schema Therapy
- Transference-Focused Psychotherapy
Most evidence exists for borderline personality disorder, though sample sizes remain small and follow-up periods short in clinical trials 4.
Adjunctive Pharmacotherapy
Medications target specific symptoms, not the personality disorder diagnosis itself. 1
Symptom-Specific Medication Strategies
- Mood stabilizers for emotional dysregulation 1, 5
- Antipsychotics (second-generation preferred) for cognitive-perceptual symptoms 1, 5
- Antidepressants for comorbid depression or anxiety 1, 5
- Anxiolytics for acute anxiety symptoms 1
- Omega-3 fatty acids may benefit borderline personality disorder 5
Borderline Personality Disorder Specific
Patients may benefit from mood stabilizers, second-generation antipsychotics, and omega-3 fatty acids 5.
Antisocial Personality Disorder Specific
Patients may benefit from mood stabilizers, antipsychotics, and antidepressants 5.
Brief Interventions for Primary Care
Family physicians can implement 5:
- Motivational interviewing
- Solution-based problem solving
Clinical Context
Personality disorders are associated with 1, 6:
- Premature mortality
- Significant disabilities
- High rates of healthcare utilization
- Increased incidence of sleep disorders, chronic pain, chronic health conditions, and obesity compared to the general population
The evidence base remains insufficient overall, with most research focused on borderline personality disorder 4. Treatment ruptures, discontinuation, reversals, and failures are relatively common, reflecting the interpersonal dysfunction at the core of these disorders 7.