Why we need a radically new classification of personality

disorders

Peter TyrerImperial College, London

Coatbridge 2015

Declaration of Interest

x No, nothing to disclose

Yes, please specify:

This is not a one man maverick show

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Revision Group for the ICD-11 classification of personality

disorders

• Peter Tyrer (Chair), Mike Crawford, Roger Blashfield (USA), Alireza Farnam (Iran),

• David Ndetei (Kenya), Andrea Fossati (Italy), Youl-Ri Kim (Korea), Nestor Koldobsky (Argentina), Dusica Lecic-Tosevski (Serbia), Roger Mulder (New Zealand), Michaela Swales (Wales), Lee Anna Clark (USA), and Geoff Reed (WHO, Geneva)

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The WHO ICD-11 revision group

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Current problems with ICD-10 and DSM-IV classifications of personality disorder

They are perceived as pejorative

They are heterogeneous

They show high levels of comorbidity with other mental state and other personality disorders (and PD-NOS is too frequently used)

They are temporally unstable but yet are defined as pervasive

As a consequence they are seldom used even though personality disorder is common

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Do they help treatment?

• Absolutely not

• The current treatments of personality disorders have been badly served by a classification that is not fit for therapeutic purpose

• As a consequence we have made limited headway

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Lancet, 2015, 385, 735-743

Why our current descriptions of personality disorder are ridiculous?

• We have eleven different personality disorders in the DSM/ICD classification

• DSM = Diagnostic and Statistical Manual of Mental Disorders

• ICD = International Classification of Diseases• They have no good empirical evidence

supporting their existence – they are ‘committee diagnoses’ only

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Paranoid –

cornered again Narcissist – largest car, big hood ornament

Dependent - relies on being close to other cars

Passive-aggressive – parks car to take up two

spaces

Borderline – rams into car of ex-lover

Antisocial – deliberately obstructs other cars

Histrionic – parks

dramatically in centre

Obsessional – perfect

alignment in parking

Avoidant – hides in corner

Schizoid – cannot tolerate being close to

other cars

Schizotypal – inter-galactic parking

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Current problems with ICD-10 and DSM-IV classifications of personality disorder

They are perceived as pejorative

They are heterogeneous

They show high levels of comorbidity with other mental state and other personality disorders (and PD-NOS is too frequently used)

They are temporally unstable but yet are defined as pervasive

As a consequence they are seldom used even though personality disorder is common

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Frequency of personality disorder in different settings

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4-10% Community

25-30% General Practice

35-45% Psychiatric Outpatient

50-60% Enhanced Community Care

70-80% Prison

80-90% Tertiary Psychiatric Services

Prevalence of personality disorder in different settings (research findings)

Medical out-patients?41% with medically unexplained symptoms and health anxiety

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Contrast with clinical practice

• In no country that uses ICD-10 classification does the proportion of patients with a primary clinical diagnosis of personality disorder exceed 4% in any hospital or setting outside prison or forensic care

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Finland, 2008, F60-F69, n = 1007

2.90%0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

F60 F61 F63

pe

rce

nt

of

F6

0-6

9 c

od

esFinland, 2007 n =33,159

3.05%

0.00%5.00%

10.00%15.00%20.00%25.00%30.00%35.00%40.00%

F20-F29

F30-F39

F10-F19

F40-F48

F00-F09

F90-F98

F60-F69

F50-F59

F80-F89

F70-F79

F99-F99%

of

To

tal F

co

de

s r

ep

ort

ed

F60 Specific personality disorders

F61 Mixed and other personality disorders

F63 Habit and impulse disorders

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Australi Gen Psych, 2001-2007, n = 1,724,516

3.33%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

F30-F39

F40-F48

F20-F29

F10-F19

F00-F09

F60-F69

F50-F59

F90-F98

F80-F89

F99 F70-F79

% o

f T

ota

l F c

od

es

re

po

rte

d

Australia F60-F69, Gen Psych, 2001-2007, n = 57,384

0.00%

5.00%

10.00%

60.00%

65.00%

F6

0.3

1

F6

0.9

F

60

.2

F6

0.7

F6

3.0

F

60

.8

F6

1

F6

0.3

0

F6

0.1

F6

8.1

F

64

.0

F6

3.9

F

60

.5

F6

0.0

F

60

.4

F6

9

F6

3.8

F

62

.8

F6

2.0

F

60

.6

F6

5.8

F

68

.8

F6

4.9

F

64

.8

F6

8.0

F6

5.9

F

63

.3F

62

.9F

65

.4

F6

0.3

F6

3.1

F

64

.1F

65

.2

F6

3.2

F

64

.2

F6

2.1

F6

5.0

F

65

.1F

65

.3

F6

5.5

% F

60

-F6

9 c

od

es

Australia Gen. Psych

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Solution to aid clinical utility

First level of classification:• Classify personality disturbance primarily by

levels of severity, not of category

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Levels of severity

• No personality disturbance• Personality difficulty (not coded)• Threshold for personality disorder – general

definition• Mild personality disorder• Moderate personality disorder• Severe personality disorder

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Lancet 2015, 385, 717-726

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ICD-10 general definition

These types of condition comprise deeply ingrained and enduring behaviour patterns, manifesting themselves as inflexible responses to a broad range of personal and social situations. They represent either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels, and particularly relates to others. Such behaviour patterns tend to be stable and to encompass multiple domains of behaviour and psychological functioning. They are frequently, but not always, associated with various degrees of subjective distress and problems in social functioning and performance.

.

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ICD-11 general definition

Personality disorders are characterized by a pervasive disturbance in the individual’s way of interpreting and thinking about himself or herself, others and the world that is manifested in both emotional experience and expression

and in patterns of behaviour. The disturbance is associated with significant problems in functioning that are particularly evident in interpersonal relationships and these are manifest across a range of personal and social situations (i.e.not limited to specific relationships or situations). The disturbance is of long duration (2 years or more). Most commonly personality disorders have their first manifestations in childhood and are fully evident in adolescence.

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Level 1 of ICD-11 – personality difficulty

A long-standing, recurrent or intermittent disturbance in an individual’s way of viewing the self, others and the world, that is manifest in both emotional experience and expression, and in patterns of behavior. The disturbance is associated with some problems of social functioning and interpersonal relationships. However, impairment in functioning is not as severe as that found among people with personality disorder and are seen only in certain social and interpersonal contexts than may not be apparent elsewhere.

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Level 2 of ICD-11 – mild personality disorder

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Level 3 of ICD-11 – moderate personality disorder

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Level 4 of ICD-11 – severe personality disorder

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More on severe pd

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Domains are qualifiers, not diagnoses

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Prevalence in people with health anxiety attending medical clinics

Total 442

ICD-10 -no personality disorder 289 (65.4)

ICD-11 – no personality disorder 258 (58.4)

ICD-10 – personality disorder 153 (34.6)

ICD-11 – personality disorder 184 (44.6)

ICD-10 – mixed diagnoses 66 (14.9)ICD-11 – no personality dysfunction 62 (14)

ICD-11 – personality difficulty 196 (44.3)

ICD-11 – mild personality disorder 142 (32.1)

ICD-11 – moderate personality disorder 40 (9)ICD-11 – severe personality disorder 2 (0.5)

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Prevalence in people in general practice psychiatric clinics

Total 198

ICD-10 -no personality disorder 138 (69.3)ICD-11 – no personality disorder 132 (66.7)ICD-10 – personality disorder 60 (30.3)ICD-11 – personality disorder 66 (33.3)ICD-10 – mixed diagnoses 25 (12.6)ICD-11 – no personality dysfunction 91 (45.7)

ICD-11 – personality difficulty 40 (20.1)ICD-11 – mild personality disorder 43 (21.6)ICD-11 – moderate personality disorder 17 (8.5)ICD-11 – severe personality disorder 6 (3)Coatbridge 2015

Prevalence in people in an acute in-patient ward

Total 82

ICD-10 -no personality disorder 51 (62)

ICD-11 – no personality disorder 40 (48.8)

ICD-10 – personality disorder 31 (38)

ICD-11 – personality disorder 42 (51.2)

ICD-10 – mixed diagnoses 7 (9)

ICD-11 – no personality dysfunction 28 (34.1)

ICD-11 – personality difficulty 12 (14.6)

ICD-11 – mild personality disorder 19 ((23.2)ICD-11 – moderate personality disorder 10 (12.2)ICD-11 – severe personality disorder 13 (15.9)Coatbridge 2015

Main reason for higher prevalence of ICD-11 in all settings

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That’s all very well. What about the categories?

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• Mild personality disorder• Moderate personality disorder• Severe personality disorder• Trait domain descriptors

– with prominent features of negative affectivity

– with prominent dissocial features– with prominent features of

disinhibition– with prominent anankastic features– with prominent features of

detachment

ICD-11 Classification of Personality Disorders in comparison with DSM

• Paranoid personality disorder

• Schizoid personality disorder

• Schizotypal personality disorder

• Antisocial personality disorder

• Borderline personality disorder

• Histrionic personality disorder

• Narcissistic personality disorder

• Avoidant personality disorder

• Dependent personality disorder• Obsessive-compulsive personality

disorder

ICD-11 DSM-5

35There is no connection between these systems at present but they will come

Advantages of new classification

• It removes comorbidity of personality disorders• It is based on evidence, not dogma• It allows for change in personality status over

time and in response to treatment • It reduces, and may remove, the stigma

attached to personality disorder as only a minority of boring people have no personality dysfunction

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Several problems to resolve

• Where is psychopathy?• Is disinhibition needed as a domain trait?• Will GP’s and other general doctors use the

classification?• How do we convert ICD-10/DSM-IV data to ICD-11?• What do we do about borderline? Loss of insurance,

rct evidence, users• Do we need an additional classification axis for

personality disorder?

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Main message of this talk

• Go forth into the personality undergrowth, cleave the old battered bushes and clear the air.

• A bold future awaits both patients and practitioners in the sensible new world of classification

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