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15th February 2025
Personality disorders
Classification of personality disorders
The ICD (International Classification of Diseases)-11 describes personality disorder as ‘a marked disturbance in personality functioning, which is nearly always associated with considerable personal and social disruption. The central manifestations of personality disorder are impairments in functioning of aspects of the self (e.g. identity, self-worth, capacity for self-direction) and/or problems in interpersonal functioning (e.g. developing and maintaining close and mutually satisfying relationships, understanding others’ perspectives, managing conflict in relationships).’
Precise definitions for personality disorder have been historically both mutable and controversial, and the ICD diagnostic requirements for personality disorder have recently been updated. Once a diagnosis of personality disorder has been established, the new ICD-11 guidelines state that it should be described in terms of level of severity.
| Classification | Severity of effect on personality | Impact on relationships and occupational/social roles | Impact on functioning | Risk of harm to self or others |
|---|---|---|---|---|
| Mild personality disorder | Disturbances affect some areas of personality functioning but not others. | Problems in many interpersonal relationships and/or expected occupational and social roles. Some relationships and/or roles are maintained. | May be associated with substantial distress or with impairment in … important areas of functioning that is either limited to circumscribed areas or present in more areas but of milder severity. | Typically not associated with substantial harm to self or others. |
| Moderate personality disorder | Disturbances affect multiple areas of personality functioning, though some may be relatively less affected. | Marked problems in most interpersonal relationships, which are likely to be characterised by conflict, avoidance, withdrawal, or extreme dependency. The performance of most expected occupational and social roles is compromised to some degree. | Associated with marked impairment in … important areas of functioning, although functioning in circumscribed areas may be maintained. | Sometimes associated with harm to self or others. |
| Severe personality disorder | Severe disturbances in personality functioning. | Problems in interpersonal functioning affect virtually all relationships. The ability and willingness to perform expected occupational and social roles is absent or severely compromised. | Associated with severe impairment in all or nearly all areas of life. | Often associated with harm to self or others. |
Table 1 Severity classifications in personality disorder (ICD-11).
As per the ICD-11, personality disorder can then be further described using five trait domain specifiers. These describe characteristics of the individual’s personality that are most prominent and contribute to the personality disturbance:
| Train domain | Core features |
|---|---|
| Negative affectivity | A tendency to experience a broad range of negative emotions (e.g. emotional lability and poor emotion regulation; negativistic attitudes; low self-esteem and self-confidence; mistrustfulness). |
| Detachment | Tendency to maintain interpersonal and emotional distance. |
| Dissociality | Disregard for the rights and feelings of others, encompassing both self-centeredness and lack of empathy. |
| Disinhibition | Tendency to act rashly based on immediate external or internal stimuli (i.e. sensations, emotions, thoughts), without consideration of potential negative consequences. |
| Anankastia | A narrow focus on one’s rigid standard of perfection and of right and wrong, and of controlling one’s own and others’ behaviour and controlling situations to ensure conformity to these standards. |
Table 2 Trait domains in personality disorder (ICD-11)
‘Borderline pattern’ can also be used as an optional additional specifier as per the ICD-11. It may be applied to individuals whose pattern of personality disturbance is characterised by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity.
Management of personality disorders
Management plans should be agreed with the patient, be tailored to the individual and set clear expectations. There has been a movement away from prolonged inpatient stays or those involving psychiatric ICUs.
Psychotherapy
Psychotherapy is the first-line treatment for personality disorders. In particular, dialectical behaviour therapy (DBT) is recommended by NICE for women with borderline personality disorder who self-harm. DBT is a long-term intervention lasting 1-2 years. Brief psychological interventions (<3 months) should be avoided.
Pharmacological management
NICE recommends that drug treatment should not be used for borderline personality disorder or its symptoms (e.g. emotional instability, repeated self-harm), although drug treatment can be utilised in treating comorbid conditions. For concurrent depression, a combination of antidepressant medication (first line usually an SSRI) and a psychological treatment can be considered, depending on the patient’s preference (NICE notes that the evidence base is limited).
Where medications are used, NICE recommend the following:
- Consider side effects, addiction risk and safety in overdose.
- Avoid polypharmacy where possible.
- Antipsychotics should not be used as medium- or long-term treatment.
- Short-term sedatives may be used in crisis but for no longer than one week.
References
- Casey P and Kelly B. Personality Disorders. In Fish’s Clinical Psychopathology: Signs and Symptoms in Psychiatry. 4th ed. Cambridge: Cambridge University Press; 2020. Pp. 109-123
- ICD-11. Personality Disorders. Online [cited 17 December 2023]. Available at: https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f37291724
- Management of Personality Disorder. In: Oxford Handbook of Psychiatry. 4th ed. Ed. Semple D and Smyth R. Oxford: Oxford University Press; 2019. Pp. 517-540
- Mind. Personality Disorder: Why is it Controversial? [Internet] [cited 21 January 2024]. Available from: https://www.mind.org.uk/information-support/types-of-mental-health-problems/personality-disorders/why-is-it-controversial
- National Institute for Health and Care Excellence. Borderline personality disorder: recognition and management [Internet]. NICE. 28 January 2009 [cited 16 January 2024]. Available from: https://www.nice.org.uk/guidance/cg78
- National Institute for Health and Care Excellence. Depression in adults: treatment and management [Internet]. NICE. 29 June 2022 [cited 21 January 2024]. Available from: https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#depression-in-people-with-a-diagnosis-of-personality-disorder
- Personality Disorders. In DSM-5. Washington, DC: American Psychiatric Publishing; 2013. Pp. 645-684]
- ICD-11. Personality Disorders. Online [cited 17 December 202]. Available at: https://icd.who.int/browse11/l-m/en#/http%253a%252f%252fid.who.int%252ficd%252fentity%252f37291724
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