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Editorial The classification of personality disorders in ICD-11: Implications for forensic psychiatry

PETER TYRER, Centre for Mental Health, Department of Medicine, Imperial College, London W6 8RP, UK

Twenty years ago, Criminal Behaviour and Mental Health carried an article from me entitled ‘Flamboyant, erratic, dramatic, borderline, antisocial, sadistic, narcissistic, histrionic and impulsive personality disorder: who cares which?’ (Tyrer, 1992). The many years since have confirmed the answer I gave in the article, the only ones who care are those with a vested interest in keeping these terms. The average clinician certainly does not seem to take much interest in these curious adjectives. When the International Classification of Diseases (11th edition) (ICD-11) working group for the revision of personality disorders met to review the use of the diagnostic categories in the ICD-10 (World Health Organisation, 1992) classification of personality disorders across different countries, we found that borderline, dissocial and mixed personality disorders were responsible for 95% of all personality disorder diagnoses, but more botheringly, they were diagnosed in well under 5% of all patients. When epidemiological studies show that the prevalence of personality disorders in the community is at or above 5% (Coid et al., 2006; Huang et al., 2009), there is clearly something wrong – this diagnostic system apparently leads to the ‘Great Clinician Switch Off ’.

Why is this? The classification clearly has no clinical utility, and possible reasons include (1) the stigmatic nature of the label, (2) the high comorbidity between different personality disorders, which is clearly a false separation as nobody is prepared to argue that this represents true comorbidity in the form of separate disorders (Livesley and Jackson, 1986) and (3) the very high proportion of what is called personality disorder not otherwise specified in the Diagnostic and Statistical Manual (DSM) classification (Verheul and Widiger, 2004), giving the clear message ‘a plague on your classification, it does not represent what I see in my clinic’. The more damning criticism is that neither the current US DSM nor

Criminal Behaviour and Mental Health 23: 1–5 (2013) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/cbm.1850

ICD classifications have a satisfactory evidence base. Each of the adjectival labels for personality disorder, first described by Kurt Schneider in 1923 but added to sequentially since, has been created by ‘expert evidence’ (i.e. advisory committees and task forces). Eight of the original Schneiderian ‘psychopathic types’ have just been reformed under different names (Tyrer, 2004). So the famous sensitive personality (der sensitive Beziehungswahn) became paranoid personality disorder and insecure sensitive, insecure anankastic, self-assertive, emotionally unstable, explosive, affectless and asthenic became relabelled, respectively, as avoidant, obsessive compulsive, narcissistic, borderline, antisocial, schizoid and dependent personalities in DSM-III. Schneider was a clever man, and the continuation of these categories would not matter if these committees had good evidence to guide their discussions, but in general, they have not, so they have been guided by whim, and as expert opinion is the lowest level of the evidence hierarchy, it can be trumped by any data from a higher level.

These data exist. The best scientific evidence for personality disturbance comes from two lines of research, trait theory and dimensional structure. Trait theory has a long-established place in the assessment of personality (Matthews et al., 2003) and, until recently, has largely been ignored by clinicians and researchers interested in personality disorder. Everyone has a unique personality, but these are made up primarily from a combination of traits that act as a substrate for the rest of personality to develop upon. Some are more prominent than others (higher order traits), and the many others secondary to these can be used to define personality further. But the task of classifying these becomes unproductive if all these traits are taken into account, and it is usually wise to concentrate any classification on a limited number. Most evidence suggests that four or five will suffice (Mulder et al., 2011).

The dimensional structure has developed from a range of studies that have shown no meaningful qualitative differences between the so-called normal personalities and pathological ones (Tyrer and Alexander, 1979; Clark et al., 1997; Kushner et al., 2011), and this is supported by genetic evidence also (Jang and Livesley, 1999). Whilst the dimensional structure is also true for many other psychiatric disorders, it is particularly relevant for personality disturbance in view of the high negative valence of the diagnosis.

These two lines of evidence underlies the justification for the ICD-11 classifi- cation of personality disorders, a new, simplified system that is informed by evidence and does not go beyond it. The proposal, developed by a multinational cross-disciplinary group approved by the World Health Organisation, is now close to reaching its final stages. Its essential elements comprise diagnosis by severity with the main features at each level of severity subsumed into four domains. The names of the severity levels are still not fully decided, but there are four graded levels of severity beyond normal personality (Tyrer et al., 2011a). These are personality difficulty (classified as a Z-code and not qualifying as a disorder in the ICD classification but still very important), mild personality

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disorder, moderate personality disorder and severe personality disorder. The domains are close to being given their final names – many constituents, including service users, are commenting on the options – and the likely four domains are internalising (emotional), externalising (antagonistic), detached and anankastic (Mulder et al., 2011; Tyrer et al., 2011b). These domains have monothetic descriptions, and any number of them can be used to qualify the main level of severity if needed.

The antagonistic domain includes many of the features currently diagnosed as antisocial or dissocial personality disorder; the revision group was not sufficiently convinced to make any distinction between these in selecting the domains, although we recognise that it is a controversial area, not least as ‘psychopathy’ as a category has never been included in formal classifications despite having widespread use. We are continuing to receive advice on this in our work group and welcome comments. In the forthcoming ICD and DSM classifications, there is a merging of child and adult diagnoses, so there is no separate section on childhood disorders. This means that personality disorder can be diagnosed at any age, whereas previously, it was not permitted before the age of 18, even though most personality abnormality develops before this age. With the study of callous and unemotional states in childhood, a strong case has been made for the identification of psychopathy at a very early age (Dadds et al., 2012; Kumsta et al., 2012). Rutter (2012) and Viding and McCrory (2012) have argued for the diagnostic separation of antisocial personality disorder and psychopathy in classification, although they also recognise that the evidence is not yet strong enough to create separate categories here. We, and others in the World Health Organisation group, are not convinced that we have enough evidence to separate these two at the domain level, and some biological evidence suggests they are similar (Raine et al., 2010).

One other interesting consequence of the new classification that has relevance for forensic psychiatry is that severe personality disorder almost always affects more than one trait domain, manifesting most clearly in the very large number of personality disorder categories identified in the current classification when research studies are undertaken (Coid et al., 1999). Most of these in the new classification will be delineated as severe personality disorder with often many additional domain traits (Tyrer and Johnson, 1996) and a range of additional pathology (Yang et al., 2010), but by using a single dimension of severity, this category will eliminate the confusion of comorbidity. The ironical postscript to the highly criticised Dangerous and Severe Personality Disorder Programme, a condition that I renamed the ‘Jack Straw Syndrome’ at the time as it was a straw syndrome invented by a government minister (Home Secretary), not a task force, may have hit on the right way of classifying personality disorder (Duggan, 2011).

The consequence of the ICD-11 revision is that categories of personality disorder are now redundant. Indeed, they have always been so, and Livesley

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(2012) has made a devastating critique of the DSM-5 classification as a failed attempt to combine traits, categories and dimensions in an unwieldy and unman- ageable classification that lacks all semblance of clinical utility. Indeed, the latest news is that even the American Psychiatric Association cannot tolerate it and will return to the old DSM-IV classification of personality disorders when the DSM-5 is published, with the DSM-5 proposal placed in a parking lot to be revisited by weary travellers at some time in the very distant future. A return to DSM-IV cannot be regarded as an advance, none of the DSM classifications have had good justification for inclusion and we hope that more people will now turn to a classification that we claim for the first time combines science, evidence and clinical utility.

References

Clark LA, Livesley WJ, Morey L (1997) Personality disorder assessment: The challenge of construct validity . Journal of Personality Disorders 11: 205–231.

Coid J, Kahtan N, Gault S, Jarman B (1999) Patients with personality disorder admitted to secure forensic psychiatry services. The British Journal of Psychiatry 175: 528–536.

Coid J, Yang M, Tyrer P, Roberts A, Singleton N (2006) Prevalence and correlates of person- ality disorder among adults aged 16 to 74 in Great Britain. The British Journal of Psychiatry 188: 423–431.

Dadds MR, Allen JL, Oliver BR, Faulkner N, Legge K, Moul C, Woolgar M, Scott S (2012) Love, eye contact and the developmental origins of empathy v. psychopathy. The British Journal of Psychiatry 200: 191–196.

Duggan C (2011) Dangerous and severe personality disorder. The British Journal of Psychiatry 198: 431–433.

Huang Y, Kotov R, de Girolamo G, Preti A, Angermeyer M, Benjet C, Demyttenaere K, de Graaf R, Gureje O, Karam AN, Lee S, Lépine JP, Matschinger H, Posada-Villa J, Suliman S, Vilagut G, Kessler RC (2009) DSM-IV personality disorders in the WHO World Mental Health Surveys. The British Journal of Psychiatry 195: 46–53.

Jang KL, Livesley WJ (1999) Why do measures of normal and disordered personality correlate? A study of genetic comorbidity. Journal of Personality Disorders 13: 1310–1317.

Kumsta R, Sonuga-Barke E, Rutter M (2012) Adolescent callous-unemotional traits and conduct disorder in adoptees exposed to severe early deprivation. The British Journal of Psychiatry 200: 197–201.

Kushner SC, Quilty LC, Tackett JL, Bagby RM (2011) The hierarchical structure of the Dimensional Assessment of Personality Pathology (DAPP-BQ). Journal of Personality Disorders 25: 504–516.

Livesley WJ (2012) Tradition versus empiricism in the current DSM-5 proposal for revising the classification of personality disorders. Criminal Behaviour and Mental Health 22: 81–90.

Livesley WJ, Jackson DN (1986) The internal consistency and factorial structure of behaviors judged to be associated with DSM-III personality disorders. The American Journal of Psychiatry 143: 1473–1474.

Matthews G, Deary IJ, Whiteman MC (2003) Personality Traits (2nd ed.). Cambridge University Press, Cambridge.

Mulder RT, Newton-Howes G, Crawford M, Tyrer PJ (2011) The central domains of personality pathology in psychiatric patients. Journal of Personality Disorders 25: 364–377.

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Raine A, Lee L, Yang Y, Colletti P (2010) Neurodevelopmental marker for limbic maldevelop- ment in antisocial personality disorder and psychopathy. The British Journal of Psychiatry 197: 186–192.

Rutter M (2012) Psychopathy in childhood: Is it a meaningful diagnosis? The British Journal of Psychiatry 200: 175–176.

Schneider K (1923) Die Psychopathischen Personlichkeiten. Berlin: Springer. Tyrer P (1992) Flamboyant, erratic, dramatic, borderline, antisocial, sadistic, narcissistic , histrionic

and impulsive personality disorders: Who cares which? Criminal Behaviour and Mental Health 2: 95–104.

Tyrer P (2004) New approaches to the diagnosis of psychopathy and personality disorder. Journal of the Royal Society of Medicine 97: 371–374.

Tyrer P, Alexander J (1979) Classification of personality disorder. The British Journal of Psychiatry 135: 163–167.

Tyrer P, Johnson T (1996) Establishing the severity of personality disorder. The American Journal of Psychiatry 153: 1593–1597.

Tyrer P, Crawford M, Mulder R (2011a) Reclassification of personality disorder. Lancet 377: 1814–1815.

Tyrer P, Crawford M, Mulder R, Blashfield R, Farnam A, Fossati A, Kim YR, Koldobsky N, Lecic-Tosevski D, Ndetei D, Swales M, Clark LA, Reed GM (2011b) The rationale for the reclassification of personality disorder in the 11th revision of the International Classification of Diseases (ICD-11). Personality and Mental Health 5: 246–259.

Verheul R, Widiger TA (2004) A meta-analysis of the prevalence and usage of the personality disorder not otherwise specified (PDNOS) diagnosis. Journal of Personality Disorders 18: 309–319.

Viding E, McCrory EJ (2012) Why should we care about measuring callous–unemotional traits in children? The British Journal of Psychiatry 200: 177–178.

World Health Organisation (1992) ICD-10: Classification of Mental and Behavioural Disorders. Geneva: World Health Organisation.

Yang M, Coid J, Tyrer P (2010) Personality pathology recorded by severity: National survey. The British Journal of Psychiatry 197: 193–199.

Address correspondence to: Peter Tyrer, Centre for Mental Health, Department of Medicine, Imperial College, London, W6 8RP UK. E-mail: [email protected]

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