personality disorders diagnosis across the different versions of DSM and ICD-11

1. Dimensional
Approach to
Personality
Disorders
Ehab Elbaz, MD, MBA
Consultant Psychiatrist, Egyptian Armed Forces
Director of psychiatry hospital, Maadi Military Medical
Complex

2. DSM-1(1952)
Consisted of (7) major diagnostic categories, including a
category entitled (Personality Disorders)
There were (3) separate sections .
The first section listed (4) ‘‘cardinal personality types,’’
which were said to be rarely if ever altered by any form of
therapy. They were as follows:
•Inadequate personality
•Schizoid personality
•Cyclothymic personality
•Paranoid personality:

3. DSM-1
(1952)
The second section listed
(4) personality trait
disturbances.
• Emotionally unstable personality
• Passive-aggressive personality
• Compulsive personality
• Personality trait disturbance,
other

4. DSM-1(1952)
The third section listed
(4) types of ‘‘sociopathic
personality disturbances”
•Antisocial reaction
•Dyssocial reaction
•Sexual deviation
•Addictions

5. DSM II (1986)
Contained (10) major
categories of mental
disorders .
Section V was
entitled
‘‘Personality
Disorders and
Certain Other
Nonpsychotic Mental
Disorders.

6. The 10 specific
DSM-II personality
disorders
Paranoid
personality
Cyclothymic
personality
Schizoid
personality
Explosive
personality
Obsessive
compulsive
personality
Hysterical
personality
Asthenic
personality
Antisocial
personality
Passive-
aggressive
personality
Inadequate
personality

7. DSM- III
(1980)
• DSM-III came in the form of an
innovative multiaxial approach
• Axis II was reserved for
personality disorders and some
types of childhood problems
• A specific list of numbered
criteria was presented for
each personality disorder.
• grouped into three clusters.

8. (5) new personality disorders were also added to DSM-
III:
schizotypal narcissistic borderline avoidant dependent
(4) specific personality disorders were eliminated:
cyclothymic inadequate explosive asthenic
Overall, the DSM-III listed 11 specific
personality disorders (compared to 12 in DSM-I
and 10 in DSM-II ).

9. DSM- III- R
(1987)
• The 11 personality disorders
remained, and they were
again coded on Axis II.
• Two new personality
disorders that were placed
in Appendix A, which
indicated that the disorders
required further
investigation. These were
the sadistic and the self-
defeating personality
disorders.

10. DSM- IV (1994) and DSM IV-
TR (2000)
• Only 10 personality disorders in on
Axis II
• Passive-aggressive personality
disorder was removed from Cluster C
and was placed in Appendix B
• A new personality disorder, the
depressive personality disorder, also
appeared in DSM IV appendix B

11. DSM-5 (2013)
and DSM-5 TR
(2022)
No changes from DSM-IV TR
An alternative model of personality
disorders appears in section III
(“Emerging Measures and Models”) of the
manual.

12. Alternative model for personality
disorder (AMPD)
Was the product of the DSM-5 Personality and Personality
Disorder Work Group
Approved by the DSM-5 Task Force and was intended for inclusion
in Section II of DSM-5, “Diagnostic Criteria and Codes.”
However, the APA Board of Trustees voted to put the new model in
Section III and to continue with the categories and criteria
from DSM-IV for the personality disorders in DSM-5 Section II.

13. AMPD
Domains
and
Facets

14. AMPD
(Hybrid
Model)

15. Stepwise Approach to
Assessment According to
the General Criteria of
the Alternative DSM-5
Model for Personality
Disorders
• Skodol, A. E., Morey, L. C., Bender, D. S.,
& Oldham, J. M. (2015). The alternative DSM-5
model for personality disorders: A clinical
application. American Journal of Psychiatry,
172(7), 606-613.

16. Personality disorders in ICD-
11
2007
Developmen
t of the
ICD-11
started
May
2011
an alpha
version
May
2012
a beta
draft
June
2018
stable
version
of the
ICD-11
was
released
May
2019
official
ly
endorsed
by all
WHO
members
1
Jan.
2022
The ICD-
11
official
ly came
into
effect
Feb. 2022
the WHO stated
that 35
countries were
actively using
the ICD-11.
Feb. 2023
WHO reported
that 64
countries
were "in
different
stages of
ICD-11
implementatio
n.

17. DSM-5 and ICD-11 models of
personality disorders
Items DSM-5 alternative model ICD-11 model
Personality
dysfunction
0 No impairment None
1 Some impairment Personality difficulty
2 Moderate impairment Mild personality disorder
3 Severe impairment Moderate personality disorder
4 Extreme impairment Severe personality disorder
Trait domain Negative affectivity Negative affectivity
Detachment Detachment
Disinhibition Disinhibition
Antagonism Dissociality
(rigid perfectionism) Anankastia
Psychoticism (Schizotypal disorder)
Specific type Six (Antisocial, Avoidant,
Borderline, Narcissistic,
Obsessive-Compulsive, Schizotypal)
personality disorder of Trait-
Specified.
Borderline pattern specifier

18. Roots of the
Dimensional Models

19. Step (1) : Diagnostic
Requirements (ICD-11)

20. Step (2): Level of severity
• 6D10.0 Mild Personality
Disorder
• 6D10.1 Moderate Personality
Disorder
• 6D10.2 Severe Personality
Disorder

21. Step (3) : Trait domain
specifiers (optional)
• 6D11.0 Negative Affectivity
• 6D11.1 Detachment
• 6D11.2 Dissociality
• 6D11.3 Disinhibition
• 6D11.4 Anankastia
• 6D11.5 Borderline pattern

22. Examples
Severe
personality
disorder with
prominent
features of
negative
affectivity,
prominent
dissocial
features and
prominent
features of
01
Severe
personality
disorder
02
Moderate
personality
disorder with
prominent
features of
negative
affectivity
03

23. Conclusion
Personality and its disorders are a controversial subject a long history
A paradigm shift in the diagnosis of personality disorders has occurred by
the emergence of the ICD-11
The dimensional approach to personality disorders offer a practical and
more clinically satisfying approach.
We encourage a translation of an Arabic version of measures of personality
functioning and personality severity scales according to ICD-11, like LPFS
and PDS-ICD-11