Differences in prevalence of ICD-10 and ICD-11 personality disorders in psychiatric settings Professor Peter Tyrer (Imperial College, London) (with the help of many colleagues)

Declaration of interest – I am Chair of ICD-11 work group for revision of classification of personality disorders These are the others who helped: Professor Mike Crawford, Drs Rahil Sanatinia, Helen Tyrer, Ms Sylvia Cooper, Centre for Mental Health, Imperial College, London W6 8RP  Drs Chris Muller-Pollard, Polyxeni Christodoulou, Hammersmith and Fulham Mental Unit, London SW6 Drs Maria Zauter-Tutt, Katerina Miloseska-Reid, Ms Gemma Loebenberg, Central North West London NHS Mental Health Foundation Trust Dr Boliang Guo, University of Nottingham Professor Min Yang, School of Public Health, Sichuan University, Chengdu, China Professor Duolao Wang, University of Liverpool Professor Scott Weich, University of Warwick

Aims To give you some boring definitions of levels of disorder in ICD-10 and ICD-11 To remind you never to use words like ‘borderline’, ‘narcissistic’, ‘paranoid’ and ‘schizotypal’ ever again when talking about personality disorder, unless of course you are referring to colleagues To describe the prevalence of ICD-10 and ICD-11 personality disorder in populations in (i) medical out-patients, (ii) general practice psychiatric clinics (iii) an acute in-patient ward To explain the results

Lancet 2015, 385, 717-726

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. .

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.

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.

Level 2 of ICD-11 – mild personality disorder

Level 3 of ICD-11 – moderate personality disorder

Level 4 of ICD-11 – severe personality disorder

More on severe pd

Domains are qualifiers, not diagnoses

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)

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)

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)

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

Main message 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