Why we need a radically new classification of personality disorders Peter Tyrer Imperial College, London

Coatbridge 2015 Declaration of Interest xNo, nothing to disclose Yes, please specify:

This is not a one man maverick show Coatbridge 2015

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) Coatbridge 2015

The WHO ICD-11 revision group Coatbridge 2015

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 Coatbridge 2015

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 Coatbridge 2015

Lancet, 2015, 385,

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 Coatbridge 2015

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 Obsessiona l – perfect alignment in parking Avoidant – hides in corner Schizoid – cannot tolerate being close to other cars Schizotypal – inter- galactic parking Coatbridge 2015

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 Coatbridge 2015

Frequency of personality disorder in different settings Coatbridge 2015

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 Coatbridge 2015

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 Coatbridge 2015

F60Specific personality disorders F61Mixed and other personality disorders F63Habit and impulse disorders Coatbridge 2015

Australia Gen. Psych Coatbridge 2015

Solution to aid clinical utility First level of classification: Classify personality disturbance primarily by levels of severity, not of category Coatbridge 2015

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 Coatbridge 2015

Lancet 2015, 385, Coatbridge 2015

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.. Coatbridge 2015

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. Coatbridge 2015

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. Coatbridge 2015

Level 2 of ICD-11 – mild personality disorder Coatbridge 2015

Level 3 of ICD-11 – moderate personality disorder Coatbridge 2015

Level 4 of ICD-11 – severe personality disorder Coatbridge 2015

More on severe pd Coatbridge 2015

Domains are qualifiers, not diagnoses Coatbridge 2015

Prevalence in people with health anxiety attending medical clinics Total 442 ICD-10 -no personality disorder289 (65.4) ICD-11 – no personality disorder258 (58.4) ICD-10 – personality disorder153 (34.6) ICD-11 – personality disorder184 (44.6) ICD-10 – mixed diagnoses 66 (14.9) ICD-11 – no personality dysfunction62 (14) ICD-11 – personality difficulty196 (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) Coatbridge 2015

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 Coatbridge 2015

That’s all very well. What about the categories? Coatbridge 2015

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 35 There 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 Coatbridge 2015

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? Coatbridge 2015

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 Coatbridge 2015