New era or false dawn?

Abstract

There is little doubt that experts in the field have had an appetite for changing the classification of personality disorders (Bernstein, Iscan, Maser, & Boards of Directors of the Association for Research in Personality Disorders International Society for the Study of Personality Disorders, 2007), but if the DSM-5 debate is any indication, it is not clear whether this is shared by rank-and-file clinicians. Many agree that the existing ICD-10 (WHO, 1992) and DSM-IV-TR (APA, 2000) systems are unsatisfactory. Tyrer and colleagues’ (this issue) diagnosis of the problem is precise, but this does not ensure that the treatment will be palatable. Indeed, some might now regret what they wished for as they read Tyrer and colleagues’ radical proposal for reclassifying personality disorder in ICD-11. Change, whether radical or not, must offer some advantage over the previous system, and although discussion regarding the DSM-5 is well advanced, the ICD-11 proposal is only just beginning to take shape and will no doubt be the subject of strenuous debate. The proposed ICD-11 classification of personality disorders has the welcome aims of improving the clinical utility of the diagnosis of personality disorder, reducing stigma and helping in the development and selection of appropriate treatment. Such practical aims are in large part due to the wide constituency of the ICD-11, which is intended for use across the globe in primary through to specialist health-care settings. This contrasts with the DSM-5, which is being produced by the American Psychiatric Association and is primarily intended for use in specialist psychiatric practice. Clinical experience suggests that the requisite skills for diagnosing personality disorders are not always available, even in specialist settings, and a more straightforward approach might improve confidence and usage of these diagnoses. ICD-10 was never really satisfactory. It imitated aspects of the DSM but without clear operational criteria was perhaps more unwieldy. The use of ICD coding internationally is not a good index of its acceptability, as in many countries these codes are used through ‘back translation’ from the DSM codes. Despite this, Tyrer and colleagues refer to the low level of usage of all the current personality disorder categories, except borderline (emotionally unstable) and antisocial (dissocial) as evidence of the shortcomings of both ICD and DSM. The ICD-11 proposal introduces a primary classification based upon five levels of severity. This is a very constructive innovation and is similar to that proposed for DSM-5, providing an opportunity to develop common ground between the two systems. Although they are likely to be separate but overlapping constructs, personality traits and personality dysfunction are often confounded (Clark, 2007), and assessing severity separately to trait domains is a significant improvement.