ICD-116D10	PERSONALITY DISORDER Personality disorder
ICD-10F60.9	Personality disorder, unspecified
DSM-5-TRF60.9	Unspecified Personality Disorder

1. Definition and nosology

Personality Disorder (ICD-11: 6D10 Personality Disorder; DSM-5-TR: F60.9; 10 categories) — persistent and pervasive pattern in personal and social functioning; thoughts, feelings, and behaviors regarding self and others. ICD-11 has fundamentally moved to a model of a single category + severity degrees + trait domains; classical 10 distinct personality disorders (paranoid, schizoid, borderline, antisocial, etc.) have been abolished as categorical diagnoses.

2. History

• DSM-III (1980) — 11 categorical personality disorders (Cluster A, B, C).
• DSM-IV (1994), DSM-5-TR (2022) — Same categorical model retained; however, DSM-5 Section III has an alternative ‘dimensional’ model in the research category.
• ICD-11 (2019) — radical change: Categorical 10 disorders abolished, unified Personality Disorder (mild, moderate, severe + Personality Difficulty) + assessment of 5 trait domains.

3. Epidemiology

• Lifetime prevalence: ~9% (Lenzenweger M.F. et al. Biol Psychiatry 2007); BPD ~1.4%, ASPD ~1%, schizoid 3%.
• Sex: BPD higher in females in clinical populations; ASPD higher in males.
• Onset: adolescence and early adulthood.
• Mortality: in BPD, suicide 8–10% lifetime; in ASPD, violent death.
• Comorbidity: MDD, anxiety, substance use, eating disorders.

4. Aetiology and pathogenesis

• Heritability 40–60%.
• Early trauma, childhood abuse (especially BPD).
• Disorganized attachment.
• Neurobiological — frontal-limbic regulation, serotonergic dysregulation.

5. Clinical features

5.1 ICD-11 5 characteristic domains

• Negative affectivity — anxiety, depression, variability.
• Detachment — social and emotional distance.
• Dissociality — lack of empathy, egocentricity.
• Disinhibition — impulsivity, irresponsibility.
• Anankastia — perfectionism, control, rigid rules.

“Borderline model” — a separate qualifier in ICD-11 (corresponding to BPD, instead of 10 categorical separate diagnoses).

5.2 DSM-5-TR 10 categorical disorders (brief)

• Cluster A (odd/eccentric): Paranoid, Schizoid, Schizotypal.
• Cluster B (dramatic/erratic): Antisocial (ASPD), Borderline (BPD), Histrionic, Narcissistic.
• Cluster C (anxious/fearful): Avoidant, Dependent, Obsessive-Compulsive (OCPD).

6. Diagnosis

6.1 Unified diagnostic criteria (ICD-11)

A. Persistent and pervasive personality dysfunction — in self (identity, self-worth, self-direction) and/or interpersonal (relationships, empathy, intimacy, responsibility) functioning.

B. Duration — long-term (years).

C. Developmental age, not consistent with cultural norm, family situation.

D. Severity: Personality Difficulty (subclinical), Mild PD, Moderate PD, Severe PD.

E. Feature domain qualifiers (above).

6.2 Source-specific clarifications

• ICD-11: Radical change to categorical system; requires training in clinical practice.
• DSM-5-TR: 10 categorical diagnoses retained; Section III alternative model.
• NICE CG78 (BPD), CG77 (ASPD): Separate clinical guidelines for BPD and ASPD.

6.3 Diagnostic algorithm

1. Clinical interview + long history.
2. SCID-5-PD (DSM categorical) or ICD-11 PD assessment.
3. Personality scales — PID-5 (DSM-5 dimensional), MMPI-2-RF.
4. Comorbidity (MDD, substance, trauma).
5. Suicide and violence risk.

6.4 Differential diagnosis

7. Examination and assessment

• SCID-5-PD, PID-5.
• MMPI-2-RF, MCMI-IV.
• Comorbidity and suicide.

8. Treatment

8.1 General Principles (NICE CG78 (BPD), CG77 (ASPD); APA 2001 (BPD))

1. Psychotherapy first line — gold standard in personality disorders.
2. Evidence-based approaches for BPD (5):
   • DBT (Dialectical Behavior Therapy, Linehan M.) — emotional regulation, distress tolerance, social skills, mindfulness; standard 12 months;
   • MBT (Mentalization-Based Treatment, Bateman A., Fonagy P.)
   • Schema Therapy (Young J.)
   • TFP (Transference-Focused Psychotherapy, Kernberg O.)
   • STEPPS (Systems Training for Emotional Predictability and Problem Solving).
3. For ASPD — therapeutic limitation; CBT in structured, motivated patient.
4. Pharmacotherapy — no specific approval for personality disorder itself; for comorbid symptoms (impulsivity, depression, anxiety, psychosis-like) — SSRIs, mood stabilizers, low-dose atypical antipsychotics.
5. Crisis management — DBT skills, short-term inpatient stay.
6. Long-term treatment (years).

8.2 Source-specific clarifications

• NICE CG78 (BPD, 2009) — DBT, MBT, and similar structured approaches; pharmacotherapy not routinely recommended for BPD itself.
• NICE CG77 (ASPD, 2009).
• APA Practice Guideline for BPD (2001).

Treatment methods

1. Dialectical Behavior Therapy (DBT) — Linehan (Linehan M.) — 4 modules (mindfulness, distress tolerance, emotional regulation, social skills); individual + group + telephone coaching + therapist consultation. 12-month standard. Evidence: Linehan M.M. JAMA Psychiatry 2015.
2. Mentalization-Based Therapy (MBT) — Bateman A., Fonagy P — Mentalization — recognition of one's own and others' mental states; based on psychodynamic roots. Bateman A. Am J Psychiatry 2009.
3. Schema Therapy — Young J. — Restructuring early maladaptive schemas; long-term psychotherapy.
4. Transference-Focused Psychotherapy (TFP — Transference-Focused Psychotherapy) — Kernberg (Kernberg O.) — Processing of primitive defense mechanisms in the context of transference.
5. STEPPS — 20-week group; participation of the patient's social system in BPD.
6. Structured Clinical Interview for Personality Disorders (SCID-5-PD) — DSM-5 categorical diagnosis.

9. Prognosis

• BPD — 50%+ remission at 10-year follow-up (Zanarini M.C. reviews).
• ASPD — worst prognosis; but aggression decreases with age.
• Treatment significantly improves the prognosis.

10. Myths and misconceptions

Myth 1: “Personality disorders are untreatable”

Evidence: DBT, MBT, Schema, TFP — evidence-based approaches; most patients improve significantly; pessimistic prognostic stance is outdated.

Myth 2: “BPD patients are manipulative and require strict boundaries”

Evidence: Term “manipulative” is stigmatizing and incorrect; BPD behaviors stem from emotional dysregulation; DBT recommends validation + structure balance.

Myth 3: “Pharmacotherapy cures BPD”

Evidence: NICE CG78 — pharmacotherapy not routinely recommended for BPD itself; psychotherapy first-line.

Myth 4: “ASPD cannot be treated”

Evidence: in severe ASPD intervention limited, but in motivated patients structured treatment may yield improvement; nihilistic stance contraindicated.

Myth 5: “Personality disorder stabilizes with age and does not require treatment”

Evidence: long-term follow-up — BPD remission rate 50%+ over 10 years; treatment accelerates this process.

Myth 6: “Hypnotherapy, esoteric interventions cure personality disorders”

Evidence: No evidence; evidenced structured psychotherapy is recommended.

11. Sources

1. WHO. ICD-11. 6D10 Personality disorder. 2024.
2. APA. DSM-5-TR. 2022.
3. NICE CG78. Borderline personality disorder: recognition and management. 2009.
4. NICE CG77. Antisocial personality disorder: prevention and management. 2009.
5. Linehan M.M. et al. Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis. JAMA Psychiatry 2015;72(5):475–482.
6. Bateman A., Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for BPD. Am J Psychiatry 2009;166(12):1355–1364.
7. Zanarini M.C. et al. Prediction of the 10-year course of borderline personality disorder. Am J Psychiatry 2006;163(5):827–832.
8. Tyrer P., Reed G.M., Crawford M.J. Classification, assessment, prevalence, and effect of personality disorder. Lancet 2015;385(9969):717–726.
9. Young J.E., Klosko J.S., Weishaar M.E. Schema Therapy: A Practitioner’s Guide. New York: Guilford Press, 2003.
10. Yeomans F.E., Clarkin J.F., Kernberg O.F. Transference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide. Washington: American Psychiatric Publishing, 2015.