Personality in the Spotlight: Activities of the WPA Section on Personality Disorders.

The WPA Section on Personality Disorders has promoted greater understanding of personality dysfunction since 20031. This subject is highly relevant to mental pathology. Personality disorders affect at least 10% of the general population2, and their high levels of comorbidity with other mental disorders (Galenic syndromes)3 means that many doctors in a variety of specialties are likely to come across these patients repeatedly in their everyday practice. In the last fifteen years, much of the work of the Section has been devoted to the development of the new classification of personality disorder in the ICD-11. A radical revision was suggested that eliminated all the existing categories in the ICD-10 and replaced them with a single dimensional spectrum of severity4. In other terms, it was proposed that, once the diagnosis of a personality disorder has been established, it should be described in terms of its level of severity: mild, moderate or severe personality disorder, or personality disorder of unspecified severity. Also described was "personality difficulty", not classified as a mental disorder but listed in the grouping of problems associated with interpersonal interactions. It was also proposed that personality disorder and personality difficulty could be further described using five trait domain specifiers: negative affectivity, detachment, dissociality, disinhibition, and anankastia. Although this solution came under criticism as being too radical and apparently ignoring recent advances in the field, particularly in relationship to work on borderline personality disorder5, the scientific justification for the change was a strong one6 and has been embraced with increasing enthusiasm over time. There are now many studies suggesting that this classification is superior to that of the ICD-10 in terms of clinical utility, internal consistency and acceptability7, 8, and it has received international support by its full incorporation into the ICD-11 Clinical Descriptions and Diagnostic Requirements for Mental Disorders. Many studies are currently in progress to establish its psychometric properties and clinical value in selecting treatment. Over the next few years, under initiatives developed by R. Mulder and Y.-R. Kim (current and future Chair of the Section), we hope to expand the knowledge base of the ICD-11 classification, facilitate its introduction in all countries covered by the WPA, and obtain research data that will guide clinical practice in an area where we currently have grossly lopsided empirical evidence. With these goals in mind, Section members are developing clinical measures of ICD-11 personality disorder severity and the five trait domain specifiers. Notably, B. Bach and M. Sellbom are working on a Diagnostic Interview for Personality Pathology in ICD-11 (DIPP-11). One of the important roles of our Section is to promote the message that all psychiatrists (and physicians, for that matter) should be familiar with the concept of personality disorder and to realize that most of the patients they see will have some form of personality disturbance. This is not an academic extra; such knowledge will help them in choosing treatment, predicting outcomes, and planning care. We need to be rid of the notion that personality disorder is an outré subject only useful to specialists. The Section will also be watching carefully and contributing to the current debate over the status of borderline personality disorder. The borderline option was included as a "pattern specifier" in the ICD-11 classification, following pressure from the large group who felt that this diagnosis was too valuable to be discarded9. But the pattern specifier is not a diagnosis; it is an option to be added to the appropriate severity diagnosis in the ICD-11, from personality difficulty to severe personality disorder. If, as it seems possible, all the categorical diagnoses of personality disorder will be abandoned in future revisions of the DSM, the status of borderline personality disorder will become increasingly uncertain. As research into all aspects of borderline pathology is currently more active than research into all other areas of personality pathology, it is understandable that many would like to see the borderline group retained in some form. There is no reason why it cannot cohabit with the current ICD-11 approach in both clinical and research practice, but improvements are needed to achieve better harmonization. We also hope that, by emphasizing that personality dysfunction is on a spectrum, and that most people in the population have some dysfunction, we can remove much of the stigma that surrounds the diagnosis. The stigma will also be reduced by showing that those with personality problems can get better, and that this can be achieved avoiding deceptively simple solutions such as changing their name.