Personality Traits in the International Classification of Diseases 11th Revision (ICD-11)

Internal consistency of measures for ICD-11 personality disorder severity and traits: A systematic review and meta-analysis

A number of measures and scales have been developed for the ICD-11 personality disorder (PD) diagnosis, including severity and trait dimensions. The present systematic review and meta-analysis sought to evaluate the internal consistency of these measures across different populations and cultures. A systematic search was conducted across four databases where relevant studies were subjected to explicit eligibility criteria resulting in 49 included studies and 370 effect sizes. Study characteristics were tabulated, their methodological quality was evaluated, and findings were synthesized using random effects meta-analysis. Findings overall indicated that measures of ICD-11 PD severity and trait domains have adequate levels of internal consistency (α/ω = 0.82, 95% CI [0.81; 0.83], I2 = 97.3%). Aspects such as sample, country, language, format, and measured construct were significant sources of variation. Additional meta-analyses revealed that some measures performed better than others for certain dimensions. Internal consistency was overall supported across ICD-11 measures of severity and trait domains. Future research should further investigate the interrater reliability, test-retest reliability and stability, and alignment with interview-based PD diagnoses.

Towards the understanding of the core of general personality disorder factor: g-PD and its relation to hostile attributions

There is a general consensus that personality disorders (PDs) share a general factor (g-PD) overlapping with the general factor of psychopathology (p-factor). The general psychopathology factor is related to many social dysfunctions, but its nature still remains to some extent ambiguous. We posit that hostile attributions may be explanatory for the factor common for all PDs, i.e., interpersonal problems and difficulty in building long-lasting and satisfying relationships of all kinds. Thus, the main objective of the current project was to expand the existing knowledge about underlying factors of g-PD with regard to hostile attributions. We performed a cross-sectional study on a representative, community sample of Poles (N = 1031). Our hypotheses were primarily confirmed as hostile attributions predicted p-factor. However, the relation was positive only for hostile attributions related to ambiguous situations involving relational harm and physical harm done by female authorities and negative in case of hostile attributions in situations involving physical harm done by peers. Additionally, paranoia-like thoughts strongly related to hostile attributions and independently predicted g-PD. The results contribute to the current discussion on the nature of the g-PD, confirm that hostile attributions and paranoia are a crucial aspect of personality pathology, and indicate the importance of working on these cognitions in the course of therapeutic work.

Practical implications of ICD-11 personality disorder classifications

Personality disorders (PDs) are associated with an inferior quality of life, poor health, and premature mortality, leading to heavy clinical, familial, and societal burdens. The International Classification of Diseases-11 (ICD-11) makes a thorough, dramatic paradigm shift from the categorical to dimensional diagnosis of PD and expands the application into adolescence. We have reviewed the recent literature on practical implications, and severity and trait measures of ICD-11 defined PDs, by comparing with the alternative model of personality disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), by mentioning the relevance in forensic and social concerns, and by referencing the developmental implication of life span, especially in adolescence. Study results strongly support the dimensional utility of ICD-11 PD diagnosis and application in adolescence which warrants early detection and intervention. More evidence-based research is needed along the ICD-11 PD application, such as its social relevance, measurement simplification, and longitudinal design of lifespan observation and treatment.

Convergence between the dimensional PD models of ICD-11 and DSM-5: a meta-analytic approach

In the current diagnostic systems, the International Classification of Diseases-11th rev. (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders-5th ed. (DSM-5), the evaluation and diagnosis of personality disorder (PD) aim at dimensional examination of the severity of its dysfunction and the stylistic features that accompany it. Since their implementation, or even before, several measures have been developed to assess PD severity and traits in both models. Thus, convergent validity metrics have been reported with various PD measures; however, the convergence of the same constructs included in the measures of these two models remains undefined. The objective of the present review was to examine whether there is a sufficient relationship between PD measures of the ICD-11 and DSM-5 AMPD in the general population. For this meta-analytic review, systematic searches were conducted in Web of Science, PubMed, Scopus, and Google Scholar. We included studies that reported Pearson's r correlations without restrictions on language, age, sex, setting, type of sample, or informant of the measures. We excluded associations with anankastia, psychoticism or the borderline pattern because they were not comparable between one dimensional model and the other. We examined the quality of the evidence with the JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies, and performed the random effects meta-analysis with the 'meta' package of the RStudio software. Of the 5,629 results returned by the search, 16 studies were eligible; and showed moderate quality. The risk of bias was manifested by not specifying the details of the sample, the recruitment environment, and the identification and control of confounding factors. Thirteen studies provided two or more correlations resulting in a total of 54 studies for meta-analysis. The overall effect size estimate (correlation) was moderate for the overall model (r = 0.62, 95% CI [0.57, 0.67], p < 0.0001, I2 = 97.6%). For the subgroup of associations, ICD-11 severity model and DSM-5 AMPD severity model, the correlation was also moderate (k = 10, r = 0.57, 95% CI [0.48; 0.66]; I2 = 92.9%); as for the subgroup of associations, ICD-11 traits model and DSM-5 AMPD traits model (k = 44, r = 0.63, 95% CI [0.57; 0.69], I2 = 97.9%). The convergent validity between measures of PD severity and traits between one diagnostic system and another has been demonstrated in this review and they can probably be used interchangeably because they also measure the same constructs. Future research can address the limitations of this study and review the evidence for the discriminant validity of these measures.

Consider the hubris syndrome for inclusion in our classification systems

Successful leaders are at risk of developing exaggerated pride, contempt for others, and a diminished sense of reality. The ancient Greeks feared this syndrome and called it hubris. Although certain contemporaneous leaders show signs of hubris and pose a great danger, the hubris syndrome does not yet figure in our classification systems. The purpose of this paper is to examine several aspects of its validity, including clinical description, laboratory study, and exclusion of other disorders. Firstly, a substantial body of evidence indicates that the hubris syndrome may develop after a person has held substantial power for a considerable amount of time. Thus, the syndrome differs from a personality disorder with its characteristic onset in late adolescence or early adulthood. It is proposed, therefore, that the syndrome is a non-organic personality change after gaining substantial power or achieving overwhelming success, characterized by the emergence or marked increase of pathological personality traits within the domains of dissociality and disinhibition. Within the domain of dissociality, grandiosity is an obligatory trait. Secondly, with reference to laboratory study, recent evidence suggests that machine learning algorithms have the ability to differentiate hubristic from non-hubristic speech patterns. Thirdly, the exclusion of other disorders is difficult, because individuals with the hubris syndrome do not collaborate in any investigation. Some suggestions are made to overcome this problem. In conclusion, there is sufficient reason to further examine the validity of the hubris syndrome and to consider it for inclusion in our classification systems.

Examining the construct validity of the Personality Assessment Questionnaire for ICD-11 (PAQ-11) personality trait domains in a community sample

The ICD-11 has a new diagnostic system for personality disorder, which includes five optional trait specifiers to characterize the diagnosed pathology. The current study evaluated the internal structure and construct validity of the Personality Assessment Questionnaire for ICD-11 (PAQ-11) personality trait domains in a US population-representative community sample. An exploratory factor analysis revealed the support for a four-factor model underlying the 17 PAQ-11 items, reflecting four of the five ICD-11 trait domains (Negative Affectivity, Detachment, Disinhibition and Anankastia). Moreover, correlation analyses revealed that the PAQ-11 domain scale scores were associated, as expected, with their counterparts from two other ICD-11 trait domain measures, as well as with traditional personality disorder scores. More broadly, the results raised questions about the structural integrity of the Dissociality domain scale, and the discriminant validity of the Disinhibition and Anankastia scales. The overall conclusion was nevertheless promising with respect to the PAQ-11 serving as a brief screening measure for the ICD-11 trait domains.

Analysis of the Relationship between Higher-Order Factor Structure of Personality Disorders and the Five-Factor Model of Personality

The growing body of evidence on the dimensional classification of personality disorders (PD) has resulted in its acceptance in the ICD-11 classification, which abolished categories and retains only a general description of PD. Specifying the type of PD is optional, and the suggested domains represent maladaptive variants of the five-factor model of personality (FFM). The aim of our study was to explore the existence of a joint structure between maladaptive and normal personality traits, and to investigate how these structures are integrated. The study included 223 patients who had been diagnosed with PD and completed the Structured Clinical Interview for DSM-5 Personality Disorders and the NEO Personality Inventory-Revised (NEO-PI-R). To determine the degree of overlap between PD domains and NEO PI–R scales, a canonical analysis of covariance was conducted. Our findings showed a relationship between the internalizing PD spectrum (consisting of avoidant, dependent, and borderline traits with detached and anankastic traits) and high neuroticism, low conscientiousness, and moderately low agreeableness and extroversion, suggesting the existence of a broad personality disorder factor. However, the internalizing dimensions exhibited a more pronounced effect within this construct. Furthermore, we identified a second function that demonstrated a link between the externalizing PD spectrum (including narcissistic, histrionic, and antisocial traits) and high extraversion, high openness, and low agreeableness, suggesting the existence of an externalizing factor. Overall, our findings provide evidence for a joint structure of maladaptive and normal personality traits in a sample of personality disorders and emphasize the importance of integrating the FFM model in PD evaluation in clinical practice, suggesting that differentiating between major subgroups could assist in adjusting therapeutic approaches.

Cross-walking personality disorder types to ICD-11 trait domains: An overview of current findings

The ICD-11 has adopted a classification of Personality Disorders (PD) that abolishes the established categorical PD types in favor of global severity classification with specification of individual trait domains. To facilitate and guide this profound transition, an overview of current research on empirical associations between established PD types and ICD-11 trait domains seems warranted. We identified a total of 9 relevant studies from 2018 to 2022, which were based on both clinical and community samples from U.S., China, Brazil, Denmark, Spain, Korea, and Canada. The patterns of associations with ICD-11 trait domains were systematically synthesized and portrayed for each PD type. Findings overall showed expected and conceptually meaningful associations between categorical PD types and ICD-11 trait domains, with only few deviations. Based on these findings, we propose a cross-walk for translating categorical PD types into ICD-11 trait domains. More research is needed in order to further guide continuity and translation between ICD-10 and ICD-11 PD classification in mental healthcare, including facet-level ICD-11 trait information. Moreover, the nine reviewed studies only relied on self-reported ICD-11 trait domains, which should be expanded with clinician-rated trait domains in future research. Finally, future research should also take ICD-11's essential PD severity classification into account.

Effects of Transcranial Magnetic Stimulation Combined with Computer-Aided Cognitive Training on Cognitive Function of Children with Cerebral Palsy and Dysgnosia

Objective

This study is aimed at researching transcranial magnetic stimulation (TMS) effects combined with computer-aided cognitive training (CACT) on cognitive function of children suffering from cerebral palsy and dysgnosia.

Methods

From December 2019 to October 2021, 86 children with cerebral palsy and dysgnosia who were treated at our hospital were recruited and assigned into observation and control groups (n = 43, each) using the random number table technique. The observation group received TMS combined with CACT (TMS+CACT), whereas the control group received only TMS. Chinese Wechsler Young Children Scale of Intelligence (C-WYCSI) and Chinese-Wechsler Intelligence Scale for Children (C-WISC) were used to evaluate the intelligence level of the two groups; Gross Motor Function Measure-88 (GMFM-88) of Fudan Chinese version was employed for evaluating the gross motor function of the two groups; a comparison was drawn among the two groups for the cerebral hemodynamic parameters before and after the treatment.

Results

For young children, the verbal intelligence quotient (VIQ) scores at 6 and 12 weeks of treatment in the observation group were increased when compared to those in the control group (48.91 ± 3.70 vs. 47.32 ± 3.33, 54.25 ± 4.46 vs. 49.48 ± 3.36), and the observation group's performance intelligence quotient (PIQ) score at 12 weeks of treatment was higher as to that of the control group (65.38 ± 4.23 vs. 62.81 ± 4.74, all P < 0.05). For older age children, the observation group's VIQ and PIQ scores were greater than the control group's at 6 and 12 weeks of treatment, with statistical significance (63.80 ± 3.76 vs. 59.50 ± 5.32, 74.64 ± 12.04 vs. 65.08 ± 6.30; 63.91 ± 5.96 vs. 58.42 ± 3.70, 72.73 ± 5.06 vs. 66.42 ± 5.93; all P < 0.05). The GMFM-88 scale scores in both groups were increased after 6 and 12 weeks of treatment. After treatment for 12 weeks, the observation group's A-E scores were greater than those of the control group (all P < 0.05). The peak systolic velocity (V s), end-diastolic velocity (V d), and mean velocity (V m) at the anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) in the observation group were dramatically increased than those in the control group (all P < 0.05) after 12 weeks of treatment.

Conclusion

TMS+CACT can effectively improve the intelligence level, cognitive ability, gross motor function, and cerebral blood flow of children suffering from cerebral palsy and intellectual disability.

Factor Convergence and Predictive Analysis of the Five Factor and Alternative Five Factor Personality Models with the Five-Factor Personality Inventory for ICD-11 (FFICD)

The authors analyze and compare the factor convergence and predictive power of the Revised NEO Personality Inventory (NEO-PI-R) and the Zuckerman-Kuhlman-Aluja Personality Questionnaire (ZKA-PQ/SF) with respect to the Five-Factor Personality Inventory for ICD-11 (FFiCD). A total of 803 White Spanish subjects were analyzed. All the personality domains had significant predictive power with regard to the FFiCD except NEO Openness. The explained variance of the personality domains with respect to FFiCD Negative Affectivity (71% and 77%) and Detachment (56% and 56%) were similar for NEO-PI-R and ZKA-PQ/SF, respectively, but the NEO-PI-R accounted for greater variance for FFiCD Anankastia, Dissociality, and Disinhibition. The FFiCD facets of Rashness, Thrill- Seeking (Disinhibition), and Unassertiveness (Detachment) were located in factors other than those theoretically expected. The authors conclude that normal personality measured by the NEO-PI-R and the ZKA-PQ/SF contribute, in a differential but complementary way, to knowledge of the maladaptive personality measured by the FFiCD.

Factor Convergence and Predictive Analysis of the Five Factor and Alternative Five Factor Personality Models With the Five-Factor Personality Inventory for ICD-11 (FFiCD)

The authors analyze and compare the factor convergence and predictive power of the Revised NEO Personality Inventory (NEO-PI-R) and the Zuckerman-Kuhlman-Aluja Personality Questionnaire (ZKA-PQ/SF) with respect to the Five-Factor Personality Inventory for ICD-11 (FFiCD). A total of 803 White Spanish subjects were analyzed. All the personality domains had significant predictive power with regard to the FFiCD except NEO Openness. The explained variance of the personality domains with respect to FFiCD Negative Affectivity (71% and 77%) and Detachment (56% and 56%) were similar for NEO-PI-R and ZKA-PQ/SF, respectively, but the NEO-PI-R accounted for greater variance for FFiCD Anankastia, Dissociality, and Disinhibition. The FFiCD facets of Rashness, Thrill- Seeking (Disinhibition), and Unassertiveness (Detachment) were located in factors other than those theoretically expected. The authors conclude that normal personality measured by the NEO-PI-R and the ZKA-PQ/SF contribute, in a differential but complementary way, to knowledge of the maladaptive personality measured by the FFiCD.

Development and initial evaluation of the ICD-11 personality disorder severity scale: PDS-ICD-11

AIM

No measure has formally been developed to assess the published ICD-11 model of Personality Disorder (PD) severity. We therefore set out to develop and evaluate the 14-item Personality Disorder Severity ICD-11 (PDS-ICD-11) scale.

METHOD

A representative U.S. community sample (N = 428; 50.9% women) and a New Zealand mental health sample (N = 87; 61.5% women) completed the PDS-ICD-11 scale along with a series of established PD and impairment measures.

RESULTS

Item response theory supported the unidimensionality of PDS-ICD-11 (median item loading of 0.68) and indicated that a PDS-ICD-11 score of 17.5 may serve as a benchmark for pronounced dysfunction. Correlation and regression analyses supported both criterion validity and incremental validity in predicting impairment and PD symptoms. The PDS-ICD-11 was particularly associated with measures of Level of Personality Functioning Scale (LPFS), Global PD severity, and Borderline PD symptom score. A comparison between clinical individuals diagnosed with an ICD-11 PD vs. no PD supported diagnostic validity.

CONCLUSION

This initial construction study suggests that the PDS-ICD-11 constitutes a promising instrument that provides a quick impression of the severity of personality dysfunction according to the official ICD-11 PD guidelines. Clearly, more research is needed to corroborate its validity and utility. The PDS-ICD-11 scale is provided as online supporting information.

ICD-11 Personality Disorders: A Psychodynamic Perspective on Personality Functioning

The new ICD-11 introduces a fully dimensional classification of personality disorders representing a fundamental change in personality disorder diagnosis with major implications for clinical practice and research. The new system centers on the evaluation of the severity of impairment in the areas of self and interpersonal functioning. This focus on personality functioning converges with long-standing psychoanalytic/psychodynamic conceptualizations of personality pathology. In a detailed conceptual analysis and review of existing empirical data, points of convergence and notable differences between major exponents of the psychodynamic tradition-object relations theory as developed by Kernberg et al. and the Operationalized Psychodynamic Diagnosis-and the ICD-11 system are critically discussed. Personality functioning can be considered to be the current "common ground" for the assessment of personality disorders and constitutes a considerable step forward in making personality disorder diagnosis both clinically meaningful and suitable for research purposes.

The ICD-11 Personality Disorder Trait Model Fits the Kurdish Population Better Than the DSM-5 Trait Model

The ICD-11 Classification of Personality Disorders and the DSM-5 Alternative Model of Personality Disorders (AMPD) operate with trait domains that contribute to the individual expression of personality disturbance (i.e., negative affectivity, detachment, dissociality, disinhibition, anankastia, and psychoticism). To date, these trait frameworks have not been investigated sufficiently in Middle Eastern cultures. Thus, the present study explored the structure of the ICD-11 and AMPD personality disorder (PD) trait domains in a large mixed sample from the Kurdistan zone of Iran. The ICD-11 and AMPD trait domains were operationalized using empirically supported algorithms for the Personality Inventory for DSM-5 (PID-5). The PID-5 was administered to a large mixed sample (N = 3,196) composed of 2,678 community and 518 clinical participants. Structural validity was investigated using Exploratory Factor Analysis (EFA), whereas differential construct validity was explored by comparing clinical and community scores. Model fit and the expected factor structure were deemed appropriate for the ICD-11 trait model, but less adequate for the DSM-5 trait model (i.e., disinhibition did not emerge as a separate factor). All domain and facet scores showed significant differences between clinical and community subsamples with moderate to large effects, mostly for disinhibition and dissociality/antagonism while least for anankastia. The findings of the present study may suggest that the ICD-11 trait model is more cross-culturally fitting than the DSM-5 AMPD trait model, at least with respect to a large mixed sample from the region of Kurdistan. Accordingly, there is evidence for using PID-5 data for WHO ICD-11 purposes in this part of the World.