Classification of personality disorders

Classification of personality disorders occurs mainly in accordance with two diagnostic frameworks: namely, the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM), the latest editions of which are the ICD-11 and DSM-5-TR, respectively, as of 2025^[update].

While the DSM-5-TR standard model diagnoses personality disorders as distinct categories, the ICD-11 diagnoses a single personality disorder dimensionally according to severity, with the possibility to additionally diagnose trait domains.^[1] In the case of the Alternative DSM-5 Model for Personality disorders, the approach chosen is a hybrid dimensional–categorical model,^[2] in which diagnosis can consist of either predefined categories based on specific combinations of traits and functioning levels,^[3] or of a general diagnosis called personality disorder – trait specified.^[3] The ICD-11 classifies schizotypal disorder among primary psychotic disorders rather than as a personality disorder as in the DSM-5.^[4]

Conceptual approaches

Personality disorder classification can generally be broken down into a categorical approach and a dimensional approach. The categorical approach views personality disorders as discrete entities that are distinct from each other as well as from normal personality. In contrast, the dimensional approach suggests that personality disorders exist on a continuum, with traits varying in degree rather than kind.^[5] There has been a sustained movement toward replacing categorical models of personality disorder classification with dimensional approaches.^[6][7] This dimensional perspective may allow for more nuanced understanding and flexible diagnostic practices.

Categorical approach

Classical views of personality disorder as discrete categories have had benefits for understanding and communicating psychopathology throughout history, such as for: a contained organization of symptoms to facilitate standardized research, organizing public awareness and stigma reduction campaigns, allocating public health funding and appropriate treatment intensities, and normalizing clear labels for communicating patient formulations (a description of symptoms and their inter-relationships) to professionals and families.^[5]

Since its inception, the categorical system has steadily accumulated criticism. Attempts to reproduce the factor structure of the DSM-IV-TR's categorical model have been unsuccessful, suggesting that the categorical structure cannot robustly describe the architecture of personality psychopathology.^[5] Such issues are exacerbated by the substantial symptom overlap between disorders that facilitates their excessive and unwarranted comorbidity,^[5][6][7] with the majority of people with a PD being eligible for another PD diagnosis.^[8] As a result, individuals are substantially more likely to be diagnosed with several PDs than a singular one, contradicting the notion that categories provide neat constellations of inter-related symptoms.^[5]

Equally, this approach appears unable to accurately capture the full range of personality psychopathology. Estimates of patients who do not fit neatly into current categories range from 21 to 49%, accordingly given the general diagnosis of Personality Disorder – Not Otherwise Specified (PD-NOS). PD-NOS also appears to be in regular usage to describe mixed or complex presentations given the difficulties in classifying individuals within the current framework.^[5] It has been found that "many patients in clinical practice misleadingly receive multiple PD diagnoses, a 'not otherwise specified' PD diagnosis, or no PD diagnosis at all, even if a PD diagnosis is relevant to the presentation".^[9] Another issue is the heterogeneity within categories.^[7]

Setting standardized diagnostic thresholds (based upon polythetic symptoms) is difficult particularly when each symptom is given equal weighting. This means that individuals with the same number of symptoms can have substantially different levels of distress. Between each PD, diagnostic thresholds occur at different levels of pathology. Due to these issues, it is likely that many clinicians use their clinical judgment based upon an internalized representation of the disorder when making diagnoses. The current categorical approach falls short of fully representing personality psychopathology and providing a scientifically robust understanding of what personality is and what disorders of personality are.^[5]

Dimensional approach

Main article: Dimensional models of personality disorders

In response to observed deficiencies in the categorical approach, dimensional models, which suggest that humans differ in degree not in kind,^[5] have been developed, assessing personality disorders in terms of severity of impairment and maladaptive personality traits.^[6] Within this perspective, PD occurs at maladaptive extremes of the standard personality traits all humans share and as specific combinations of these trait extremes. The degree of life impairment forms the basis for a PD diagnosis. This approach has gained substantial support, with broad calls and movements toward mainstream adoption.^[5]

The shift towards dimensional models is reflected in the inclusion of the AMPD in Section III of the DSM-5, and in the ICD-11’s adoption of a dimensional system. These are believed to ameliorate several shortcomings of the categorical model,^[7] as well as improve clinical utility^[5] and potentially reduce stigma,^[6][5] although no research has so far specifically examined the effect on stigma.^[5] Emerging research indicates that dimensional models may also facilitate the personalization of psychotherapy by aligning treatment strategies with underlying trait dimensions rather than diagnostic categories.^[10] Despite some important differences in the prevailing approaches, dimensional models of PD typically consider two key criteria: severity and style.^[5]

Severity

Mapping of ICD-11 PD classification to the AMPD^[1][11]

ICD-11	AMPD
Severity level	Criterion A
None	No impairment (0)
Personality difficulty	Mild impairment (1)
Mild personality disorder	Moderate impairment (2)
Moderate personality disorder	Severe impairment (3)
Severe personality disorder	Extreme impairment (4)
Traits and patterns	Criterion B
Negative affectivity	Negative Affectivity
Detachment	Detachment
Disinhibition	Disinhibition
Dissociality	Antagonism
Anankastia	(Rigid perfectionism)[a]
(Schizotypal disorder)	Psychoticism

Severity captures the core distress that is common to all PDs, its impact on the individual's self-direction and identity (intrapersonal functioning), as well as their ability to form close relationships and empathize with others (interpersonal functioning). Indices of global severity are robust predictors of both the presence of a personality disorder and prognosis, and track with fluctuations in clinical functioning. According to the ICD-11, severity is the key and sole requirement for making a diagnosis of PD. The central placement of impairment is grounded in research that global severity ratings are sensitive and specific predictors of PD, and provide better estimates of clinician-rated psychosocial impairment than specific categorical diagnoses do. The severity of personality disorder (i.e., mild, moderate, severe) may be more indicative of dysfunction and outcomes than the specific typology of the disorder.^[5]

Style

The second criterion describes the stylistic features of the presentation, largely in relation to some derivation of the Five-Factor Model (FFM) of personality. The DSM-5's Alternative Model of Personality Disorders (AMPD) Criterion B comprises the traits of negative affectivity (continua from emotional stability to neuroticism), detachment (introversion to extroversion), antagonism (agreeableness to antagonism), disinhibition (conscientiousness to impulsivity), and psychoticism (closed to experience to open to experience). The DSM-5's approach to diagnosing PD in the AMPD differs from the ICD-11 as it requires the presence of one or more elevated traits. Nevertheless, there is a growing interest in using only Criterion A for understanding, diagnosing, and managing PD. The FFM has the ability to explain all personality variation, with current dimensional PD models capturing dysfunctional versions or extremes of these traits.^[5]

DSM-5

The cover of the latest DSM edition

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders stresses that a personality disorder is an enduring and inflexible pattern of long duration leading to significant distress or impairment and is not due to use of substances or another medical condition. The DSM-5 lists personality disorders in the same way as other mental disorders, rather than on a separate 'axis', as previously.^[12] DSM-5 lists ten specific personality disorders: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive–compulsive personality disorder.^[13]

The DSM-5 and the more recent DSM-5-TR provide a definition and six criteria for General Personality Disorder. Any of its ten personality disorder diagnoses^[14] is subject to this definition, which requires that a differential diagnosis is performed in order to verify that the disturbance is not the result of other mental disorders, medical conditions or substances, and that the disturbance is stable over time and "inflexible and pervasive across a broad range of personal and social situations", having evident continuity since "at least to adolescence or early adulthood". Additionally, disturbance must be evident in regards to at least two of four specified aspects of functioning, namely: cognition, affectivity, interpersonal functioning and impulse control.^[14][15]

The specific personality disorders are grouped into the following three clusters based on descriptive similarities:

Cluster A

People with these disorders can be paranoid and have difficulty being understood by others, as they often have odd or eccentric modes of speaking and an unwillingness and inability to form and maintain close relationships.^[16] Significant evidence suggests a small proportion of people with Cluster A personality disorders, especially schizotypal personality disorder, have the potential to develop schizophrenia and other psychotic disorders. These disorders also have a higher probability of occurring among individuals whose first-degree relatives have either schizophrenia or a Cluster A personality disorder.^[17]

Paranoid personality disorder (PPD) is a personality disorder characterized by paranoia, and a pervasive, long-standing suspiciousness and generalized mistrust of others. People with this disorder may be hypersensitive, easily insulted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions that may validate their fears or biases. They are eager observers and they often think they are in danger and look for signs and threats of that danger, potentially not appreciating other interpretations or evidence.^[18]

Schizoid personality disorder (/ˈskɪtsɔɪd, ˈskɪdzɔɪd, ˈskɪzɔɪd/, often abbreviated as SzPD or ScPD) is a personality disorder characterized by a lack of interest in social relationships,^[19] a tendency toward a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment, and apathy.^[20] Affected individuals may be unable to form intimate attachments to others and simultaneously possess a rich and elaborate but exclusively internal fantasy world.^[21] Other associated features include stilted speech, a lack of deriving enjoyment from most activities, feeling as though one is an "observer" rather than a participant in life, an inability to tolerate emotional expectations of others, apparent indifference when praised or criticized, being on the asexual spectrum, and idiosyncratic moral or political beliefs.^[22]

Schizotypal personality disorder (StPD or SPD), also known as schizotypal disorder, is a mental disorder characterized by thought disorder, paranoia, a characteristic form of social anxiety, derealization, transient psychosis, and unconventional beliefs.^[23][24] People with this disorder often feel pronounced discomfort in forming and maintaining social connections with other people, primarily due to the belief that other people harbor negative thoughts and views about them.^[25] People with StPD may react oddly in conversations, such as not responding as expected, or talking to themselves.^[25] They frequently interpret situations as being strange or having unusual meanings for them; paranormal and superstitious beliefs are common.

Cluster B

Cluster B personality disorders are characterized by dramatic, impulsive, self-destructive, emotional behavior and sometimes incomprehensible interactions with others.^[16]

Antisocial personality disorder (ASPD) is a personality disorder defined by a chronic pattern of behavior that disregards the rights and well-being of others. People with ASPD often exhibit behavior that conflicts with social norms, leading to issues with interpersonal relationships, employment, and legal matters. The condition generally manifests in childhood or early adolescence, with a high rate of associated conduct problems and a tendency for symptoms to peak in late adolescence and early adulthood.

Borderline personality disorder (BPD) is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, acute fear of abandonment, and intense emotional outbursts.^[26][27][28] People with BPD frequently exhibit self-harming behaviours and engage in risky activities, primarily caused by difficulties in regulating emotions.^[29][30][31] Symptoms such as dissociation, a pervasive sense of emptiness, and distorted sense of self are prevalent.^[27]

Histrionic personality disorder (HPD) is a personality disorder characterized by a pattern of excessive attention-seeking behaviors, usually beginning in adolescence or early adulthood, including inappropriate seduction and an excessive desire for approval. People diagnosed with the disorder are said to be lively, dramatic, vivacious, enthusiastic, extroverted, and flirtatious.

Narcissistic personality disorder (NPD) is a complex and heterogeneous personality disorder characterized by patterns of grandiosity, entitlement, low empathy, and interpersonal difficulties, which can manifest as either grandiose (“thick-skinned”) or vulnerable (“thin-skinned”) forms.^[32][33] Grandiose individuals display arrogance, social dominance, and exploitative behaviors, while vulnerable individuals show shame, inferiority, hypersensitivity, and extreme reactions to criticism. NPD often involves impaired emotional empathy, superficial relationships, and difficulty tolerating disagreement. It is often comorbid with other mental disorders and associated with significant functional impairment and psychosocial disability.^[32]

Cluster C

Cluster C personality disorders are characterised by a consistent pattern of anxious thinking or behavior.^[16]

Avoidant personality disorder (AvPD), or anxious personality disorder, is a cluster C personality disorder characterized by excessive social anxiety and inhibition, fear of intimacy (despite an intense desire for it), severe feelings of inadequacy and inferiority, and an overreliance on avoidance of feared stimuli (e.g., self-imposed social isolation) as a maladaptive coping method.^[34] Those affected typically display a pattern of extreme sensitivity to negative evaluation and rejection, a belief that one is socially inept or personally unappealing to others, and avoidance of social interaction despite a strong desire for it.^[35] It appears to affect an approximately equal number of men and women.^[36]

Dependent personality disorder (DPD) is a personality disorder characterized by a pervasive dependence on other people and subsequent submissiveness^[37][38] and clinginess.^[38] This personality disorder is a long-term condition^[39] in which people depend on others to meet their emotional and physical needs. Individuals with DPD often struggle to make independent decisions and seek constant reassurance from others.^[38] This dependence can result in a tendency to prioritize the needs and opinions of others over their own.^[40]

Obsessive–compulsive personality disorder (OCPD) is a cluster C personality disorder marked by a spectrum of obsessions with rules, lists, schedules, and order, among other things. Symptoms are usually present by the time a person reaches adulthood, and are visible in a variety of situations.^[41] The cause of OCPD is thought to involve a combination of genetic and environmental factors, namely problems with attachment.^[42]

Other personality disorders

The DSM-5 chapter on personality disorders also contains three diagnoses for conditions not matching these ten disorders,^[43] which nevertheless exhibit characteristics of a personality disorder:

• Personality change due to another medical condition – personality disturbance due to the direct effects of a medical condition^[44]
• Other specified personality disorder – used when recording the presence of personality disorder along with the reasons for the condition not being classified as one of the specific personality disorders.^[43]
• Unspecified personality disorder – used when a patient presents with personality disorder symptoms that cause distress or impairment, but the clinician either chooses not to indicate the specific reason these criteria are not met for any one disorder, or there isn’t enough information available to make a more precise diagnosis.^[43]

Alternative DSM-5 model for personality disorders

Main article: Alternative DSM-5 model for personality disorders

The Alternative DSM-5 Model for Personality Disorders (AMPD) presents a dimensional–categorical approach to diagnosis,^[2] contrasting with existing categorical systems such as those in DSM-5 section II and ICD-10.^[9] It aims to address several limitations of categorical systems, particularly the issues imprecision of excessive comorbidity.^[45] This model evaluates personality pathology through two fundamental components: impaired personality functioning (criterion A) and pathological personality traits (criterion B).^[9]

Personality functioning (criterion A) is assessed across self and interpersonal domains. The self domain encompasses identity and self-direction, while the interpersonal domain consists of empathy and intimacy.^[46] Clinicians rate the degree of impairment using the Level of Personality Functioning Scale (LPFS), which ranges from 0 (little or no impairment) to 4 (extreme impairment).^[47] Criterion B is based on five pathological trait domains, that characterize pathological personality expression: Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism.^[48] These domains are further divided into 25 specific trait facets,^[48] such as irresponsibility and risk taking within the domain of disinhibition.^[9]

The AMPD includes six specific personality disorders, which are defined by specific combinations of criteria A and B;^[9] these are: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal.^[3] It excludes four personality disorder categories (dependent, histrionic, paranoid, and schizoid) that are present in the standard model.^[49] For cases that don't meet criteria for specific disorders but still show significant impairment, the model provides the Personality Disorder-Trait Specified (PD-TS) category, which documents the particular pattern of functional impairment and pathological traits.^[50]

For diagnosis, the AMPD requires that the disturbance must be pervasive across situations and stable over time, typically emerging in adolescence or early adulthood. The disturbances cannot be better explained by other mental disorders, substance use, medical conditions, or attributed to developmental stages or sociocultural contexts.^[47]

ICD-11

Main article: ICD-11 classification of personality disorders

Logo of the ICD-11

The ICD-11 classification of personality disorders^[1][11][51] is an implementation of a dimensional model of personality disorders,^[1] meaning that individuals are assessed along continuous trait dimensions,^[52] with personality disorders reflecting extreme or maladaptive variants of traits that are continuous with normal personality functioning,^[53] and classified according to both severity of dysfunction and prominent trait domain specifiers.^[52] The ICD-11 classification of personality disorders differs substantially from the one in the previous edition, ICD-10;^[52] all distinct PDs have been merged into one: personality disorder (6D10), which can be coded as mild, moderate, severe, or severity unspecified.^[1]

Severity levels

Once the presence of personality disorder is established, its severity may be determined; classified as mild, moderate, or severe, it is based on how pervasive and disabling the disturbances are. The evaluation considers impairments in several areas of functioning, such as identity and self-direction, interpersonal relationships, emotional and behavioural problems, the extent of psychosocial dysfunction or distress, and risk of harm to self or others. These indicators serve as guidelines for global clinical judgment rather than as fixed diagnostic criteria.^[51] Severity may also be coded as unspecified (6D10.Z).^[1]

• Mild Personality Disorder (6D10.0): Disturbance is limited to certain aspects of personality functioning. The person may struggle with decisions, relationships, or handling criticism while retaining a coherent identity and overall reality testing. Distress and impairment are present but circumscribed, and harm to self or others is uncommon.^[52]
• Moderate Personality Disorder (6D10.1): Disturbance extends across multiple domains, such as self-concept, relationships, and moderation of behaviour, yet some capacities remain intact. Harm to self or others may occur but is typically moderate.^[52]
• Severe Personality Disorder (6D10.2): There are profound disturbances in identity and interpersonal functioning. The person may lack a stable sense of self, display rigid or chaotic self-concepts, and experience pervasive conflict or exploitation in relationships. Social and occupational functioning is severely compromised, and significant risk of self-injury or violence is common.^[52]

Trait and pattern qualifiers

In addition to coding severity, clinicians may use trait and pattern qualifiers to describe the specific stylistic dimensions and configurations of personality disturbance.^[51] These qualifiers indicate prominent traits contributing to the overall dysfunction but do not represent distinct categories or syndromes. Although the traits exist dimensionally, for coding purposes they are recorded as either present or absent.^[1] The combination and number of trait qualifiers typically reflect the individual’s global severity, with more complex or numerous traits often accompanying greater impairment.^[1][51]

• Negative Affectivity (6D11.0): Involves a tendency to experience frequent and intense negative emotions, such as anxiety, anger, guilt, or shame, accompanied by impaired emotional self-regulation. Common problems are excessive dependency on others, suicidal ideation and hopelessness.^[52]
• Detachment (6D11.1): Characterized by social withdrawal and emotional detachment, anhedonia, and avoidance of intimacy or social engagement.^[52]
• Dissociality (6D11.2): Characterized by self-centeredness, lack of empathy, and disregard for the rights and feelings of others. Individuals often display grandiosity, entitlement, and manipulativeness, pursuing their own needs and comfort without concern for others, or expecting attention or admiration from them. Lack of empathy may be manifested in callousness, aggression, and exploitation, and sometimes in taking pleasure in others’ suffering.^[1][52]
• Disinhibition (6D11.3): Involves impulsivity, recklessness, and poor self-control, with actions driven by immediate desires without regard for long-term consequences.^[52]
• Anankastia (6D11.4): Marked by perfectionism, rigidity, and excessive orderliness, accompanied by a preoccupation with rules, control, and moral standards.^[52]
• Borderline Pattern (6D11.5): A pattern qualifier corresponding closely to the DSM-5 borderline personality disorder diagnosis.^[51]

ICD-10

The specific personality disorders (F60) are: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant) and dependent.^[54] This category also includes Other specific personality disorders (includes PDs characterized as eccentric, haltlose, immature, narcissistic, passive–aggressive, or psychoneurotic), as well as Personality disorder, unspecified (includes "character neurosis" and "pathological personality"). In addition to specific PDs, there are also the following categories:

• Mixed and other personality disorders (F61; defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders).
• Enduring personality changes, not attributable to brain damage and disease (F62; for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness).

Notes

1. Conceptualized as low level of Disinhibition in the AMPD.