The following five cases demonstrate how the ICD-11 Personality Disorder classification may be applied to individuals with varying severity of personality dysfunction and configuations of trait qualifiers. All five cases meet the general diagnostic requirements for Personality Disorder, except for Case 4 (Fig. 4) whose clinical presentation is only characterized by subthreshold Personality Difficulty.

Case 1 (Fig. 1) is a 29-year-old women, who has a history of numerous serious suicide attempts resulting in repeated hospitalizations, multiple treatment providers, and medication trials typically with little to no benefit. She has been diagnosed with ICD-10 F60.3 Emotionally unstable Personality Disorder, but her clinical presentation is also complicated by substance abuse (i.e., cannabis and amphetamine), eating disorder, panic attacks, aggressive/impulsive behaviors leading to a total loss of reliable friends, and severe self-harm that has endangered her life. During her childhood she was verbally and physically abused by her mother, and sexually abused by two of her mother’s male acquantances; she never knew her dad. Under stress she suffers from trauma-related dissociative states including symptoms of depersonalization and psychotic-like voices telling her to punish herself or vanish from the present reality, though, she is mostly aware that the voices only exist in her mind. When experiencing minor defeats or perceived rejection, she responds with feelings of self-loathing or anger. Due to excessive mistrust of other people, her ability to form intimate relationships and capacity for empathy is severily compromised, and she has no idea what to do with her life or what she has to offer. Apart from experiencing mistrust, emptiness, and anger, she occasionally uses ingratiation and charm in her attempts to have her need for warmth and approval met. As displayed in the figure, Case 1’s (Fig. 1) clinical presentation is classified as Severe Personality Disorder (e.g., serious difficulty with regulation of emotional experience, self-esteem, and impulses with a past history and future expectation of severe harm to self, psychotic-like perceptions, and she lacks reliable friends) with prominent trait qualifiers of Negative Affectivity (e.g., experiences negative emotions that are out of proportion to the situation including shame, mistrustfulness, and anger), Disinhibition (e.g., tendency to act impulsively in response to immediate stimuli in a harmful manner), and Dissociality (e.g., mistrust-related aggression and tendency to manipulate or seduce others). In this case Moderate Personality Disorder does not apply because Case 1 (Fig. 1) is not even able to maintain a few friendships or a regular job, and her self-injuries have caused long-term damage and endangered her life. Additionally, Case 1’s (Fig. 1) diagnosis may be further elucidated using the Borderline Pattern qualifier as indicated by nearly all of the features presented in Table 6.

Fig. 1 Severe Personality Disorder with Borderline Pattern and prominent traits of Negative Affectivity, Dissociality, and Disinhibition Full size image

Case 2 (Fig. 2) is a 36-year-old man with a history of panic attacks and recurrent depressive episodes. He is intelligent and sensitive but has not managed to finish any degree after high school. A psychiatric evaluation at an outpatient psychotherapy unit concluded that his personality features met ICD-10 criteria for F60.6 Avoidant Personality Disorder and F60.7 Dependent Personality Disorder. Case 2 (Fig. 2) grew up in a home with poor resources and a family climate characterized by emotional and physical neglect along with some emotional abuse by both parents. During adolescence, he suffered from loneliness, insecurity, poor self-worth, and self-defeating behaviors such as letting peers take advantage of him. He virtually had no friends in school and he generally felt anxious, shy, and unaccepted among peers. Accordingly, he was prone to act as an underdog or people-pleaser. These features were preserved in adulthood in terms of social withdrawal and intimacy avoidance in order not to feel criticized, ashamed, or rejected. However, today he maintains a permanent job and a couple of relationships beyond his two brothers. As displayed in the figure, Case 2’s (Fig. 2) clinical presentation is classified as Mild Personality Disorder (e.g., some distortions in interpersonal appraisal, difficulty maintaining positive self-esteem, is highly submissive in relationships but at least some healthy relationships and occupational roles are maintained) with prominent features of Negative Affectivity (e.g., anxiety, shame, low self-esteem, vulnerability, and depression depressivity) and Detachment (e.g., avoidance of social interactions). Notably, when Case 2 (Fig. 2) was younger, he would probably have been classified as Moderate Personality Disorder because he virtually had no friends; but he has improved since then as he now maintains a stable job and at least a couple of relationships.

Fig. 2 Mild Personality Disorder with prominent traits of Negative Affectivity and Detachment Full size image

Case 3 (Fig. 3) is a 26-year-old man incarcerated for brutal violence (e.g., purposely injured a shop owner with a blunt instrument just to get his money). Although he claimed to feel no suffering from any symptoms or dysfunction, he sought rehabilitation for his dependency on cocaine which had caused him certain problems while imprisoned including withdrawal symptoms and symptoms of intoxication (e.g., tremor and dry mouth). A psychiatric evaluation concluded that his personality features met ICD-10 criteria for F60.2 Dissocial Personality Disorder including some characteristic psychopathic (e.g., callousness and exploitativeness) and narcissistic (e.g., entitlement) features as well as recklessness without concern for others’ safety. Case 3 (Fig. 3) did not recall much from his childhood and appeared aloof and emotionally detached while mentioning that his father was extremely physically abusive towards him and his mother. He did not experience anything positive from friendships, unless they could provide him with certain favors. Moreover, he was not ashamed of admitting that he did not care about harming others, but was rather proud of it, and he generally never felt any emotional or physical pain nor remorse. Case 3’s (Fig. 3) clinical presentation is classified as Severe Personality Disorder (e.g., past history and future expectation of severe harm to others, friendships have no genuine value to him, and self-view is characterized by entitlement) with prominent features of Dissociality (e.g., callousness, exploitation of others, and entitlement), Disinhibition (e.g., recklessness with no regard for others’ safety), and some Detachment (e.g., aloofness). In this case Moderate Personality Disorder would not apply because Case 3 (Fig. 3) is not even interested in maintaining a single friendship and the risk of dangerous harm to others is not just “sometimes” but “often” taking place.

Fig. 3 Severe Personality Disorder with prominent traits of Dissociality and Disinhibition Full size image

Case 4 (Fig. 4) is a 19-year-old highschool student, who was referred for treatment of ICD-10 F41.2 mixed anxiety and depressive disorder along with symptoms of anorexia nervosa, which she had previously been treated for in a private adolescent psychiatric clinic. Case 4 (Fig. 4) is from a relatively stable familiy, where the father works as physician and the mother as dentist. She has always been good at school and at finishing her duties in the home. Even though her parents have been busy with their own careers, they have persistently encouraged her to play the piano at different occasions and excel at horse riding competitions because they knew and expected that she was good at that. For that reason, her father never responded positively when she performed very well, whereas he showed disaoppointment if she did not get an A at her exams. While she was 13 her world fell apart as she discovered her father having an affair with another woman from his workplace, and she started overperforming in school and in sport while gradually developing eating disorder symptoms (restricting food leading to abnormally low weight) and even more unrelenting standards. However, she managed to maintain satisfying relationships with her friends as well as her mother and siblings. Case 4’s (Fig. 4) clinical presentation is primarily classified as Anorexia Nervosa in the context of Personality Difficulty (i.e., some long-standing difficulties in her way of thinking about the self and the world, including unrelenting standards, which are insufficiently severe to cause notable disruption in school and most relationships) with prominent features of Negative Affectivity (e.g., depressivity, shame, and anxiety) and Anankastia (e.g., perfectionism, concern with meeting obligations, perseveration, deliberatetiveness, and tight control of own emotional expression). In this case Mild Personality Disorder would not apply because Case 4’s (Fig. 4) habitual personality issues are not leading to any notable psychosocial impairment, whereas her problems are mainly attributable to other current mental problems.

Fig. 4 Personality Difficulity with prominent traits of Negative Affectivity and Anankastia Full size image

Case 5 (Fig. 5) is a 53-year-old highly skilled and well-groomed accountant who has worked for several companies during his carreer. At his current job, Case 5 (Fig. 5) was referred to a psychologist at the company’s HR department. Overall his personality characteristics were consistent with the ICD-10 Personality Disorder diagnoses F60.5 Anankastic Personality Disorder and F60.8 Other: Narcissistic Personality Disorder. Since adolescence, Case 5 (Fig. 5) has been more or less preoccupied with order, details, rules, and organization, including excessive pedantry and stubbornness. He always knew the “right” solution to most problems, and felt more capable of solving complicated things than nearly anyone else. Furthermore, he felt more important and entitled than most other people, and turned hostile when this was not recognized by others. Therefore, at work he has been reluctant to collaborate with others or to delegate “important” tasks to others, unless they submit to exactly his way of doing it. Colleagues and other people who know him well describes him as officious, supercilious, high-handed, unimaginative, intrusive, petty-minded, meddlesome, and nosy. An ex-wife has called Case 5 (Fig. 5) “a narcissist”, whereas he refers to her as “too vulnerable and unintelligent”. For those reasons he has not been able to maintain his occupational positions due to conflicts with superiors and emotional abuse of co-workers who he perceives as less efficient than himself. According to his account of things, it was his decision to leave the different companies during his career simply because they were not professional enough. According to ICD-11 guidelines, Case 5’s (Fig. 5) clinical presentation may be classified as Moderate Personality Disorder (e.g., a compromized capacity for understanding and appreciating others’ perspectives, work relationships are disrupted, and persistent conflicts result in emotional harm to others) with prominent traits of Anankastia (e.g., stubbornness, orderliness, and perfectionism) and Dissociality (e.g., entitlement, grandiosity, lack of empathy, meanness, and hostility). In this case, Severe Personality Disorder does not apply because while Case 5’s (Fig. 5) intimate and occupational relationships have been disrupted by frequent conflicts, he is still able to maintain work productivity and at least some relationships for a certain period of time. Likewise, Mild Personality Disorder does not apply because he is virtually incapable of or unwilling to sustain employment due to interpersonal issues, and he does not have any positive/healthy relationships not even with family members.