Camille Jantzi
Valerie Moulin- 1University Center of Legal Medicine (CURML), Geneva University Hospital, Geneva, Switzerland
- 2Université Grenoble Alpes, Laboratoire Inter-universitaire de Psychologie, Personnalité, Cognition et Changement Social-LIP/PC2S, Grenoble, France
This paper examines the implications of the transition from ICD-10 to ICD-11 for the diagnosis of personality disorders in forensic psychiatric evaluations. The ICD-11 introduces a dimensional approach, replacing the previous categorical system with a focus on severity and maladaptive personality traits. This shift addresses longstanding criticisms of the ICD-10, such as underdiagnosis, diagnostic instability, and lack of scientific validity. The new model classifies personality disorders by severity (mild, moderate, severe) and five trait domains, enhancing clinical nuance but also introducing challenges in continuity and communication. While the ICD-11 aims to improve diagnostic accuracy and treatment planning, concerns remain regarding overdiagnosis, increased stigma-especially among adolescents and the adequacy of trait coverage. The absence of validated diagnostic tools and clear severity thresholds further complicates forensic application. Preliminary studies suggest a dramatic increase in diagnosed cases under ICD-11, raising questions about the risk of pathologizing normative behavior and the potential for excessive intervention. The paper highlights the need for further research and careful implementation to balance improved recognition of personality pathology with the avoidance of unintended negative consequences in forensic practice.
Introduction
Pre-sentencing forensic psychiatric evaluations represent a challenge in retrospective diagnosis. In these cases, determining whether the assessed individual was suffering from a “serious mental disorder” at the time of the act is paramount. (1, 2). This determination, as outlined by Article 19 of the Swiss Penal Code, assesses whether the disorder could have impaired their ability to appreciate the unlawfulness of their actions or act accordingly.
This issue is central to pre-sentencing evaluations, as stipulated by Article 20 of the Swiss Penal Code. The diagnosis influences both the type of therapeutic measures proposed and, to some extent, the evaluation of the individual’s dangerousness. It is essential to adopt an internationally recognized diagnostic framework to ensure consistency and reproducibility in medico-legal contexts (3, 4).
At the Forensic Psychiatry Unit in Geneva, the ICD-10 (International Classification of Diseases) was historically used. However, since January 1, 2022, the new ICD-11 classification has come into effect, necessitating training and adaptation. While some diagnostic areas remain unchanged, such as psychoses, others—like personality disorders, paraphilias, substance use disorders, and trauma-related disorders—have undergone major paradigm shifts (5, 6).
This paper focus on personality disorders, as this domain presents the most radical changes and clear implications for forensic psychiatric practice, specifically, the ICD-11 transitions from a categorical to a dimensional approach. Unlike the ICD-10, which described personality disorders using ten specific categories with detailed criteria, the ICD-11 prioritizes evaluating the severity of functional impairment and identifying predominant personality traits. This focus on severity is particularly relevant in forensic settings, as it is a major predictor of outcomes (7). In forensic populations, the prevalence of personality disorder is high (8, 9) and could impact the evaluation of the needs for intervention to reduce recidivism (10).
The aim of this paper is to highlight the changes and their impact on forensic psychiatric evaluations.
Context and definitions
The need for change
Numerous authors have highlighted the challenges associated with the ICD-10 categorical classification of personality disorders (7, 11, 12), advocating for a paradigm shift. A significant critique of the ICD-10 was its overly strict diagnostic criteria, which often led to underdiagnosis. The suspicion of underdiagnosis arose from the fact that the prevalence of personality disorders, regardless of type, was consistently reported to be much lower than other mental health disorders in research databases (13, 14).
Additionally, among those diagnosed with personality disorders, 95% were classified under only three categories: “antisocial personality,” “emotionally unstable personality,” or “mixed personality disorder” (15, 16). This suggested that existing categories did not adequately capture the clinical presentations observed by practitioners. Another criticism was the instability of diagnoses over time, despite requiring symptom stability over time as a diagnostic criterion.
The primary critique, however, was the lack of scientific validity behind these categories, which were based solely on clinical observations and historical work on personality disorders. A meta-analysis concluded that personality disorders represent extreme values along a continuum between normal and pathological personality traits, as described in the Five-Factor Model (17). This model, derived from Cattell’s personality theory (18), was initially considered during the development of the DSM-5 but ultimately abandoned in favor of a categorical approach (19).
The dimensional model views personality disorders as existing on a continuum, ranging from normal personality traits to maladaptive extremes. This allows for a more nuanced understanding of personality pathology, rather than rigidly categorizing individuals as having or not having a disorder. Dimensional models reduce issues like diagnostic overlap and the “not otherwise specified” (NOS) category seen in categorical systems. They provide incremental validity by describing all personality traits and eliminating artificial boundaries between disorders. Dimensional frameworks account for the fluctuating expression of traits depending on environmental factors or stress levels, making them more adaptable to changes in an individual’s condition over time (20).
ICD-11 classification of personality disorders
General diagnostic features
Personality disorders are defined by impairments in self-functioning (e.g., identity, self-worth, self-direction) and/or interpersonal functioning (e.g., ability to maintain relationships, empathy, conflict management). These impairments must be pervasive, persistent, and not attributable to developmental stages or cultural norms.
Severity levels
Personality disorders are classified based on severity: mild, moderate, or severe. Severity reflects the degree of dysfunction in self and interpersonal functioning and the associated risks (e.g., harm to self or others).
Trait domains
Five maladaptive personality trait domains describe the nature of personality dysfunction:
● Negative Affectivity: Emotional instability, anxiety, and depressive tendencies.
● Detachment: Social withdrawal, avoidance of intimacy.
● Dissociality: Disregard for others, manipulativeness.
● Disinhibition: Impulsivity, irresponsibility.
● Anankastia: Perfectionism, rigidity.
Borderline pattern qualifier
A specific “borderline pattern” qualifier can be added if the individual meets criteria similar to DSM-5’s Borderline Personality Disorder (e.g., emotional instability, fear of abandonment).
Other relevant diagnostic entities
Schizotypal personality disorder
In the ICD-11, schizotypal personality disorder (6A22) is classified under psychotic disorders and retains the same criteria as in the ICD-10. This alignment emphasizes the close relationship between schizotypal traits and psychotic disorders, maintaining consistency in its diagnostic approach.
Dissocial or disruptive behavior disorders
A key distinction in the ICD-11 is the removal of age-specific classifications for many disorders, allowing diagnoses to be applied across all ages unless explicitly restricted (e.g., reactive attachment disorder, which can only be diagnosed before the age of five). For instance, the Oppositional Defiant Disorder (6C90) and the Conduct Disorder (6C91), previously restricted to children and adolescents, can now theoretically be diagnosed in adults.
This diagnosis may apply to adults, particularly young adults with an adolescent-like context, though caution must be exercised to avoid the over-psychiatrization of criminal behavior.
Intermittent explosive disorder
Intermittent Explosive Disorder (6C73), part of impulse-control disorders, is highly relevant in forensic settings due to its implications for evaluating legal responsibility. The disorder is characterized by Brief episodes of verbal or physical aggression or property destruction reflecting an inability to control aggressive impulses.
This disorder is particularly pertinent for individuals who commit repeated acts of violence without meeting the criteria for a personality disorder. Its diagnosis could significantly influence assessments of volitional capacities and legal accountability.
Complex post-traumatic stress disorder
The ICD-11 introduces Complex Post-Traumatic Stress Disorder (CPTSD, 6B41), defined as a disorder that may develop following exposure to events of an extremely threatening or horrifying nature. In addition to meeting the criteria for PTSD, CPTSD is characterized by severe and persistent difficulties in affect regulation, self-perception, and interpersonal relationships.
This diagnosis aims to differentiate CPTSD from personality disorders, particularly emotionally unstable personality disorder, ensuring appropriate therapeutic interventions. Advocacy groups, such as #TraumaNotPD, have campaigned for this distinction to prevent misdiagnosis and mistreatment (21).
Personality difficulty
The ICD-11 also includes the non-diagnostic category Personality Difficulty (QE50.7), which corresponds to the former “accentuated personality traits” category. This designation is intended for individuals who exhibit specific personality traits that may complicate treatment but do not meet the criteria for a personality disorder.
In forensic settings, using this category requires caution to avoid pathologizing normal psychological defenses under stress. Additionally, it should not be confused with a mental disorder that might affect legal responsibility.
Literature review
Increased incidence
The ICD-11 has sparked considerable academic discussion, even prior to its official release. Many authors have advocated for this new classification, particularly for its redefinition of personality disorder diagnosis (7, 11, 12). The aim of the new classification was to increase the recognition and diagnosis of personality disorders, and studies indicate that this goal has been achieved (22). This outcome is primarily due to the broader diagnostic criteria, including a shorter temporal requirement (only two years for diagnosis) and the allowance for diagnosing minors.
A meta-analysis highlighted the clinical utility of the new classification but also identified limitations, particularly regarding its clarity and ease of communication with patients and their families (23).
Diagnostic tools
Currently, limited clinical studies validate the ICD-11 classification, largely due to a lack of established diagnostic tools. Several scales are under exploration, such as the Personality Inventory for ICD-11 (PiCD), a 60-item self-assessment scale evaluating the five trait domains, which also has an informant-report form (PiCD-IRF) (24–26). Another tool, the Standardized Assessment of Severity of Personality Disorder (SASPD), is a 9-item self-report questionnaire assessing functional impairment of personality traits (27). A third tool, the Personality Disorder Severity Scale (PDS-ICD-11), evaluates severity using 14 items and identifies severe personality disorders with a threshold score of 175, though it struggles to differentiate between mild and moderate disorders (28). The DSM-5 Personality Disorder Instrument (PDI), developed as an experimental tool for assessing dimensional personality pathology, has also been evaluated in forensic settings. Preliminary studies indicate that the PDI may offer valuable insights into the assessment of personality dysfunction in offenders, providing incremental validity over categorical approaches (29). However, its routine use in forensic practice remains limited, and further research is needed to establish its utility and comparability with ICD-11-based assessments.
In forensic settings, the assessment of psychopathy may also be useful but must be used with care regarding the stigma around this denomination. The gold standard for the assessment of psychopathy in adults is the Psychopathy Checklist-Revised (PCL-R; 30), a 20-item clinician-rated instrument that evaluates interpersonal, affective, and behavioral features associated with psychopathy. The PCL-R has been extensively validated in forensic and clinical populations and is widely used for risk assessment and research purposes (30, 31). For young people, two key instruments are widely used: the Psychopathy Checklist: Youth Version (PCL-YV; 32), which is adapted for adolescents, and the Comprehensive Assessment of Psychopathic Personality (CAPP; 33). The PCL-YV is considered the gold standard for assessing psychopathic traits in youth, while the CAPP provides a theoretically grounded, trait-based approach compatible with dimensional models such as ICD-11. However, neither instrument has been specifically validated for use within the ICD-11 personality disorder framework, and their integration into new diagnostic paradigms remains an open question.
For borderline traits specifically, the Borderline Pattern Scale (BPS) is being tested (34). Notably, studies in forensic settings have shown poor concordance between self-reports and informant reports, underscoring the importance of avoiding self-assessment tools in forensic evaluations (35).
Five-trait model
Validation studies of the five-trait model suggest that it may conceptually be more accurate as a four-trait model. This adjustment merges anankastia and disinhibition, as they represent opposite poles of the same dimension. This alignment reflects the challenges of diagnosing individuals who exhibit traits of both impulsivity and emotional repression simultaneously (36–39).
Genetic and neuroimaging research
Recent advances in genetic and brain imaging research have not yet provided robust biomarkers or clear neurobiological correlates for the ICD-11 personality disorder revisions. While some studies have explored heritability and neural correlates of personality pathology, findings remain inconsistent and do not currently support the use of genetic or neuroimaging data for diagnosis or for distinguishing between ICD-10 and ICD-11 models (40, 41). This highlights a significant limitation in the current scientific foundation for the ICD-11 revisions, emphasizing the need for further interdisciplinary research.
Severity and prognosis
The evaluation of disorder severity has been shown to inform treatment intensity and prognosis (42, 43). While there is limited forensic literature directly examining the predictive validity of ICD-11 personality disorder severity for recidivism risk, recent research has extensively explored the relationship between adolescent psychopathy and long-term offending. For example, McCuish et al. (44) conducted a large cohort study following youth with psychopathic traits into adulthood, demonstrating significant predictive validity for recidivism. These findings suggest that certain personality pathology dimensions, particularly those related to psychopathy, may have important implications for risk assessment, even if direct evidence for ICD-11 categories is still emerging.
Critiques
Despite its advantages, the ICD-11 has faced several criticisms. One justification for the shift to a dimensional model was to reduce the stigma associated with personality disorder diagnoses. However, some researchers question whether this goal will be achieved. In fact, they argue that the broader diagnostic criteria and increased prevalence might amplify stigma, especially when diagnosing adolescents. For example, labeling adolescents with personality disorders could lead to self-fulfilling prophecies, negatively impacting their self-image and increasing marginalization (45, 46).
A study by Perkins et al. (47) found that being labeled as having a personality disorder can harm an individual’s self-esteem and does not necessarily improve access to care. Moreover, clinicians may perceive patients with personality disorders more negatively, often overlooking other symptoms like anxiety or depression, interpreting them solely through the lens of the personality disorder (48, 49).
The “Borderline Pattern” descriptor in the ICD-11 has also been criticized for lacking scientific validity, as it is rarely addressed in clinical studies and relies solely on the five-trait model (50). Furthermore, certain traits, such as “Negative Affectivity,” are criticized for being overly broad and potentially applicable to a wide range of disorders (51). Lastly, critics argue that key personality types, such as avoidant, dependent, or narcissistic personalities, are inadequately captured in the ICD-11 framework (52).
A problem of continuity
The introduction of the ICD-11 marks a clear break from previous diagnostic approaches, creating challenges in research and clinical practice. Conducting a literature review now requires attention to both ICD-10 and ICD-11 terminology to ensure comprehensive results. In forensic practice, continuity issues also arise when comparing past and present evaluations. Experts must navigate these differences by focusing on symptom descriptions rather than rigid diagnostic categories.
The lack of clearly defined thresholds for severity levels (e.g., mild, moderate, severe) in the ICD-11 could also lead to variability between examiners, potentially complicating reevaluations and forensic decisions. Preliminary studies suggest that the three-tiered severity model may lack empirical support and require further validation (28, 52).
Another important limitation in the current ICD-11 literature is the insufficient discussion of comorbidity, particularly with key neurodevelopmental disorders such as Autism Spectrum Disorder (ASD) and Fetal Alcohol Spectrum Disorder (FASD). Both ASD and FASD can present with overlapping features of personality dysfunction, complicating differential diagnosis and risk assessment in forensic populations (53, 54). The ICD-11 does not provide specific guidance on addressing these complex comorbidities, which remains a significant challenge for clinicians.
In the forensic domain
The implications of the ICD-11 for forensic psychiatry remain insufficiently explored. Some researchers, such as Frances and Nardo (55), argue that the DSM-5 may be more suitable for forensic settings due to its perceived precision and reliability. They caution that the broader diagnostic criteria in the ICD-11 could lead to the pathologization of clinical presentations previously deemed borderline normal. Overdiagnosis in this context could result in excessive therapeutic recommendations for individuals who may not genuinely require intervention. The Risk-Need-Responsivity (RNR) model (56), now widely adopted in recidivism prevention frameworks, warns that excessively intensive interventions for low-risk offenders may paradoxically increase their risk of recidivism by fostering marginalization and stigma.
An English study conducted in a high-security forensic hospital (57) reported a prevalence of personality disorders of 30.8% using ICD-10 criteria, which rose dramatically to 100% when applying ICD-11 criteria. While the study’s authors emphasized the improved clinical validity of the ICD-11, the significant increase raises concerns about overly inclusive diagnostic thresholds. Notably, the ICD-11 diagnoses in this study were made retrospectively from medical records, rather than based on live assessments by clinicians. This methodological limitation might have amplified the apparent prevalence under the new classification system.
The study further identified predominant traits among forensic patients diagnosed with “antisocial personality disorder” and “emotionally unstable personality disorder.” For individuals with antisocial traits, dissociality and disinhibition were frequently observed, accompanied by low levels of negative affectivity. In contrast, patients classified under emotionally unstable personality disorder exhibited strong negative affectivity in addition to dissociality and disinhibition, often with the “borderline pattern” descriptor.
Efforts to map ICD-10 categories to ICD-11 traits have been made (52), such as linking “negative affectivity and detachment” to avoidant personalities, or “dissociality and anankastia” to narcissistic personalities. However, these attempts face limitations due to the fundamentally different paradigms of the two classification systems. The ICD-11’s emphasis on individualization resists rigid categorization, aiming instead to provide a flexible framework that describes psychological traits without confining individuals to predefined diagnostic “boxes.”
From a forensic perspective, the ICD-11’s dimensional model offers significant advantages. For instance, determining the severity of a personality disorder is critical when assessing legal responsibility (58). In Switzerland, the Penal Code requires forensic experts to evaluate whether an individual suffers from a “serious mental disorder” that significantly deviates from societal norms (Federal Court Ruling 116 IV 273). Mild personality disorders, especially under the broad ICD-11 criteria, are unlikely to meet this threshold.
The dimensional approach also addresses disparities in how responsibility mitigation was applied under the categorical model. Previously, individuals with narcissistic, antisocial, or obsessive-compulsive personality disorders often received less consideration for responsibility reduction. The ICD-11 encourages forensic experts to focus on clinically relevant traits, such as empathy deficits, impulsivity, and emotional regulation difficulties, rather than diagnostic labels. This nuanced analysis enhances the credibility of expert testimony in judicial settings.
Finally, the ICD-11 improves therapeutic recommendations by targeting specific maladaptive traits rather than attempting to resolve the entire disorder. This approach allows clinicians to set realistic goals, such as reducing impulsivity or improving emotional regulation, while acknowledging that complete remission may not be feasible. The dimensional framework also facilitates tracking improvements over time, as severity reductions can signal meaningful progress even if the diagnosis persists.
Conclusion
The new ICD-11 classification introduces an important paradigm shift in the diagnosis of personality disorders. In forensic psychiatry, evaluating the severity of the disorder is essential, as jurisprudence requires determining if a defendant’s mental state significantly deviates from that of individuals who have committed similar acts. Furthermore, avoiding terms with stigmatizing connotations, such as “paranoid” or “narcissistic,” helps focus on the fundamental nature of the disorder as a mental health issue, for which the individual is not at fault.
The ICD-11’s broader and more flexible terminology encourages forensic experts to provide detailed descriptions of observed symptoms rather than relying solely on diagnostic criteria. This descriptive approach helps humanize the evaluated individual and facilitates a better understanding of their psychological functioning by judges and legal professionals.
However, the ICD-11 also presents challenges. The discontinuity with the ICD-10 complicates comparative evaluations, and many clinicians may continue using the previous categories due to their familiarity and ease of communication. Adopting the ICD-11 will require comprehensive training and widespread practice to ensure consistency in its application.
Further research is needed to validate diagnostic tools specific to the ICD-11 and to confirm the utility of the new classification in forensic contexts, such as predicting recidivism risk and guiding treatment recommendations. Despite these challenges, the dimensional approach offers a promising path toward more individualized, scientifically grounded, and less stigmatizing forensic psychiatric evaluations.
Author contributions
CJ: Writing – review & editing, Writing – original draft. VM: Writing – review & editing, Writing – original draft.
Funding
The author(s) declare financial support was received for the research and/or publication of this article. Open access funding by University of Geneva.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declare that Generative AI was used in the creation of this manuscript. AI was used for the layout.
Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1. Meyer LF and Valença AM. Factors related to bias in forensic psychiatric assessments in criminal matters: A systematic review. Int J Law Psychiatry. (2021) 75:101681. doi: 10.1016/j.ijlp.2021.101681
2. Sher L. Forensic psychiatric evaluations: an overview of methods, ethical issues, and criminal and civil assessments. Int J Adolesc Med Health. (2015) 27:109–15. doi: 10.1515/ijamh-2015-5001
4. Franklin K. Psychological evaluation and testing in the court-martial context. In Stein CT and Younggren JN, editors., Forensic psychology in military courts. American Psychological Association. (2019) pp. 175–204. doi: 10.1037/0000141-010
5. Reed GM, First MB, Kogan CS, Hyman SE, Gureje O, Gaebel W, et al. Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders. World Psychiatry. (2019) 18:3–19. doi: 10.1002/wps.20611
6. Seemüller F. ICD-11 and mental disorders: important changes, controversies, and future directions. BMC Psychiatry. (2023) 23:698. doi: 10.1186/s12888-023-05186-w
7. Mulder RT. ICD-11 personality disorders: utility and implications of the new model. Front Psychiatry. (2021) 12:655548. doi: 10.3389/fpsyt.2021.655548
8. Tressová D, De Caluwé E, and Bogaerts S. Identity and personality pathology in adult forensic psychiatric patients and healthy controls. Int J offender Ther Comp criminology. (2024) 68:1558–78. doi: 10.1177/0306624X241248364
9. Hutsebaut J, Weekers LC, Tuin N, Apeldoorn JS, and Bulten E. Assessment of ICD-11 personality disorder severity in forensic patients using the semi-structured interview for personality functioning DSM-5 (STiP-5.1): preliminary findings. Front Psychiatry. (2021) 12:617702. doi: 10.3389/fpsyt.2021.617702
10. Lutz M, Zani D, Fritz M, Dudeck M, and Franke I. A review and comparative analysis of the risk-needs-responsivity, good lives, and recovery models in forensic psychiatric treatment. Front Psychiatry. (2022) 13:988905. doi: 10.3389/fpsyt.2022.988905
11. Hopwood CJ, Kotov R, Krueger RF, Watson D, Widiger TA, Althoff RR, et al. The time has come for dimensional personality disorder diagnosis. Pers Ment Health. (2018) 12:82. doi: 10.1002/pmh.1408
12. Hauser NC, Herpertz SC, and Habermeyer E. Das überarbeitete Konzept der Persönlichkeitsstörungen nach ICD-11: Neuerungen und mögliche Konsequenzen für die forensisch-psychiatrische Tätigkeit. Forensische Psychiatrie Psychologie Kriminologie. (2021) 15:30–8. doi: 10.1007/s11757-020-00648-3
13. Volkert J, Gablonski TC, and Rabung S. Prevalence of personality disorders in the general adult population in Western countries: systematic review and meta-analysis. Br J Psychiatry. (2018) 213:709–15. doi: 10.1192/bjp.2018.202
14. Hopwood CJ, Krueger RF, Watson D, Widiger TA, Althoff RR, Ansell EB, et al. Commentary on” The challenge of transforming the diagnostic system of personality disorders. J Pers Disord. (2019) 34:1–4. doi: 10.1521/pedi_2019_33_00
15. Coid J, Yang MIN, Tyrer P, Roberts A, and Ullrich S. Prevalence and correlates of personality disorder in Great Britain. Br J Psychiatry. (2006) 188:423–31. doi: 10.1192/bjp.188.5.423
16. Tyrer P. The classification of personality disorders in ICD-11: Implications for forensic psychiatry. Crim. Behav Ment Health. (2013) 23:1. doi: 10.1002/cbm.1850
17. Saulsman LM and Page AC. The five-factor model and personality disorder empirical literature: A meta-analytic review. Clin Psychol Rev. (2004) 23:1055–85. doi: 10.1016/j.cpr.2002.09.001
18. McCrae RR and Costa PT. Perspectives de la théorie des cinq facteurs (TCF): traits et culture. Psychol française. (2006) 51:227–44. doi: 10.1016/j.psfr.2005.09.001
19. Gøtzsche-Astrup O and Moskowitz A. Personality disorders and the DSM-5: Scientific and extra-scientific factors in the maintenance of the status quo. Aust New Z J Psychiatry. (2016) 50:119–27. doi: 10.1177/0004867415595872
20. Monaghan C and Bizumic B. Dimensional models of personality disorders: challenges and opportunities. Front Psychiatry. (2023) 14:1098452. doi: 10.3389/fpsyt.2023.1098452
21. Giourou E, Skokou M, Andrew SP, Alexopoulou K, Gourzis P, and Jelastopulu E. Complex posttraumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma? World J Psychiatry. (2018) 8:12. doi: 10.5498/wjp.v8.i1.12
22. Tyrer P, Crawford M, Sanatinia R, Tyrer H, Cooper S, Muller-Pollard C, et al. Preliminary studies of the ICD-11 classification of personality disorder in practice. Pers Ment Health. (2014) 8:254–63. doi: 10.1002/pmh.1275
23. Tracy M, Tiliopoulos N, Sharpe L, and Bach B. The clinical utility of the ICD-11 classification of personality disorders and related traits: a preliminary scoping review. Aust New Z J Psychiatry. (2021) 55:849–62. doi: 10.1177/00048674211025607
24. Bach B, Christensen S, Kongerslev MT, Sellbom M, and Simonsen E. Structure of clinician-reported ICD-11 personality disorder trait qualifiers. psychol Assess. (2020) 32:50. doi: 10.1037/pas0000747
25. Oltmanns JR and Widiger TA. A self-report measure for the ICD-11 dimensional trait model proposal: The personality inventory for ICD-11. psychol Assess. (2018) 30:154. doi: 10.1037/pas0000459
26. Somma A, Gialdi G, and Fossati A. Reliability and construct validity of the Personality Inventory for ICD-11 (PiCD) in Italian adult participants. psychol Assess. (2020) 32:29. doi: 10.1037/pas0000766
27. Bach B and Anderson JL. Patient-reported ICD-11 personality disorder severity and DSM-5 level of personality functioning. J Pers Disord. (2018) 34:231–49. doi: 10.1521/pedi_2018_32_393
28. Bach B, Brown TA, Mulder RT, Newton-Howes G, Simonsen E, and Sellbom M. Development and initial evaluation of the ICD-11 personality disorder severity scale: PDS-ICD-11. Pers Ment Health. (2021) 15:223–36. doi: 10.1002/pmh.1510
29. Zimmermann J, Kerber A, Rek K, Hopwood CJ, and Krueger RF. A brief but comprehensive review of the Personality Disorder Interview for DSM-5 (PDI-5) and its utility in forensic settings. Pers Ment Health. (2020) 14:202–12. doi: 10.1002/pmh.1473
31. Mokros A, Neumann CS, Stadtland C, Osterheider M, Nedopil N, and Hare RD. Assessing measurement invariance of PCL-R assessments from file reviews of North American and German offenders. Int J Law Psychiatry. (2011) 34:56–63. doi: 10.1016/j.ijlp.2010.11.009
32. Forth AE, Kosson DS, and Hare RD. The Psychopathy Checklist: Youth Version (PCL: YV): Technical Manual. Toronto: Multi-Health Systems (2003).
33. Cooke DJ, Hart SD, Logan C, and Michie C. Comprehensive Assessment of Psychopathic Personality (CAPP): Technical Manual. Glasgow: University of Glasgow (2012).
34. Oltmanns JR and Widiger TA. Evaluating the assessment of the ICD-11 personality disorder diagnostic system. Psychol Assess. (2019) 31:674. doi: 10.1037/pas0000693
35. Spaans M, Molendijk ML, de Beurs E, Rinne T, and Spinhoven P. Self-reported personality traits in forensic populations: A meta-analysis. Psychol Crime Law. (2017) 23:56–78.
36. Bach B and Bernstein DP. Schema therapy conceptualization of personality functioning and traits in ICD-11 and DSM-5. Curr Opin Psychiatry. (2019) 32:38–49.
37. Gutiérrez F, Aluja A, Ruiz J, García LF, Gárriz M, Gutiérrez-Zotes A, et al. Personality disorders in the ICD-11: Spanish validation of the PiCD and the SASPD in a mixed community and clinical sample. Assessment. (2021) 28:759–72. doi: 10.1177/1073191120936357
38. Brown TA and Sellbom M. Examining the validity and factor structure of the ICD-11 trait domains. psychol Assess. (2024) 36:311–22. doi: 10.1037/pas0001308
39. Mulder RT, Newton-Howes G, Crawford MJ, and Tyrer PJ. The central domains of personality pathology in psychiatric patients. J Pers Disord. (2011) 25:364. doi: 10.1521/pedi.2011.25.3.364
40. Viding E, McCrory EJ, and Seara-Cardoso A. The neurobiology of personality disorders: Insights from genetic and brain imaging research. Curr Opin Psychiatry. (2022) 35:77–84. doi: 10.1016/j.cub.2014.06.055
41. Hyatt CS, Owens MM, Crowe ML, Carter NT, Lynam DR, and Miller JD. Personality disorders and the brain: A review of structural and functional neuroimaging studies. Pers Disorders: Theory Research Treat. (2021) 12:357–70. doi: 10.1521/pedi_2020_34_467
42. Bach B and First MB. Application of the ICD-11 classification of personality disorders. BMC Psychiatry. (2018) 18:1–14. doi: 10.1186/s12888-018-1908-3
43. Clark LA, Nuzum H, and Ro E. Manifestations of personality impairment severity: comorbidity, course/prognosis, psychosocial dysfunction, and ‘borderline’personality features. Curr Opin Psychol. (2018) 21:117–21. doi: 10.1016/j.copsyc.2017.12.004
44. McCuish EC, Corrado RR, Hart SD, and DeLisi M. Psychopathic traits and criminal careers: A 20-year longitudinal study of adjudicated male adolescents. Law Hum Behav. (2022) 46:116–30.
45. Watts J. Problems with the ICD-11 classification of personality disorder. Lancet Psychiatry. (2019) 6:461–3. doi: 10.1016/S2215-0366(19)30127-0
46. Farrington DP and Murray J. Labeling theory: Empirical tests Vol. 1. New Jersey, USA: Transaction Publishers (2013).
47. Perkins A, Ridler J, Browes D, Peryer G, Notley C, and Hackmann C. Experiencing mental health diagnosis: a systematic review of service user, clinician, and carer perspectives across clinical settings. Lancet Psychiatry. (2018) 5:747–64. doi: 10.1016/S2215-0366(18)30095-6
48. Bodner E, Cohen-Fridel S, and Iancu I. Staff attitudes toward patients with borderline personality disorder. Compr Psychiatry. (2011) 52:548–55. doi: 10.1016/j.comppsych.2010.10.004
49. Black DW, Pfohl B, Blum N, McCormick B, Allen J, North CS, et al. Attitudes toward borderline personality disorder: a survey of 706 mental health clinicians. CNS spectrums. (2011) 16:67–74. doi: 10.1017/S109285291200020X
50. Tyrer P, Mulder R, Kim YR, and Crawford MJ. The development of the ICD-11 classification of personality disorders: An amalgam of science, pragmatism, and politics. Annu Rev Clin Psychol. (2019) 15:481–502. doi: 10.1146/annurev-clinpsy-050718-095736
51. Bach B, Sellbom M, Skjernov M, and Simonsen E. ICD-11 and DSM-5 personality trait domains capture categorical personality disorders: Finding a common ground. Aust New Z J Psychiatry. (2018) 52:425–34. doi: 10.1177/0004867417727867
52. Bach B, Kramer U, Doering S, di Giacomo E, Hutsebaut J, Kaera A, et al. The ICD-11 classification of personality disorders: a European perspective on challenges and opportunities. Borderline Pers Disord Emotion Dysregulation. (2022) 9:1–11. doi: 10.1186/s40479-022-00182-0
53. Rutherford M, McKenzie K, Johnson T, Catchpole C, O’Hare A, McClure I, et al. The overlap between autistic spectrum conditions and borderline personality disorder. PloS One. (2018) 13:e0203886. doi: 10.1371/journal.pone.0184447
54. Popova S, Lange S, Shield K, Burd L, and Rehm J. Prevalence of fetal alcohol spectrum disorder among special subpopulations: A systematic review and meta-analysis. Addiction. (2019) 114:1150–72. doi: 10.1111/add.14598
55. Frances AJ and Nardo JM. ICD-11 should not repeat the mistakes made by DSM-5. Br J Psychiatry. (2013) 203:1–2. doi: 10.1192/bjp.bp.113.127647
56. Andrews DA, Bonta J, and Wormith JS. The risk-need-responsivity (RNR) model: Does adding the good lives model contribute to effective crime prevention? Criminal justice Behav. (2011) 38:735–55. doi: 10.1177/0093854811406356
57. Soni A, Sengupta S, and Treasaden I. Establishing prevalence of diagnosis of personality disorder across high secure forensic services using the ICD 10 and ICD 11 classification. BJPsych Open. (2021) 7:S291–1. doi: 10.1192/bjo.2021.773
Keywords: criminology, forensic psychiatry, ICD 11, personality disorder, psychiatric evaluation
Citation: Jantzi C and Moulin V (2025) The new ICD-11 diagnosis of personality disorder in forensic psychiatry. Front. Psychiatry 16:1630512. doi: 10.3389/fpsyt.2025.1630512
Received: 17 May 2025; Accepted: 28 July 2025;
Published: 19 August 2025.
Edited by:
Gunda Wössner, Protestant University for Applied Sciences Freiburg, GermanyReviewed by:
Raymond Corrado, Simon Fraser University, CanadaCopyright © 2025 Jantzi and Moulin. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Camille Jantzi, Y2FtaWxsZS5qYW50emlAaHVnLmNo