There has been increasing consensus that the classification of personality disorder in the DSM-IV and ICD-10 was no longer fit for purpose. There was no good evidence that there are nine to eleven discrete personality disorder categories, the system was too complex, and most categories were not used. The evidence pointed toward the dimensional nature of personality disturbance, with severity being the strongest determinant of disability and prognosis¹.

It was therefore not surprising that the American Psychiatric Association in the DSM-5 and the World Health Organization in the ICD-11 moved toward dimensional models of personality disorder classification. The DSM-5 Work Group proposed a model that included an evaluation of severity (Criterion A) and a description of 25 traits (Criterion B) which were organized into five domains, as well as six individual personality disorders based on DSM-IV categories. The proposal was rejected, but published in the DSM-5 Section III and labelled the Alternative Model of Personality Disorders. Despite not being part of the official classification, the model has acquired an acronym – AMPD – and has received multiple studies evaluating its utility and validity.

The ICD-11 model also involves a dimensional measure of severity (mild, moderate and severe personality disorder) and a subsyndromal condition called “personality difficulty”. Once severity has been determined, the personality dysfunction can be further delineated using one or more of the five trait domains labelled negative affectivity, detachment, disinhibition, dissociality and anankastia. The model does not retain traditional personality types, with the exception of a borderline specifier².

Research on the AMPD model progressed rapidly once a self-report instrument, the Personality Inventory for DSM-5 (PID-5), was developed. This instrument demonstrated adequate psychometric properties, including a replicable factor structure, convergence with existing personality instruments, and expected associations with clinical constructs³. Contradicting the beliefs of the DSM-5 Committee that the AMPD model lacked clinical utility, clinicians reported that the model demonstrated stronger relationships to ten of eleven clinical judgments than the DSM-5 categories⁴.

Due to its more recent development, the ICD-11 model has received less clinical scrutiny. However, studies generally report good construct validity and test/retest reliability⁵. Five domains also appear to be the best fitting model for traditional personality disorder symptoms, although the anankastia, detached and dissocial domains may be more clearly delineated than the negative affective and disinhibition domains⁶.

It has been documented that the AMPD traits (measured using the PID-5) can describe the ICD-11 trait domains⁷. Despite being derived independently, the AMPD and ICD-11 share four of the five domains; the exceptions are anankastia in the ICD-11 and psychoticism in the AMPD. Both models show relative continuity with traditional personality disorder categories and capture most of their information. The ICD-11 model is superior in capturing obsessive-compulsive personality disorder, whereas the DSM-5 model is superior in capturing schizotypal personality disorder⁸.

In addition, both models show some continuity with dimensions of personality in the general population, measured using the Five Factor Model. Negative affectivity is linked with neuroticism, detachment with low extraversion, disinhibition with low conscientiousness, and dissociality with low agreeableness. The ICD-11 anankastia is linked with high conscientiousness, while AMPD psychoticism does not particularly align with any of the five factors⁸.

On the face of it, both new models seem more “true” to the existing evidence about personality pathology than the DSM-5 official classification. Yet, the most important rationale for making such a paradigm shift – the development and evaluation of treatments – has not yet been subjected to significant study. It should be noted that there is little justification for retaining the old model of personality disorder classification regardless of how the new model performs. Only borderline personality disorder has an evidence base, and this essentially tells us that a host of treatments are similarly effective and none have shown specific efficacy for this disorder as opposed to general psychological distress and dys­function⁹.

Nevertheless, treatment studies using the new classification are urgently needed. A number of frameworks have been put forward which, on the basis of a careful assessment of severity and trait domains, lead to a coherent and holistic formulation which is usually shared with the patient and results in the adoption of a consensual approach to treatment⁹.

A potential problem is the retention of traditional personality disorder categories in both models. In the AMPD model, six individual personality disorders are retained. Since non-personality disorder specialist clinicians generally only use three diagnoses (borderline personality disorder, antisocial personality disorder, and personality disorder not otherwise specified), a danger is that they will simply continue with their current practice. The ICD-11 model only retains one personality disorder – the borderline personality disorder specifier – but its inclusion may also compromise the change to more evidence-based practice. While the old categories have no scientific underpinnings, their familiarity may hinder clinicians embracing the new classifications.

In summary, the changes in the classification of personality dis­order represent the beginning of a paradigm shift in diagnosis. The ICD-11 and AMPD are reasonably consistent with each other. Both place severity of personality disorder at the centre of diagnosis, as the evidence suggests. Both have dimensional trait domains consistent with models of personality such as the Five Factor Model. Both seem to be understood and preferred by clinicians. It is unfortunate that in both models the need has been felt to cling on to traditional categories. The complexity that this created in the AMPD model may be a part of the reason why it was rejected by the DSM-5 Committee. The ICD-11 Committee felt the need to compromise with a borderline specifier in order not to suffer a similar fate².

The ICD-11 personality disorder classification is now official and will be required to be used in many countries from January 2022. Whether and when the AMPD, or some form of it, becomes official is unclear. It is hoped that clinicians will see the new classifications as useful and that their use will lead to greater understanding of the concept of personality disorder, resulting in better clinical care.

The importance of personality in the treatment of psychiatric disorders (and physical disorders for that matter) is obvious in most studies which have measured it. Yet, personality is often an afterthought in clinical practice, given to patients when things go awry. If personality pathology can be recorded with relative ease (through brief questionnaires and interviews) and we can let go of traditional categories, then it is my view that its utility in planning and predicting the outcome of treatment will become self-evident.

越来越多的共识认为 DSM-IV 和 ICD-10 中的人格障碍分类不再适用。没有很好的证据表明有九到十一个离散的人格障碍类别，系统太复杂，大多数类别都没有使用。证据指向人格障碍的维度性质，严重程度是残疾和预后的最强决定因素¹。

因此，DSM-5 中的美国精神病学协会和 ICD-11 中的世界卫生组织转向人格障碍分类的维度模型也就不足为奇了。DSM-5 工作组提出了一个模型，其中包括对严重性的评估（标准 A）和对 25 个特征（标准 B）的描述，这些特征分为五个领域，以及基于 DSM-IV 类别的六个个体人格障碍。该提案被拒绝，但发表在 DSM-5 第三部分，并标记为人格障碍的替代模型。尽管不是官方分类的一部分，但该模型已获得首字母缩写词——AMPD——并已收到多项评估其实用性和有效性的研究。

ICD-11 模型还涉及严重程度（轻度、中度和重度人格障碍）的维度测量和称为“人格困难”的亚综合征状况。一旦确定了严重程度，就可以使用标记为负面情感、超脱、去抑制、社交障碍和 anankastia 的五个特征域中的一个或多个来进一步描述人格功能障碍。该模型不保留传统的人格类型，但边界说明符²除外。

Research on the AMPD model progressed rapidly once a self-report instrument, the Personality Inventory for DSM-5 (PID-5), was developed. This instrument demonstrated adequate psychometric properties, including a replicable factor structure, convergence with existing personality instruments, and expected associations with clinical constructs³. Contradicting the beliefs of the DSM-5 Committee that the AMPD model lacked clinical utility, clinicians reported that the model demonstrated stronger relationships to ten of eleven clinical judgments than the DSM-5 categories⁴.

由于最近的发展，ICD-11 模型受到的临床审查较少。然而，研究通常报告良好的结构效度和测试/重测信度⁵。五个领域似乎也是最适合传统人格障碍症状的模型，尽管 anakastia、分离和社交障碍可能比负面情感和去抑制领域⁶更清楚地描述。

据记载，AMPD 特征（使用 PID-5 测量）可以描述 ICD-11 特征域⁷。尽管是独立派生的，AMPD 和 ICD-11 共享五个域中的四个；例外是ICD-11中的anankastia和AMPD中的精神病。两种模型都显示出与传统人格障碍类别的相对连续性，并捕获了它们的大部分信息。ICD-11 模型在捕捉强迫性人格障碍方面表现出色，而 DSM-5 模型在捕捉分裂型人格障碍方面表现出色⁸。

此外，这两个模型都显示出与一般人群的人格维度的一些连续性，使用五因素模型进行测量。消极情感与神经质、低外向性的超脱、低责任心的去抑制和低宜人性的社交性有关。ICD-11 anankastia 与高度尽责性有关，而 AMPD 精神病与五个因素中的任何一个都没有特别一致⁸。

从表面上看，这两个新模型似乎比 DSM-5 官方分类更“真实”关于人格病理学的现有证据。然而，进行这种范式转变的最重要的理由——治疗的开发和评估——尚未经过重要的研究。应该注意的是，无论新模型表现如何，都没有什么理由保留旧的人格障碍分类模型。只有边缘性人格障碍有证据基础，这本质上是告诉我们，治疗主机也同样有效，并没有表现出特定的功效，适用于这种疾病，而不是一般的心理困扰和失调的功能⁹。

然而，迫切需要使用新分类的治疗研究。已经提出了许多框架，这些框架基于对严重性和特征域的仔细评估，导致通常与患者共享的连贯和整体制定，并导致采用双方同意的治疗方法⁹。

一个潜在的问题是在两种模型中都保留了传统的人格障碍类别。在AMPD模型中，保留了六个个体人格障碍。由于非人格障碍专科临床医生通常只使用三种诊断（边缘型人格障碍、反社会人格障碍和未另作说明的人格障碍），因此危险在于他们只会继续目前的做法。ICD-11 模型只保留了一种人格障碍——边缘型人格障碍说明符——但它的包含也可能影响到更多循证实践的改变。虽然旧的分类没有科学依据，但对它们的熟悉可能会阻碍临床医生接受新分类。

总之，人格障碍分类的变化代表了诊断范式转变的开始。ICD-11 和 AMPD 彼此合理一致。正如证据所表明的那样，两者都将人格障碍的严重程度置于诊断的中心。两者都具有与人格模型（例如五因素模型）一致的维度特征域。两者似乎都为临床医生所理解和偏爱。不幸的是，在这两种模型中，都感到需要坚持传统类别。这在 AMPD 模型中造成的复杂性可能是它被 DSM-5 委员会拒绝的部分原因。ICD-11 委员会认为有必要与边界说明符妥协，以免遭受类似的命运²。

ICD-11 人格障碍分类现已正式发布，并将要求从 2022 年 1 月起在许多国家/地区使用。AMPD 或其某种形式是否以及何时成为正式分类尚不清楚。希望临床医生将新分类视为有用，并且它们的使用将导致对人格障碍的概念有更深入的了解，从而提供更好的临床护理。

人格在治疗精神疾病（以及与此相关的身体疾病）中的重要性在大多数对其进行测量的研究中是显而易见的。然而，个性在临床实践中往往是事后的想法，当事情出错时才会给予患者。如果人格病理学可以相对容易地记录下来（通过简短的问卷调查和访谈）并且我们可以放弃传统的分类，那么我认为它在规划和预测治疗结果方面的效用将变得不言而喻。