19c
Bo Bach
Sauer-Zavala and Ringwald, Edershile, Woods, and Wright raise some important points about trait-informed treatment, particularly with regard to the importance of simplicity and trait dynamics for clinical treatment. In this rejoinder, I briefly propose how these issues may be addressed within the realm of ICD-11 classification of PDs, including the five trait qualifiers expressing specific styles of personality dysfunction (Reed, 2018).
Sauer-Zavala underscores the importance of simplicity by focusing on the five higher-order domains (e.g., Neuroticism or Negative Affectivity) without getting sidetracked by the various subfacets and corresponding treatment approaches (which involve a large training burden for clinicians). Consistent with this point, the ICD-11 trait qualifiers are aimed at capturing essential maladaptive features of the FFM domains without providing any code for subfacets. The ICD-11 model was developed to be useful across all WHO member countries by providing a manageable number of trait qualifiers and corresponding treatment components, which may, eventually, reduce the therapist training burden. This aligns with the vision of the WHO Personality Disorder Working Group “that any classification system of PDs for the ICD-11 must be usable and useful for health care workers in lower-resource settings who are not highly trained specialist mental health professionals” (Reed, 2018, p. 227). Thus, from a WHO perspective, simplicity seems obvious, although it may also frustrate some clinicians who appreciate the palette of ten PD types or 25 subfacets. Therefore, the simple coding of one, two, or three ICD-11 trait qualifiers (after classification of severity) may only serve as the first step in a process that leads to the development of a clinical management plan. For clinicians with sufficient resources, a second step may involve elaboration of the trait domain coding by means of 25 clinically informative DSM-5 Alternative Model of Personality Disorders (AMPD) subfacets (Bach et al., 2017) or dynamic conceptualizations (Bach & Kongerslev, 2018).
Ringwald et al. highlight the importance of taking dynamic elements of traits into account (including the mechanistic relationship between traits and trait-relevant expressions), which they argue is valuable for effective clinical conceptualization and treatment. The ICD-11 diagnostic guidelines appear to take such dynamic aspects of trait qualifiers into account. For example, the ICD-11 model suggests that individuals with Negative Affectivity sometimes vacillate between a range of emotions in a short period of time. Additionally, individuals with Negative Affectivity may exhibit low self-esteem in several ways, for example: (a) avoidance of situations that are judged too difficult; (b) dependency on others for advice, help, and direction; (c) envy of others’ abilities and indicators of success; and (d) suicidal ideation due to believing themselves to be useless (WHO, 2019). These four multi-causal response patterns comprise different situational and motivational expressions of Negative Affectivity, often resulting in different treatment implications.
Dynamic aspects of trait qualifiers may also involve specific constellations of co-occurring traits. For example, the ICD-11 guideline states that individuals with Negative Affectivity, who are also characterized by Dissociality, are more likely to experience “externalized” features of Negative Affectivity (e.g., anger, hostility, contempt), whereas those who are characterized by co-occurring Detachment are more likely to experience “internalized” features of Negative Affectivity (e.g., anxiety, depression, pessimism, guilt). Moreover, according to the ICD-11 guideline, individuals with Negative Affectivity often exhibit negativistic attitudes, which may be expressed differently depending on the individual’s other traits. Negativistic individuals high on Detachment are most likely to blame themselves for poor outcomes, whereas those high on Dissociality are most likely to blame others for offering such bad ideas (WHO, 2019). Thus, rather than being narrowly or categorically defined, the ICD-11 trait qualifiers allow for various constellations and potential manifestations across situations and interpersonal dynamics. Whereas the trait profiles of two patients may be very similar, their behavior, interpersonal dynamics, and indicated treatments may be very dissimilar.
The aforementioned trait dynamics are also acknowledged in the ICD-11 definition of core PD dysfunction (WHO, 2019). Accordingly, an individual may be characterized as having difficulty maintaining positive self-esteem in one situation (e.g., self-contempt), while having an unrealistically positive self-view in another situation (e.g., entitlement), which may even be observed during one session of therapy. Moreover, poor emotion regulation may cause an individual to give up easily in one situation but to persist unreasonably in pursuit of goals that have no chance of success in others. Finally, certain interpersonal conflicts may cause the individual to surrender to others (e.g., in an attempt to achieve others’ love and protection), whereas others may result in fits of temper (e.g., when the individual’s own needs have been suppressed for too long).
Taken together, the ICD-11 trait qualifiers provide a parsimonious framework that is manageable across all WHO member countries, while also allowing for the assessment of features of personality trait dynamics. The field of PDs needs to move on from questions about which traits exist to questions about how the traits function. However, future psychometric development is needed to operationalize this for research and clinical practice. For example, it could be useful to develop an instrument that takes different situational expressions of ICD-11 trait qualifiers into account across different life settings (e.g., in social surroundings, in intimate relationships, and when under stress or pressure). In line with this, Ringwald et al.’s proposal of integrating insights from the cybernetics theory of personality and psychopathology seems fascinating and worthwhile, and hopefully we will see such integration in relation to DSM-5 AMPD and ICD-11 trait qualifiers within the near future.
References
Bach, B., & Kongerslev, M. T. (2018). Personality dynamics in schema therapy and the forthcoming ICD-11 classification of personality disorder. European Journal of Personality, 32(5), 527–528.
Bach, B., Sellbom, M., Kongerslev, M., Simonsen, E., Krueger, R. F., & Mulder, R. (2017). Deriving ICD-11 personality disorder domains from DSM-5 traits: Initial attempt to harmonize two diagnostic systems. Acta Psychiatrica Scandinavica, 136(1), 108–117.
Reed, G. M. (2018). Progress in developing a classification of personality disorders for ICD-11. World Psychiatry, 17(2), 227–228.
World Health Organization. (2019). ICD-11 Clinical Descriptions and Diagnostic Guidelines for Mental and Behavioural Disorders. Geneva: World Health Organization.