191 - Specifiers for prominent trait domains in per

Specifiers for prominent trait domains in personality disorder

559 Personality disorders and related traits Secondary-parented category in personality disorders and related traits Personality difficulty As noted above, personality difficulty is not considered a mental disorder but rather is listed in the grouping of problems associated with interpersonal interactions in Chapter 24 on factors influencing health status or contact with health services. Personality difficulty refers to pronounced personality characteristics that may affect treatment or health services but do not rise to the level of severity to merit a diagnosis of personality disorder. Personality difficulty is characterized by longstanding difficulties (e.g. at least 2 years) in the individual’s way of experiencing and thinking about the self, others and the world. In contrast to personality disorder, personality difficulty is manifested in cognitive and emotional experience and expression only intermittently (e.g. during times of stress) or at low intensity. Personality difficulty is typically associated with some problems in functioning, but these are insufficiently severe to cause notable disruption in social, occupational and interpersonal relationships, or may be limited to specific relationships or situations. Specifiers for prominent trait domains in personality disorder Trait domain specifiers may be applied to personality disorders or personality difficulty to describe the characteristics of the individual’s personality that are most prominent and that contribute to personality disturbance. Trait domains are continuous with normal personality characteristics in individuals who do not have personality disorder or personality difficulty. They are not diagnostic categories but rather represent a set of dimensions that correspond to the underlying structure of personality. As many trait domain specifiers may be applied as necessary to describe personality functioning. Individuals with more severe personality disturbance tend to have a greater number of prominent trait domains. However, a person may have a severe personality disorder and manifest only one prominent trait domain (e.g. detachment). Trait domain specifiers that may be recorded include the following. Negative affectivity The core feature of the negative affectivity trait domain (sometimes referred to as “neuroticism”) is the tendency to experience a broad range of negative emotions. Common manifestations of negative affectivity, not all of which may be present in a given individual at a given time, include the following. QE50.7 6D11.0 Personality disorders and related traits | General diagnostic requirements for personality disorder

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Experiencing a broad range of negative emotions with a frequency and intensity out of proportion to the situation Common negative emotions include – but are not limited to – anxiety, worry, depression, vulnerability, fear, anger, hostility, guilt and shame. The particular negative emotions that are most characteristic of any particular person vary across individuals, and are largely dependent on the presence or degree of other trait domains. For example, individuals with prominent dissociality are more likely to experience “externalizing” negative emotions (e.g. anger, hostility, contempt), whereas those with prominent detachment are more likely to experience “internalizing” negative emotions (e.g. anxiety, depression, pessimism, guilt). Emotional lability and poor emotion regulation Individuals with prominent negative affectivity are overreactive to both their own negative cognitions and to external events. They can become overwrought through their own thought processes, such as by ruminating over their shortcomings or past mistakes; over real or perceived threats, slights or insults; or over potential future problems. They are overreactive to external threats or criticism, problems and setbacks. They have low frustration tolerance and easily become visibly upset over even minor issues. They often experience and display multiple emotions simultaneously, or vacillate among a range of emotions in a short period of time. Once upset, they have difficulty regaining their composure and must rely on others or on leaving the situation to calm down. Negativistic attitudes Individuals with prominent negative affectivity typically reject others’ suggestions or advice, arguing that enacting others’ ideas would be too complicated or difficult; or that the suggested actions would not lead to the desired outcomes, or have a high likelihood of negative consequences. The manner of rejection is largely dependent on the individual’s other traits. For example, those with prominent detachment are most likely to blame themselves for the likely difficulties or poor outcomes, whereas those with prominent dissociality are most likely to blame others for offering such bad ideas. Low self-esteem and self-confidence Individuals with prominent negative affectivity may exhibit low self-esteem and self-confidence in several different ways. These include avoidance of situations and activities that are judged to be too difficult (e.g. intellectually, physically, socially, interpersonally, emotionally), even despite evidence to the contrary; dependency, which may be manifested in frequent reliance on others for advice, direction and other kinds of help; envy of others’ abilities and indicators of success; and, in more severe cases of low self-esteem, believing themselves to be useless, to have lived a worthless life, or to be incapable of accomplishing anything of value, which may be associated with suicidal ideation or behaviours. Mistrustfulness Interpersonally, this is typically manifested in suspicion that others have ill intent, and that neutral or even benign remarks and positive behaviours are hidden threats, slights or insults. Individuals with prominent negative affectivity tend to hold grudges and be unforgiving, even over long time periods. In non-interpersonal situations, this mistrustfulness typically takes the form of bitterness and cynicism (e.g. the belief that the “system is rigged”). Personality disorders and related traits | General diagnostic requirements for personality disorder

561 Personality disorders and related traits Detachment The core feature of the detachment trait domain is the tendency to maintain interpersonal distance (social detachment) and emotional distance (emotional detachment). Common manifestations of detachment, not all of which may be present in a given individual at a given time, include the following. Social detachment Social detachment is characterized by avoidance of social interactions, lack of friendships and avoidance of intimacy. Individuals with prominent detachment do not enjoy social interactions, and avoid all kinds of social contact and social situations as far as possible. They engage in little to no “small talk”, even if initiated by others (e.g. at store check-out counters), seek out employment that does not involve interactions with others, and even refuse promotions if these would entail more interaction with others. They have few to no friends or even casual acquaintances. Their interactions with family members tend to be minimal and superficial. They rarely, if ever, engage in any intimate relationships, and are not particularly interested in sexual relations. Emotional detachment Emotional detachment is characterized by reserve, aloofness and limited emotional expression and experience. Individuals with prominent detachment keep to themselves as far as possible, even in obligatory social situations. They are typically aloof, responding to direct attempts at social engagement only briefly and in ways that discourage further conversation. Emotional detachment also encompasses emotional inexpressiveness, both verbally and non-verbally. Individuals with prominent detachment do not talk about their feelings, and it is difficult to discern what they might be feeling from their behaviours. In extreme cases, there is a lack of emotional experience itself, and they are non-reactive to either negative or positive events, with a limited capacity for enjoyment. Dissociality The core feature of the dissociality trait domain is disregard for the rights and feelings of others, encompassing both self-centredness and lack of empathy. Common manifestations of dissociality, not all of which may be present in a given individual at a given time, include the following. Self-centredness Self-centredness in individuals with prominent dissociality is manifested in a sense of entitlement, believing and acting as if they deserve – without further justification – whatever they want, preferentially above what others may want or need, and that this “fact” should be obvious to others. Self-centredness can be manifested both actively/intentionally and passively/unintentionally. Active – and usually intentional – manifestations of self-centredness include expectation of others’ admiration, attention-seeking behaviours to ensure being the centre of others’ focus, and negative behaviours (e.g. anger, “temper tantrums”, denigrating others) when the admiration and attention that the individual expects are not granted. Typically, such individuals believe that they have many admirable qualities, that their accomplishments are outstanding, that they have achieved or will achieve greatness, and that others should admire them. Passive and unintentional manifestations of self-centredness reflect a kind of obliviousness that other individuals matter as much as oneself. In this aspect of dissociality, the individual’s concern is with their own needs, desires and comfort, and those of others simply are not considered. 6D11.2 Personality disorders and related traits | General diagnostic requirements for personality disorder 6D11.1

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Lack of empathy Lack of empathy is manifested in indifference to whether one’s actions inconvenience others or hurt them in any way (e.g. emotionally, socially, financially, physically). As a result, individuals with prominent dissociality are often deceptive and manipulative, exploiting people and situations to get what they want and think they deserve. This may include being mean and physically aggressive. In the extreme, this aspect of dissociality can be manifested in callousness with regard to others’ suffering and ruthlessness in obtaining one’s goals, such that these individuals may be physically violent with little to no provocation, and may even take pleasure in inflicting pain and harm. Note that this aspect of dissociality does not necessarily imply that individuals with prominent dissociality do not cognitively understand the feelings of others; rather, they are not concerned about them and instead are likely to use this understanding to exploit others. Disinhibition The core feature of the disinhibition trait domain is the tendency to act rashly based on immediate external or internal stimuli (i.e. sensations, emotions, thoughts), without consideration of potential negative consequences. Common manifestations of disinhibition, not all of which may be present in a given individual at a given time, include the following. Impulsivity Individuals with prominent disinhibition tend to act rashly based on whatever is compelling at the moment, without consideration of negative consequences for themselves or others, including putting themselves or others at physical risk. They have difficulty delaying reward or satisfaction, and tend to pursue immediately available short-term pleasures or potential benefits. In this way, the trait is strongly associated with such behaviours as substance use, gambling and impulsive sexual activity. Distractibility Individuals with prominent disinhibition also have difficulty staying focused on important and necessary tasks that require sustained effort. They quickly become bored or frustrated with difficult, routine or tedious tasks, and are easily distracted by extraneous stimuli, such as others’ conversations. Even in the absence of distractions, they have difficulty keeping their attention focused and persisting on tasks, and tend to scan the environment for more enjoyable options. Irresponsibility Individuals with prominent disinhibition are unreliable and lack a sense of accountability for their actions. As a result, they often do not complete work assignments or perform expected duties; they fail to meet deadlines, do not follow through on commitments and promises, and are late to or miss formal and informal appointments and meetings because they allow themselves to become engaged in something more compelling that has caught their attention. Recklessness Individuals with prominent disinhibition lack an appropriate sense of caution. They tend to overestimate their abilities and thus frequently do things that are beyond their skill level, without considering potential safety risks. Individuals with prominent disinhibition may engage in reckless driving or dangerous sports, or perform other activities that put them or others in physical danger without sufficient preparation or training. 6D11.3 Personality disorders and related traits | General diagnostic requirements for personality disorder

563 Personality disorders and related traits Lack of planning Individuals with prominent disinhibition prefer spontaneous over planned activities, leaving their options open should a more attractive opportunity arise. They tend to focus on immediate feelings, sensations and thoughts, with relatively little attention paid to longer-term or even shortterm goals. When they do make plans, they often fail to follow through on them, so they are seldom able to reach long-term goals, and often fail to achieve even short-term goals. Anankastia The core feature of the anankastia trait domain is a narrow focus on one’s rigid standard of perfection and of right and wrong, on controlling one’s own and others’ behaviour, and on controlling situations to ensure conformity to these standards. Common manifestations of anankastia, not all of which may be present in a given individual at a given time, include the following. Perfectionism Perfectionism is manifested in concern with social rules, obligations, norms of right and wrong; scrupulous attention to detail; rigid, systematic, day-to-day routines; excessive scheduling and planning; and an emphasis on organization, orderliness and neatness. Individuals with prominent anankastia have a very clear and detailed personal sense of perfection and imperfection that extends beyond community standards to encompass the individual’s idiosyncratic notions of what is perfect and right. They believe strongly that everyone should follow all rules exactly and meet all obligations. Individuals with prominent anankastia may redo the work of others because it does not meet their perfectionistic standards. They have difficulty in interpersonal relationships because they hold others to the same standards as themselves, and are inflexible in their views. Emotional and behavioural constraint Emotional and behavioural constraint is manifested in rigid control over emotional expression, stubbornness and inflexibility, risk-avoidance, perseveration and deliberativeness. Individuals with prominent anankastic traits tightly control their own emotional expression, and disapprove of others’ displays of emotion. They are inflexible and lack spontaneity, stubbornly insisting on following set schedules and adhering to plans. Their risk-avoidance includes both refusal to engage in obviously risky activities and a more general overconcern about avoiding potential negative consequences of any activity. They often perseverate and have difficulty disengaging from tasks because they are perceived as not yet perfect down to the last detail. They are highly deliberative and have difficulty making decisions due to concern that they have not considered every aspect and all alternatives to ensure that the right decision is made. Borderline pattern Note: the borderline pattern specifier has been included to enhance the clinical utility of the classification of personality disorder. There is considerable overlap between this pattern and information contained in the trait domain specifiers (most typically negative affectivity, dissociality and disinhibition). However, use of this specifier may facilitate the identification of individuals who may respond to certain psychotherapeutic treatments. 6D11.4 6D11.5 Personality disorders and related traits | General diagnostic requirements for personality disorder

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders The borderline pattern specifier may be applied to individuals whose pattern of personality disturbance is characterized by a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity, as indicated by five (or more) of the following: • frantic efforts to avoid real or imagined abandonment; • a pattern of unstable and intense interpersonal relationships, which may be characterized by vacillations between idealization and devaluation, typically associated with both strong desire for and fear of closeness and intimacy; • identity disturbance, manifested in markedly and persistently unstable self-image or sense of self; • a tendency to act rashly in states of high negative affect, leading to potentially self-damaging behaviours (e.g. risky sexual behaviour, reckless driving, excessive alcohol or substance use, binge eating); • recurrent episodes of self-harm (e.g. suicide attempts or gestures, self-mutilation); • emotional instability due to marked reactivity of mood – fluctuations of mood that may be triggered either internally (e.g. by one’s own thoughts) or by external events, as a consequence of which, the individual experiences intense dysphoric mood states, which typically last for a few hours but may last for up to several days; • chronic feelings of emptiness; • inappropriate intense anger or difficulty controlling anger, manifested in frequent displays of temper (e.g. yelling or screaming, throwing or breaking things, getting into physical fights); • transient dissociative symptoms or psychotic-like features (e.g. brief hallucinations, paranoia) in situations of high affective arousal. Other manifestations of borderline pattern, not all of which may be present in a given individual at a given time, include the following: • a view of the self as inadequate, bad, guilty, disgusting and contemptible; • an experience of the self as profoundly different and isolated from other people, and a painful sense of alienation and pervasive loneliness; • proneness to rejection hypersensitivity, problems in establishing and maintaining consistent and appropriate levels of trust in interpersonal relationships, and frequent misinterpretation of social signals. Additional clinical features of personality disorder • Personality disorder tends to arise when individuals’ life experiences provide inadequate support for typical personality development, given the person’s temperament (the aspect of personality that is considered to be innate, reflecting basic genetic and neurobiological processes). Thus, early life adversity is a risk factor for later development of personality disorder, as it is for many other mental disorders. However, it is not determinative: some individuals’ temperament allows typical personality development despite an extremely adverse early environment. Nonetheless, in the context of a history of early adversity, ongoing behavioural, emotional or interpersonal difficulties suggest that a personality disorder diagnosis should be considered. Personality disorders and related traits | General diagnostic requirements for personality disorder

565 Personality disorders and related traits • Personality disorder often complicates and lengthens treatment of other clinical syndromes. Thus, poor or incomplete response to standard treatments of, for example, depressive disorders and anxiety and fear-related disorders may suggest the presence of personality disorder. Relatedly, persistent functional impairment after resolution of the clinical syndrome(s) being treated may suggest the presence of personality disorder. • There is often considerable variability in the degree to which individuals and those around them agree that the individual’s behaviours reflect a particular trait. If there is a marked discrepancy between an individual’s self-description and the kinds of problematic behaviours exhibited, it often is helpful to interview someone who knows the person well. Marked differences between the individual’s self-description and the informant’s description may be suggestive of personality disorder. Boundary with normality (threshold) for personality disorder • Personality refers to an individual’s characteristic way of behaving and experiencing life, and of perceiving and interpreting themselves, other people, events and situations. Personality is manifested most directly in how individuals think and feel about themselves and their interpersonal relationships, how they behave in response to those thoughts and feelings and in response to others’ behaviours, and how they react to events in their lives and changes in the environment. An important characteristic of non-disordered personality is sufficient flexibility to react appropriately and to adapt to other people’s behaviours, life events and changes in the environment. In personality disorder, patterns of cognition, emotional experience, emotional expression and behaviour are sufficiently maladaptive (e.g. inflexible or poorly regulated) that they result in substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. • To warrant a diagnosis of personality disorder, personality disturbance must be manifested across a range of personal and social situations over an extended period of time (e.g. lasting 2 years or more). Behaviour patterns that are apparent only in the context of specific relationships, social roles or environmental circumstances, or that have lasted for a shorter period of time, are not a sufficient basis for a diagnosis of personality disorder. Instead, the possibility that such behaviour patterns are a response to environmental circumstances must be considered. A focus on problems in the relevant relationship or in the environment (e.g. with family or school) may be more appropriate than a diagnosis of personality disorder in such cases. Course features • Manifestations of personality disturbance tend to appear first in childhood, increase during adolescence, and continue into adulthood, although individuals may not come to clinical attention until later in life. Caution should be exercised in applying the diagnosis to children because their personalities are still developing. Personality disorders and related traits | General diagnostic requirements for personality disorder

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders • Overt behavioural manifestations of certain traits (dissociality, disinhibition) tend to decline over the course of adulthood. Other traits (detachment, anankastia) are less likely to do so. In both cases, functional impairment in broad areas of life (e.g. employment, interpersonal relationships) among people with personality disorder is often persistent. • Personality disorder is relatively stable after young adulthood, but may change such that a person who had personality disorder during young adulthood no longer meets the diagnostic requirements by middle age. • Much less commonly, a person who earlier did not have a diagnosable personality disorder develops one later in life. Emergence of personality disorder in older adults may be related to the loss of social support that had previously helped to compensate for personality disturbance. • When there is a change in personality during middle adulthood or later in life, in the absence of change in the individual’s environment, the possibility that the change is due to an underlying medical condition (e.g. secondary personality change) or to an unrecognized disorder due to substance use should be considered. Developmental presentations • Personality disorder is not typically diagnosed in pre-adolescent children. Over the course of their development, children integrate knowledge and experience about themselves and other people into a coherent identity and sense of self, as well as into individual styles of interacting with others. Different children vary substantially in the rate at which this integration occurs, and there is also substantial variation in the rate of integration within individuals over time. Therefore, it is very difficult to determine whether a pre-adolescent child exhibits problems in functioning in aspects of the self, such as identity, self-worth, accuracy of self-view or self-direction, because these functions are not fully developed in children. This is also true of interpersonal functions such as the ability to understand others’ perspectives and to manage conflict in relationships. • However, prominent maladaptive traits may be observable in pre-adolescent children and may be precursors to personality disorder in adolescence and adulthood. For example, individual differences in negative affectivity and disinhibition, as well as more specific features such as lack of empathy (an aspect of dissociality) and perfectionism (an aspect of anankastia) may be observed in very young children. However, such traits are also associated with the development of other mental disorders (e.g. mood disorders, anxiety and fear-related disorders) and should not be interpreted as childhood forms of personality disorder. • Features of personality disorder manifest in similar ways in adolescents and in adults. However, in evaluating adolescents, it is important to consider the developmental typicality of the relevant behaviour patterns. For example, risk-taking behaviour, selfharm and moodiness are more common during adolescence than during adulthood. Therefore, thresholds for evaluating whether such behaviour patterns are indicative of personality disorder or of elevations in trait domains such as disinhibition and negative affectivity among adolescents should be correspondingly higher. The wide variability in normal adolescent development that may affect the expression of these behaviours or characteristics should also be considered. Personality disorders and related traits | General diagnostic requirements for personality disorder

567 Personality disorders and related traits Culture-related features • Assessment of personality across cultures is challenging, requiring knowledge of normative personality function for the sociocultural context, variations in cultural concepts of the self, and evidence for consistent traits and behaviours across time and multiple social contexts. • Culture shapes modes of self-construal, social presentation and levels of insight about behaviours that are related to personality development, including what are considered normal and abnormal personality states in a given setting. For example, children reared in collectivist societies may develop attachment styles and traits that are viewed as dependent or avoidant related to the norms of more individualistic cultures. In turn, traits of selfinvolvement that are accepted or positively valued in individualistic cultures may be considered narcissistic in collectivist cultures. • Diagnosis of personality disorder must take into account the person’s cultural background. Collateral information may be needed to assess whether certain disruptive self-states and behaviours are considered culturally uncharacteristic and therefore consistent with personality disorder in a given culture. In general, a diagnosis of personality disorder should be assigned only when the symptoms exceed thresholds that are normative for the sociocultural context. • Among ethnic minority, immigrant and refugee communities, responses to discrimination, social exclusion and acculturative stress may be confused with personality disorder. For example, suspiciousness or mistrust may be common in situations of endemic racism and discrimination. • Sociocultural contexts of exclusion affecting marginal social groups can evoke repeated attempts at self-affirmation or acceptance by others that are based on ambiguous or troubled relationships with authority figures and limited adaptability. These reactions may be confounded with manifestations of borderline pattern, such as impulsivity, instability, affective lability, explosive/aggressive behaviour or dissociative symptoms. However, a diagnosis should be assigned only when the symptoms exceed thresholds that are normative for the sociocultural context. Sex- and/or gender-related features • Available evidence indicates that gender distribution of personality disorder is approximately equal. However, there are significant gender differences in the behavioural expression of personality disorder and in the associated trait domains. Specifically, elevations on dissociality and disinhibition are more common among men, and elevations on negative affectivity are more common among women. Personality disorders and related traits | General diagnostic requirements for personality disorder

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Boundaries with other disorders and conditions (differential diagnosis) Boundary with personality difficulty Individuals with pronounced personality characteristics that do not rise to the level of severity to merit a diagnosis of personality disorder may be considered to have personality difficulty if the characteristics affect treatment or health services. In contrast to personality disorder, personality difficulty is manifested only intermittently (e.g. during times of stress) or at low intensity. The difficulties are associated with some problems in functioning, but these are insufficiently severe to cause notable disruption in social, occupational and interpersonal relationships, and may be limited to specific relationships or situations. Boundary with persistent mental disorders A number of persistent and enduring mental disorders (e.g. autism spectrum disorder, schizotypal disorder, dysthymic disorder, cyclothymic disorder, separation anxiety disorder, obsessivecompulsive disorder, complex post-traumatic stress disorder, dissociative identity disorder) are characterized by enduring disturbances in cognition, emotional experience and behaviour that are maladaptive, manifested across a range of personal and social situations, and are associated with significant problems in functioning of aspects of the self (e.g. self-esteem, self-direction) and/ or interpersonal dysfunction (e.g. ability to develop and maintain close and mutually satisfying relationships, ability to understand others’ perspectives and to manage conflict in relationships). Accordingly, individuals with these disorders may also meet the diagnostic requirements for personality disorder. Generally, individuals with such disorders should not be given an additional diagnosis of personality disorder unless additional personality features are present that contribute to significant problems in functioning of aspects of the self or interpersonal functioning. However, even in the absence of these additional features, there may be specific situations in which an additional diagnosis of personality disorder is warranted (e.g. entry into clinically indicated forms of treatment that are connected to a personality disorder diagnosis). Boundary with conduct-dissocial disorder with limited prosocial emotions Conduct-dissocial disorder is characterized by a recurrent pattern of behaviour in which the basic rights of others or major age-appropriate social or cultural norms, rules or laws are violated; this may range in duration from a discrete period lasting a number of months to one that persists across the lifespan. Conduct-dissocial disorder with limited prosocial emotions is further characterized by limited or absent empathy or sensitivity to others’ feelings, and limited or absent remorse, shame or guilt. Conduct-dissocial disorder with limited prosocial emotions has features in common with personality disorder with dissociality, which is characterized by disregard for the rights and feelings of other, self-centredness and lack of empathy. Conductdissocial disorder may be diagnosed among pre-adolescent children, based on a shorter duration of symptoms than personality disorder. Among individuals with conduct-dissocial disorder, an additional diagnosis of personality disorder is warranted only if there are personality features in addition to dissociality that contribute to significant impairments in functioning of aspects of the self or problems in interpersonal functioning. Boundary with secondary personality change Secondary personality change is a persistent personality disturbance that represents a change from the individual’s previous characteristic personality pattern that is judged to be a direct pathophysiological consequence of a medical condition not classified under mental, behavioural Personality disorders and related traits | General diagnostic requirements for personality disorder

569 Personality disorders and related traits Personality disorders and related traits | General diagnostic requirements for personality disorder and neurodevelopmental disorders, based on evidence from the history, physical examination or laboratory findings. Personality disorder is not diagnosed if the symptoms are due to another medical condition. Boundary with disorders due to substance use Disorders due to substance use often have pervasive effects on functioning of the self and interpersonal functioning. For example, they may exhibit problems with self-direction and selfesteem, difficulties and conflicts in relationships, dissocial behaviour related to obtaining or using drugs, and a wide range of other features that are commonly seen in individuals with personality disorder. If the personality disturbance is entirely accounted for by a disorder due to substance use, a diagnosis of personality disorder should not be given. However, if the personality disturbance is not entirely accounted for by the disorder due to substance use (e.g. if the personality disturbance preceded the onset of substance use) or if there are features of a personality disorder that are not accounted for by substance use (e.g. perfectionism), an additional diagnosis of personality disorder may be assigned.

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders