BRIEF RESEARCH REPORT published: 06 April 2021 doi: 10.3389/fpsyt.2021.591934 Integration of the ICD-11 and DSM-5 Dimensional Systems for Personality Disorders Into a Unified Taxonomy With Non-overlapping Traits Fernando Gutiérrez 1,2*, Josep M. Peri 1 , Miguel Gárriz 3 , Gemma Vall 4,5 , Estela Arqué 6 , Laura Ruiz 6 , Jaume Condomines 6 , Natalia Calvo 7,8 , Marc Ferrer 7,8 and Bárbara Sureda 1 1 Institute of Neuroscience, Hospital Clinic, Barcelona, Spain, 2 Institut d’Investigacións Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain, 3 Neuropsychiatry and Drug Addiction Institute, Parc de Salut Mar, Barcelona, Spain, 4 Department of Psychiatry, Mental Health, and Addiction, GSS–Hospital Santa Maria, Lleida, Spain, 5 Biomedical Research Institute, Lleida, Spain, 6 La Coma Therapeutic Community, ATRA Group, Barcelona, Spain, 7 Psychiatry Department, Vall d’Hebron University Hospital, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain, 8 Psychiatry and Legal Medicine Department, Autonomous University of Barcelona, Barcelona, Spain The promise of replacing the diagnostic categories of personality disorder with a better-grounded system has been only partially met. We still need to understand whether our main dimensional taxonomies, those of the International Classification of Diseases, Edited by: 11th Revision (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders, Jared Keeley, Fifth Edition (DSM-5), are the same or different, and elucidate whether a unified structure Virginia Commonwealth University, United States is possible. We also need truly independent pathological domains, as they have shown Reviewed by: unacceptable overlap so far. To inquire into these points, the Personality Inventory Meredith A. Bucher, for DSM-5 (PID-5) and the Personality Inventory for ICD-11 (PiCD) were administered Purdue University, United States to 677 outpatients. Disattenuated correlation coefficients between 0.84 and 0.93 Antonella Somma, Vita-Salute San Raffaele revealed that both systems share four analogous traits: negative affectivity, detachment, University, Italy dissociality/antagonism, and disinhibition. These traits proved scalar equivalence too, *Correspondence: such that scores in the two questionnaires are roughly interchangeable. These four Fernando Gutiérrez fguti@clinic.cat domains plus psychoticism formed a theoretically consistent and well-fitted five-factor structure, but they overlapped considerably, thereby reducing discriminant validity. Only Specialty section: after the extraction of a general personality disorder factor (g-PD) through bifactor This article was submitted to Psychopathology, analysis, we could attain a comprehensive model bearing mutually independent traits. a section of the journal Keywords: ICD-11, DSM-5, personality disorders, discriminant validity, general factor Frontiers in Psychiatry Received: 05 August 2020 Accepted: 26 February 2021 INTRODUCTION Published: 06 April 2021 Citation: Despite being increasingly close to a scientifically based personality disorder (PD) classification, we Gutiérrez F, Peri JM, Gárriz M, Vall G, still do not have a unique, generally accepted, and unproblematic dimensional substitute for the Arqué E, Ruiz L, Condomines J, traditional categories (1, 2). An important step in this direction would entail collating the different Calvo N, Ferrer M and Sureda B dimensional models currently at our disposal, each of them somewhat different from the others, (2021) Integration of the ICD-11 and DSM-5 Dimensional Systems for such that we can elucidate which personality domains are common, which differ, and how we Personality Disorders Into a Unified can arrange all them in the best possible way to form a comprehensive nosology. Agreement is Taxonomy With Non-overlapping particularly important regarding the ICD-11 model (3) and the DSM-5 alternative model for PD Traits. Front. Psychiatry 12:591934. (AMPD) (4), both because they are our two main dimensional classificatory systems, and because doi: 10.3389/fpsyt.2021.591934 they themselves have been attempts to unify the pre-existing trait taxonomies (5, 6). Frontiers in Psychiatry | www.frontiersin.org 1 April 2021 | Volume 12 | Article 591934 Gutiérrez et al. Integration of ICD-11 and DSM-5 As the ICD-11 will be the authoritative diagnostic taxonomy attempt so far has indeed provided a clearer factor structure (11). since 2022, it is the natural framework against which other However, the exclusion of psychoticism in accordance with the models should be compared. Attempts have been made to capture ICD-11 model precluded the appearance of a fifth substantial the ICD-11 domains from the more broadly studied Personality factor in this study, and model fit and correlations between Inventory for DSM-5 (PID-5) (7, 8), and the resulting factors the resulting factors were not reported. Nor has exploratory confirmed the presumption that both models are commensurate. structural equation modeling (ESEM) (19, 20) been hitherto However, these studies did not take psychoticism into account, applied to the common structure of the PiCD and the PID-5, as it does not form part of the ICD-11 classification, and though it has been to DSM-based algorithms (7, 8). This method their design did not allow testing a common structure for is strongly recommended instead of the more usual exploratory the AMPD and the ICD-11. Given the clinical relevance of (EFA) and confirmatory (CFA) approaches, as it relaxes some psychoticism (or schizotypy) (9), such a comprehensive model unreal constraints such as zero cross-loadings, which are unlikely would be worthwhile. Six further studies have compared the to be fulfilled by personality structures (20). Therefore, it can PID-5 with instruments directly designed to capture the ICD- adjust previously obtained exploratory structures that are rarely 11 domains, either the Personality Inventory for ICD-11 (PiCD) supported by CFA (21). (10) or the Five-Factor Personality Inventory for ICD-11 (FFiCD) Finally, no studies have tested the direct equivalence of the (11). Convergence between both systems was found to be PiCD and PID-5 scores beyond Pearson correlations. On the one good for four of the domains: negative affectivity (r = 0.75– hand, disattenuated correlations, which discount measurement 0.86), detachment (0.60–0.80), dissociality/antagonism (0.67– error, will be closer to the true associations between domains (22). 0.81), and disinhibition (0.73–0.89) (10–15). Even so, results need On the other, scalar equivalence between the two instruments to be replicated and extended in several respects. is untested, that is, whether a certain score on the PiCD would These studies have not examined face-to-face clinical samples, correspond with a similar score on the PID-5, qualifying them as which are the natural target of a diagnostic taxonomy. Four interchangeable (23). studies used internet-based self-declared patients (10, 11, 13, 14) Due to its recent publication, there is a paucity of data on the and the other two were conducted with community subjects ICD-11 classification of PD. The present study sought to replicate (12, 15). On the other hand, common structure has been analyzed and extend the relationships between our main classificatory at the PID-5 domain level, with one sole exception (14). This systems for PD, the ICD-11 and the AMPD. Specifically, we reduces the number of indicators per construct to unacceptable examined in a sample of 677 outpatients, the extent to which both levels, then precluding psychoticism to form a separate factor systems are similar or different, and how a unified and maximally and leaving little room for testing alternative solutions (16). comprehensive taxonomic system, comprising non-overlapping Furthermore, most factor analyses have been conducted in pathological traits, should ultimately look like. conjunction with other models, either the Big Five or those of Zuckerman, Livesley, or Clark (11–13, 15). Even if insightful, MATERIALS AND METHODS this approach may reshape the resulting structure, such that the shared configuration of the two official classifications is Subjects obscured. This has been specially the case with the anankastia The PID-5-SF and the PiCD were administered to 677 and psychoticism domains. The well-stablished bipolar factor outpatients, 65.7% women, aged 13–81 years (M = 38.4, SD with disinhibition and anankastia at opposite extremes has been = 13.2), consecutively referred for assessment or treatment replicated in some studies (10, 14, 15), but has split in different to five different mental health or drug addiction units in ways in others, depending on the accompanying model (12, 13). Catalonia, Spain. Patients were clinically diagnosed at their Concerning psychoticism, it has been sometimes excluded from respective centers according to the DSM-5 (4), with 18.6% of analysis (11), while others has formed an independent factor (10, them presenting a phobic or other anxiety disorder, 18.6% mixed 14), and still others has loaded into the dissociality, disinhibition, anxious and depressive symptoms, 11.5% a mild to moderate or negative affectivity factors (12, 13, 15). depressive disorder, 8.1% other affective disorders (dysthymia, Importantly, good convergent validity for the four analogous cyclothymia, bipolar disorder), 15.4% drug abuse disorders, and domains has invariably been coupled with poor discriminant 15.9% other disorders—eating, obsessive-compulsive, impulse validity, with non-corresponding correlations averaging 0.29 in control disorders—each with a frequency of under 5%. the community and 0.40 in patients (10–15). Thus, the promise that blurred boundaries between traditional diagnostic categories Instruments would be fixed by a dimensional system has not be met. In The Personality Inventory for ICD-11 (PiCD) (10) is a 60-item this respect, it has been proposed that a general factor of self-report assessing the five-dimensional personality disorder personality disorder (g-PD) may permeate every dimension of classification of the ICD-11 (3): negative affectivity, detachment, personality pathology (17), producing undue overlap. A suitable dissociality, disinhibition, and anankastia. Each domain has 12 approach to examine this issue is bifactor analysis (18). It involves items rated from 1 (strongly disagree) to 5 (strongly agree). The extracting an all-inclusive factor that captures variance of all Personality Inventory for DSM-5 Short Form (PID-5-SF) (24, 25) traits (the general factor) and that is orthogonal to a variable is a 100-item self-report measuring the 25 facets and five domains number of other factors gathering the remaining covariance of the alternative model of the DSM-5 (4): negative affectivity, between narrower groups of traits (specific factors). The only detachment, antagonism, disinhibition, and psychoticism. It is Frontiers in Psychiatry | www.frontiersin.org 2 April 2021 | Volume 12 | Article 591934 Gutiérrez et al. Integration of ICD-11 and DSM-5 scored on a scale ranging from 0 (strongly disagree) to 3 (strongly Disinhibition Psychoticism Total score agree) and has shown psychometric properties similar to the 0.82 0.71 0.56 0.71 0.69 0.90 0.93 0.72 0.69 0.88 0.84 — 220-item PID-5, on which it is based (26). The questionnaires were administered in their Spanish versions (27–29) as part of PID-5, Personality Inventory for the DSM-5—Short Form; PiCD, Personality Inventory for ICD-11. Correlations are significant at p < 0.05 from r = 0.07 and at p < 0.01 from r = 0.10. Coefficients ≥ 0.60 are in bold type. a routine personality evaluation by an experienced, doctoral- level clinical psychologist. They were delivered in the same order −0.01 −0.15 −0.47 −0.06 −0.12 0.07 0.69 0.56 0.43 0.64 0.77 — (PID-5 and then PiCD), in pencil-and-paper format, following an interview in which procedures were explained. 0.53 0.44 0.53 0.93 0.52 0.72 0.68 0.51 0.60 0.57 0.81 RESULTS — PID-5 Summary statistics for the PID-5 and the PiCD are shown in Antagonism Supplementary Tables 1–8. Normative T-scores were taken from the Spanish validation studies (27, 28). We first examined by 0.48 0.34 0.86 0.63 0.52 0.68 0.43 0.25 0.54 0.39 0.65 — means of Pearson’s correlations the extent to which the PiCD and PID-5-SF domains measure the same constructs and can be considered equivalent. In order to count out measurement error, Detachment coefficients were disattenuated, that is, divided by the square root 0.39 0.84 0.15 0.36 0.47 0.54 0.53 0.23 0.45 0.50 0.67 — of the product of the alpha reliabilities of each pair of variables r rc = √r xy×r (22). Table 1 confirms a clear correspondence xx yy between four of the domains —negative affectivity, detachment, affectivity dissociality/antagonism, and disinhibition—, with r coefficients Neg. TABLE 1 | Pearson’s (lower triangle) and disattenuated correlations (upper triangle) between the PiCD and PID-5 domains (n = 677). 0.87 0.39 0.25 0.54 0.54 0.72 0.48 0.40 0.62 0.62 0.88 — from 0.72 to 0.80, and rc from 0.84 to 0.93. Assuming that there is not a biunivocal correspondence between the two models, we also examined if each domain Total score in one model can be explained by a linear combination of −0.10 0.87 0.82 0.80 0.75 0.24 0.65 0.48 0.60 0.65 0.80 — several domains in the other. Although multiple regression analyses confirmed that four out of five factors in each model were reasonably well-explained by the other model, additional Anankastia predictors did not bring an improvement with respect to −0.13 −0.57 −0.05 0.11 0.14 0.19 0.46 0.40 0.44 0.45 0.59 — correlations: R coefficients ranged from 0.72 to 0.80 for the four corresponding PiCD domains predicted by the PID-5 (mean R = 0.77, R2 = 0.53) and from 0.75 to 0.84 for the four corresponding Disinhibition PID-5 domains predicted by the PiCD (mean R = 0.79, R2 = 0.57; −0.46 −0.39 0.51 0.35 0.61 0.63 0.47 0.31 0.53 0.80 0.61 Supplementary Table 2). Coefficients for PiCD anankastia (R = — 0.55 using domains and 0.70 using facets) and PID psychoticism PiCD (0.62) were not as high as for the other domains, though anankastia was clearly predicted by disinhibition and negative Dissociality −0.10 affectivity. Both models were about equally comprehensive of the −0.13 0.34 0.29 0.50 0.65 0.22 0.13 0.74 0.47 0.49 — other’s domains, but the inclusion of the PID-5 facets rather than domains improved prediction to R = 0.81 (R2 = 0.62) on average. In order to study scalar equivalence, we compared T-scores Detachment between the two questionnaires. We sought to know whether the −0.01 0.35 0.24 0.29 0.11 0.68 0.34 0.72 0.29 0.38 0.61 — corresponding domains of each questionnaire scored similarly, and therefore they are interchangeable. To this end, we used the two one-sided tests (TOST) procedure for paired data affectivity implemented in the TOSTER package for R (23). Rather than Neg. 0.29 0.28 0.43 0.09 0.73 0.77 0.34 0.41 0.47 0.06 0.72 — testing mean differences, TOST more appropriately checks for mean equivalences, that is, whether patients scoring at a given level in one domain fall within predefined lower and upper bounds in the other model’s corresponding domain. With bounds set at 1T < ±5, only PID-5 detachment failed to show significant Neg. affectivity Neg. affectivity equivalence (t = 2.93, p = 0.998), whereas negative affectivity Psychoticism Detachment Detachment Antagonism Disinhibition Disinhibition Total Score Total Score Dissociality Anankastia (t = 12.00, p < 0.001), antagonism (t = 11.81, p < 0.001), and disinhibition (t = −7.33, p < 0.001) proved to be equivalent PID-5 PiCD between models. Similar results were found when this approach Frontiers in Psychiatry | www.frontiersin.org 3 April 2021 | Volume 12 | Article 591934 Gutiérrez et al. Integration of ICD-11 and DSM-5 FIGURE 1 | Loess curves showing similar scores for the PiCD and the PID-5 domains as severity increases (n = 677). For each domain, severity is the total score of its corresponding questionnaire: PiCD or PID-5. was applied in four different levels of severity, defined as the total Parallel analysis and Bayesian information criterion (BIC) score of each questionnaire expressed in T-scores. Whereas PID- suggested retaining four factors (Supplementary Figure 1), 5 negative affect, antagonism, and disinhibition differed little, and Velicer’s MAP suggested one. The 4-factor solution PID-5 detachment scored between half and three quarters of a reproduced four of the expected constructs—negative affectivity, standard deviation higher all along the gradient from T = 50 detachment, dissocial/antagonism, and disinhibition/anankastia, to 90 (Supplementary Table 3). These results can be illustrated whereas extracting a fifth factor failed to recover psychoticism through a locally weighted scatterplot smoothing (LOESS) graph (Supplementary Tables 4, 5). This approach was unsatisfactory with severity in the x-axis and the four domains in the y-axes in other respects. Congruence with alternative extractions— (Figure 1). weighted and unweighted least squares and principal axis Whereas Table 1 confirms the convergence between the PiCD factoring—and with Oblimin, Promax, and Equamax rotations and PID-5 corresponding domains, it also reveals considerable was acceptable for the 4-factor solution (Tucker’s Φ between overlap between non-corresponding domains (mean r = 0.91 and 1.00, mean 0.98) but failed for the 5-factor solution 0.36). We undertook a series of factor analyses to examine (Φ between 0.55 and 1.00, mean 0.88), suggesting an unstable whether the PiCD and the PID-5 can share a common and hardly replicable structure (30). Moreover, factors were structure formed by sufficiently differentiated constructs. Joint highly intercorrelated (mean r = 0.38 in the 4-factor and exploratory factor analyses (EFA) were conducted at the domain 0.46 in the 5-factor solutions). Using orthogonal instead of level first, using maximum likelihood extraction (ML) and oblique rotations fixed this problem at the cost of unduly oblique Geomin rotation, as factors were expected to correlate. increasing cross-loadings. Frontiers in Psychiatry | www.frontiersin.org 4 April 2021 | Volume 12 | Article 591934 Gutiérrez et al. Integration of ICD-11 and DSM-5 Hence, we jointly analyzed the 25 PID-5 facets and factors. Two domains, anankastia and psychoticism, maintain five PiCD domains, expecting that more indicators would more complex relationships between the two models. However, produce a clearer structure. This was accomplished to some because of their clinical relevance (9, 34), they must be kept in the extent. Parallel analysis, Velicer’s MAP, and BIC coincided in nosology, which legitimates the attempt to integrate both models suggesting five factors. A 5-factor solution showed excellent instead of selecting one over the other. Indeed, our 5-factor congruence with alternative extraction and rotation methods and 5+1-factor models capture anankastia (R = 0.84 and 0.86, (Φ between 0.96 and 1.00, mean 0.99) and reproduced well respectively) and psychoticism (both R = 0.96) at once, while the the original constructs (Supplementary Table 6): negative affect ICD-11 and the AMPD taken individually cannot. Furthermore, (r = 0.86 with PiCD and 0.95 with PID-5), detachment the PiCD and the PID-5-SF use the same metric, such that scores (0.86 and 0.85), dissocial/antagonism (0.84 and 0.96) and are approximately equivalent between them. A relative exception disinhibition/anankastia (0.75 and 0.62 with disinhibition, −0.83 is detachment, for which the PID-5 scored about half a standard with anankastia). An ESEM analysis was then performed in deviation higher than the PiCD. Supplementary Table 1 suggests lavaan R package (31) to evaluate model fit. To this end, factor that this may be attributed to high levels of anhedonia in our variances were fixed, and all cross-loadings estimated through patients, a feature which is less prominent in the PiCD. robust ML with the EFA loadings as starting points. Fit was within We confirmed the prior finding that the extraction of a g- acceptable limits: χ 2 = 1302.06, df = 420, p < 0.001, CFI = 0.924, PD fixes the otherwise serious problems of blurred boundaries TLI = 0.921, RMSEA = 0.056, and SRMR = 0.028. The 4-factor between domains (11). Under factor analysis as usual, constructs solution also showed good congruence between methods, but overlap extensively with each other—as the original domains fused the negative affectivity and psychoticism factors together also do—, thus decreasing discriminant validity. Contrarily, (Supplementary Table 7) and showed lower fit: χ 2 = 1769.21, df bifactor modeling produces an unequivocal general factor that = 425, p < 0.001, CFI = 0.884, TLI = 0.882, RMSEA = 0.068, and uniformly underlies every trait except anankastia, as well as SRMR = 0.039. Both solutions partially improved discriminant five factors that correspond with the four ICD-11 domains validity, with factor intercorrelations averaging 0.22 in the 5- plus psychoticism. The latter is one major difference with factor and 0.24 in the 4-factor solution (Supplementary Table 6). Oltmanns and Widiger (11), who circumscribed the analysis Finally, we tested the existence of a general factor of to the four-factor ICD-11 framework. Furthermore, the 5 + 1 personality disorder (g-PD) underlying all traits, which would model fits the data well in ESEM and produces quasi-orthogonal explain the considerable overlap between them. PiCD domains constructs. Although giving preference to a bifactor model on and PID-5 facets were subjected to a purely exploratory bifactor the sole basis of good fit is discouraged (21), this is not our analysis in FACTOR 10.10 (32, 33), retaining 4 + 1 and 5 + 1 case: Obtaining sufficiently differentiated traits is a worthwhile factors. Loadings were then targeted in ESEM analysis as above. achievement in itself, and the empirical and theoretical bases Fit was slightly better for the 5 + 1 solution (χ 2 = 1127.09, df = supporting the existence of a general factor underlying PD are on 419, p < 0.001, CFI = 0.939, TLI = 0.937, RMSEA = 0.050, and the rise (17). SRMR = 0.025) than for the 4 + 1 solution (χ 2 = 1256.38, df = This does not imply an agreement on the interpretation of the 390, p < 0.001, CFI = 0.923, TLI = 0.920, RMSEA = 0.057, and g-PD. This construct has been understood quite heterogeneously SRMR = 0.028). In the former (Table 2), the g-PD factor received as a response bias, as another name for neuroticism or borderline substantial and homogeneous contributions from all traits except organization, as a general vulnerability to psychopathology, anankastia and rigid perfectionism, which qualifies it as a genuine or as the conjoint of maladaptive consequences shared by general factor. Specific factors still correlated in the range all disorders (17). Either way, it is a plausible explanation 0.56–0.74 with their corresponding PiCD and PID-5 domains. for the well-established fact that all personality disorders—in Discriminant capacity was improved, with quasi-orthogonal fact, all mental disorders—correlate with each other (35). For factors (mean r = 0.12) and low correlations (<0.30) with non- example, the psychoticism factor correlates 0.51 on average corresponding domains. Only anankastia and dissociality showed with the non-corresponding PID-5 domains in our study intrusions into negative affectivity and disinhibition, respectively. (Supplementary Table 6), but only 0.11 after the g-PD has Similar remarks can be made regarding the 4+1 model, whose been factorially isolated (Table 2). Thus, the g-PD may partly factor intercorrelations averaged 0.08, but in which psychoticism explain why psychoticism maintains unspecific associations was assimilated by the g-PD (Supplementary Table 8). with all other domains and with the Big Five, including high neuroticism and low agreeableness and conscientiousness (36), and why it predicts psychosis but also other psychopathology DISCUSSION (37, 38). At the facet level, this effect seems more pronounced for eccentricity than for perceptual dysregulation and unusual We examined the relationships between the ICD-11 and DSM- beliefs (Table 2), which are also better able to predict psychosis 5 systems for PD as measured through the PiCD and PID- (37, 39). Our findings are in line with the proposal that 5-SF questionnaires in 677 outpatients. We found that both pathological traits are a mixture of normal-range traits plus systems share four basic constructs of personality pathology: unspecific personality dysfunction (40), but leave unsolved negative affectivity, detachment, dissociality/antagonism, and how to interpret pathological traits once the maladaptation disinhibition/anankastia. Once measurement error is taken into component has been removed. Not less important, the ICD- account, correlations range from 0.84 to 0.93 between these 11 and AMPD systems have proposed separate constructs for Frontiers in Psychiatry | www.frontiersin.org 5 April 2021 | Volume 12 | Article 591934 Gutiérrez et al. Integration of ICD-11 and DSM-5 TABLE 2 | ESEM 5+1-factor solution for the PiCD domains and PID-5 facets targeted to the purely exploratory bifactor analysis (n = 677). g-PD Neg. affectivity Detachment Dissocial Disinhibition Psychoticism Factor solution PiCD negative affectivity 0.44 0.69 −0.03 −0.06 0.26 0.06 PiCD detachment 0.47 0.03 0.69 −0.15 0.04 0.05 PiCD dissociality 0.51 0.02 0.00 0.60 0.21 0.04 PiCD disinhibition 0.69 −0.04 −0.05 −0.05 0.54 −0.06 PiCD anankastia −0.23 0.40 0.19 0.25 −0.52 0.06 PID-5 anxiousness 0.42 0.68 −0.04 −0.03 0.05 0.02 PID-5 rigid perfectionism 0.25 0.55 0.07 0.28 −0.12 0.18 PID-5 emotional lability 0.36 0.55 −0.25 −0.11 0.29 0.11 PID-5 separation insecurity 0.37 0.44 −0.31 0.04 0.03 −0.04 PID-5 perseveration 0.54 0.42 −0.02 −0.01 0.19 −0.04 PID-5 submissiveness 0.39 0.35 −0.03 −0.06 −0.10 −0.17 PID-5 suspiciousness 0.59 0.32 0.05 0.13 0.08 0.21 PID-5 depressiveness 0.62 0.32 0.22 −0.23 0.21 0.10 PID-5 restricted affect 0.43 −0.19 0.62 0.03 −0.05 0.00 PID-5 withdrawal 0.46 0.14 0.60 −0.19 0.07 0.08 PID-5 intimacy avoidance 0.30 −0.16 0.43 −0.19 0.14 0.15 PID-5 anhedonia 0.63 0.31 0.32 −0.16 0.15 −0.07 PID-5 manipulativeness 0.49 −0.08 −0.15 0.68 0.02 −0.10 PID-5 deceitfulness 0.66 −0.04 −0.16 0.56 −0.02 −0.19 PID-5 attention seeking 0.39 0.10 −0.39 0.55 −0.01 −0.11 PID-5 grandiosity 0.39 0.09 −0.06 0.54 −0.14 −0.03 PID-5 callousness 0.55 −0.17 0.11 0.36 0.08 −0.02 PID-5 impulsivity 0.55 0.15 −0.17 −0.01 0.54 0.07 PID-5 hostility 0.48 0.34 0.10 0.12 0.37 0.01 PID-5 risk taking 0.49 −0.14 −0.06 0.20 0.31 0.27 PID-5 unusual beliefs 0.55 −0.01 −0.02 −0.03 0.06 0.62 PID-5 perceptive distortion 0.61 0.03 −0.07 −0.18 −0.12 0.61 PID-5 eccentricity 0.57 0.17 0.15 −0.05 0.16 0.33 PID-5 irresponsibility 0.69 −0.09 0.01 0.11 0.26 −0.17 PID-5 distractibility 0.55 0.24 0.04 −0.21 0.24 −0.06 Correlations with domains PiCD negative affectivity 0.47 0.74 0.03 −0.03 0.26 0.16 PiCD detachment 0.50 0.13 0.76 −0.03 −0.04 0.10 PiCD dissociality 0.55 −0.02 0.10 0.73 0.40 0.25 PiCD disinhibition 0.73 −0.08 −0.12 0.04 0.66 −0.07 PiCD anankastia −0.25 0.49 0.36 0.19 −0.61 0.20 PID-5 negative affectivity 0.69 0.70 0.05 0.06 0.18 0.22 PID-5 detachment 0.65 0.14 0.69 −0.05 0.03 0.09 PID-5 antagonism 0.68 −0.10 −0.11 0.72 0.15 0.04 PID-5 disinhibition 0.81 0.03 −0.10 0.10 0.56 0.08 PID-5 psychoticism 0.73 0.18 0.10 0.08 0.06 0.68 Factor intercorrelations g-PD – Neg. affectivity 0.06 – Detachment 0.07 0.11 – Dissociality 0.11 −0.11 0.09 – Disinhitibition 0.16 −0.12 −0.20 0.11 – Psychoticism 0.10 0.14 0.08 0.22 −0.06 – PID-5, Personality Inventory for the DSM-5—Short Form; PiCD, Personality Inventory for ICD-11. Correlations and factor loadings ≥ 0.30 are in bold type. Frontiers in Psychiatry | www.frontiersin.org 6 April 2021 | Volume 12 | Article 591934 Gutiérrez et al. Integration of ICD-11 and DSM-5 personality traits and severity/dysfunction, but these have been ETHICS STATEMENT found to be ultimately redundant (41, 42). It is a pending question if the g-PD might represent this common component This study involves human participants and was reviewed of dysfunction, and if it could explain the overlap between and approved by the Comité de Ética de Investigación con dysfunction and traits. Medicamentos (CEIm, Drug Research Ethics Committee), A weakness of this study is that sample size did not allow Hospital Clínic, Barcelona, Spain. Written informed consent to to have exploratory and confirmatory subsamples, so our factor participate in this study was provided by the participants’ legal solutions may partially capitalize on chance. Furthermore, we guardian/next of kin. have focused in only a part of the ICD-11 and AMPD systems, namely trait models. Although the inclusion of additional AUTHOR CONTRIBUTIONS components—the borderline specifier in the ICD-11, six diagnostic categories in the AMPD, and the severity/dysfunction FG, JP, MG, GV, and BS contributed to the conception and measures of each system—would have offered a more complete design of the study. FG performed the statistical analysis and picture, it would also have led to excessive complexity for wrote the first draft of the manuscript. JP, MG, GV, NC, MF, one sole study. Furthermore, using the FFiCD (11) instead and BS made amendments to the manuscript and rewrote of the PiCD would have enriched our facet-level analyses, parts of it. All authors contributed to the manuscript revision but this instrument was not yet been published when our and approved the submitted version, recruited samples in study began. their respective centers, assessed outpatients, and organized In sum, we have found considerable agreement between the the database. two main dimensional taxonomies for PD, the ICD-11 and the AMPD. As they have been developed independently, this FUNDING can be regarded as a strong validation for both. Interestingly, divergences between models can be settled if we integrate them This work was supported by project PI15/00536, part of into a comprehensive framework, and discriminant validity the Plan Estatal de Investigación Científica y Técnica y de issues can be addressed if we consider the existence of Innovación 2013–2016, financed by the ISCIII Subdirección an underlying general factor. The fact that we can partial General de Evaluación, and cofinanced by the European Regional out this component does not mean, however, that we are Development Fund (ERDF, A way to build Europe; PI: FG). able to understand it yet, and calling it maladaptation is conjectural. Neither does it mean that we know what exactly ACKNOWLEDGMENTS maladaptation is. Thus, putting all the pieces together to form a theoretically sound and clinically useful taxonomy We would like to thank Editage (www.editage.com) for English of PD still requires extensive empirical work, as well as language editing. careful thought. SUPPLEMENTARY MATERIAL DATA AVAILABILITY STATEMENT The Supplementary Material for this article can be found The datasets presented in this study can be found in the Open online at: https://www.frontiersin.org/articles/10.3389/fpsyt. Science Framework [https://osf.io/a3shm/]. 2021.591934/full#supplementary-material REFERENCES 7. 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Gutiérrez F, Aluja A, Ruiz J, García LF, Gárriz M, Gutiérrez-Zotes A, et al. Ferrer and Sureda. This is an open-access article distributed under the terms Personality disorders in the ICD-11: Spanish validation of the PiCD and the of the Creative Commons Attribution License (CC BY). The use, distribution or SASPD in a mixed community and clinical sample. Assess. (2020) 28:759–72. reproduction in other forums is permitted, provided the original author(s) and the doi: 10.1177/1073191120936357 copyright owner(s) are credited and that the original publication in this journal 29. Diaz-Batanero C, Ramirez-López J, Dominguez-Salas S, Fernandez- is cited, in accordance with accepted academic practice. No use, distribution or Calderon F, Lozano OM. Personality Inventory for DSM-5-Short reproduction is permitted which does not comply with these terms. Frontiers in Psychiatry | www.frontiersin.org 8 April 2021 | Volume 12 | Article 591934