766 vII. APPLICATIONS  AND  IMPLICATIONS
ICD-11 and DSM -5 Section III
A major step toward a conceptualization of 
personality disorders from the perspective of 
the FFM has occurred with the forthcom -
ing ICD-11 (WHO, 2018; Reed et al., 2019; 
Tyrer et al., 2019). As noted earlier, ICD-11 is 
replacing the ICD-10 categorical syndromes 
(e.g., antisocial, obsessive–  compulsive, and 
dependent) with a five-  domain dimensional 
trait model (only the borderline syndrome 
is retained). The five domains are negative 
affectivity, detachment, dissocial, disinhi -
bition, and anankastia (Tyrer et al., 2011, 
2019). These five domains are conceptual -
ized as maladaptive variants of the FFM: 
“Negative Affective with neuroticism, De -
tachment with low extraversion, Dissocial 
with low agreeableness, Disinhibited with 
low conscientiousness and Anankastic with 
high conscientiousness” (Mulder, Horwood, 
Tyrer, Carter, & Joyce, 2016, p. 85). The 
predominant measure for the assessment of 
the trait model is provided by the Personality 
Inventory for ICD-11 (PiCD; J. Oltmanns & 
Widiger, 2018). Research with the PiCD has 
confirmed that the ICD-11 trait domains 
are maladaptive variants of the FFM (e.g., 
Crego & Widiger, 2020; J. Oltmanns & 
Widiger, 2019; Somma, Gialdi, & Fossati, 
2020). In summary, once a member coun -
try of the WHO has adopted the ICD-11 
(and this may not occur until the year 2022 
for many countries), clinicians within that 
country will be diagnosing personality dis -
orders as maladaptive variants of the FFM.
A comparable proposal was made for 
DSM-5 (Skodol, 2012). Included within this 
proposal was a five-  domain dimensional trait 
model that comprised the domains of nega -
tive affectivity, detachment, psychoticism, 
antagonism, and disinhibition, assessed by 
the Personality Inventory for DSM-5 (PID-
5; Krueger, Derringer, Markon, Watson, & 
Skodol, 2012). DSM-5 negative affectivity, 
detachment, antagonism, and disinhibition 
align closely with ICD-11 negative affectiv -
ity, detachment, dissocial, and disinhibition, 
respectively (albeit the domains are not de -
fined precisely in the same manner). DSM-5 
Section III does not include the anankastia 
domain, albeit a closely congruent compul -
sivity domain was part of the original pro -
posal (Krueger et al., 2011, 2012). In turn, ICD-11 does not include a psychoticism 
domain, because STPD was not recognized 
within ICD-10 to be a disorder of personal -
ity; it is conceptualized instead as a variant 
of schizophrenia (WHO, 1992), and DSM-5 
psychoticism is largely defined by the 
cognitive–  perceptual aberrations of STPD. 
More importantly, though, for our purposes 
in this chapter, the DSM-5 trait model is 
again aligned with the FFM. As stated in 
DSM-5, the five domains of the dimensional 
trait model “are maladaptive variants of the 
five domains of the extensively validated 
and replicated personality model known as 
the ‘Big Five,’ or the Five Factor Model of 
personality” (American Psychiatric Asso -
ciation, 2013, p. 773), with DSM-5 nega -
tive affectivity, detachment, psychoticism, 
antagonism, and disinhibition aligning with 
FFM neuroticism, introversion, openness, 
antagonism, and low conscientiousness, re -
spectively (Krueger & Markon, 2014). A 
considerable body of research supports this 
alignment (e.g., Crego, Oltmanns, & Widi -
ger, 2018; Crego & Widiger, 2017; De Fruyt 
et al., 2013; De  Young, Carey, Krueger, & 
Ross, 2016; Gore & Widiger, 2013; Grif -
fin & Samuel, 2014; Moorman & Samuel, 
2018; Thomas et al., 2012).
An important difference between ICD-
11 and the proposal for DSM-5 is that the 
latter still includes six of the DSM-IV per -
sonality syndromes: borderline, antisocial, 
obsessive–  compulsive, narcissistic, schizo -
typal, and avoidant. If DSM-5 Section III 
had been approved, clinicians would still be 
using these categorical syndromes in clinical 
practice (albeit with new diagnostic criterion 
sets). Clinicians will still be using the bor -
derline syndrome in clinical practice when 
countries shift from ICD-10 to ICD-11, but 
the DSM-5 proposal was clearly much more 
conservative than ICD-11.
Finally, another important difference is 
that the DSM-5 proposal includes a Level of 
Personality Functioning Scale (LPFS) that is 
hypothesized to define the core of personal -
ity disorder (i.e., common to all personality 
disorders) and to be distinct from the mal -
adaptive trait domains (American Psychiat -
ric Association, 2013; Skodol, 2012). The 
LPFS consists of impairments or deficits in 
the sense of self (identity and self-  direction) 
and interpersonal relatedness (empathy and 