ICD-12 Preparation
ICD-12 PREPARATION
From Categorical to Dimensional: Preparing for ICD-12 Through Trauma-Informed Cluster Mapping
This work emerged from my psychiatry master’s thesis, where I set out to explore the limitations of existing diagnostic frameworks for Borderline Personality Disorder (BPD) and trauma-related conditions. Over the course of that research, it became increasingly clear that categorical models, such as those found in DSM-5 and ICD-11—were inadequate in capturing the lived realities of trauma survivors. They not only failed to provide precision in diagnosis but also actively contributed to stigma, exclusion from services, and misaligned treatment.
Driven by a desire to create a more accurate and humane system, I began developing a cluster mapping framework: a way of understanding trauma symptoms, schemas, and neurobiological patterns in terms of dimensional severity and propagation, rather than rigid categories. The purpose was not purely academic. The aim has always been to create a framework that clinicians can use, survivors can recognise, and regulators can adopt, providing the best possible foundation for treatment and recovery.
This work has since evolved into the Trauma Impact and Recovery Classification Model (TIRCM), which is now being prepared as part of a submission to the ICD-12.
Borderline Personality Disorder (BPD) has long been one of the most debated categories in psychiatry. While it describes a recognisable constellation of difficulties, its categorical status, defined by meeting five of nine criteria—has contributed to stigma, misdiagnosis, and service exclusion (Linehan, 1993; Gunderson, 2009). Increasingly, evidence highlights that many individuals diagnosed with BPD present with complex trauma histories, overlapping significantly with Complex PTSD (C-PTSD) and attachment-related disorders (Ford & Courtois, 2021; Karatzias et al., 2017).
My current research and thesis work respond to this diagnostic misalignment. By using cluster mapping of symptom patterns, we are developing a dimensional framework that captures the propagation of trauma responses across affect regulation, relational capacity, and self-concept. This work is directly informing a forthcoming submission to the ICD-12, under the proposed Trauma Impact and Recovery Classification Model (TIRCM).
Why the Categorical Model Fails
The categorical approach to BPD has several well-documented limitations:
Stigma and exclusion: The label of “personality disorder” is frequently equated with untreatability, leading to barriers to services (NICE, 2009; Aviram et al., 2006).
Misdiagnosis: Many trauma survivors are subsumed under BPD despite symptom profiles more consistent with trauma-adapted states (Lewis & Grenyer, 2009).
Lack of nuance: Binary thresholds obscure gradients of severity and overlook recovery potential.
This problem is not unique to BPD. Traditional psychiatric categories often reify surface descriptions of distress rather than tracing back to underlying trauma pathways (Frances, 2013).
The Case for Dimensional Classification
The ICD-11 already began the transition from rigid categories toward dimensional models, particularly in the area of personality disorders (WHO, 2019). This shift reflects recognition that functioning exists on a spectrum of severity, not as discrete categories. In trauma research, dimensional approaches have been shown to better capture overlaps and gradients of C-PTSD and BPD symptoms, improving both diagnostic accuracy and treatment alignment (Hyland et al., 2019; Cloitre et al., 2014).
Cluster mapping builds upon this direction. While full details remain under development, the model groups trauma-related symptoms into dimensional domains that can be measured, tracked, and linked directly to treatment pathways. The aim is to ensure that classification is not only descriptive but clinically actionable.
Towards ICD-12: Trauma Impact and Recovery Classification Model (TIRCM)
The TIRCM proposal advances four central innovations for ICD-12:
Dimensional trauma profiles that replace categorical misclassifications such as BPD.
Severity ratings that allow dynamic monitoring of symptom burden and recovery trajectory.
Integration of trauma science—including schema theory and neurobiological evidence—without fragmenting into multiple overlapping diagnoses.
Direct alignment with phased treatment, ensuring diagnosis informs intervention rather than obstructs it.
This model does not discard professional codes or existing classifications, but it re-anchors them in trauma science. By reframing BPD as a trauma-linked dimensional profile, ICD-12 can reduce stigma, increase service accessibility, and improve treatment outcomes.
Conclusion
The categorical framework of BPD has outlived its clinical usefulness. A dimensional, trauma-informed approach better reflects the lived reality of survivors, supports recovery, and aligns with contemporary psychiatric science. Cluster mapping offers the methodological bridge, enabling psychiatry to evolve toward classification systems that are not only scientifically valid but ethically congruent. As we prepare the ICD-12 submission, the TIRCM framework represents both a scholarly contribution and a practical roadmap to transform how trauma is recognised and treated worldwide.
References (Harvard style)
Aviram, R.B., Brodsky, B.S. & Stanley, B. (2006). Borderline personality disorder, stigma, and treatment implications. Harvard Review of Psychiatry, 14(5), pp.249–256.
Cloitre, M., Garvert, D.W., Weiss, B.J., Carlson, E.B. & Bryant, R.A. (2014). Distinguishing PTSD, complex PTSD, and borderline personality disorder: A latent class analysis. European Journal of Psychotraumatology, 5(1), p.25097.
Ford, J.D. & Courtois, C.A. (2021). Treating complex traumatic stress disorders: Scientific foundations and therapeutic models. 2nd ed. New York: Guilford Press.
Frances, A. (2013). Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis. New York: William Morrow.
Gunderson, J.G. (2009). Borderline personality disorder: Ontogeny of a diagnosis. American Journal of Psychiatry, 166(5), pp.530–539.
Hyland, P., Karatzias, T., Shevlin, M. & Cloitre, M. (2019). Examining the discriminant validity of complex PTSD and borderline personality disorder symptoms: Results from a trauma-exposed population. Journal of Anxiety Disorders, 68, p.102148.
Karatzias, T., Shevlin, M., Fyvie, C. & Hyland, P. (2017). Evidence of distinct profiles of Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD) based on the new ICD-11 Trauma Questionnaire. Journal of Affective Disorders, 207, pp.181–187.
Lewis, K.L. & Grenyer, B.F.S. (2009). Borderline personality or complex posttraumatic stress disorder? An update on the controversy. Harvard Review of Psychiatry, 17(5), pp.322–328.
Linehan, M.M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.
NICE (2009). Borderline Personality Disorder: Recognition and Management. Clinical Guideline 78. London: National Institute for Health and Care Excellence.
World Health Organization (2019). International Classification of Diseases 11th Revision (ICD-11). Geneva: WHO.
