A guideline the psychiatric nurse and the psychiatrist open at the same page
- The German S3 guideline "Diagnostik, Therapie und Rehabilitation von Patientinnen und Patienten mit schwerer Beeinträchtigung der Persönlichkeitsfunktionen", abbreviated LL-SBPF, was led by the DGPT and agreed by 33 professional societies and associations. It carries register number 134-001 in the AWMF guideline register, version 1.0, dated 08.08.24 and valid to 07.08.29, and was funded by the Innovation Committee of the Federal Joint Committee under grant 01VSF21013.
- Four files download from the register free of charge and open to anyone who follows the link: a long version of 287 pages, a short version of 88, a methods report of 268, and a patient version of 51 pages. Copyright rests with the editorial team and reproduction is by written permission.
- Section 2.3.7 names the readership by profession: physicians in psychiatry and psychotherapy, physicians in psychosomatic medicine and psychotherapy, psychological psychotherapists, psychiatric nurses, occupational therapists and social workers, described as "a broad spectrum of professions in cross-sectoral care".
- The guideline holds 56 numbered recommendations and statements across twelve chapters, one chapter per key question. Of these, 23 are evidence-based recommendations, 26 rest on expert consensus, 5 are evidence-based statements and 2 are consensus statements. Ten of them are printed twice, once in the opening selection headed "Die wichtigsten Empfehlungen", which brings the count of printed boxes to 66.
- Recommendation 2.1 carries grade B and 100% consensus and asks that the assessment of impaired personality functioning be dimensional and reach beyond categorical personality disorder diagnoses. Table 6 on page 39 puts a figure on who meets the severity threshold: a survey of 346 clinicians who rated 1403 of their own patients across 38 ICD-10 and ICD-11 diagnoses.
Who the guideline is written for
Section 2.3.7 lists the readers by profession. Physicians in psychiatry and psychotherapy stand first, then physicians in psychosomatic medicine and psychotherapy and psychological psychotherapists, and then, in the same sentence and with the same standing, psychiatric nurses, occupational therapists and social workers. The guideline calls this "a broad spectrum of professions in cross-sectoral care" and puts the coordination between them inside its own remit. Four files carry the work: a long version of 287 pages, a short version of 88, a methods report of 268, and a patient version of 51 pages addressed to patients and to the people close to them. A closing section of open research questions is addressed to researchers. All four download from the AWMF register free of charge, open to anyone who follows the link.
That readership follows from where the guideline sets its subject. The LL-SBPF is organised around the severity of impairment in personality functioning, and its axis is the Level of Personality Functioning Scale of the DSM-5 alternative model: four areas – identity, self-direction, empathy and intimacy – rated across five steps from 0 to 4. Personality functioning is the central criterion for personality disorder in ICD-11 as well, and the guideline cites four cross-walk studies for the two operationalisations being closely similar. Care above the threshold runs through wards, home visits, primary care and rehabilitation, so the recommendations are addressed to whoever is standing there.
The severity axis and Table 6
Recommendation 2.1 carries grade B at 100% consensus: assessment of impaired personality functioning should be dimensional and should reach beyond categorical personality disorder diagnoses. The 56 numbered recommendations and statements that follow are written to the threshold. They fall across the twelve chapters as 8, 3, 5, 1, 2, 1, 4, 16, 9, 1, 4 and 2, with chapter 8 on the therapeutic relationship the largest of them; recommendation 8.2 inside it carries grade A. Consensus reached 100% on 51 of the 66 printed boxes, and 87% at its lowest.
The code in the chart decides who arrives at that threshold, and the guideline measures the passage. Table 6 on page 39 reports the group's own survey: 346 clinicians rated 1403 of their own patients across 38 ICD-10 and ICD-11 diagnoses on the LPFS, with Bayesian 95% intervals. Dissocial personality disorder F60.2 heads the whole table at 100%, mean LPFS 3.11 [2.92; 3.31]. Mixed and other personality disorders F61.0 follow at 94% [83%; 98%], paranoid F60.0 at 93% [82%; 98%], emotionally unstable F60.3 at 90% [76%; 96%], schizotypal F21 at 86% [70%; 96%] and schizoid F60.1 at 79% [59%; 92%]. Anxious-avoidant F60.6 and anankastic F60.5 both sit at 55%, and a mild depressive episode F32.0 at 4% [1%; 11%]. The diagnosis is the entry, and the severity sets the route.
Dissocial personality disorder heads a table of 38 diagnoses at 100%, and from there the severity of personality functioning decides which of the 56 recommendations apply.
This is a national guideline for Germany and its recommendations are written for German care structures. The axis is the Level of Personality Functioning Scale of the DSM-5 alternative model; ICD-11 is treated as a converging system, and the review of instruments in chapter 11 was deliberately confined to instruments other than those built on the ICD-11 severity concept, so this document should not be described as an implementation of ICD-11. The target population was defined indirectly and the group says so: because no trial has selected its sample by severity of personality functioning, the searches used disorders in which most patients were expected to meet the threshold, and the meta-analyses behind key question 1 were conducted in borderline samples and imported on a printed assumption that 90% of those patients are severely impaired, with both outcomes downgraded to ⊕⊕⊖⊖ in GRADE. Key question 12, on psychopharmacological treatment, is reported by the guideline as yielding no recommendations or statements, and the group states that translating categorical recommendations into a two-axis model of severity and HiTOP would risk widening indications beyond the evidence. The counts of 56 unique items and 66 printed boxes are ours, taken from the numbered items in the long and short versions, which agreed exactly; the document prints no total of its own. Pages read for this note: the long version and short version in full, the register page, and the file headers of the methods report and patient version.