35 Cluster B Personality Disorders
Cluster B is the dramatic, emotional, or erratic cluster and consists of Antisocial Personality Disorder, Borderline Personality Disorder, Histrionic Personality Disorder, and Narcissistic Personality Disorder. Individuals with these personality disorders often experience problems with impulse control and emotional regulation (APA, 2013). Due to the dramatic, emotional, and erratic nature of these disorders, it is nearly impossible for individuals to establish healthy relationships with others.
Borderline Personality Disorder
Clinical Description
Individuals with borderline personality disorder display a persistent pattern of instability in interpersonal relationships, self-image, and affect (APA, 2013). The key characteristic of borderline personality disorder is unstable and/or intense relationships. For example, individuals may idealize or experience intense feelings for another person immediately after meeting them and then switch to devaluing them. It is not uncommon for people with borderline personality disorder to experience intense fluctuations in mood (i.e., mood lability), often observed as volatile interactions with family and friends (Herpertz & Bertsch, 2014). Those with borderline personality disorder may be friendly one day and hostile the next. The combination of these symptoms causes significant impairment in establishing and maintaining personal relationships.
Individuals with this disorder will often go to great lengths to avoid real or imagined abandonment. Fears related to abandonment can lead to inappropriate anger as they often interpret the abandonment as a reflection of their own behaviors. In efforts to prevent abandonment, individuals with borderline personality disorder will often engage in impulsive behaviors such as self-harm and suicidal behaviors. In fact, individuals with borderline personality disorder engage in more suicidal attempts and completion of suicide is higher among these individuals than the general public (Linehan et al., 2015). Other impulsive behaviors such as non-suicidal self-injury (cutting) and sexual promiscuity are often seen within this population, typically occurring during high-stress periods (Sansone & Sansone, 2012). Occasionally, hallucinations and delusions are present, particularly of a paranoid nature; however, these symptoms are often transient and recognized as unacceptable by the individual (Sieswerda & Arntz, 2007).
Borderline personality disorder
Case vignette
A 23 year-old woman reacted with depressive symptoms and suicidal thoughts to the death of her grandfather. She was treated with antidepressant medication without addressing the loss. Three years later after a suicide attempt, she was admitted to hospital where she first presented with depressed mood and suicidal thoughts, but quickly engaged in vivid conversations with the others patients. She was discharged with the diagnosis of personality disorder, but soon re-admitted because of suicidal thoughts, and referred to an outpatient program specialized on treatment of personality disorder. Since childhood she had unstable mood, aggressive temperament and self-destructive behavior (head banging). At the age of 10 she was sexually abused by an older man. Suicidal thoughts and urges to kill herself was first experienced at age 11. Since age 13 she has had multiple sexual partners but also one 7 year long relationship which was quite unstable with frequent conflicts and impulsive acts. She dropped out of school and has been living on sickness benefits, interrupted by short periods of unskilled employment. In a two year psychoanalytic treatment program with one individual session and one group session a week in addition to psychoeducation, she worked together with other patients on identifying and understanding the characteristic features of BPD, and the dynamics of borderline pathology with a special focus on self-destructive behavior. Her self-destructive behavior tapered off after 3 months as she began to process her feelings of aggression and sadness. The pharmacological treatment terminated after 6 months and she quickly became less sedated and anxious. She resumed school towards the end of the first year of treatment, with the intention of taking a degree in teaching. The relationship with her boyfriend stabilized. Contacts with class became more satisfying, and conflicts with her teachers stopped. Her ability to begin to contain feelings increased dramatically.
Epidemiology
Borderline personality disorder, one of the more commonly diagnosed personality disorders, is observed in 1.6% –5.9% of the general population, with women making up 75% of the diagnoses (APA, 2013). Approximately 10% of individuals with borderline personality disorder have been seen in an outpatient mental health clinic, and nearly 20% have sought treatment in a psychiatric inpatient unit (APA, 2013). This high percentage of inpatient treatment is likely related to the high incidence of suicidal and self-harm behaviors.
One must note that adolescents and younger adults who are undergoing identity issues may appear to have some of the symptoms of BPD. Also, BPD is disproportionately diagnosed in females (whereas antisocial PD is disproportionately diagnosed in men) and an argument has been made in the literature that perhaps the diagnosis unfairly pathologizes stereotypically female experiences or responses to trauma. Another discussion topic has been that the exact same symptoms in case studies are diagnosed by mental health professionals as symptoms of borderline personality disorder in females, but antisocial personality disorder in males.
Treatment
Borderline personality disorder is the one personality disorder with the most effective treatment option – Dialectical Behavioral Therapy (DBT). DBT is a form of cognitive behavioral therapy developed by Marsha Linehan (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). There are four main goals of DBT: reduce suicidal behavior, reduce therapy interfering behavior, improve quality of life, and reduce post-traumatic stress symptoms.
Within DBT, there are five main treatment components that together help reduce harmful behaviors (i.e. self-mutilation and suicidal behaviors) and replace them with effective, life-enhancing behaviors (Gonidakis, 2014). The first component is skills training. Generally performed in a group therapy setting, individuals engage in 4 core skills: mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation. Second, individuals focus on enhancing motivation and applying skills learned in the previous component to specific challenges and events in their everyday life. The third, and often the most distinctive component of DBT, is the use of telephone and in vivo coaching. It is not uncommon for clients to have the cell phone number of their clinician for 24/7 availability of in-the-moment support. The fourth component, case management, consists of allowing the client to become their own “case manager” and effectively use the learned DBT techniques to problem solve ongoing issues. Within this component, the clinician will only intervene when absolutely necessary. Finally, the consultation team, which is a service for the clinicians providing the DBT treatment. Due to the high demands of clients with borderline personality disorder, the consultation team provides support to the providers in their work to ensure they remain motivated and competent in DBT principles in an effort to provide the best treatment possible.
Support for the effectiveness of DBT in the treatment of borderline personality disorder has been implicated in a number of randomized control trials (Harned, Korslund, & Linehan, 2014; Neacsiu, Eberle, Kramer, Wisemeann, & Linehan, 2014). More specifically, DBT has shown to significantly reduce suicidality and self-harm behaviors in those with borderline personality disorders. It also reduces anger and hospitalizations as well as improves emotional regulation and interpersonal functioning. Additionally, the drop-out rates for treatment are extremely low, suggesting that clients value the treatment components and find them effective in managing symptoms.
Antisocial Personality Disorder
Clinical Description
The defining feature of antisocial personality disorder is a consistent pattern of disregard for, and violation of, the rights of others (APA, 2013). While antisocial personality disorder can only be diagnosed in individuals who are 18 years of age or older, a diagnosis can only be made if there is evidence of conduct disorder prior to the age of 15. Although not discussed in this book, conduct disorder is a disorder of childhood that involves a repetitive and persistent pattern of behaviors that violate the rights of others (APA, 2013). Common behaviors exhibited by individuals with conduct disorder that go on to develop antisocial personality disorder are aggression toward people or animals, destruction of property, deceitfulness or theft, or serious violation of rules (APA, 2013).
While commonly referred to as “psychopaths” or “sociopaths” these are both separate (but related) terms that are not recognized as “disorders” by the DSM. However, much like those with psychopathy and sociopathy, individuals with antisocial personality disorder fail to conform to social norms. This also includes legal rules, as individuals with antisocial personality disorder are often repeatedly arrested for crimes such as property destruction, harassing/assaulting others, stealing, etc. (APA, 2013). Deceitfulness is another hallmark symptom of antisocial personality disorder as individuals often lie repeatedly, generally as a means to gain profit or pleasure. There is also a pattern of impulsivity, in that decisions are made spontaneously without forethought of personal consequences or consideration for others (Lang et al., 2015). This impulsivity also contributes to their inability to maintain employment as they are more likely to impulsively quit their jobs (Hengartner et al., 2014). Employment instability, along with impulsivity, also impacts their ability to manage finances; it is not uncommon to see individuals with antisocial personality disorder accumulate large debts that they are unable to pay (Derefinko & Widiger, 2016).
While also likely related to impulsivity, individuals with antisocial personality disorders tend to be extremely irritable and aggressive, repeatedly getting into fights. Their disregard for their own safety, as well as the safety of others, is also observed in reckless behavior such as speeding, driving under the influence, and engaging in sexual and substance abuse behavior that may put themselves and others at risk (APA, 2013).
Of course, one of the better-known symptoms of antisocial personality disorder is the lack of remorse for the consequences of their actions, regardless of how severe they may be (APA, 2013). Individuals with this disorder often rationalize their actions at the fault of the victim, minimize the harmfulness of the consequences of their behaviors, or display indifference (APA, 2013). Overall, individuals with antisocial personality disorder have limited personal relationships due to their selfish desires and lack of moral conscious.
Terminology
Psychopath, Sociopath, or Antisocial Personality Disorder: Which is the correct term?
Psychopaths are utterly fascinating to both scientists and non-scientists alike. The discovery of the existence of psychopaths has led to the creation of a vast number of books, TV shows, and movies. Some examples of these are the book and TV series Dexter, and the book and film The Silence of the Lambs. The more accurate versions of these entertainment sources (e.g., the novel and film American Psycho) depict psychopaths for what they really are: individuals that never feel genuine guilt or concern for others; cold, inhuman beings that lack the ability to empathize and whose main focus is always on themselves.
Psychopathy is a term that was created by Hervey Cleckley in 1941. This word was initially used to discuss individuals that possessed artificial charisma and intellect, and that were non-empathetic, deceitful in nature, careless, incapable of guilt or real concern for people, and fearless (Larsen & Buss, 2010). Psychopaths feel no compassion for other humans, which is why they frequently abuse (emotionally and/or physically), murder, manipulate, deceive, con, and abandon other people. They are able to do this because they are often masterful manipulators and actors, often times being able to keep up the appearance of being completely normal. Many of them are observant, charming, human chameleons that can easily blend in with their social environment (Hare, 1993). From an evolutionary standpoint, this makes plenty of sense. Humans that blatantly show zero concern for fellow humans, through such actions as murder and abandonment, are going to stick out in a negative manner. Of course, not all psychopaths avoid behaving in violent or conning ways that can get them put into prison. Certain serial killers that are currently incarcerated or were incarcerated prior to their death are prime examples of this. Prison is where many people assume that most psychopaths are located, but this is an inaccurate and dangerous belief (Hare, 1993). The incarcerated psychopaths, however, are what a great deal of the available research on psychopathy has been conducted on. It can be very difficult to successfully identify psychopaths, even the ones that are in prison for violent crimes. This is so because the majority of them are exquisite liars, and a lot of them are smart enough to know what researchers are looking for on psychological tests and in one-on-one interviews.
It is quite common for the terms psychopath and sociopath to be used synonymously by scientists and non-scientists alike. Reading articles and other research writings in the areas of psychopathy and sociopathy can easily be confusing because different terms are preferred by different researchers. Adding to the confusion is the fact that antisocial personality disorder is frequently used as an equivalent of psychopath and sociopath (Hare, 1993). Sociopath is sometimes preferred by some individuals because, unlike psychopath, it does not indicate that someone is psychotic or insane. Some common misconceptions are that psychopaths are completely insane and unaware of what they are doing and why they are doing it. Psychopaths are actually fully aware of their behaviors and the motivations behind them; they are logical and live in reality. Psychopaths know what they are doing, and they make decisions out of their own free will. Unfortunately for those around them, these individuals are not acting in socially deviant or harmful ways because they are delusional or suffering from hallucinations. (Hare, 1993). Psychopaths choose to act in certain socially unacceptable ways, all the while cognizant of how they are acting; they know what they are doing and they do not care if it negatively affects the people around them.
Robert Hare (1993) believes that the preference for psychopath or sociopath is a clear indication of what that person’s causal theories are. Many different social scientists (e.g., psychologists, criminologists, and sociologists) like to use sociopathy because they think that this disorder is directly a result of social factors and experiences that an individual underwent while growing up. On the other hand, psychopathy is more preferable to scientists that believe that the disorder is caused by a mix of cognitive, physiological, social, and genetic elements. Hare (1993) goes on to say that antisocial personality disorder is a phrase that was intended to be almost synonymous with psychopath and sociopath, but that this was not quite accurate due to a difference in diagnostic requirements. The symptoms that are required in order for one to receive a diagnosis of antisocial personality disorder are numerous antisocial and illegal actions. As a result, most criminals meet the necessary qualifications for diagnosis of antisocial personality disorder (Hare, 1993). Psychopaths, however, are described as performing various antisocial and unlawful behaviors in addition to having a certain set of personality characteristics. It can easily be seen that the symptoms of antisocial personality disorder are quite similar to those of psychopathy (Lack, 2010), but symptoms are not present in the extreme form like they are in psychopathy.
As previously mentioned, it is very difficult to identify actual psychopaths. There is, however, one research scale that has a lot of empirical results to back up its effectiveness at correctly diagnosing psychopaths, Robert Hare’s Psychopathy Checklist-Revised (PCL-R). The PLC-R is employed across the globe to help scientists attain accurate diagnoses of true psychopaths, differentiating them from people that are merely just somewhat socially deviant in their behavior (Hare, 1993). This method involves an in-person interview in addition to the researcher or clinician looking over the interviewee’s personal records, such as crimes carried out in the past. The scale is comprised of three different-labeled, but alike personality trait labels: interpersonal deficiencies (e.g., manipulation), affective deficiencies (e.g., inability to empathize), and rash/illegal behaviors (e.g., arson) (Lilienfeld & Arkowitz, 2007).
Epidemiology
Antisocial personality disorder has an estimated prevalence rate of up to 3.3% of the population with men comprising 75% of the cases (APA, 2013). It is more commonly diagnosed in men, particularly those with substance abuse disorders. It is also observed more commonly in those from disadvantaged socioeconomic settings. While the majority of individuals with antisocial personality disorder end up incarcerated at some point throughout their lifetime, criminal activities appear to decline after the age of 40 (APA, 2013).
Treatment
Treatment options for antisocial personality disorder are limited, and generally not effective (Black, 2015). Like cluster A disorders, many individuals are forced to participate in treatment, thus impacting their ability to engage in and continue with treatment. Cognitive therapists have attempted to address the lack of moral conscious and encourage clients to think about the needs of others (Beck & Weishaar, 2011). Medications including lithium, atypical antipsychotics and SSRIs are sometimes prescribed to help reduce impulsive and aggressive behaviors but there is very little research on this topic and medication compliance can be a major issue.
Histrionic Personality Disorder
Clinical Description
Histrionic personality disorder is characterized by a persistent and excessive need for attention from others. Individuals with this disorder are uncomfortable in social settings unless they are the center of attention. In efforts to gain attention, they are often very lively and dramatic, using emotional displays, physical gestures, and mannerisms along with grandiose language. These behaviors are initially very charming to their audience; however, they begin to wear due to the constant need for attention to be on them.
If their theatrical nature does not gain the attention they desire, individuals with histrionic personality disorder may go to great lengths to gain that attention such as make-up a story or create a dramatic scene (APA, 2013). Similarly, they often dress and engage in sexually seductive or provocative ways. These sexually charged behaviors are not only directed at those with whom they have a sexual or romantic interest but to the general public as well (APA, 2013). They often spend significant amounts of time on their physical appearance to gain the attention they desire.
Individuals with histrionic personality disorder are easily suggestible. Their opinions and feelings are influenced by not only their friends but also by current fads (APA, 2013). They also have a tendency to over exaggerate relationships, considering casual acquaintanceships as more intimate in nature than they really are.
Epidemiology
Histrionic personality disorder is one of the most uncommon personality disorders, occurring in only 1.84% of the general population (APA, 2013). While it was once believed to be more commonly diagnosed in females than males, more recent findings suggest the diagnosis rate is equal between genders.
Treatment
Individuals with histrionic personality disorder are actually more likely to seek out treatment than other those with other personality disorders. Unfortunately, due to the nature of the disorder, they are very difficult to treat as they are quick to employ their demands and seductiveness within the treatment setting. The overall goal for treatment of histrionic personality disorder is to help the individual identify their dependency and become more self-reliant. Cognitive therapists utilize techniques to help clients change their helpless beliefs and improve problem-solving skills (Beck & Weishaar, 2011).
Narcissistic Personality Disorder
Clinical Description
The key features of narcissistic personality disorder are a need for admiration, a pattern of grandiosity, and a lack of empathy for others (APA, 2013). The grandiose sense of self often leads to an overvaluation of their abilities and accomplishments. They often come across as boastful and pretentious, repeatedly proclaiming their superior achievements. These proclamations may also be fantasized as a means to enhance their success or power. Oftentimes they identify themselves as “special” and will only interact with others of high status.
Given the grandiose sense of self, it is not surprising that individuals with narcissistic personality disorder need excessive admiration from others. While it appears that their self-esteem is extremely inflated, it is actually very fragile and dependent on how others perceive them (APA, 2013). Because of this, they may constantly seek out compliments and expect favorable treatment from others. When this sense of entitlement is not upheld, they can become irritated or angry that their needs are not being met.
A lack of empathy is also displayed in individuals with narcissistic personality disorder as they often fail to recognize the desires or needs of others. This lack of empathy also leads to exploitation of interpersonal relationships, as they are unable to empathize other’s feelings (Marcoux et al., 2014). They often become envious of others who achieve greater success or have nicer possessions than them. Conversely, they believe everyone should be envious of their achievements, regardless of how small they may actually be.
Epidemiology
Finally, narcissistic personality disorder is reportedly diagnosed in 0 – 6.2% of the general public, with 75% of these individuals being men (APA, 2013).
Treatment
Of all the personality disorders, narcissistic personality disorders are among the most difficult to treat (with maybe the exception of antisocial personality disorder). In fact, most individuals with narcissistic personality disorder only seek out treatment for those disorders secondary to their personality disorder, such as depression (APA, 2013). The focus of treatment is to address the grandiose, self-centered thinking, while also trying to teach clients how to empathize with others (Beck & Weishaar, 2014).
Narcissistic personality disorder
- Case vignette
A 42-year-old male professional in public office, was forced to resign after being arrested when visiting a brothel. In the aftermath he suffered from depression and considerable alcohol consumption, and was admitted for a three months treatment. He stopped drinking, but his depression remained nonresponsive to anti-depressant medication. Still without meaningful activities he felt empty and restless, and he was referred to psychotherapy. Developmental history indicates that at age 5 his father left the family, and they did not meet until he was in law school. He was always ahead of his age and went through school without difficulty. In law school he got high marks without hard work. He had many acquaintances but no friends, and he felt like an outsider. He got married and had two children. Reaching mid-thirties he felt bored. He had everything: house, career, and family. He was respected and accomplished, but felt he didn’t belong. He started drinking heavily and visiting brothels. The psychotherapist found him self-assured, easily irritated, and quick to make devaluating remarks, and felt a mixture of irritation, compassion and powerlessness. Interactions during weekly appointments were extremely difficult. Unwilling to explore his situation or his feelings, he blamed the therapist for the impasse and told him that he will not change and that the therapist could not help. The therapist dreaded the appointments, while the patient despite finding the sessions unhelpful, always showed up. When the therapist announced a three weeks break his patient suggested the treatment to end and did not return. Nine months later he informed the therapist that he moved to another city, had a leading position working with international trade, and was greeted as a king. He said nothing about his wife and children. Nor did he indicate how he felt about the treatment.
Key Takeaways
Antisocial
A pervasive pattern of disregard and violation of the rights of others. These behaviors may be aggressive or destructive and may involve breaking laws or rules, deceit or theft.
Borderline
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity.
Cluster B (“dramatic, emotional, or erratic”)
Includes antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder.
Histrionic
A pervasive pattern of excessive emotionality and attention seeking.
Narcissistic
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy.
“Cluster B Personality Disorders” is adapted from Abnormal Psychology by Coursehero, used under CC BY-SA: Attribution-ShareAlike.
