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Cluster B Personality Disorders

Personality disorders Personality Disorders A major deviation from normal patterns of behavior. Cluster A Personality Disorders are ego-syntonic behaviors that begin in childhood or adolescence and are classified into 3 clusters: A, B, and C. They can considerably interfere with a patient’s adherence to medical treatment for a variety of reasons. It is important to rule out organic causes of a mental disorder (e.g., endocrine hormone imbalances, medication adverse effects, alcohol and/or substance use, other mental health co-morbidities) before ascribing a personality disorder to a patient. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders Personality Disorders A major deviation from normal patterns of behavior. Cluster A Personality Disorders, which can be behaviorally described as dramatic, erratic, and threatening/disturbing.

Last updated: 8 Jan, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Antisocial Personality Disorder

Key features

  • < 18 years of age: conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder
  • > 18 years of age: antisocial personality disorder, characterized by the following behaviors, which begin by age 15:
    • Deceitfulness: lying, manipulating, and exploiting others
    • Repeated criminal behavior and aversion toward social norms/laws
    • Unable to consistently fulfill responsibilities with work or finances
    • Impulsivity Impulsivity Attention Deficit Hyperactivity Disorder and recklessness: lack of regard for others’ and own safety
    • Aggressiveness
      • Irritability
      • Being part of physical fights
    • Lack of remorse: disregard for other people’s feelings and how they are affected by the patient’s actions

Risk factors

  • Family history Family History Adult Health Maintenance of antisocial personality disorder
  • Associated with mood disorders
  • Associated with substance use disorder
  • Affects men far more commonly than women (high prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency in prisons)

Management

  • Antisocial patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship typically end up incarcerated prior to receiving medical treatment for their disorder.
  • Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy (first line, especially anger management Anger management System of psychological and/or therapeutic techniques used to control and or reduce the triggers, degrees, and effects of anger. Oppositional Defiant Disorder)
  • Pharmacotherapy is generally not recommended unless the patient is overly aggressive ( second-generation antipsychotics Second-Generation Antipsychotics Second-generation antipsychotics (SGAs) are also called atypical antipsychotics. Medications in this class include aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lumateperone, lurasidone, olanzapine, paliperidone, pimavanserin, quetiapine, risperidone, and ziprasidone. Second-Generation Antipsychotics may be beneficial).

Clinical associations

  • Acting out Acting out Expressing unconscious emotional conflicts or feelings, often of hostility or love, through overt behavior. Defense Mechanisms is the predominant defense mechanism Defense mechanism Unconscious process used by an individual or a group of individuals in order to cope with impulses, feelings or ideas which are not acceptable at their conscious level; various types include reaction formation, projection and self reversal. Psychotherapy.
  • > 18 →  antisocial personality disorder
  • < 18 →  conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder
  • < 18 with no damage to others or property →  oppositional defiant disorder Oppositional Defiant Disorder Oppositional defiant disorder is a pediatric psychiatric disorder characterized by a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness directed at adults or other authority figures. Symptoms must be present for at least 6 months to make a diagnosis of ODD. Oppositional Defiant Disorder
  • Should be differentiated from intermittent explosive disorder Intermittent Explosive Disorder Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. Intermittent Explosive Disorder
  • Should be differentiated from disruptive mood dysregulation disorder Disruptive Mood Dysregulation Disorder Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder
  • Distinction: “Antisocial” means “against society,” whereas “asocial” means “away from society.” Therefore, when someone is colloquially described as being antisocial, that person is actually asocial.

Borderline Personality Disorder

Key features

  • Intense fear of abandonment, unstable relationships
  • Disturbed sense of self
  • Repeated suicidal behavior and self-harm Self-harm Psychiatric Assessment
  • Lack of impulse control
  • Feelings of emptiness
  • Emotional lability:
    • Difficulty controlling anger 
    • Episodes of intense anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder or dysphoria

Risk factors

  • Family history Family History Adult Health Maintenance of borderline personality disorder
  • Associated with mood disorders
  • Associated with substance use disorders
  • Affects women more commonly than men

Management

  • Dialectical behavior therapy
    • A specific form of cognitive behavioral therapy Cognitive behavioral therapy A directive form of psychotherapy based on the interpretation of situations (cognitive structure of experiences) that determine how an individual feels and behaves. It is based on the premise that cognition, the process of acquiring knowledge and forming beliefs, is a primary determinant of mood and behavior. The therapy uses behavioral and verbal techniques to identify and correct negative thinking that is at the root of the aberrant behavior. Psychotherapy
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder, depression, mood instability)

Clinical associations

  •   Splitting Splitting Defense Mechanisms (i.e., seeing things as either “good” or “bad,” with no gray area or compromise) is a predominant defense mechanism Defense mechanism Unconscious process used by an individual or a group of individuals in order to cope with impulses, feelings or ideas which are not acceptable at their conscious level; various types include reaction formation, projection and self reversal. Psychotherapy.
  • Acting out Acting out Expressing unconscious emotional conflicts or feelings, often of hostility or love, through overt behavior. Defense Mechanisms is another prevalent defense mechanism Defense mechanism Unconscious process used by an individual or a group of individuals in order to cope with impulses, feelings or ideas which are not acceptable at their conscious level; various types include reaction formation, projection and self reversal. Psychotherapy (cutting or other forms of self-mutilation are pathognomonic).
  • Increased risk of suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide
  • Very common in clinical populations (along with avoidant personality disorder Avoidant Personality Disorder Cluster C Personality Disorders [cluster C])
  • Should be differentiated from bipolar Bipolar Nervous System: Histology disorder (i.e., mood swings from manic to depressive episodes Depressive episodes Depressive states usually of moderate intensity in contrast with major depression present in neurotic and psychotic disorders. Bipolar Disorder)

Histrionic Personality Disorder

Key features

  • Attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment-seeking behavior:
    • Exaggerated, grandiose displays of emotions 
    • Through physical appearance
    • Drastic actions when not center of attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment
  • Inappropriate seductive or sexually provocative behavior
  • Misjudging the degree of intimacy in relationships; i.e., believing it to be higher than it is

Risk factors

  • Associated with mood disorders
  • Associated with substance use disorders
  • Affects women more commonly than men

Management

  • Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy (first line)
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder, depression, mood instability)

Clinical associations

Narcissistic Personality Disorder

Key features

  • Grandiose self-image: 
    • Sees self as inherently superior to others
    • Difficulty handling criticism
  • Entitlement: 
    • Expects and needs to be admired
    • Expects special treatment
  • Exploitative behavior:
    • Lack of empathy Empathy An individual’s objective and insightful awareness of the feelings and behavior of another person. It should be distinguished from sympathy, which is usually nonobjective and noncritical. It includes caring, which is the demonstration of an awareness of and a concern for the good of others. Psychotherapy
    • Uses others to achieve own goals
    • Is envious of others’ success

Risk factors

  • Associated with substance use disorders
  • Associated with mood disorders
  • Associated with anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorders

Management

  • Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy (first line)
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder, depression, mood instability)

Clinical associations

  • Acting out Acting out Expressing unconscious emotional conflicts or feelings, often of hostility or love, through overt behavior. Defense Mechanisms is the predominant defense mechanism Defense mechanism Unconscious process used by an individual or a group of individuals in order to cope with impulses, feelings or ideas which are not acceptable at their conscious level; various types include reaction formation, projection and self reversal. Psychotherapy.
  • Denial Denial Refusal to admit the truth or reality of a situation or experience. Defense Mechanisms is another defense mechanism Defense mechanism Unconscious process used by an individual or a group of individuals in order to cope with impulses, feelings or ideas which are not acceptable at their conscious level; various types include reaction formation, projection and self reversal. Psychotherapy, often used to make their ideas/perspectives seem more important compared to others’.
  • Regression Regression Corneal Abrasions, Erosion, and Ulcers is another defense mechanism Defense mechanism Unconscious process used by an individual or a group of individuals in order to cope with impulses, feelings or ideas which are not acceptable at their conscious level; various types include reaction formation, projection and self reversal. Psychotherapy (i.e., a child-like need to be the center of attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment).
  • Should be differentiated from:

Summary

Cluster B disorder Antisocial Borderline Histrionic Narcissistic
Key features Disregard and violation of others’ rights, social norms, and laws
  • Dramatic
  • Superficial
  • Attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment-seeking
  • Ego-centric
  • Grandiosity
  • Lack of empathy Empathy An individual’s objective and insightful awareness of the feelings and behavior of another person. It should be distinguished from sympathy, which is usually nonobjective and noncritical. It includes caring, which is the demonstration of an awareness of and a concern for the good of others. Psychotherapy
Defense mechanism Defense mechanism Unconscious process used by an individual or a group of individuals in order to cope with impulses, feelings or ideas which are not acceptable at their conscious level; various types include reaction formation, projection and self reversal. Psychotherapy Acting out Acting out Expressing unconscious emotional conflicts or feelings, often of hostility or love, through overt behavior. Defense Mechanisms
Differentials
  • Conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder
  • Oppositional defiant disorder Oppositional Defiant Disorder Oppositional defiant disorder is a pediatric psychiatric disorder characterized by a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness directed at adults or other authority figures. Symptoms must be present for at least 6 months to make a diagnosis of ODD. Oppositional Defiant Disorder
  • Intermittent explosive disorder Intermittent Explosive Disorder Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. Intermittent Explosive Disorder
  • Disruptive mood dysregulation disorder Disruptive Mood Dysregulation Disorder Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder
Bipolar Bipolar Nervous System: Histology disorder (fluctuating between manic and depressive episodes Depressive episodes Depressive states usually of moderate intensity in contrast with major depression present in neurotic and psychotic disorders. Bipolar Disorder) Bipolar Bipolar Nervous System: Histology disorder (manic talkativeness and delusions of grandeur Delusions of grandeur Delusional Disorder)
Management Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy (pharmacotherapy is generally not recommended) Dialectical behavior therapy (DBT) (first line) with low-dose pharmacotherapy for applicable symptoms (e.g., anxiolytics, mood stabilizers, antidepressants) Tip: BorDerline gets DBT Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy (first line) with low-dose pharmacotherapy for applicable symptoms (e.g., anxiolytics, mood stabilizers, antidepressants) Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy (first line) with low-dose pharmacotherapy for applicable symptoms (e.g., anxiolytics, mood stabilizers, antidepressants)
Epidemiology ♂>>>♀ ♀>>♂ ♀>>♂ ♂=♀
Example A 20-year-old man is caught stealing from his neighbor and then lying about it. He has “no regrets.” A woman with epilepsy Epilepsy Epilepsy is a chronic brain disorder marked by recurrent and unprovoked seizures. These seizures can be classified as focal or generalized and idiopathic or secondary to another condition. Clinical presentation correlates to the classification of the epileptic disorder. Epilepsy interprets her physician’s delay in returning her call as a personal slight and “retaliates” by not taking her seizure medication. A woman wearing a revealing shirt comes in for a routine check-up, during which she flirts with you and asks you if you’re single. A world-famous surgeon with uncontrolled type 2 Type 2 Spinal Muscular Atrophy diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus refuses to take his medication because he feels it is “beneath him.”

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