Cluster B Personality Disorders

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, which can be behaviorally described as dramatic, erratic, and threatening/disturbing.

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Antisocial Personality Disorder

Key features

  • < 18 years of age: 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 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 of antisocial personality disorder
  • Associated with mood disorders
  • Associated with substance use disorder
  • Affects men far more commonly than women (high prevalence in prisons)

Management

  • Antisocial patients typically end up incarcerated prior to receiving medical treatment for their disorder.
  • Psychotherapy (first line, especially anger management)
  • Pharmacotherapy is generally not recommended unless the patient is overly aggressive (second-generation antipsychotics may be beneficial).

Clinical associations

  • Acting out is the predominant defense mechanism.
  • > 18 →  antisocial personality disorder
  • < 18 →  conduct disorder
  • < 18 with no damage to others or property →  oppositional defiant disorder
  • Should be differentiated from intermittent explosive disorder
  • Should be differentiated from 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
    • Unstable self-image
    • Possible severe symptoms of dissociation
  • Repeated suicidal behavior and self-harm
  • Lack of impulse control
  • Feelings of emptiness
  • Emotional lability:
    • Difficulty controlling anger 
    • Episodes of intense anxiety or dysphoria

Risk factors

  • Family history 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
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety, depression, mood instability)

Clinical associations

  •  Splitting (i.e., seeing things as either “good” or “bad,” with no gray area or compromise) is a predominant defense mechanism.
  • Acting out is another prevalent defense mechanism (cutting or other forms of self-mutilation are pathognomonic).
  • Increased risk of suicide
  • Very common in clinical populations (along with avoidant personality disorder [cluster C])
  • Should be differentiated from bipolar disorder (i.e., mood swings from manic to depressive episodes)

Histrionic Personality Disorder

Key features

  • Attention-seeking behavior:
    • Exaggerated, grandiose displays of emotions 
    • Through physical appearance
    • Drastic actions when not center of attention
  • 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 (first line)
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety, depression, mood instability)

Clinical associations

  • Regression is the predominant defense mechanism (i.e., a child-like need to be the center of attention)
  • Should be differentiated from bipolar disorder (i.e., manic talkativeness and delusions of grandeur)

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
    • 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 disorders

Management

  • Psychotherapy (first line)
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety, depression, mood instability)

Clinical associations

  • Acting out is the predominant defense mechanism.
  • Denial is another defense mechanism, often used to make their ideas/perspectives seem more important compared to others’.
  • Regression is another defense mechanism (i.e., a child-like need to be the center of attention).
  • Should be differentiated from:
    • Bipolar disorder (i.e., manic delusions of grandeur)
    • Intermittent explosive disorder
    • Disruptive mood dysregulation disorder
    • Delusional disorder

Summary

Cluster B disorderAntisocialBorderlineHistrionicNarcissistic
Key featuresDisregard and violation of others’ rights, social norms, and laws
  • Chaotic relationships
  • Sensitivity to abandonment
  • Labile mood
  • Impulsivity
  • Self-harm
  • Dramatic
  • Superficial
  • Attention-seeking
  • Ego-centric
  • Grandiosity
  • Lack of empathy
Defense mechanismActing out
  • Splitting
  • Acting out
  • Regression
  • Acting out
  • Acting out
  • Denial
  • Regression
Differentials
  • Conduct disorder
  • Oppositional defiant disorder
  • Intermittent explosive disorder
  • Disruptive mood dysregulation disorder
Bipolar disorder (fluctuating between manic and depressive episodes)Bipolar disorder (manic talkativeness and delusions of grandeur)
  • Bipolar disorder
  • Intermittent explosive disorder
  • Disruptive mood dysregulation disorder
  • Delusional disorder
ManagementPsychotherapy (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 DBTPsychotherapy (first line) with low-dose pharmacotherapy for applicable symptoms (e.g., anxiolytics, mood stabilizers, antidepressants)Psychotherapy (first line) with low-dose pharmacotherapy for applicable symptoms (e.g., anxiolytics, mood stabilizers, antidepressants)
Epidemiology♂>>>♀♀>>♂♀>>♂♂=♀
ExampleA 20-year-old man is caught stealing from his neighbor and then lying about it. He has “no regrets.”A woman with 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 diabetes refuses to take his medication because he feels it is “beneath him.”

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