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 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 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 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)
  • 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 is the predominant defense mechanism.
  • > 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
    • 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 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 [cluster C])
  • Should be differentiated from bipolar disorder Bipolar disorder Bipolar disorder is a highly recurrent psychiatric illness characterized by periods of manic/hypomanic features (distractibility, impulsivity, increased activity, decreased sleep, talkativeness, grandiosity, flight of ideas) with or without depressive symptoms. 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 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, 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 Bipolar disorder Bipolar disorder is a highly recurrent psychiatric illness characterized by periods of manic/hypomanic features (distractibility, impulsivity, increased activity, decreased sleep, talkativeness, grandiosity, flight of ideas) with or without depressive symptoms. 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 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, 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 Delusional disorder In delusional disorder, the patient suffers from 1 or more delusions for a duration of 1 month or more, without any other psychotic symptoms or behavioral changes and no decline in functioning abilities. Delusional Disorder

Summary

Cluster B disorder Antisocial Borderline Histrionic Narcissistic
Key features Disregard 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 mechanism Acting 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 Delusional disorder In delusional disorder, the patient suffers from 1 or more delusions for a duration of 1 month or more, without any other psychotic symptoms or behavioral changes and no decline in functioning abilities. 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 diabetes refuses to take his medication because he feels it is “beneath him.”

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