Cluster B Personality Disorders

by Helen Farrell, MD

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    00:01 Now we'll go through the Cluster B Personality Disorders.

    00:04 Let's start with the histrionic personality. This is a pervasive pattern of excessive emotionally and attention seeking behaviors beginning by early adulthood and present in a variety of contexts.

    00:21 Patients meet at least five of the following criteria.

    00:25 They're uncomfortable when he or she is not the center of attention.

    00:29 They're sexually seductive or provocative. They rapidly shift and are shallow in expression of emotions. They use physical appearance to draw attention to one self.

    00:41 They have an impressionistic style of speech. They have self-dramatization.

    00:48 They're theatrical and give exaggerated expressions of emotions.

    00:53 They're very suggestible and easily influenced, and they considered relationships to be often more intimate than they really are. So this is more often associated with women than man. There's a variable course for the illness.

    01:08 Some will experience attenuation of symptoms as they age and others have some co-morbid mood shifts and dissociations in stressful life events.

    01:20 The way to treat histrionic personality disorder is through psychodynamic psychotherapy. Here the emphasis is on emotional clarification, practical problem solving, and adherence to structure and detail to counter their diffuse cognitive style. Medications that are used include low-dose benzodiazepines that are helpful in transient emotional states and very occasionally, low-dose antipsychotics can be used for dissociation.

    01:52 Borderline personality disorder is another important disorder in the Cluster B group.

    01:59 This is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts. Patient must meet five or more of the following.

    02:17 Frantic efforts to avoid real or imagined abandonment.

    02:21 They are unstable and intense in interpersonal relationships.

    02:26 They often alternate between extremes of idealization of people and then devaluing them.

    02:32 There's an identity disturbance, marked by persistent, unstable self-image.

    02:38 There's impulsivity, recurrent suicidal behavior, or gestures were threats, affects instability due to marked reactivity of chronic feelings of emptiness.

    02:51 There's inappropriate and intense anger or difficulty controlling anger and there's transient stress-related paranoid ideation in these patients.

    03:02 It's also an enduring pattern that is inflexible and pervasive across a broad range of personal and social situations. The enduring pattern leads to clinically significant distress or impairment in functioning.

    03:17 The pattern is stable and of long duration and its onset can usually be traced back to teenage years. The enduring pattern is also not better explained as a manifestation or consequence of another mental disorder, and it's also not attributable to a substance abuse problem or a general medical condition. When it comes to borderline personality disorder, patients have a tendency to act out impulsively in any of the following ways that can get them into danger - spending money, sex, substance abuse, reckless driving, binge-eating. The differential diagnosis for borderline personality disorder includes other personality disorders, bipolar disorders, and anxieties.

    04:04 The borderline personality disorder is two times more prevalent in women than in men.

    04:11 There's an increased risk for co-morbid disorders like eating disorders and substance abuse along with other anxiety disorders like PTSD, and actually suicide is very common. Approximately 10% of patients with borderline personality disorder will commit suicide before the age of 30.

    04:32 The treatment includes psychotherapy. It's most helpful when emphasizing DBT, dialectical behavioral therapy. This focuses on opposing statements and views for almost every subject highlighting to the patient different ways to think about things and how to take in others point of views without feeling empty or unstable.

    04:53 There's also individual therapy. In that increasing coping skills, distress tolerance, mindfulness, affect regulation, and crisis management.

    05:04 And many clinicians will experience a very strong countertransference towards patients with borderline personality disorder.

    05:13 So it is very important for the clinician to be aware of how they are experiencing the patient. So you can continue to be helpful and not take out any of your own aggressions on the patient. Medication can be used when there are targets symptoms along with borderline personality disorder such as impulsivity, emotional lability, intermittent psychosis and mood symptoms.

    05:36 Often think of medications like antidepressants or low-dose anti-psychotics.

    05:42 Pharmacotherapy has been shown to be more useful in borderline personality disorder than actually in any other personality disorder.

    05:52 Now let's talk a little bit about narcissistic personality.

    05:57 This is a pervasive pattern of grandiosity in either fantasy or behavior, a need for admiration and a lack of empathy beginning from early adulthood and presenting in a variety of contexts. Patients meet at least five of the following criteria.

    06:17 A grandiose sense of self-importance. They're preoccupied with fantasies of unlimited success. There's a belief that he or she is special.

    06:28 They require excessive admiration. There's a sense of entitlements.

    06:34 It's interpersonally exploitative. And there's a lack of empathy.

    06:39 Often this person is envious of others, and they believe that others are envious of them.

    06:45 And they show arrogant and haughty behaviors.

    06:50 The narcissistic individual will often exaggerate achievements and talents.

    06:56 And they expect to be recognized as superior without commensurate achievements.

    07:02 They often have unreasonable expectations and want favorable or special treatments.

    07:09 The course for narcissism is chronic. And the biggest blow to the narcissist is actually for them to age. They tend, this is because narcissist tend to hinge their self-esteem on things like youth and beauty, career and their health, and therefore they're highly prone to having a midlife crisis when some of these things start to dwindle.

    07:35 Finally, let's look at anti-social personality disorder.

    07:39 This is a pervasive pattern of disregard for and violation of the rights of others.

    07:45 Occurring since the age of 15, patient?s will meet three or more of the following criteria.

    07:52 A failure to conform to social norms, deceitfulness, impulsivity, irritability and aggressiveness, reckless disregard for the safety of others, consistent irresponsibility and lack of remorse. The individual must be at least 18 years old to qualify for this diagnosis, but there has to have been evidence of a conduct disorder occurring before the age of 15. And the occurrence of anti-social behavior is not exclusively during the course of schizophrenia or, bipolar or any other mental illness. This personality disorder is most resistant to treatment.

    08:38 It's more common in men than women and tends to occur five times more commonly in first degree relatives of males with the disorder.

    08:47 The course is variable and some people improve with age, but others will end up in prison.

    08:54 The treatment is very difficult. Holding people legally responsible for their actions is most important. Medication really serves no role on the treatment unless there are concerns for violence against oneself or others and then you may use medication management to target that impulsivity and violence.

    09:16 Let's now go through a quiz to see how well you understand Cluster B personality disorders. Here is a case example: A 24-year-old woman is admitted to inpatient psychiatry after cutting her arms and legs.

    09:30 She did this in response to feeling abandoned by her outpatient psychiatrist who went on a scheduled vacation. The patient has an extensive history of making suicide attempts by cutting and also overdose in the past.

    09:45 She tells you that her life is empty and she's glad you're her new doctor.

    09:51 She says, "I can tell you are the very best".

    09:55 What personality disorder do you think she has? It's borderline personality disorder.

    10:04 Moving on to the next case, a 55-year-old woman comes to the office wearing bright red lipstick, heavy eyeliner, and scantily dressed for her doctor's appointment.

    10:15 She cries profusely when talking about how much her dog means to her and then laughs hysterically when asking the doctor about his personal life.

    10:25 What personality disorder do you think she has? She has a histrionic personality disorder.

    10:33 A 45-year-old man is brought to the emergency department by police after he was arrested for assault, on route to jail, he complained of feeling suicidal.

    10:45 On evaluation, you learn that he has several prior convictions for violent crimes.

    10:50 He expresses no remorse for his victims and he also used to torture pets when he was a child. So what personality disorder does he have? He has an anti-social personality disorder.

    11:05 A 55-year-old man has risen to president of his company after taking advantage of his peers by accepting credit for their hard work.

    11:16 He tells others that if they stick with him, they can also have wealth and power.

    11:22 This man will only spend time with people whom he considers to be his equal in terms of status. When challenged at board meetings, he often throws tantrums by yelling and calling other people names.

    11:36 What personality disorder do you think he has? He has a narcissistic personality.

    11:45 That concludes our discussion of Cluster B personality disorders.

    11:50 There are four of them and you now know the diagnostic criteria and a little bit about how to approach the patient.

    About the Lecture

    The lecture Cluster B Personality Disorders by Helen Farrell, MD is from the course Personality Disorders. It contains the following chapters:

    • Cluster B
    • Borderline Personality
    • Narcissistic Personality
    • Assessment – Antisocial Personality

    Included Quiz Questions

    1. High doses of diazepam is used as the first line of treatment
    2. It is more commonly seen in females than males
    3. Some experience attenuation of symptoms with age
    4. A rapidly shifting and shallow expression of emotions
    5. They consider relationships to be more intimate than they actually are
    1. Narcissistic personality disorder
    2. Borderline personality disorder
    3. Avoidant personality disorder
    4. Paranoid personality disorder
    5. Histrionic personality disorder
    1. Inappropriately cool demeanor with which they handle situations
    2. Identity disturbances
    3. Unstable and intense interpersonal relationships
    4. The pattern is stable and of long duration, often tracing back to adolescent age
    5. The enduring pattern is not attributable to drug abuse or another medical condition
    1. Delusion of grandiosity
    2. Eating disorders
    3. Post-traumatic stress disorder
    4. Drug abuse
    5. Suicidal ideation
    1. Dialectical behavioral therapy
    2. Biofeedback
    3. Cognitive behavior therapy
    4. Functional analytical psychotherapy
    5. Intensive short-term psychotherapy
    1. Narcissistic
    2. Borderline
    3. Avoidant
    4. Antisocial
    5. Histrionic
    1. It is very sensitive to treatment
    2. it is more common in men than in women
    3. It tends to occur 5 times more often in first-degree relative of males with the disorder
    4. There is evidence of conduct disorder, with the onset occuring before the age of 15 years
    5. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder

    Author of lecture Cluster B Personality Disorders

     Helen Farrell, MD

    Helen Farrell, MD

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