CLUSTER B PERSONALITY DISORDERS BY BANU JOTHIMALARR P83009

WHAT ARE THE CLUSTER B PERSONALITY DISORDERS? Cluster B is a group of personality disorders (long-lasting maladaptive patterns of cognition, emotions, social functioning and impulse control) that falls under the second axis of disorders within the DSM. These personality disorders are also categorized as dramatic personality disorders or referred to as erratic types. There are four personality disorders that serve as Cluster B Personality Disorders: Antisocial Personality Disorder Borderline Personality Disorder Narcissistic Personality Disorder Histrionic Personality Disorder

ANTISOCIAL PERSONALITY DISORDER A pervasive pattern of disregard for the welfare and rights of others since age 15. Indicators are three or more of the following symptoms: -Failure to conform to social norms. Evidence of this lies in being arrest multiple times/ violations of laws -Deceitfulness via means of lies, conning, the use of aliases for the purposes of personal gain -Impulsivity or unable to plan ahead -Irritable and aggressive. Easily provoked into fights or assaults. -Disregard for the safety of self and others -Irresponsible and consistently unable to fulfil obligations -Lack of remorse and rationalizes wrongful actions Individual must be aged 18 and above Evidence of conduct disorder before age 15 The antisocial behaviour does not coincide with schizophrenia or bipolar disorder

OTHER ASSOCIATED FEATURES SUPPORTING THE DIAGNOSIS OF ASPD Lack of empathy and self-appraisalSuperficial charm and promiscuous Very irresponsible, may be impoverished, homeless and likely to die earlier than usual population in violent manners May also exhibit having symptoms of mood disorders, impulse-control disorders or other personality disorders. ASPD considered to be more likely for children/adolescents with conduct disorder and accompanying ADHD Other factors presumed to be increase likelihood for conduct disorder turning into ASPD: childhood abuse/neglect, unstable parenting, inconsistent disciplining from parents

Prevalence -12-month prevalence of 0.2%-3.3% -Highest rate among males with alcohol abuse disorder within forensic settings -Higher in populations affected by adverse socioeconomic and sociocultural factors. i.e. Urban poor (possible protective survival strategy) Risk and prognostic factors - Biological relatives (higher for female relatives) - Genetics and environment play an important role - Females have higher tendency for somatic symptom disorder and males tend to develop ASPD along with substance use disorders -General prevalence higher for males Development - Chronic but may recede as the individual ages above 40 - Remission associated with criminal behaviour reduction - Might only be decrease with respect to spectrum of behaviour - Cannot be diagnosed before age 18.

NEUROBIOLOGICAL CONTRIBUTIONS OF ASPD Prevailing Neurobiological Theories  Brain damage – Little support for this view  Underarousal hypothesis – Cortical arousal is too low  Cortical immaturity hypothesis – Cerebral cortex is not fully developed  Fearlessness hypothesis – Psychopaths fail to respond with fear to danger cues  Gray’s model of behavioral inhibition and activation  Study found person with psychopathic tendencies showed decreased amygdala and orbitofrontal cortex responses to emotionally provocative stimuli which the author felt was suggestive of difficulties with basic forms of emotional learning and decision making (Blair, 2010).

DIFFERENTIAL DIAGNOSIS FOR ASPD Substance Use Disorders Can occur co- morbidly with ASPD However diagnosis for ASPD only given if onset was below age 15 as conduct disorder and symptoms were prevalent in adulthood before noticeable substance abuse Schizophrenia and Bipolar Disorders Refers to symptoms exhibited during course of these disorders Cannot be considered ASPD as such Other personality disorders Must be vigilant in observing criteria met for other personality disorders ASPD can be comorbid with NPD, BPD, and HPD Important to note whether criteria for the other disorders are fully met Criminal behaviour not associated with a personality disorder Can be distinguished by examining the perceived gain for criminal behaviour Can be considered ASPD if individual shows inflexible, maladaptible, persistence and cause significant impairment and distress

MNEMONIC FOR APSD - CORRUPT C - cannot follow law O - obligations ignored R - remorselessness R – reckless disregard for safety U – underhanded (deceitful) P - planning deficit (impulsive) T - temper (irritable, aggressive) + Childhood conduct disorder

OVERLAP AND LACK OF OVERLAP AMONG ANTISOCIAL PERSONALITY DISORDER, PSYCHOPATHY, AND CRIMINALITY

LIFETIME COURSE OF CRIMINAL BEHAVIOR IN PSYCHOPATHS AND NON-PSYCHOPATHS

TREATMENTS FOR ASPD Some believe that ASPD is very difficult to treat. Hospitalization for those in danger of self-harm or harm towards others Addiction and family counselling – to treat substance use disorders/impulse control such as gambling. Family/marital counselling for reduction in conflict-causing behaviour and increase in responsibility Behaviour therapy – conditioning behaviour of individual to be more functional Incarceration for the most severe and persistent cases Medication  Lithium carbonate - reduce anger, threatening behaviour and combativeness  Phenytoin (Dilantin)- reduce impulsive aggression  Carbamazepine, valproate, propranolol, buspirone and trazodone – used to treat aggression  Antipsychotic medications - may deter aggression, but potentially induce irreversible side effects  Medications used for treatment of comorbid mood disorders Psychotherapy:  Cognitive therapy - to help the patient understand how he creates his own problems and how his distorted perceptions prevent him from seeing himself the way others view him

CASE STUDY From Seattle, Washington Intelligent, attractive, articulate Law student at University of Washington One of the most notorious serial killers in the early eighties Raped and murdered 12 women from Washington state to Florida Executed in 1989 Rationally executed his crimes Normalized the killings as a form of fulfilment of emotional need for control and power as well as sexual gratification Demonstrated inability to experience empathy, affection, or even a conscience TED BUNDY

BORDERLINE PERSONALITY DISORDER A pervasive pattern of instability of interpersonal relationships, self-image, and affects and marked impulsivity, beginning by early adulthood and present in the below contexts: -Frantic efforts to avoid real or imagined abandonment -Unstable and intense interpersonal relationship patterns with extremes of idealization or devaluation -Identity disturbance: significant and persistent unstable self-image or sense of self -Self-damaging impulsivity in at least two areas e. g. drug abuse and engaging in unsafe sex -Recurrent suicidal behavior, gestures, or threats, or self-mutilating behaviour - Emotions that are highly unstable and moods that are highly reactive (affect instability) -Chronic feelings of emptiness -Inappropriate, intense anger or difficulty controlling anger -Transient, stress-related paranoid ideation or severe dissociative symptoms Recurrent job losses, interrupted education, and separation or divorce Physical and sexual abuse, neglect, hostile conflict, and early parental loss are more common in the childhood histories Common co-occurring disorders: depressive and bipolar disorders, substance use disorders, eating disorders (notably bulimia nervosa), posttraumatic stress disorder, other personality disorders and attention-deficit/hyperactivity disorder.

OTHER ASSOCIATED FEATURES SUPPORTING THE DIAGNOSIS OF BPD Individual are extremely reactive and sensitive to their environment and symptomatic behaviour can be triggered by a variety of stressors or events Sometimes develop psychotic symptoms in times of stressPattern of undermining self at the moment a goal is about to be realized Individuals with BPD have difficult, temperamental an unstable relationships Completed suicide occurs in 8%-10% of such individuals and attempts at suicide can end in physical handicap

Prevalence -Median population prevalence from 1.6% to as high as 5.9% -6% in primary care settings, approx. 10% in outpatient mental health clinics, and approx.20% among psychiatric inpatients -Prevalence decreases with age Risk and prognostic factors - Five times more common among first- degree biological relatives - Increased familial risk for substance use disorders, antisocial personality disorder, and depressive or bipolar disorders -75% of BPD diagnosed in females - Adolescents and young adults with identity problems exhibit symptoms Development - Chronic instability in early adulthood, with episodes of serious affective and impulsive dyscontrol and high levels of use of health and mental health resources. - Impairment most severe in early adult sated and decrease with age - May no longer meet full citeria for BPD after 10 years

NEUROBIOLOGICAL AND OTHER SOCIOCULTURAL FACTORS IN THE ETIOLOGY OF BPD Genetic component  Highly heritable  May play a role in impulsivity and emotional dysregulation Decreased functioning of serotonin system Frontal lobe dysfunction Increased activation of amygdala Parental separation Verbal and emotional abuse during childhood Object-Relations Theory (Kernberg, 1985)  Introjection  Object-representation  BPD involves disturbed object representations, possibly due to inconsistent parenting  Conflict between introjected values and current needs  Splitting Linehan’s Diathesis-Stress Theory

LINEHAN’S DIATHESIS-STRESS THEORY Individuals with BPD have difficulty controlling their emotions - Possible biological diathesis Family invalidates or discounts emotional experiences and expression Interaction between extreme emotional reactivity and invalidating family → BPD

DIFFERENTIAL DIAGNOSIS FOR BPD Personality change due to another medical condition Traits that emerge are attributable to the effects of another medical condition on the central nervous system To be distinguished from actual BPD Depressive and Bipolar Disorders Refers to symptoms exhibited during course of these disorders Cannot be considered ASPD as such clinician should not diagnose BPD based only on cross- sectional presentation without examining without examining early onset and long- standing course of behaviour Other personality disorders Must be vigilant in observing criteria met for other personality disorders BPD can be similar to HPD, schizotypal personality disorder, paranoid personality disorder, NPD, ASPD, dependent personality disorder, in some characteristics Identity problems Identity concerns related to a developmental phase do not qualify as a mental disorder Substance use disorders BPD symptoms should be distinguished from symptoms that arise from substance use that is persistent

CASE STUDY - Attempted suicide before being admitted to an institution - Sexually promiscuous – security guard, boyfriend, English professor etc. - Verbally abusive towards her nurse - Unstable self-concept, fragile identity, dependent on others for support and attention - Depersonalization – randomly thought her had had no bones and bit it to prove her point - Eventually accepted her diagnosis and began to work towards improvement SUSANNA KAYSEN (Girl, Interrupted)

MNEMONIC FOR BPD – AM SUICIDE A - Abandonment fears M - Mood instability S - Suicidal / self-injurious behavior U - Unstable, intense relationships I - Impulsivity C - Control of anger poor I - Identity disturbance D - Dissociative / paranoid symptoms E - Emptiness

TREATMENTS FOR BPD Dialectical behaviour therapy - focuses on the concept of mindfulness, or paying attention to the present emotion and teaches skills to control intense emotions, reduce self-destructive behaviour, manage distress, and improve relationships Cognitive behaviour therapy - help people with BPD recognize and change both their beliefs and the ways they act that reflect inaccurate or negative opinions of themselves and others Transference-focused therapy– help patients understand their emotions and interpersonal problems through the relationship between the patient and therapist Mentalization-based therapy– talk therapy that helps people identify and understand what others might be thinking and feeling Medication - no drugs have actually been approved by the Food and Drug Administration specifically for the treatment of borderline personality disorder. But to alleviate symptoms, patients may be treated with antidepressants, antipsychotics or mood-stabilizing drugs.  SSRI’s- treatment of depression if present  MAOI’s – antidepressant used for patients resistant to antipsychotic drugs and mood stabilizers  Tricyclic antidepressants  Anti-anxiety agents and sedatives Self-care activities - regular exercise, good sleep habits, a nutritious diet, taking medications as prescribed, and healthy stress management Schema-focused therapy - identify unmet needs that have led to negative life patterns, which at some time may have been helpful for survival, but as an adult are impeding healthy emotions in life Systems training for emotional predictability and problem-solving (STEPPS) - 20-week treatment which involves working in groups that incorporate family members, caregivers, friends or significant others into treatment.

HISTRIONIC PERSONALITY DISORDER A pervasive pattern of instability of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts: -Uncomfortable when not the centre of attention -Inappropriately seductive or provocative behaviour with others -Rapidly shifting and shallow expression of emotions -Always uses physical appearance to draw attention to self -Style of speech is excessively impressionistic but lacking in detail -Self-dramatization, theatricality, and exaggerated expression of emotion -Suggestible -Considers relationships to be more intimate than they actually are Associated with higher rates of somatic symptom disorder, conversion disorder (functional neurological symptom disorder), and major depressive disorder. Co-occurrence of BPD, NPD, ASPD and dependent personality disorder is also possible. Onset can be as early as childhood with greater risk for those experiencing childhood pervasive trauma. Can also be a product of social environment whereby person was reinforced to develop histrionic personality

OTHER ASSOCIATED FEATURES SUPPORTING THE DIAGNOSIS OF HPD Difficulty achieving emotional intimacy in romantic or sexual relationships with tendency to act out a role with others. Seek to control their partner through emotional manipulation or seductiveness on one level, while displaying a marked dependency on them at another level Impaired relationships with same-sex friends. Also tend to alienate friends with demands for constant attention. Easily bored and frustrated when there is delay of gratification Increased risk for suicidal gestures and threats to get attention and coerce better caregiving National Epidemiologic Survey on Alcohol and Related Conditions suggest prevalence of 1.84% Cultural factors important to be considered when making diagnosis Some studies indicate equal prevalence in male and females. In clinical settings however, diagnosis were made for mostly females

ETIOLOGY OF HISTRIONIC PERSONALITY DISORDER Psychoanalytic theory  Emotional displays and seductiveness result from parental seductiveness  Father’s sexual attention towards daughter  Conflicting family attitudes towards sexuality  Negative attitudes towards sex while simultaneously acknowledging titillation Theory untested due to difficulty in empiricising psychoanalytic theory Question posited in academic knowledge of HPD:  Is histrionic personality a sex-typed variant of antisocial personality?

DIFFERENTIAL DIAGNOSIS FOR HPD Personality change due to another medical condition Traits that emerge are attributable to the effects of another medical condition on the central nervous system To be distinguished from actual HPD Other personality disorders and personality traits Must be vigilant in observing criteria met for other personality disorders HPD can be similar to BPD, NPD, ASPD, dependent personality disorder, in some characteristics Must not be confused with histrionic traits as the disorder is persistent, maladaptive, inflexible and causes significant impairment to the person Substance use disorders BPD symptoms should be distinguished from symptoms that arise from substance use that is persistent

MNEMONIC FOR HPD – PRAISE ME P - provocative (or seductive) behavior R - relationships, considered more intimate than they are A - attention, must be at center of I - influenced easily S - speech (style) - wants to impress, lacks detail E - emotional lability, shallowness M - made-up (physical appearance get attention) E - exaggerated emotions (theatrical)

TREATMENTS FOR HPD Psychodynamic therapy – clarify symptoms, modify defensive processes to modify behaviour and relationship management Cognitive behaviour therapy - help people with BPD recognize and change both their beliefs and the ways they act that reflect inaccurate or negative opinions of themselves and others Medication - no drugs have actually been specified for the treatment of borderline personality disorder. But to alleviate symptoms, patients may be treated with antidepressants if depression is present. Pharmacological treatment is also considered necessary if HPD is in occurrence with other disorders Group psychotherapy - symptom reduction using a therapeutic community Family therapy Meditation/hypnosis

CASE STUDY Scott seeks attention every opportunity he gets - interferes with his ability to function in his job as manager Interrupts his subordinates from working to discuss his personal life - interferes with the overall productivity of the office. Wants to be more of a close friend and even family member, to the dismay of his subordinates. This Expectation of a close bond leads Scott to display rapidly shifting emotions, from exuberant and hopeful, to depressed and hopeless Feels as if the entire office should be focused on his problem and that others’ problems pale in comparison, such as his birthday being of more importance than a coworkers cancer scare. Easily suggestible and is often the victim of pyramid schemes and persuasive coworkers. Shows a pattern of theatric behavior, including different characters, voices, and personalities, in which he uses as distractions on a daily basis. MICHAEL SCOTT (The Office – TV Series)

NARCISSISTIC PERSONALITY DISORDER A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts: -Grandiose sense of self-importance -Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love -Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). -Wants excessive admiration from others -Sense of entitlement -Interpersonally exploitative -Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others -Is often jealous of others or believes others are jealous of him/her -Displays arrogance and haughtiness Very sensitive to criticism or defeat Impaired interpersonal relationships Sometimes avoid participating in events that may diminish their achievement or in which defeat is highly possible

OTHER ASSOCIATED FEATURES SUPPORTING THE DIAGNOSIS OF NPD Associated with social withdrawal, depressed mood, and persistent depressive disorder (dysthymia) or major depressive disorder in times of sustained feelings of shame or humiliation Sustained periods of grandiosity may also be associated with a hypomanic mood Can also be associated with HPD, BPD, ASPD and paranoid personality disorders Also associated with anorexia nervosa and substance use disorders

Development - Particularly common in adolescents- - May not necessarily continue as such - NPD individuals will have special difficulties due to the disorder as they grow older Prevalence -Based on DSM-IV definitions, range from 0% to 6.2% in community samples - Of those diagnosed, 50%-75% are male

DIFFERENTIAL DIAGNOSIS FOR NPD Mania or hypomania Grandiosity may emerge as part of manic or hypomanic episodes To be distinguished from actual NPD by examining other criteria in the person Other personality disorders and personality traits The most useful feature in discriminating NPD from HPD, ASPD, and BPD is the grandiosity characteristic of NPD Relative stability of self-image as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns also help distinguish NPD from BPD Excessive pride in achievements, a relative lack of emotional display, and disdain for others' sensitivities distinguish from HPD NPD does not necessarily include characteristics of impulsivity, aggression, and deceit while emphasizes on attention that is admiring from others Different from OCD as OCD relies on self-criticism while NPD focuses on self- perfection Does not have suspiciousness or social withdrawal like in paranoid or schizotypal personality disorder Not to be confused with the traits of high-achieving people Substance use disorders NPD symptoms should be distinguished from symptoms that arise from substance use that is persistent

ETIOLOGY OF NPD Kohut’s Self-Psychology Model  Characteristics mask low self-esteem  In childhood, narcissist valued as a means to increase parent’s own self-esteem  Not valued for his or her own competency and self worth  People with high levels of narcissism report cold parents who overemphasized child’s achievement Social cognitive model  Narcissist has low self esteem  Sense of self depends on “winning”  Interpersonal relationships are a way to bolster sagging self esteem rather than increase closeness to others  Lab studies reveal cognitive biases that maintain narcissism

MNEMONIC FOR NPD - SPECIAL S – Special (believes they are) P – Preoccupied with fantasies of success, etc E 3 – Envious (of others), Entitled, Excessive admiration needed C -- Conceited I -- Interpersonally Exploitive A -- Arrogant L -- Lacks Empathy

TREATMENTS FOR NPD Brief hospitalization– for NPD patients who are quite impulsive or self-destructive, or who have poor reality-testing Cognitive-behavioral therapy or schema-focused therapy- repairing narcissistic schemas and the defective moods and coping styles associated with them. Encourages patients to confront narcissistic cognitive distortions. Psychoanalytic psychotherapy- actively interpret the patient’s narcissistic defenses while at the same time illuminating the patient’s negative transferences through direct confrontation Medication - no psychiatric medications are specifically approved for the treatment of NPD. Medications that may be considered include antidepressants (specifically, selective serotonin reuptake inhibitors [SSRIs]), antipsychotics, and mood stabilizers. Group psychotherapy - long-term group therapy can benefit patients with narcissism by providing them with a safe haven in which they can explore boundaries, receive and accept feedback, develop trust, and increase self-awareness

CASE STUDY Feels she is not receiving the attention and recognition she feels she deserves. Has desire to be "worshipped," and adored. Feels she is entitled to special treatment and when this fails to occur within her career or social life, she becomes explosive and stubborn. Seems to have no empathy regarding others, and on the rare occasions empathy is displayed by Jenna, it is not genuine empathy, but a means to an end. Severely jealous of her co-star in her current television series, and is constantly looking for ways to undermine him. Dreams of unparalleled success and believes she is the most beautiful, talented woman to grace this planet. Rest of society fails to agree with her assessment of herself, and this causes much frustration for Jenna. Reacts very unfavourably to even the slightest criticism, as she believes herself to be perfect and unique. JENNA MARONEY 30 Rock (TV Series)