borderline , antisocial, histrionic and narcissistic personality disorder

1. CLUSTER B PERSONALITY DISORDERS
DR. M. RAMYA MAHESWARI
ASST PROF & HEAD, DEPARTMENT OF PSYCHOLOGY
ETHIRAJ COLLEGE FOR WOMEN

2. HISTRIONIC PERSONALITY DISORDER
• Excessive attention seeking behaviour and emotionality are the key characteristics .
• Feel unappreciated when they are not the centre of attention
• Behaviour is highly theatrical with exaggerated expression of emotion
• Interaction with others is often characterised by inappropriate sexually seductive or
provocative behaviour
• Speech is vague and impressionistic and are usually considered self centered and
excessively concerned about the approval of others.
• Others consider them as overly reactive, shallow and insincere
• Is Suggestible

3. HISTRIONIC PERSONALITY DISORDER
• The prevalence of this disorder in the general population is estimated at 2-3%, although
the prevalence of this disorder may be decreasing (Blashfield ,2012).
• Some studies suggest that this disorder occurs more often in woman than in men(Leynum
& Widger,2007). Difference in prevalence rate not attributable to sex differences in
personality traits.
• Co-morbid with antisocial, narcissistic, borderline dependent personality disorder and
diagnosis is very difficult.

4. NARCISSISTIC PERSONALITY DISORDER
• A pervasive pattern of grandiosity, exaggerated sense of self–importance, need for
admiration, lack of empathy, interpersonally exploitative
• Types: Grandiose(Pain and suffering experienced by his /her significant others) and
Vulnerable( Pain experienced by oneself) (Cain et al, 2008).
• Grandiose Presentation: Tendency to over estimate their abilities and accomplishments of
others. Consistent self referrals and bragging shock others, while they themselves regard
their lavish expectations as merely what they deserve. They believe they are so special
that they can be understood only by high status people Their sense of entitlement is
associated with the unwillingness to forgive

5. NARCISSISTIC PERSONALITY DISORDER
• Vulnerable Narcissism: Described as worrying, emotional, defensive, anxious ,bitter, tense
and complaining. Have a very fragile and unstable sense of self esteem. For them arrogance is
a façade for intense shame and hypersensitivity to rejection and criticism. They become
occupied with fantasies of outstanding achievement. But at the same time experience profound
shame about their ambition.
• In terms of the five factor model, both subtypes are associated with high levels of interpersonal
antagonism ,low agreeableness (low modesty) ,low altruism and empathy.
• But primarily grandiose narcissist is exceptionally low in certain facets of neuroticism and
high on extraversion. For the grandiose narcissist, close friends are more distressed than the
narcissist himself . But the reverse is true of vulnerable narcissist . Some narcissistic
individuals may fluctuate between grandiosity and vulnerability. Pineus & Lukowitsky, 2010)

6. NARCISSISTIC PERSONALITY DISORDER
• Unwilling or unable to take others perspective . Tend to be hypercritical of others and
retaliatory when they don’t get validation or assistance they desire.
• Greater tendencies towards sexual coercion. Tend to rate filmed depictions of rape as
more enjoyable and sexually arousing (Bushman et al,2003).
• Narcissistic personality disorder may be more frequently observed in men than in women
(Golomb et al,1995).
• Estimated to occur in about 1% of the population.

7. CAUSAL FACTORS OF NARCISSTIC PERSONALITY
DISORDER
• Little data available on the genetic, social and environmental factors
involved in the etiology of this disorder.
• Grandiose and Vulnerable Narcissism is associated with different causal
factors.
• Grandiose Narcissism is associated with parental over evaluation
• Vulnerable Narcissism associated with poor parenting( characterized as
intrusive, controlling and cold) , neglect or childhood abuse (emotional,
physical and sexual abuse) (Miller,2011).

8. BORDERLINE PERSONALITY DISORDER
• A pervasive pattern of instability of interpersonal relationships, self image and affect.
• Affective instability is manifested by unusually intense emotional responses to
environmental triggers, with delayed recovery to a baseline emotional state. It is also
characterised by drastic and rapid shifts from one emotion to the another(Livesly,2008).
• Interpersonal relationships tend to be stormy typically involving over idealization of
friends and lovers and later end in bitter disillusionment, disappointment and anger.
• Marked impulsivity characterised by rapid responding to environmental triggers
(substance, sex, spending, reckless driving, binge eating, gambling sprees) beginning by
early adulthood

9. BORDERLINE PERSONALITY DISORDER
• Suicidal attempts sometimes manipulative can be part of clinical picture. However 8 to 10
% may complete suicide
• Self mutilation is present. In some cases, the self injurious behaviour was associated with
relief from anxiety and depression and it also serves to communicate the level of distress
to others ( Paris, 2007).
• Research has also documented that borderline personality disorder is associated with
analgesia in as many as 70 to 80% of women with BPD

10. COMORBIDITY WITH OTHER DISORDERS
• Co – occurs with unipolar and bipolar mood disorders and anxiety (especially panic and
PTSD), to substance use and eating disorders(Hooley et al,2012).
• Recent neuroimaging data shows that Individuals with BPD show different neural
responses to emotional stimuli than do individuals with chronic depression.
• There is also substantial co –occurrence with other personality disorders such as
histrionic, dependent, antisocial and schizotypal personality disorders. However there are
differences between these disorders.
• There are differences in the prototypic cases of these disorders.

11. CAUSAL FACTORS
• Genetic factors play a significant role in the development of BPD.
• There is also some preliminary evidence that certain parts of the 5 – HTT gene implicated
in depression may also be associated with BPD.
• People with BPD appear to be characterized by lowered functioning of the
neurotransmitter serotonin.
• Patients with BPD can also show disturbances in the regulation of noradrenergic
neurotransmitters . In particular their hyperresponsive noradrenergic system may be
related to their hypersensitivity to environmental changes (Siever et al, 2002).
• Structural abnormalities such as reduction in both hippocampal and amygdala volume,
features associated with aggression and impulsivity .

12. CAUSAL FACTORS
• Prospective studies have shown that childhood adversity and maltreatment has been linked to
adult BPD (Johnson et al, 1999).These studies are consistent with retrospective research.
• Results of the detailed interviews of over 350 patients with BPD reported significantly higher
rates of abuse than did patients with other personality disorders. (Zanarani &
Colleagues,1997).
• Though the rates seem alarming ,not all children who experience abuse end up with personality
disorder.
• Childhood abuse certainly not a specific risk factor for borderline pathology.
• Child abuse nearly always occurs in families with other pathological dynamics such as marital
discord and family violence and these factors play a more important role in the development of
BPD.

14. NON SUICIDAL SELF INJURY(NSSI)
• Many people with self injurious behaviour do not have BPD.
• Self mutilation can occurs in the absence of an intent to die
• However they are at a elevated risk for suicide
• Found both in males and females , in all ethnicities and economic background. Prevalence
rates from different studies show life time prevalence rate between 11.5 – 56%
• Intense relief from the massive anxiety is cited as a reason
• Individuals with this disorder may have higher pain endurance and self critical cognitive
style(Ex: “ I deserve pain”)

15. ANTISOCIAL PERSONALITY DISORDER
• Show disregard for the right of others. They tend to be impulsive, irritable and aggressive
and to show a pattern of generally irresponsible behaviour.
• These people have a lifelong pattern of unsocialized and irresponsible behaviour with
little regard safety- either their own or others. These characteristics bring them into
repeated conflict with society
• Diagnosis : This pattern of behaviour must have been occurring since the age of 15 and
the person must have had symptoms of conduct disorder .

16. PSYCHOPATHY AND ASPD
• Many of the central features of this disorder have long been labelled Psychopathy or
Sociopathy.
• The most comprehensive early description of psychopathy was made by Cleckley in 1940.
• Research suggest that ASPD and Psychopathy are related and differ in significant ways.
• In addition to the defining features noted in the DSM criteria, psychopathy also includes
affective and interpersonal traits.

17. TWO DIMENSIONS OF PSYCHOPATHY
• The first dimension involves the affective and interpersonal core of this disorder and reflects traits such as superficial
charm, grandiose sense of self worth and pathological lying.
• The second dimension reflects behaviour – the aspects of psychopathy that involve antisocial and impulsive acts , social
deviance , need for stimulation, poor behaviour controls, parasitic living ,irresponsibility .
• The second dimension is closely related the DSM diagnosis of ASPD. (Hare et al;1999).
• With the strong emphasis on behavioural criteria , the features included in DSM do not fully map on to the construct of
psychopathy .
• Therefore in a prison setting more than 70 to 80 % will qualify for a diagnosis of ASPD and only 25 to 30 % meet the
criteria for Psychopathy.
• This is to say that many inmates may show antisocial and aggressive behaviour but may not show selfish ,callous and
exploitative behaviour to qualify for the diagnosis of psychology. Not all with ASPD will show signs of psychopathy

18. CLINICAL PICTURE IN PSYCHOPATHY AND ASPD
• Inadequate conscience development: Unable to understand ethical values except on a verbal
level. Claim to adhere to high moral standards that have no connection with behaviour.
However they have normal intellectual development even though their conscience
development is stunted. Intelligence has different relationships with the two dimensions of
psychopathy. Affective and interpersonal dimension positively related to verbal intelligence
(Salekin et al.,2004);the second antisocial dimension is negatively related to intelligence
• Irresponsible and Impulsive behaviour: Psychopaths learn to take rather than earn, No
regard for consequences. Many studies have shown that antisocial personalities and
psychopaths have high rates of alcohol abuse and other substance abuse/dependence disorder,
They also have elevated levels of suicide attempts and completed suicides, which are
associated with the second dimension of psychopathy.
• Ability to impress and exploit others: They seem to have good insights into others people’s
needs and weakness and adept at exploiting them. Seem sincerely sorry when caught in a lie

19. CAUSAL FACTORS IN PSYCHOPATHY AND ANTISOCIAL
PERSONALITY
Genetic Influences:
• Research on criminality and antisocial behaviour: Twin Studies and adoption studies show a
moderate heritability for antisocial and criminal behaviour.(Hare et al., 2012).
• Research on Psychopathy: Psychopathy and some of the important features show a moderate
heritability (Blonigen et al.,2006).
• Strong environmental influences interact with genetic predisposition to determine which
individuals become criminals or antisocial personalities.
• Cadorat & collegaues (1995) found that adopted away children of biological parents with
ASPD were more likely to develop antisocial personalities if their adoptive parents exposed
them to adverse encvironments (Marital conflict or Divorce, Legal problems & Parental
Psychopathology)

20. CAUSAL FACTORS IN PSYCHOPATHY AND ANTISOCIAL
PERSONALITY
Genetic Influences:
• Study by Capsi et al , 2002 :A gene known as monoamine oxidase –A gene (MAO-A) ,is
involved in the breakdown of neurotransmitters like norepinephrine, dopamine and serotonin –
neurotransmitters affected by the stress of maltreatment.
• Researchers followed a thousand children from birth to age 26 and found that individuals with
low MAO-A activity were far more likely to develop ASPD if they had experienced early
maltreatment that without such experiences.
• Similar findings have been reported for conduct disorder and ADHD – both common
precursors of psychopathy and ASPD.
• ASPD and other externalizing disorders all share a strong common genetic vulnerability .
However environmental factors determine which disorder a particular person developed.

21. CAUSAL FACTORS IN PSYCHOPATHY AND ANTISOCIAL PERSONALITY
The Low Fear Hypothesis and Conditioning: Lykkan (1957)
• Psychopaths who are high on egocentric, callous and exploitative dimension have low
trait anxiety and show poor fear conditioning.
• Psychopaths show deficient conditioning of skin conductance responses (reflecting the
activation of sympathetic nervous system) when anticipating an unpleasant or painful
event and that they were slow at learning to stop responding in order to avoid punishment)
• As a result psychopaths fail to acquire many of the conditioned reactions essential to
normal passive avoidance of punishment, to conscience development, and to socialization
(Fowler and Dinto,2006). Psychopaths are deficient in the conditioning of atleast
subjective and certain physiological components of fear.

22. CAUSAL FACTORS IN PSYCHOPATHY AND ANTISOCIAL PERSONALITY
• According to Grey, deficient conditioning of fear seems to stem from psychopaths having a
deficient behavioural inhibition system .
• This is the neural system underlying anxiety. It is also the system responsible for learning to inhibit
responses to cues that signal punishment. In this passive avoidance learning, one learns to avoid
punishment by not making the response.
• Deficiencies in the neural system ----- Deficiencies in conditioning of anticipatory anxiety ----
Deficits in learning to avoid punishment . Recent research shows that successful psychopaths do not
show the same deficits.
• Support from low fear hypothesis comes from the work of Patrick and Colleagues on the human
startle response. Psychopaths do not show fear potentiated startle. This is related only to the
affective dimension of psychopathy.

23. CAUSAL FACTORS IN PSYCHOPATHY AND ANTISOCIAL PERSONALITY
• The second important neural system in greys model is the behavioural activation system. This
system activates behaviour in response to cues to reward as well as cues to active avoidance of
threatened punishment .
• The behavioural activation system is thought to be normal or overactive which is why they are quite
focused on obtaining the reward. If caught in a misdeed they are very focused on actively avoiding
threatened punishment.
• Psychopaths have a dominant response set for rewards(Newman , 2008). Their excessive focus on
reward is thought to interfere with their ability to use punishment or other information to modify
their responding when rewards are no longer forthcoming at the same rate that they once
were.
• However there is controversy over the response modulation deficit hypothesis.

24. BIS /BAS SCALE
INSTRUCTIONS
• Each item of this questionnaire is a statement that a person may either agree with or
disagree with. For each item, indicate how much you agree or disagree with what the
item says. Please respond to all the items; do not leave any blank. Choose only one
response to each statement. Please be as accurate and honest as you can be. Respond to
each item as if it were the only item. That is, don't worry about being "consistent" in your
responses. Choose from the following four response options:
• 1 = very true for me
2 = somewhat true for me
3 = somewhat false for me
4 = very false for me

25. ITEMS OF THE SCALE
• 1. A person's family is the most important thing in life.
2. Even if something bad is about to happen to me, I rarely experience fear or nervousness.
3. I go out of my way to get things I want.
4. When I'm doing well at something I love to keep at it.
5. I'm always willing to try something new if I think it will be fun.
6. How I dress is important to me.
7. When I get something I want, I feel excited and energized.
8. Criticism or scolding hurts me quite a bit.
9. When I want something I usually go all-out to get it.
10. I will often do things for no other reason than that they might be fun.

26. ITEMS OF THE SCALE
• 11.It's hard for me to find the time to do things such as get a haircut.
12. If I see a chance to get something I want I move on it right away.
13. I feel pretty worried or upset when I think or know somebody is angry at me.
14. When I see an opportunity for something I like I get excited right away.
15. I often act on the spur of the moment.
16. If I think something unpleasant is going to happen I usually get pretty "worked
up."
17. I often wonder why people act the way they do.
18. When good things happen to me, it affects me strongly.
19. I feel worried when I think I have done poorly at something important.
20. I crave excitement and new sensations.

27. ITEMS OF THE SCALE
• 21. When I go after something I use a "no holds barred" approach.
22. I have very few fears compared to my friends.
23. It would excite me to win a contest.
24. I worry about making mistakes.

28. SCORING
• Items other than 2 and 22 are reverse-scored.
• BAS Drive: 3, 9, 12, 21
BAS Fun Seeking: 5, 10, 15, 20
BAS Reward Responsiveness: 4, 7, 14, 18, 23
• BIS: 2, 8, 13, 16, 19, 22, 24
• Items 1, 6, 11, 17, are fillers.
• The fact that there are three BAS-related scales and only one BIS-related scales was not planned or
theoretically motivated. The factors emerged empirically, from an item set that was intended to
capture diverse manifestations of the BAS, according to various theoretical statements. It is likely
that a broader sampling of items on the BIS side would also have resulted in more than one scale. I
do not encourage combining the BAS scales, however, because they do turn out to focus on
different aspects of incentive sensitivity. In particular, Fun Seeking is known to have elements of
impulsiveness that are not contained in the other scales.

29. CAUSAL FACTORS IN PSYCHOPATHY AND ANTISOCIAL
PERSONALITY
MORE GENERAL EMOTIONAL DEFICITS
• Psychopaths show less significant physiological reactivity to distress cues. This is consistent
with the idea that psychopaths are low on empathy.(Blair,2006)
• However they were not underresponsive to unconditioned threat cues such as slides of sharks
,pointed guns or angry faces.
• Patrick and colleagues have demonstrated that the effect of showing a smaller startle response
when viewing unpleasant slides is especially pronounced with slides depicting scenes of
victims who have been mutilated or assaulted but not with slides representing threats to self.
• This specific failure to show larger startle responses with victims scenes might be related to
lack of empathy common in psychopathy Such dysfunction seem to be atleast partly due to
dysfunction in the amygdala not only during fear conditioning but also when viewing sad and
frightened faces.

30. MORE GENERAL EMOTIONAL DEFICITS
• Hare has hypothesized that the kind of emotional deficits that we see are subset of more
general emotional deficits that psychopaths have with processing and understanding the
meaning of affective stimuli , including positive words and sounds
• It has been suggested that such deficits are closely linked to the deficits in moral
reasoning and behaviour seen in people with psychopathy because to reason about moral
issues requires that one has concern for the right and welfare for others

31. CAUSAL FACTORS IN PSYCHOPATHY AND ANTISOCIAL PERSONALITY
• EARLY PARENTAL LOSS, PARENTAL REJECTION, AND INCONSISTENCY
• Not a specific psychological risk factor.
• Studies on gene environment interactions reviewed earlier clearly indicates that these kind
of disturbances are not sufficient explanations for the origin of psychopathy or ASPD.

32. A DEVELOPMENTAL PERSPECTIVE ON PSYCHOPATHY AND ASPD
• These disorders generally begin in adulthood ,especially for boys
• The number of antisocial behaviours exhibited in childhood is the single best predictor of
who will develop an adult diagnosis of ASPD
• The younger they start , higher the risk
• Early antisocial symptoms are associated with the diagnosis of conduct disorder.
• Prospective studies have shown that family factors that are most important in determining
which children will show antisocial behaviours are poor parental supervision, harsh and
erratic parental discipline, physical abuse and neglect ,disrupted family life and a
convicted mother (Farrington ,2006)

33. A DEVELOPMENTAL PERSPECTIVE ON PSYCHOPATHY AND ASPD
• Prospective studies have shown that it is the children with an early history of oppositional
defiant disorder – characterized by a pattern of defiant behaviours towards authority
figures that usually begins by 6 years of age , followed by early onset of conduct disorders
around age 9 – who are more likely to develop ASPD.
• For these children, antisocial behaviours exhibited across 25 years of life change with
development but are persistent in nature as opposed to children who develop conduct
disorder in adolescence . That is they don’t become lifelong ASPD’s but the problem is
limited to the adolescent years.
• When ADHD co-occurs with conduct disorder , this leads to a high likelihood that the
person will develop a severely aggressive form of ASPD.

34. A DEVELOPMENTAL PERSPECTIVE ON PSYCHOPATHY AND ASPD
• There is increasing evidence that mild neuropsychological problems such
as those leading to attentional difficulties and hyperactivity along with
difficult temperament may be important predisposing factors for the early
onset conduct disorder
• Many other psychosocial and sociocultural contextual variables contribute
to the probability that a child with genetic liability will develop a conduct
disorder

36. DIMENSIONS OF DIFFICULT TEMPERAMENT WITH DIFFERENT
DEVELOPMENTAL OUTCOMES
• Difficulty in regulating emotions and show high emotional reactivity , including antisocial
and aggressive behaviours. Such children score high on the second dimension of
psychopathy.
• Others show fearlessness and callous attitude. Low anxiety, and reduced amygdala
activation while responding to fearful stimuli. These children are more likely show poor
development of consciencw and their aggressive impulses are more pre-mediated. Such
children will show high score on the first dimension of psychopathy .

37. SOCIO CULTURAL CAUSAL FACTORS AND PSYCHOPATHY
• Cross Cultural studies have revealed that psychopathy occurs in wide range of cultures
even in tribal communities such as the Inuit of Alaska, and Yoruba in Nigeria.
• Manifestation of the disorder is influenced by cultural factors and the prevalence of the
disorder also seem to vary with socio-cultural influences that encourage /discourage its
development.
• One of the primary symptoms in which cultural variation occurs is the frequency of
aggressive and violent behaviour .
• Socialization forces have an enormous impact on the expression of aggressive impulses.
• However the affective – interpersonal dimension of psychopathy is consistent across
cultures (Crooke et al.,2005)

38. SOCIO CULTURAL CAUSAL FACTORS AND PSYCHOPATHY
• Individualistic Societies emphasize competitiveness ,self – confidence and independence
from others while Collectivistic Societies emphasize contributions, subservience to the
social group, acceptance of authority, and stability of relationships.
• Hence we can expect Individualistic Societies to promote some behavioural traits that
carried to the extreme, result in psychopathy. These characteristics include “grandiosity,
glibness, superficiality, promiscuity……. As well as lack of responsibility for others.
• Although evidence bearing on this is minimal, it is interesting to note that prevalence of
ASPD are much lower in Taiwan than in the US.

39. TREATMENT AND OUTCOME IN PSYCHOPATHIC AND ASPD
• BIOLOGICAL TREATMENTS: Electroconvulsive therapy and Drugs. Lithium and
Anticonvulsants – have had some success in keeping a check on aggressive impulses. But
evidence on this is scant . SSRI’s.: To reduce aggression and improve interpersonal skills
• COGNITIVE BEHAVIOUR THERAPY
• A) Increasing self control and self –critical thinking and social perspective taking
• B) Increasing victim awareness
• C) Teaching anger management
• D) Changing antisocial attitudes
• E) Curing Drug Addiction.

40. THANK YOU