Cluster B Personalty disorders

1. CLUSTER B PERSONALITY
DISORDERS
DR.R.G.ENOCH
MD Psychiatry I yr
GMKMCH, Salem

2. PERSONALITY
 Personality is defined as the ingrained patterns of
thought, feeling and behavior characterizing an
individual’s unique lifestyle and mode of adaptation
and resulting from constitutional factor, development
and social experience.

3.  Allport defined personality as the “dynamic
organization within the individual of those
psychophysical systems that determine his/her unique
adjustment to his/her environment.”
 “dynamic organization” - constantly evolving and
changing
 “within the individual” - intrapsychic processes
 “psychophysical” - that personality is neither
exclusively mental nor exclusively neural but a
combination of the two.
 “unique adjustment to the environment” -
personality as a mode of survival and, more generally,
learning and adaptation, which is unique to each
individual.

4. PERSONALITY DISORDERS
 They occur in 10 to 20 percent of the general population
 Approximately 50 percent of all psychiatric patients have a
personality disorder, which is frequently comorbid with other
clinical syndromes.
 Personality disorder is also a predisposing factor for other
psychiatric disorders (e.g., substance use, suicide, affective
disorders, impulse-control disorders, eating disorders, and
anxiety disorders)
 In general, personality disorder symptoms are ego syntonic (i.e.,
acceptable to the ego, as opposed to ego dystonic) and alloplastic
(i.e., alter the external environment rather than themselves).

5. HISTORY
 19th century, the French psychiatrist Pinel coined the phrase
"manie sans delire" (insanity without delusions). Antisocial
Personality Disorder
 In 1835, the British J. C. Pritchard suggested the neologism
"moral insanity". He then proceeded to elucidate the
psychopathic (antisocial) personality in great detail
 1891, the German doctor J. L. A. Koch suggested the phrase
"psychopathic inferiority" then he replaced "inferiority" with
"personality" to avoid sounding judgmental. Hence the
"psychopathic personality"
 Kraepelin suggested six additional types of disturbed
personalities: excitable, unstable, eccentric, liar, swindler, and
quarrelsome.
 Schneider developed the first comprehensive system of
personality disorder categories which provided the template
for ICD and DSM.

6. DEFINITION
Personality disorders are an enduring pattern of inner
experience and behavior that deviates markedly from the
expectations of the individual’s culture.
The pattern is manifested in two (or more) of the following
areas:
 Cognition
 Affectivity
 Interpersonal functioning; and
 Impulse control

7. FEATURES
 Early onset
 Stable and persistent
 Pervasive
 Interpersonal context
 Impairment

8. CLASSIFICATION
CLUSTER A
“WEIRD” – ODD, ECCENTRIC

9. CLUSTER B
“WILD” – DRAMATIC, IMPULSIVE AND ERRATIC

10. CLUSTER C
“WORRIED”- ANXIOUS AND FEARFUL

11. Other disorders
 “personality change due to another medical
condition,”
 “other specified personality disorder” such as people
with mixed features of more than one personality
category, and
 “unspecified personality disorder”
Two other disorders, Passive aggressive and Depressive,
that were recognized for further study in DSMIV are
omitted in DSM-5 but can be diagnosed as: “other
specified PD.”
The corressponding normal temperament traits of the
three clusters are
 Cluster A - low Reward dependence
 Cluster B - high Novelty Seeking
 Cluster C - high Harm Avoidance

12. Other Classifications
 ICD-10 classifies schizotypal PD on Axis I, among
Schizophrenic disorders, whereas DSM-5 keeps this
disorder on Axis II, among PDs.
 Alternative DSM-5 criteria involve two major steps, as
proposed by Cloninger (2000):
 Rating the presence of PD and its severity in terms of
levels of adaptive functioning.
 Describing the specific traits that are prominent in
the person.
 In the alternative DSM-5 criteria, the presence of PD is
based on character traits such as Self-Directedness and
Cooperativeness, which provide a description of
personalities that are healthy or disordered.

14. F60 Specific personality disorders
 F60.0 Paranoid personality disorder
 F60.1 Schizoid personality disorder
 F60.2 Dissocial personality disorder
 F60.3 Emotionally unstable personality disorder
 .30 Impulsive type
 .31 Borderline type
 F60.4 Histrionic personality disorder
 F60.5 Anankastic personality disorder
 F60.6 Anxious [avoidant] personality disorder
 F60.7 Dependent personality disorder
 F60.8 Other specific personality disorders
 F60.9 Personality disorder, unspecified

15. 
 Tyrer and Seivewright described 2 groups of
personality disorders
o Mature PD – persist into late middle or old age
o Immature PD – improves over time

16.  CLUSTER B PERSONALITY
DISORDERS

17. ETIOLOGY
BIOLOGICAL FACTORS
Genetics and Familial factors
 Cluster B personality disorders apparently have a genetic base.
Anti Social Personality Disorder
 Antisocial PD is more frequent among the first-degree biological relatives of
probands with this disorder.
 Biological relatives of females pts with Antisocial PD are at increased risk for the
same disorder than biological relatives of males with Antisocial PD.
 Genetic studies have suggested familial transmission of Antisocial PD, Substance
Use, and Somatization Disorder
 Adoption studies have shown that both genetic and environmental factors
contribute to the risk for this disorder. Both adopted and biological children of
parents with Antisocial PD are at increased risk for this disorder.
 Conduct Disorder (before the age of 10 years) and accompanying ADHD increase
the likelihood of developing antisocial personality in adult life. Conduct Disorder is
more likely to develop into Antisocial Disorder with erratic parenting, neglect, or
inconsistent parental discipline.

18. Borderline Personality Disorder
 Mood disorder is common in the family backgrounds of patients
with borderline personality disorder
 Persons with borderline personality disorder often have a mood
disorder as well.
 Numerous studies have pointed to early traumatic experiences
in the etiology of this PD. Recently, a tripartite etiopathogenetic
model, including childhood trauma, vulnerable temperament,
and a series of triggering events, has been formulated.
 Physical and sexual abuse, neglect, hostile conflict, and early
parental loss or separation are more common in childhood
histories of patients with this disorder.
 Borderline PD is five times more common among relatives of
probands with this disorder than in the general population.
 It also increases familial risk for Antisocial PD and Substance
Abuse

19. Narcissistic Personality disorder
 There may be a higher risk for this PD in the
offsprings of narcissistic parents who impart on
their children an unrealistic sense of grandiosity.
Histrionic Personality disorder
 This disorder tends to run in families.
 A genetic “link” between Histrionic and Antisocial
PD and Alcoholism has been suggested.
 A strong association is found between histrionic
personality disorder and somatization disorder
(Briquet's syndrome).

20.  Hormones.
 Testosterone, 17-estradiol, and estrone. - impulsivity
 Androgens increase the likelihood of aggression and
sexual behavior
 DST results are abnormal in some patients with
borderline personality disorder who also have
depressive symptoms.
 Platelet Monoamine Oxidase.
MAO levels - increased sociability

21. Neurotransmitters.
 Endorphins -- suppression of arousal.
 High endogenous endorphin levels --- persons who are withdrawn.
 Studies of personality traits and the dopaminergic and serotonergic
systems indicate an arousal-activating function for these
neurotransmitters.
 Levels of 5-HIAA a metabolite of serotonin, are low in persons who
attempt suicide and in patients who are impulsive and aggressive.
 Increased dopamine concentrations in the central nervous system can
induce euphoria.
Electrophysiology.
Changes in electrical conductance on the EEG occur in some patients
with personality disorders, most commonly antisocial and borderline
types; these changes appear as slow-wave activity on EEG.

22. PSYCHOLOGICAL FACTORS
 Sigmund Freud suggested that personality traits
are related to a fixation at one psychosexual stage
of development.
- Those with an oral character are passive and
dependent because they are fixated at the oral
stage, when the dependence on others for food is
prominent.
- Those with an anal character are stubborn,
parsimonious, and highly conscientious because of
struggles over toilet training during the anal
period.

23.  Wilhelm Reich subsequently coined the term character armor to
describe persons' characteristic defensive styles for protecting
themselves from internal impulses and from interpersonal anxiety in
significant relationships.
 Each human being's personality is determined by his or her
characteristic defense mechanisms
 When defenses work effectively, persons with personality disorders
master feelings of anxiety, depression, anger, shame, guilt, and other
affects.
 Their behavior is ego syntonic; that is, it creates no distress for them
even though it may adversely affect others. They may also be reluctant
to engage in a treatment process.
 In addition to characteristic defenses in personality disorders, another
central feature is internal object relations. During development,
particular patterns of the self in relation to others are internalized
called as introjection. These internal self-representations and object
representations are crucial in developing the personality.

24. ANTI SOCIAL PERSONALITY DISORDER
Antisocial personality disorder is an inability to conform to the social
norms that ordinarily govern many aspects of a person's adolescent
and adult behavior.
SEX RATIO.
3:1 males: female
EPIDEMIOLOGY.
 The 12-month prevalence rates are between 0.2 and 3 percent according to
DSM-5.
 It is more common in poor urban areas and among mobile residents of these
areas.
 The highest prevalence is found among the most severe samples of men with
alcohol use disorder (over 70 percent) and in prison populations, where the
prevalence is 75 percent.
 The onset of the disorder is before the age of 15 years.
 Girls usually have symptoms before puberty and boys even earlier

25. CLINICAL CRITERIA.
 The hallmarks of antisocial PD are pervasive
disregard for and violation of rights of others
occurring since the age of 15 years and
continuing into adulthood.
 A person has to be 18 years of age or older,
and there has to be evidence of conduct
disorder before the age of 15 years
 Indicated by three (or more) of the following:

26. 1. Failure to conform to social norms (resulting in frequent
arrests)
2. Deceitfulness, including lying and conning ( persuading
to do by lying )others for personal profit or pleasure

27. 3. Impulsivity or failure to plan ahead
4. Irritability and aggressiveness, including repeated physical
fights or assaults
5. Reckless disregard for safety of self of others.

28. 6. Irresponsibility, indicated by the failure to honor financial
obligations or to sustain consistent work behavior
7. Lack of remorse, indicated by indifference or rationalizing
having hurt, mistreated, or stolen from others

29. Some of the associated features include the following:
 Promiscuity and inability to sustain a monogamous relationship
 Inflated and arrogant self-appraisal
 Lying, truancy, running away from home, thefts, fights, substance
abuse, and illegal activities
 They often impress opposite-sex clinicians
 exhibit no anxiety or depression although suicide threats and
somatic preoccupations may be common.
 Have good verbal intelligence.
 They are extremely manipulative and can frequently talk others into
participating in schemes for easy ways to make money.
 Those with this disorder do not tell the truth and cannot be trusted
to carry out any task
 Promiscuity, spousal abuse, child abuse, and drunk driving are
common events in their lives

30. COURSE.
 After the age of 30 years, both the most
flagrant antisocial behaviors (promiscuity,
crime) and the less severe behaviors and
substance use tend to decrease.
 Even after the severe antisocial behavior
“burns out,” people diagnosed with antisocial
PD usually continue to be irritable, impulsive,
and detached.

32. BORDERLINE PERSONALITY DISORDER
Alternate Names for BPD
 Borderline Personality Disorder (BPD)
 Emotional Regulation Disorder (ERD)
 Emotional Dysregulation Disorder
 Emotional Intensity Disorder (EID)
 Emotionally Unstable Personality Disorder
(EUPD)
 Emotion-Impulse Regulation Disorder (EIRD)
 Impulsive Personality Disorder (IPD)

33. BORDERLINE PERSONALITY DISORDER
BORDERLINE BETWEEN NEUROSIS AND PSYCHOSIS
EXTRAORDINARILY UNSTABLE
AFFECT,MOOD,BEHAVIOUR,RELATIONS AND SELF-IMAGE

34. SEX RATIO.
 According to DSM-5, this disorder is more
commonly diagnosed in females (75 percent of
diagnosed cases are females).
EPIDEMIOLOGY.
 Prevalence rates of about 2 percent in the general
population
 10 percent for psychiatric outpatients
 20 percent for psychiatric inpatients
 30 to 60 percent among patients with PDs
 The diagnosis is more common in younger than in
older samples

35. CLINICAL CRITERIA.
 The hallmarks of Borderline PD are pervasive
and excessive instability of affects, self-image,
and interpersonal relationships as well as
marked impulsivity.
 Diagnostic features also include at least five of
the following:

36. 1. Frantic efforts to avoid real or imagined abandonment.
2. Unstable and intense interpersonal relationships, with
alternating between idealization and devaluation
3. Markedly and persistently unstable self-image or sense of
self

37. 4. Impulsivity in at least two potentially self-damaging
areas (spending, sex, substance abuse, binge eating,
reckless driving).
5. Recurrent suicidal behavior, gestures, threats, or self-
mutilating behaviors

38. 6. Instability of affect due to marked reactivity of mood
7. Chronic feelings of emptiness

39. 8. Inappropriately intense anger or difficulty controlling
anger
9. Stress related, transient paranoid ideation or
dissociative symptoms

40. Some of the associated features include the following:
 Tendency to undermine self when close to realizing a goal
 Feeling more secure with nonhuman objects (pets,
inanimate objects) than in interpersonal relationships
 Mood swings are common.
 Patients can have short-lived psychotic episodes (so-called
micropsychotic episodes) rather than full-blown psychotic
breaks, and the psychotic symptoms of these patients are
almost always fleeting, or doubtful.
 Their achievements are rarely at the level of their abilities.
 Patients with borderline personality disorder cannot
tolerate being alone, and they prefer a frantic search for
companionship
 Some clinicians use the concepts of panphobia, pananxiety,
panambivalence, and chaotic sexuality to delineate these
patients' characteristics.

41. PROJECTIVE IDENTIFICATION.
 Otto Kemberg described the defense mechanism of
projective identification that occurs in patients with
borderline personality disorder. It consists of three steps.
 First, an aspect of the self is projected onto someone else.
 The projector then tries to coerce the other person into
identifying with what has been projected.
 Finally, the recipient of the projection and the projector feel a
sense of oneness or union.
SPLITTING.
 In splitting, persons toward whom patients' feelings are, or
have been, ambivalent are divided into good and bad.
 For example, in an inpatient setting, a patient may idealize
some staff members and uniformly disparage others.

42.  COURSE.
 Variable. Most commonly follows a pattern of
chronic instability in early adulthood, with
episodes of serious affective and impulsive
dyscontrol.
 The impairment and the risk of suicide are the
greatest at the young adult years and
gradually wane with advancing age.
 In the fourth and fifth decades, these
individuals tend to attain greater stability in
their relationships and functioning.

44.  HEIGHTENED SENSE OF SELF-IMPORTANCE, LACK OF
EMPATHY AND GRANDIOSE FEELING
 HOWEVER, UNDERNEATH, THEIR SELF-ESTEEM IS FRAGILE
AND VULNERABLE TO MINOR CRITICISM
 CHRONIC AND IS DIFFICULT TO TREAT
NARCISSISTIC PERSONALITY DISORDER

45. SEX RATIO.
 It is more commonly diagnosed in males (50 to
75 percent of diagnosed cases are males).
EPIDEMIOLOGY.
 Prevalence rates of 2 to 16 percent in the clinical
population
 less than 1 percent in the general population

46.  CLINICAL CRITERIA.
 The hallmarks of Narcissistic PD are pervasive
sense of grandiosity (in fantasy or in behavior),
need for admiration, lack of empathy, and
chronic intense envy.
 Diagnostic features also include at least five of
the following:

47. 1. Grandiose sense of self-importance and specialness
2. Preoccupation with fantasies of unlimited success,
power, brilliance, beauty, or ideal love

48. 3. Sense of entitlement (having a right to do something)
4. Regards self as “special” and unique
5. Interpersonal exploitativeness such as taking
advantage of others to achieve own needs

49. 6. Lack of empathy
7. Excessive need for admiration and acclaims

50. 8. Intensive and chronic envy (jealous)
9. Arrogant and haughty (superior, lack of respect)attitude

51. Some of the associated features include the
following:
 Fragile self-esteem (which exclusively
depends on external admiration) with
hypersensitivity to criticism
 High achievements more frequent than in any
other PD
 Strong feelings of shame and humiliation
 Exhibitionism (behavior motivated by the
pleasure of being looked at)
 Fear of having their “hidden” imperfections and
flaws revealed

52. COURSE.
 Chronic.
 However, narcissistic symptoms tend to
diminish after the age of 40 years, when
pessimism usually develops.

54. HISTRIONIC PERSONALITY DISORDER
 EXCITABLE AND EMOTIONAL
 ATTENTION-SEEKING
 EXAGGERATE THEIR THOUGHTS AND FEELINGS
 COLOURFUL, DRAMATIC AND EXTROVERT
 FLAMBOYANT BUT INABILITY TO MAINTAIN DEEP,
LONG-LASTING ATTACHMENTS

55. SEX RATIO.
There seems to be a general agreement that this
disorder occurs far more frequently among
women. According to DSM-5, the disorder might
be equally frequent among men and women.
EPIDEMIOLOGY.
Prevalence rates of about 2 percent in the
general population, 10 to 15 percent for
psychiatric inpatients and outpatients are reported
in DSM-IV-TR and DSM-5.

56. CLINICAL CRITERIA.
 The hallmarks of histrionic PD are pervasive
and excessive self-dramatization, excessive
emotionality, and attention seeking.
 Diagnostic features also include at least five of
the following:

57. 1. Inappropriate sexual seductiveness or provocativeness
2. Excessive need to be in the center of attention

58. 3. Rapidly shifting and shallow expression of emotions
4. Suggestibility

59. 5. Physical appearance used for attention-seeking
purposes
6. Impressionistic speech lacking detail

60. 7. Self-dramatization, theatricality, exaggerated
expression of emotions
8. Relationships considered more intimate than they
really are

61. Some of the associated features include the
following:
 Difficulties in achieving emotional intimacy in
romantic or sexual relationships
 Promiscuity
 Seductive behavior is common in both sexes.
Sexual fantasies about persons with whom
patients are involved are common but patients.
 In fact, histrionic patients may have a
psychosexual dysfunction; women may be
anorgasmic, and men may be impotent.
 Their need for reassurance is endless.
 They may act on their sexual impulses to reassure
themselves that they are attractive to the other
sex.

62. COURSE
 With age, persons with histrionic personality
disorder show fewer symptoms, but because
they lack the energy of earlier years, the
difference in number of symptoms may be
more apparent than real. Persons with this
disorder are sensation seekers, and they may
get into trouble with the law, abuse
substances, and act promiscuously

64. COMPLICATIONS.
 Premature death or physical handicaps from
suicide
 Social withdrawal, depressed mood, and
Dysthymic or Major Depressive Disorder
 Interpersonal relations are unstable, shallow,
and generally ungratifying.
 Frequent marital problems
 Frequent job losses, interrupted education
 Dysphoria, tension

65. COMORBIDITY.
These patients are at increased risk for
 Impulse Control Disorders
 Major Depression,
 Substance Abuse or Dependence,
 Pathological Gambling,
 Anxiety Disorders,
 Somatization Disorder.
 Eating Disorder
 Conversion Disorder.

66. PSYCHOLOGICAL ASSESSMENT
 Among the categorical self-reports, the two most frequently
used are
 The Personality Diagnostic Questionnaire (PDQ R), and
 the MMPI scales for PDs (MMPI PD).

 Several semistructured interviews have been developed to
diagnose PDs. These typically take more than an hour to
conduct, so they have limited use in clinical practice. Among
the interviews that categorically diagnose PDs, the most
commonly used is
 The Structured Interview for DSM-IV PDs (SIDP IV).
 Other popular interviews for categorical classification of PDs
include
 The Structured Clinical Interview for DSM-IV PDs (SCID II),
 The Diagnostic Interview for Personality Disorders (DIPD),
and
 The Personality Disorder Examination (PDE).

67.  Dimensional tests of PDs are formatted as self-
reports
 The most frequently used are
 The Millon Clinical Multiaxial Inventory (MCMI),
 NEO Personality Inventory NEO PI
 The Temperament and Character Inventory TCI.
 These tests have been originally designed to
evaluate
 normal personality (the NEO PI),
 psychiatric patients (the MCMI), and
 both normal personality and deviant personality
(the TCI).

68. TREATMENT
 PSYCHOTHERAPY
 When placed in hospitals, they often become amenable to
psychotherapy. When patients feel that they are among peers, their
lack of motivation for change disappears. Perhaps for this reason,
self-help groups have been more useful than jails in alleviating the
disorder.
 Patients regress easily, act out their impulses, and show negative or
positive transference applies expectations of another person onto
the therapists.
 Projective identification may also cause countertransference
problems when therapists are unaware that patients are
unconsciously trying to persuade them to act out a particular
behavior.
 The splitting defense mechanism causes patients to alternately love
and hate therapists and others in the environment.
 Behavior therapy to control patients' impulses and angry outbursts
and to reduce their sensitivity to criticism and rejection.
 Social skills training, especially with videotape playback, helps
enable patients to see how their actions affect others and thereby
improve their interpersonal behavior.

69. DIALECTICAL BEHAVIOR THERAPY
 It is the psychosocial treatment that has received the most
empirical support for patients with borderline personality
disorder.
 Developed for chronically self-injurious patients and
parasuicidal behavior.
 Patients are seen weekly, with the goal of improving
interpersonal skills and decreasing self-destructive behavior
using techniques involving advice, metaphor, storytelling, and
confrontation, among others.
 They are helped to deal with the ambivalent feelings that are
characteristic of the disorder.
 Marsha Linehan, Ph.D., developed the treatment method,
based on her theory that such patients cannot identify
emotional experiences and cannot tolerate frustration or
rejection.
 As with other behavioral approaches, DBT assumes all
behavior (including thoughts and feelings) is learned and that
patients with borderline personality disorder behave in ways
that reinforce or even reward their behavior, regardless of
how maladaptive it is.

70.  FUNCTIONS OF DBT
 As described by its originator, there are five essential
"functions" in treatment:
(1) to enhance and expand the patient's repertoire of
skillful behavioral patterns;
(2) to improve patient motivation to change by reducing
reinforcement of maladaptive behavior, including
dysfunctional cognition and emotion;
(3) to ensure that new behavioral patterns generalize
from the therapeutic to the natural environment;
(4) to structure the environment so that effective
behaviors, rather than dysfunctional behaviors, are
reinforced; and
(5) to enhance the motivation and capabilities of the
therapist so that effective treatment is rendered.

71. The four modes of treatment in DBT are as
follows:
 group skills training,
 individual therapy,
 phone consultations, and
 consultation team.

72. MENTALIZATION-BASED TREATMENT.

Mentalization is a social construct that allows a person to be
attentive to the mental states of oneself and of others.

MBT is based on a theory that borderline personality
symptoms, such as difficulty regulating emotions and
managing impulsivity, are a result of patients' reduced
capacities to mentalize.
 Thus, it is believed that recovery of mentalization helps
patients build relationship skills as they learn to better
regulate their thoughts and feelings.
TRANSFERENCE-FOCUSED PSYCHOTHERAPY.
Transference-focused psychotherapy (TFP) is a modified
form of psychodynamic psychotherapy that is based on Otto
Kemberg's object relations theory.

73. Pharmacotherapy.
 Pharmacotherapy is useful to deal with specific personality
features that interfere with patients' overall functioning.
 Antipsychotics have been used to control anger, hostility, and
brief psychotic episodes.
 Antidepressants improve the depressed mood common in
patients with borderline personality disorder.
 The MAO inhibitors (MAOis) have successfully modulated
impulsive behavior in some patients.
 Benzodiazepines, particularly alprazolam (Xanax), help
anxiety and depression, but some patients show a
disinhibition with this class of drugs.
 Anticonvulsants, such as carbamazepine, may improve global
functioning for some patients.
 Serotonergic agents such as selective serotonin reuptake
inhibitors (SSRis) have been helpful in some cases.
 Lithium (Eskalith) has been used with patients whose clinical
picture includes mood swings.

77.  The hallmarks of antisocial PD are pervasive
disregard for and violation of rights of others
occurring since the age of 15 years and
continuing into adulthood.
 The hallmarks of Borderline PD are pervasive and
excessive instability of affects, self-image, and
interpersonal relationships as well as marked
impulsivity.
 The hallmarks of Narcissistic PD are pervasive
sense of grandiosity (in fantasy or in behavior),
need for admiration, lack of empathy, and chronic
intense envy.
 The hallmarks of histrionic PD are pervasive and
excessive self-dramatization, excessive
emotionality, and attention seeking.

78. References
 Kaplan and Sadocks Comprehensive textbook
of Psychiatry – 10th edition
 Kaplan and Sadocks Synopsis of Psychiatry –
11th edition
 Postgraduate Textbook of Psychiatry - Ahuja