Cluster B Personality Disorder

Aka: Cluster B Personality Disorder, Dramatic Personality Disorder, Histrionic Personality, Antisocial Personality, Narcissistic Personality, Sociopath, Psychopath

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II. Definitions

  1. Cluster B Personality Disorder
    1. Dramatic, emotional or eratic personalities

III. General Features of all Cluster B personalities

  1. Dissociation or Denial
    1. Inadvertent liars
    2. Borderline
    3. Abuse
  2. Splitting ("the good, the bad, and the ugly")
  3. Hysteria to Somatization
  4. Conversion ("now maybe you can see it")
  5. Acting Out ("I'll show you")

IV. Type: Antisocial Personality (Sociopath, Psychopath)

  1. Characteristics (onset as child)
    1. Disregards and violates other's rights
      1. Aggressive, fights, difficult peer relationships
      2. Hyperactive, irresponsible, frequent job change
      3. Lying, theft, Drug Abuse and Alcohol Abuse
    2. No remorse for wrongdoing and no empathy
    3. Consistently irresponsible, unable to maintain consistent work or to honor financial responsibilities
  2. Altered interpretation of illness and physician
    1. Anger, manipulation, lies mask fear
    2. Sense of entitlement
    3. Impulsive
  3. Recommended physician approach
    1. Communicate clearly in non-punishing manner
    2. Set limits clearly
    3. Carefully Look into patient's concerns and motives
      1. Check information - do not rely on self-report
  4. Evaluate for comorbid conditions
    1. Drug Abuse or Alcohol Abuse
    2. Schizophrenia
    3. Mania

V. Type: Borderline Personality

  1. See Borderline Personality
  2. Characteristics
    1. Emotional dysregulation
      1. Mood lability (changes within hours from intense transient dysphoria to irritability to anxiety)
      2. Inappropriate intense outbursts of anger, displaying a temper and may get into physical fights
      3. Recurrent suicidal behavior, gestures, threats or self-mutilation
      4. Impulsive (spending, sex, Drug Abuse, Binge Eating)
    2. Interpersonal problems
      1. Unstable relationships, self image, and affect
      2. Loneliness, boredom and sense of emptiness
      3. Unstable and intense interpersonal relationships fluctuating between idealization to devaluation
    3. Disturbed self-identity
      1. Unstable self-image persists
      2. Lacks integrated sense of self
    4. Associated Conditions
      1. High healthcare utilization
      2. Often associated with other mental health disorders
  3. Altered interpretation of illness and physician
    1. Often considered to be "difficult patients"
    2. Fears rejection and isolation
    3. Self-destructive behavior (e.g. exercising on an injury)
    4. Alternates admiration and devaluation of physician
  4. Recommended physician approach
    1. Avoid being overly familiar with patient
    2. Be aware of patient's feelings
    3. Encourage frequent clinic visits
    4. Offer clear, nontechnical explanations
    5. Set limits, but tolerate angry outbursts
    6. Consider psychiatry Consultation
    7. May respond to psychotherapy
  5. Evaluation for comorbid conditions
    1. Major Depression
    2. Delirium
    3. Drug Abuse (e.g. LSD)
    4. Reactive Psychosis

VI. Type: Histrionic Personality

  1. Characteristics (most often occurs in women)
    1. Outwardly appear charming, lively
    2. Inappropriately sexually seductive or provocative behavior
    3. Threatened self-esteem and sense of attractiveness
    4. Egocentric, shallow, immature and dramatic with exaggerated expression of emotion
    5. Seek excitement and attention, often exhibitionists, and uncomfortable when not the center of attention
    6. Suggestable, easily easily influenced by others
    7. Speech style lacks detail
    8. Describes relationships as more intimate than they are
  2. Altered interpretation of illness and physician
    1. Unable to focus on facts and details
    2. Somatization
  3. Recommended physician approach
    1. Avoid being overly familiar with patient
    2. Show professional concern for patient's feelings
    3. Focus on objective concerns
  4. Evaluate for comorbid conditions
    1. Major Depression (higher risk of Suicidality)
    2. Substance Abuse
    3. Somatization Disorders

VII. Type: Narcissistic Personality

  1. Characteristics
    1. Grandiosity, unrealistic self-expectation
    2. Preoccupied with fantasies of unlimited success, power, brilliance, beauty
    3. Believes that he or she is special, unique and can only be understood by high status people or institutions
    4. Sense of entitlement
    5. Need constant admiration
    6. Impulsive and anxious
    7. Takes advantage of others to achieve his or her own ends
    8. Doubts own adequacy
    9. Arrogant and displays haughty behavior
    10. Envious of others
    11. Lacks empathy
  2. Altered interpretation of illness and physician
    1. Alternates admiration and devaluation of physician
    2. Denies illness
    3. Demanding with sense of entitlement
  3. Recommended physician approach
    1. Acknowledge patient's concerns
    2. Respond to questions appropriately and factually
    3. Direct patient's skills to dealing with illness

VIII. Management: Sub-Cluster 1 - Depression

  1. Target symptoms
    1. Major Depression
    2. Interpersonal sensitivity
    3. Impulsivity and Aggression
  2. Medications
    1. SSRI
    2. Consider Mood stabilizer
    3. Consider Atypical Antipsychotic

IX. Management: Sub-Cluster 2 - Bipolar or Mania

  1. Target symptoms
    1. Mood lability
    2. Impulsivity and Aggression
  2. Medications
    1. Mood stabilizer
    2. Consider SSRI
    3. Consider Atypical Antipsychotic

X. Management: Sub-Cluster 3 - Psychosis

  1. Target symptoms
    1. Paranoia
    2. Psychosis
    3. Hostility
    4. Anxiety
  2. Medications
    1. Atypical Antipsychotic
    2. Consider Mood stabilizer
    3. Consider SSRI

XI. References

  1. Tomb (1992) Psychiatry, p. 147-52
  2. (2000) Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Washington D.C., APA
  3. Angstman (2011) Am Fam Physician 84(11): 1253-60 [PubMed]
  4. Ward (2004) Am Fam Physician 70(8):1505-12 [PubMed]

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