Cluster B Personality Disorders

Each individual possesses a unique set of traits which influence behavioural, cognitive and emotional development also future patterns of behaviour. These are features of our ‘personalities’ and also mould the way in which we relate to the rest of the world and those we encounter. By adulthood, these traits will have formulated the manner in which we self identify. They can be described as sitting on a scale or spectrum. Personality disorders are diagnosed when these traits begin to cause problems in life. This article will lay out the different types of personality disorder that are grouped beneath the Cluster B personality disorder umbrella. 

A diagnosis of a personality disorder can affect how we cope with aspects of life such as relationships and emotional attachments. Those with a personality disorder often find themselves fixed in a pattern of beliefs and life skills regarding ways of dealing with daily life which is difficult to change. Emotions may be particularly intense and problematic to control. In turn, this can prove to be a distressing experience for both the person diagnosed and others close to them. It is common for those with a personality disorder to experience secondary mental health problems such as anxiety or depression. Self-harm is also prevalent alongside the comorbidity of alcohol and substance misuse. These behaviours can be used as coping strategies. Coid and Ullrich state that personality disorders are reasonably common[1]. Whilst the NHS claim that approximately five percent of people are living with a type of personality disorder[2].

The primary guidelines used in the diagnostic process for mental health conditions are set out in the International Classification of Diseases (ICD-10) produced by the World Health Organisation (WHO), and the Diagnostic and Statistical Manual (DSM-5) produced by the American Psychiatric Association. All personality disorders are listed in these pieces of literature and have been arranged into three clusters, A, B and C. The assessment process can be lengthy and problematic for the health professional (usually a psychiatrist) who is undergoing the task. Some difficulties include: overlapping symptoms of other mental health conditions which creates a hurdle when attempting to identify signs and symptoms specific to a personality disorder; the complexities of personality disorders often mean that individual presentations reveal multiple symptoms that do not fit into any one of the clusters or perhaps overlap between two or three of them; alcohol and drug use alongside presenting symptoms at assessment; reluctance of medical professionals due to potential associated post diagnostic stigma which may hinder a patient accessing the appropriate support.

There is no definitive reason for the cause of personality disorders. Overlapping factors including biological and environmental are seen to be contributing factors to the development of personality disorders in later life (NHS). However, there is often a history of trauma for many of those diagnosed with a personality disorder. Problematic upbringing including experiences of neglect, physical, sexual or emotional abuse have been reported in a high number of cases of personality disorders. Within the parameters of normal childhood development we are taught how to create bonds with other people and become emotionally mature by being nurtured. Those who are damaged through neglect or abuse have not experienced these steps towards appropriate development and may struggle to manage and express their feelings during adulthood[3].

Those with cluster B personality disorders experience great emotional instability and can be viewed by others as unpredictable. Examples of these are:

Antisocial Personality Disorder (ASPD) 

Antisocial personality disorder (ASPD) is thought by many to be an untreatable disorder. Antisocial personality disorder manifests itself as a set of core personality traits which allow one to disregard the rights of others in pursuit of impulsive, self-serving goals. Individuals with this disorder typically disregard the welfare of others, display superficial charm in social situations, display a lack of guilt or regret, break the law, behave irresponsibly, manipulate or lie to others, act impulsively, seek stimulation through reckless activity and maintain an inflated sense of self-importance.

Antisocial personality disorder can be a devastating condition thus having a considerable impact on individuals, families and society. ASPD has the same prevalence in men as schizophrenia, which receives the greatest attention from mental health services. Furthermore, ASPD is associated with significant costs, arising from emotional and physical damage to victims and property, use of police resources and involvement of the criminal justice and prison services. Related costs include increased use of healthcare facilities, lost employment opportunities, family disruption, gambling and problems related to alcohol and substance misuse[4].

In 2001 a study by Scott and colleagues revealed that the lifetime public services costs for a group of adults with a history of conduct disorder (of which 50% will go onto develop adult ASPD) were found to be 10 times those for a similar group without the disorder. ASPD is closely associated with criminal offending and any intervention that seeks to improve the outcome of ASPD is also likely to impact upon this offending[5].

Borderline Personality Disorder (BPD)

DSM -5 (American Psychiatric Association) classification defines Borderline Personality Disorder (BPD) as a “pervasive pattern of instability of interpersonal relationships, self-image and affects and marked impulsivity”. Presentation of the disorder typically involves a history of chaotic interpersonal relationships, unstable mood and self-image disturbances, self-injurious behaviours and other maladaptive coping behaviours[6]. It has been said that the extent of disability associated with the disorder ‘involves a terrible way to experience life[7]’.

Symptoms of BPD include significant emotional distress and impaired interpersonal and occupational functioning.  Also, to be diagnosed, a person must have at least five of the identified symptoms which are grouped into three clusters according to the DSM –5 Classification[9].

There is some divergence between ICD-10 World Health Organisation WHO (1992) and DSM-5 (APA 2013) as to whether BPD can be diagnosed in an adolescent younger than eighteen years of age.  The ICD-10 sets out a criteria and classifies overall groups of disorders of adult personality and behaviour, whereas the DSM-5 (APA 2013) specifies that adolescents with BPD can be diagnosed if the features of the disorder have been present for at least one year[10]. 

BPD is difficult to define and although a high percentage of people in mental health setting may have been diagnosed with such a disorder, professionals are still undecided in their approach. It is very important to understand the above symptoms and borderline personality itself as it can easily be misdiagnosed as another mental illness particularly a mood disorder[11].

BPD is more likely to develop in women than men. It should also be noted that drug and alcohol use often occurs with personality disorders and also appears more apparent in those suffering with borderline personality disorder. The cause of borderline personality disorder is still suggested as a grey area and complex. A strong thought is that the cause of BPD could arise from childhood abuse, neglect, separation from loved ones or caregivers. These are seen to be major contributing factors particularly if the abuse is severe and sustained[12]. However, another school of thought is that BPD could run in families or that it may be related to a chemical imbalance in the brain[13]. Leib et al agree that  genetic components and adverse childhood experiences may cause childhood dysregulation leading to dysfunctional behaviours and conflicts later on in life[14].

It is important to note that the United Kingdom is the only country in the world to have a health service in which personality disorders are considered to be of great importance. As a result, in 2003, it was decided to include the treatment of personality disorders as part of the National Health Service. However, the development of these services remains inconsistent and in some cases undeveloped[15].

The implementation of relevant legislation and guidelines has been set out in England and Wales to support all who meet the criteria of BPD. The National Institute for Health and Clinical Excellence draft consultation document has commissioned a clinical guideline for anyone that has developed this disorder. Aims set out by this document include the evaluation of specific psychosocial and pharmacological interventions regarding treatment, whilst providing choice, best practice and advice for the care and treatment of the individual[16].

The Welsh Assembly Government document Raising the Standard: The Revised Adult Mental Health National Service Framework and an Action Plan for Wales sets out guidelines relating to the diagnosis of BDP using the DSM- 5 (APA 2013) and criteria to combat over- diagnosis. These guidelines lay down paramount importance on the delivery of client centred care. If the usual treatment is not sufficient, the drug treatment must be tailor made to meet the individual’s needs with BPD and then combined with psychotherapy or behavioural strategies to be effective. All team members involved must be educated fully in the presentation of BPD and it is vital that the team approach is integrated to provide consistency[17].

Narcissistic Personality Disorder (NPD)

Narcissistic personality disorder (NPD) presents with behavioural traits which are in fact the polar opposite to an underlying condition blanketed from fragile vulnerability. Sufferers are predisposed to act upon an inherent over inflated ego and regularly display behaviours indicative to someone who possesses a superior sense of self importance. Those diagnosed with NPD harbour a deep rooted desire for regard and overwhelming appraisal. Unfortunately, they tend to experience difficulties throughout their lifelong relationships and fail to display empathy for others. Many of those diagnosed with NPD appear to be bursting with excessive confidence and self-esteem. However, this presentation is merely a mask which protects a damaged individual, wide open to the slightest criticism.

An individual diagnosed with NPD will encounter significant problems in several aspects of their life. These include: Interpersonal and family relationships; education; career; economics.  People with narcissistic personality disorder are likely to face great disappointment when they are overlooked for special favours they believe they are deserving of. They are likely to experience unfulfilling relationships without exceptional admiration and others may find their company unpleasant.

Histrionic Personality Disorder (HPD)

Individuals with this diagnosis strive to be the centre of attention in social situations and often present in an excessively dramatic, emotional and highly provocative (sometimes sexual) manner. Failure to be given such recognition or a perception of being ignored can result in extreme anxiety. People with HPD are often overly concerned about their physical appearance as this is viewed as a significant way in which to gain the attention of others. Personal opinions are often expressed with much gusto, however they lack substance. Emotional outbursts are common as they are fluid and rapidly changing but ultimately, shallow. HPD seriously affects the manner in which those diagnosed are able to relate to others as they can be easily influenced and often believe that bonds with companions are tighter than they actually are. Individuals may come to depend on approval from other people and often blame others for personal failures or disappointments. Criticism can be met with extreme sensitivity and an unwillingness to accept any changes in personal habits or mannerisms is most likely viewed in a threatening way.

During the month of February, Khiron will be looking in depth at the personality disorders discussed in cluster B. The remaining cluster C will be explored during the month of April. Please keep an eye out for our forthcoming articles on these topics and if you have a client, or know of someone who is struggling with a personality disorder, or recognise that they have symptoms discussed in this article – reach out to Khiron. We believe that we can stop the revolving door of treatment and misdiagnosis by providing effective residential and out-patient therapies for underlying psychological trauma. Allow us to help you find the path to effective, long lasting recovery. For information, call us today. UK: 020 3811 2575 (24 hours). USA: (866) 801 6184 (24 hours).

Sources:

1. Coid, J. & Ullrich, S. (2006). Prevalence and correlates of personality disorder in Great Britain.The British Journal of Psychiatry. 188: 423-431

2. NHS Choices, personality disorders (http://www.nhs.uk/conditions/personality- disorder/Pages/Definition.aspx) accessed 26/12/2019

3. http://www.emergenceplus.org.uk/what- is-personality-disorder/93-causes.html accessed 26/12/2019

4. Myres MG (1998). Progression from Conduct Disorder to Antisocial Personality Disorder following Treatment for Adolescent Substance Abuse. American Journal of Psychiatry, April; 155 (4): 479-85.

5. Scott, S., Knapp, M., Henderson, J., & Maughan, B. (2001). Financial cost of social exclusion: Follow up study of antisocial children into adulthood. British Medical Journal, 323(7306), 191.

6. Otong.A (2003) Evidence-Based Care of the Patient with Borderline Personality Disorder. 2016 Jun; Vol. 51 (2), pp. 299-308.

7. Gunderson, J G & Kolb J E (2008) Discriminating features of borderline patients. American  Journal of  Psychiatry. 135 792-796 Lieb, K Zanarini, M C Schmahl, C

8. Zanarini MC, Gunderson JG, Frankenburg FR, Chauncey DL. (1989). The Revised Diagnostic Interview for Borderlines: discriminating BPD from other axis II disorders. J Personal Disord.: 3:10–18.

9. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders. (5^hedn.) DSM-V. Washington DC: APA.

10. National Institute of Clinical Excellence (2008) Borderline Personality Disorder: Treatment and Management. A draft Consultation.  http//www.nice.org.uk/guidance/index.jsp?action=folder&o=4039 Accessed 26/12/2019.

11. Arntz A (1999) Do personality disorders exist? On the validity of the concept and its cognitive-behavioural formulation and treatment. Behaviour Research and Therapy.37 97- 134.

12. Lieb, K Zanarini, M C Schmahl, C Linehan, M Bohus M (2004)  Borderline Personality Disorder. The Lancet: 364, 9432, RCN Edition: Pro-Quest Nursing and Allied Health Source. 453

13. Alper, G Peterson S J (2001) Dialectical Behavior Therapy for Patients with Borderline Personality Disorder. Journal of Psychosocial Nursing and Mental Health Services. 39 10.

14. Lieb, K Zanarini, M C Schmahl, C Linehan, M Bohus M (2004)  Borderline Personality Disorder. The Lancet: 364, 9432, RCN Edition: Pro-Quest Nursing and Allied Health Source. 453

15. National Institute of Clinical Excellence (2008) Borderline Personality Disorder: Treatment and Management. A draft Consultation. http//www.nice.org.uk/guidance/index.jsp?action=folder&o=4039 Accessed 26/12/2019

16. ibid.

17. Welsh Assembly Government (2005) Raising the Standard: The Revised Adult mental Health National Service Framework and Action Plan for Wales: Welsh Assembly Government.

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