Section Learning Objectives

• Describe the symptoms of each cluster B personality disorder.
• Describe the epidemiology of cluster B personality disorders.
• Describe the treatments for cluster B personality disorders.

9.3.1 Antisocial Personality Disorder

9.3.1.1 Clinical Description

The defining feature of antisocial personality disorder is a consistent pattern of disregard for, and violation of, the rights of others (APA, 2022). While antisocial personality disorder can only be diagnosed in individuals who are 18 years of age or older, a diagnosis can only be made if there is evidence of conduct disorder prior to the age of 15. Although not discussed in this book, conduct disorder is a childhood disorder that involves a repetitive and persistent pattern of behaviors that violate the rights of others (APA, 2022). Common behaviors exhibited by individuals with conduct disorder are aggression toward people or animals, destruction of property, deceitfulness or theft, or other serious violations of rules (APA, 2022).

While commonly referred to as “psychopaths” or “sociopaths” these are both separate (but related) disorders that are not recognized by the DSM. However, much like those with psychopathy and sociopathy, individuals with antisocial personality disorder fail to conform to social norms. This also includes legal rules as individuals with antisocial personality disorder are often repeatedly arrested for crimes such as property destruction, harassing/assaulting others, stealing, etc. (APA, 2022). Deceitfulness is another hallmark symptom of antisocial personality disorder as individuals often lie repeatedly, generally as a means to gain profit or pleasure. There is also a pattern of impulsivity, in that decisions are made spontaneously without forethought of personal consequences or consideration for others (Lang et al., 2015). This impulsivity also contributes to their inability to maintain employment as they are more likely to impulsively quit their jobs (Hengartner et al., 2014). Employment instability, along with impulsivity, also impacts their ability to manage finances; it is not uncommon to see individuals with antisocial personality disorder accumulate large debts (Derefinko & Widiger, 2016).

Individuals with antisocial personality disorders also tend to be extremely irritable and aggressive, repeatedly getting into fights. Their disregard for their own safety, as well as the safety of others, is also observed in reckless behavior such as speeding, driving under the influence, and engaging in sexual and substance abuse behavior that may put themselves and others at risk (APA, 2022).

Of course, one of the better-known symptoms of antisocial personality disorder is the lack of remorse for the consequences of their actions, regardless of how severe they may be (APA, 2022). Individuals with this disorder often rationalize their actions as the fault of the victim, minimize the harmfulness of the consequences of their behaviors, or display indifference (APA, 2022).

9.3.1.2 Epidemiology 

Antisocial personality disorder has an estimated prevalence rate of approximately 3.6% with men comprising 75% of the cases (APA, 2022). It is more commonly diagnosed in men, particularly those with substance abuse disorders. It is also observed more commonly in those from disadvantaged socioeconomic and urban settings. While many individuals with antisocial personality disorder end up incarcerated at some point throughout their lifetime, criminal activities appear to decline after the age of 40 (APA, 2022).

9.3.1.3 Treatment 

Treatment options for antisocial personality disorder are limited, and generally not effective (Black, 2015). Like cluster A disorders, many individuals are forced to participate in treatment, thus impacting their ability to engage in and continue with treatment. Cognitive therapists have attempted to address the lack of moral conscious and encourage clients to think about the needs of others (Beck & Weishaar, 2011). Medications including lithium, atypical antipsychotics and SSRIs are sometimes prescribed to help reduce impulsive and aggressive behaviors but there is very little research on this topic and medication compliance can be a major issue.

9.3.2 Borderline Personality Disorder

9.3.2.1 Clinical Description

Individuals with borderline personality disorder display a persistent pattern of instability in interpersonal relationships, self-image, and affect (APA, 2022). The key characteristic of borderline personality disorder is unstable and/or intense relationships. For example, individuals may idealize or experience intense feelings for another person immediately after meeting them and then switch to devaluing them over time. It is not uncommon for people with borderline personality disorder to experience intense fluctuations in mood (i.e., mood lability), often observed as volatile interactions with family and friends (Herpertz & Bertsch, 2014). Those with borderline personality disorder may be friendly one day and hostile the next. The combination of these symptoms causes significant impairment in establishing and maintaining personal relationships.

Individuals with this disorder will often go to great lengths to avoid real or imagined abandonment. Fears related to abandonment can lead to inappropriate anger as they often interpret the abandonment as a reflection of their own behaviors. In efforts to prevent abandonment, individuals with borderline personality disorder will often engage in impulsive behaviors including self-harm and suicidal behaviors and approximately 6% of people with this disorder die by suicide (APA, 2022, Linehan et al., 2015). Other impulsive behaviors such as non-suicidal self-injury (cutting) and sexual promiscuity are often seen within this population, typically occurring during high-stress periods (Sansone & Sansone, 2012). Occasionally, hallucinations and delusions are present, particularly of a paranoid nature; however, these symptoms are often transient and short-lived (Sieswerda & Arntz, 2007).

9.3.2.2 Epidemiology

Borderline personality disorder has an estimated prevalence rate of 2.7% (APA, 2022). Women are more likely to be diagnosed with the disorder but community samples show no gender discrepancy in the prevalance of the disorder. This suggests that women may be more likely to seek help for the disorder (APA, 2022) or suggests the presence of clinician bias in diagnosing women.  Approximately 10% of individuals with borderline personality disorder have been seen in an outpatient mental health clinic, and nearly 20% have sought treatment in a psychiatric inpatient unit (APA, 2013). This high percentage of inpatient treatment is likely related to the high incidence of suicidal and self-harm behaviors.

9.3.2.3 Treatment

Borderline personality disorder is the one personality disorder with the most effective treatment option – Dialectical Behavioral Therapy (DBT). DBT is a form of cognitive behavioral therapy developed by Marsha Linehan (Linehan et al., 1991). There are four main goals of DBT: reduce suicidal behavior, reduce therapy-interfering behavior, improve quality of life, and reduce post-traumatic stress symptoms.

Within DBT, there are five main treatment components that together help reduce harmful behaviors (i.e. self-mutilation and suicidal behaviors) and replace them with effective, life-enhancing behaviors (Gonidakis, 2014). The first component is skills training. Generally performed in a group therapy setting, individuals engage in mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation. Second, individuals focus on enhancing motivation and applying skills learned in the previous component to specific challenges and events in their everyday life. The third, and often the most distinctive component of DBT, is the use of telephone and in vivo coaching. It is not uncommon for clients to have the cell phone number of their clinician for 24/7 availability of in-the-moment support. The fourth component, case management, consists of allowing the client to become their own “case manager” and effectively use the learned DBT techniques to problem-solve ongoing issues. Within this component, the clinician will only intervene when absolutely necessary. The fifth component is the consultation team, which is a service for the clinicians providing the DBT treatment. Due to the high demands of clients with borderline personality disorder, the consultation team provides support to the clinician to ensure they remain motivated and competent in DBT principles in an effort to provide the best treatment possible.

Support for the effectiveness of DBT in the treatment of borderline personality disorder has been demonstrated in a number of randomized control trials (Harned, Korslund, & Linehan, 2014; Neacsiu, Eberle, Kramer, Wisemeann, & Linehan, 2014). More specifically, DBT has been shown to significantly reduce suicidality and self-harm behaviors in those with borderline personality disorders. It also reduces anger and hospitalizations as well as improves emotional regulation and interpersonal functioning. Additionally, the drop-out rates for treatment are extremely low, suggesting that clients value the treatment components and find them effective in managing symptoms.

9.3.3 Histrionic Personality Disorder

9.3.3.1 Clinical Description

Histrionic personality disorder is characterized by a persistent and excessive need for attention from others. Individuals with this disorder are uncomfortable in social settings unless they are the center of attention. In efforts to gain attention, they are often very lively and dramatic, using emotional displays, physical gestures, and mannerisms along with sexually provocative behaviors. These behaviors are initially very charming to their audience; however, their constant need for attention can begin to wear on others.

If their theatrical nature does not gain the attention they desire, individuals with histrionic personality disorder may go to great lengths to gain that attention such as making up a story or creating a dramatic scene (APA, 2013). Similarly, they often use their physical appearance to capture attention and behave in sexually seductive or provocative ways. These sexually charged behaviors are not only directed at those with whom they have a sexual or romantic interest but also toward people for whom they have no sexual interest (APA, 2022). They often spend significant amounts of time on their physical appearance to gain the attention they desire.

Individuals with histrionic personality disorder are easily suggestible. Their opinions and feelings are influenced by not only their friends but also by current fads (APA, 2022). They also have a tendency to over-exaggerate relationships, considering casual acquaintanceships as more intimate in nature than they really are.

9.3.3.2 Epidemiology

Histrionic personality disorder is estimated to occur in approximately 0.9% of the general population (APA, 2022). While it was once believed to be more commonly diagnosed in women than men, more recent findings suggest the diagnosis rate is equal between genders.

9.3.3.3 Treatment

Individuals with histrionic personality disorder are actually more likely to seek out treatment than those with other personality disorders. Unfortunately, due to the nature of the disorder, they are very difficult to treat as they are quick to employ their  seductiveness and demand attention within the treatment setting. The overall goal for the treatment of histrionic personality disorder is to help the individual identify their dependency and become more self-reliant. Cognitive therapists utilize techniques to help clients change their dysfunctional beliefs and improve problem-solving skills (Beck & Weishaar, 2011).

9.3.4 Narcissistic Personality Disorder

9.3.4.1 Clinical Description

The key features of narcissistic personality disorder are a need for admiration, a pattern of grandiosity, and a lack of empathy for others (APA, 2022). The grandiose sense of self often leads to an overvaluation of their abilities and accomplishments. They often come across as boastful and pretentious, repeatedly proclaiming their superior achievements. They commonly fantasize about success, power, ideal love, brilliance and beauty. Oftentimes they identify themselves as “special” and will only interact with others of high status.

Given the grandiose sense of self, it is not surprising that individuals with narcissistic personality disorder need excessive admiration from others. While it appears that their self-esteem is extremely inflated, it is actually very fragile and dependent on how others perceive them (APA, 2022). Because of this, they may constantly seek out compliments and expect favorable treatment from others. When this sense of entitlement is not upheld, they can become irritated or angry that their needs are not being met.

A lack of empathy is also displayed in individuals with narcissistic personality disorder as they often fail to recognize the desires or needs of others. They are also prone to exploiting others, as they are unable to empathize with others’ feelings (Marcoux et al., 2014). They often become envious of others who achieve greater success or have nicer possessions. Conversely, they believe everyone should be envious of their achievements, regardless of how small they may actually be.

9.3.4.2 Epidemiology

Finally, narcissistic personality disorder is estimated to affect 1.6% of the general public. 50-75% of those diagnosed with the disorder are men (APA, 2013).

9.3.4.3 Treatment

Of all the personality disorders, narcissistic personality disorder can be the most difficult to treat (with maybe the exception of antisocial personality disorder). In fact, most individuals with narcissistic personality disorder only seek out treatment for those disorders secondary to their personality disorder, such as depression (APA, 2022). The focus of treatment is to address the grandiose, self-centered thinking, while also trying to teach clients how to empathize with others (Beck & Weishaar, 2014).