CLUSTER B

PERSONALITY
DISORDERS
V M SALIMA HABEEB
1St MSc Clinical Psychology
Cluster B (emotional
or erratic disorders)
personality disorders
are characterized by
dramatic, impulsive,
self-destructive,
emotional behavior
and sometimes
incomprehensible
interactions with
others.
Antisocial Narcissistic
Personality Personality
Disorder Disorder

CLUSTER B
PERSONALITY
DISORDERS

Borderline
Histrionic
Personality
Personality
Disorder
Disorder
 - Characterized by a pattern of
disregard for the safety and rights of
others, without feeling remorse.
ANTI
SOCIAL - Individuals with this disorder are
unreliable, manipulative, incapable of
PERSONALITY lasting relationships, and unable to
DISORDER conform to social norms.

- Early onset (before the age of 15),

pervasive, and manifests in a variety
of contexts.

DSM Diagnostic Criteria
A. There is a pervasive pattern of disregard for and violation of the rights of

others occurring since age 15 years, as indicated by three (or more) of the

following

1 Failure to conform to social norms with respect to lawful behaviours as

indicated by repeatedly performing acts that are ground for arrest

2 Deceitfulness, as indicated by repeated lying, use of aliases, or conning

others for personal profi t or pleasure

3 Impulsivity or failure to plan ahead

4 Irritability and aggressiveness, as indicated by repeated physical fi ghts

or assaults

5 Reckless disregard for safety of self or others

6 Consistent irresponsibility, as indicated by repeated failure to sustain

consistent work behaviour or honour fi nancial obligations

7 Lack of remorse, as indicated by being indifferent to or rationalizing

having hurt, mistreated, or stolen from another

B. The individual is at least age 18 years

C. There is evidence of conduct disorder with onset before 15 years

D. The occurrence of antisocial behaviour is not exclusively during the course

of Schizophrenia or a Manic Episode.
 AETIOLOGY

- Twin, adoption, and family studies have demonstrated that genetic

factors strongly contribute to the development of antisocial personality.

- Antisocial personality in males is often associated with hysteria in

women of the same family which suggests that the two conditions
might be alternative expressions of the same genetic endowment,
belonging to ‘spectrum conditions’.

Longitudinal studies of hyperactive children have suggested a

‘developmental’ relationship between antisocial behaviour and
childhood hyperactivity.

- A- ggression in antisocial personality disorder is associated with indexes
of reduced brain serotonin activity

- Parental deprivation, inconsistent maternal care, family violence, and

severe childhood physical abuse have been reported as strong predictors
for development of antisocial personality disorders.
• Patients with antisocial personality disorder often appear quite
normal, charming, and understanding.
• However, their history reveals disturbed functioning in the
domains of behaviour and self-concept, love and sexuality,
interpersonal relations, and cognitive style.

The absence of internalized moral values is manifested by lying,

truancy, running away from home, thefts, fights, substance abuse,
and illegal activities, often starting in early childhood.
COURSE AND PROGNOSIS

• Antisocial behavior is most pronounced in early adult

years, and gradually decreases with age.
• Professional motivation and establishing a stable couple
or partnership may have beneficial effects.
• Maturation of the personality might also take with
depression or hypochondriasis emerging when rage and
aggression are abandoned.
• Substance abuse and promiscuity are risky behaviors
TREATMENT
Patients often do not seek psychiatric help and if they do, it is
usually under pressure from the legal authorities. The therapeutic
alliance is often not sustained. The treatment methods include:

1. Individual psychotherapy.
2. Psychoanalysis or psychoanalytical psychotherapy.
3. Group psychotherapy and self-help groups.
4. Drug therapy: Pharmacotherapy is of little help. Earlier claims of
beneficial effect of pericyazine (an antipsychotic drug) in certain
behavior patterns of antisocial personality disorder have not been
substantiated.
 CONCEPTUALIZATION OF
ANTISOCIAL PERSONALITY
DISORDER
Psychodynamic Conceptualizations

- Psychoanalytic writers describe the antisocial personality as

similar to the narcissistic personality. Both personalities form
a pathological grandiose self.
- In antisocial individuals, the self is based on an aggressive
introject known as the "stranger self-object."
- This self-object reflects an experience of the parent as a
stranger who cannot be trusted and harbors bad will toward
the infant. The threatening internalized object derives from
experiences of parental neglect or cruelty.

Kernberg (1984) notes that antisocial individuals are similarly

stunted in superego development.
Biosocial Conceptualization
Low levels of the neurotransmitter serotonin have been obser ved
in individuals prone to aggressive and impulsive behavior. Meloy
(1988) suggests that antisocial individuals often have histories of
childhood abuse or neglect and are likely to have had a di cult
infant temperament.

Millon and Everly (1985) suggest that low thresholds for limbic
system stimulation are likely in antisocial individuals.

Environmental factors such as parental hostility, deficient

parental role modeling, and reinforcement of vindictive behavior
interact with biological predisposing factors in individuals prone
to antisocial behavior.
Cognitive-Behavioral Conceptualization
According to Beck (2015), the behavior of individuals with this disorder
is persistently irresponsible. They hold various core, conditional, and
instrumental beliefs.

Their core beliefs are that they must look out for themselves and be
aggressive so as not to be victimized by others. They also believe they
are entitled to break rules. They believe that their thoughts and
feelings are always accurate, and that their choices are always right
aTnhdeigrocoodn.ditional belief is that if they don’t manipulate, exploit, or
attach others, they will never get what they deser ve. Their
instrumental belief is to get others before they get you, and take
what you need since you deser ve it.
These individuals tend to view themselves as strong, clever, self-
su cient, and invulnerable. They tend to view others as either weak
and vulnerable, or stupid and exploitable.
Interpersonal Conceptualization

For Benjamin (2003a), persons with Antisocial Personality

Disorders typically have developmental histories of harsh,
neglectful parenting. The adult consequence of this is that the
antisocial individual neglects and is insensitive to others’
needs, or exploits others.
Furthermore, this pattern of inept parental caring can be
internalized by the antisocial individual as substance abuse,
criminal behavior, or parental dereliction of duty. The
antisocial-to-be is likely to “take over” parental responsibilities,
since no one else did. As a consequence of this inappropriate
parental role-taking, the antisocial individual is likely to
continue controlling others as an end in itself, without
emotionally bonding with those being controlled.
 - Borderline personality disorder
(BPD) is the denomination of a
syndromal picture characterized by
intense affective instability and
BORDERLINE
impulsivity together with an unstable
PERSONALITY sense of self-identity.
DISORDER
- It is often manifested by impulsive
self-aggression and suicide attempts,
substance abuse, chronic feelings of
emptiness, and persistent pattern of
severely unstable interpersonal
relationships.
AETIOLOGY

- Family studies indicate that parents of patients with BPD

have a greater incidence of mood disorders

- Additionally, there is also high family incidence of

antisocial personality disorder and alcoholism.
- Among the biochemical findings, those indicating a brain
serotonin deficiency are the more consistent.

- Hypothalamic-pituitar y—adrenal axis dysfunctions,

suggesting increased feedback inhibition, as well as
increased sensitivity of some areas of the amygdala, have
been reported in samples of BPD patients.

Current available data suggest that BPD might be associated
with abnormal emotional reactivity in the limbic areas and
insu cient regulator y function at the cingulated and
prefrontal areas of the brain.

- The role of childhood trauma in the development of

borderline personality disorder could be crucial.

- Higher incidence of childhood traumatic experiences,

both for sexual/physical abuse or for neglect, has been
demonstrated in these patients.
COURSE AND OUTCOME

• Borderline patients often experience profound

dysfunction in many important aspects of life including
education, jobs, partner relationships, and marriage.

• Alcohol and psychosexual problems are also frequent.

• Repeated suicide attempts and premature death from

suicide are frequent complications of borderline
personality disorder; therefore suicidal gestures and
intentions should be always taken seriously.
• The long-term outcome of borderline patients has not
been studied, but the diagnosis is rarely made in
patients aged over 40.

• It is speculated that neural structures and defence

mechanisms mature with age and that these changes,
together with social learning, reduce symptomatology.
TREATMENT

Treatment options for borderline personality disorder include:

1. Psychoanalysis or psychoanalytical psychotherapy.

2. Supportive psychotherapy.
3. Cognitive behavior therapy (CBT) or dialectical behavior
therapy (DBT) approaches have shown success in treatment.
4. Drug therapy: Antidepressants are effective for depression,
while antipsychotics, lithium, valproate, or carbamazepine may
be used for aggression or impulsivity. However, drug therapy is
not the first choice for treatment of borderline personality
disorder.
Conceptualizations of the
Borderline Personality
Disorder
Psychodynamic Conceptualization

Adler ’s (1985) understanding of borderline pathology, is that

inconsistency in maternal behavior and availability results in the
borderline’s failure to develop a “holding-nothing” internalized
object. This leads to feelings of emptiness, depressive tendencies,
and oral rage.

Bateman and Fonagy ’s (2007) mentalization approach to Borderline

Personality Disorder is rooted in object relations and attachment
theor y. Sometimes referred to as “mentalizing,” this is the process
by which individuals interpret their own subjective cognitions,
behaviors, and emotions, as well as those of others.
The ability to mentalize is believed to arise as a function of
childhood development by age 4.
To fully develop this capacity, infants must have

a stable, affectionate, safe, and attentive adult to mirror their
experiences.

Bateman and Fonagy suggest that those with borderline personality

lack the ability to interpret mental states and accurately understand
their relationships due to psychological trauma in early or late
childhood.

Neglect, abuse, and incongruent emotional mirroring all lead to

insecure/hypersensitive attachments and poor self regulation.
 Biosocial Conceptualization
Millon and Everly (1985) contend that the borderline syndrome is
essentially more severe and regressed variants of the Dependent,
H.istrionic, or passive-aggressive personality disorders. They describe
three subtypes of this disorder:

Borderline-dependent individuals tend to exhibit a passive infantile

pattern and possess family histories of low energy levels. Parental
warmth and overprotection lead to strong attachments and
dependency on a single caregiver, limiting opportunities for social
independence and self-e cacy. This often results in rejection by
those they rely on.
Borderline-histrionic individuals typically have family histories
characterized by high autonomic reactivity and exhibit
hyperresponsiveness due to exposure to high levels of stimulation.
They seek approval through contingent reinforcement patterns,
performing to secure support, attention, and nurturance.

Borderline-passive aggressive individuals often exhibit "di cult

child" temperaments and received inconsistent responses from
caregivers. They may have experienced broken homes and had a
parent model erratic, passive-aggressive behavior, which they
replicate as adults.
Cognitive-Behavioral Conceptualization

According to Beck, three basic assumptions are noted in those

with this personality disorder: “I am powerless and vulnerable”;
“I am inherently unacceptable”; and “the world is dangerous
and malevolent".
Because of their inherent beliefs, they feel helpless in a hostile
world, vacillating between autonomy and dependence without
being able to rely on either. Additionally, borderlines tend to
display “dichotomous thinking,” evaluating experiences in
mutually exclusive categories, such as all good or all bad,
success or failure, trustworthy or deceitful. The combination
of dichotomous thinking and basic assumptions forms the
basis of borderline emotion and behavior, including acting-out
and self-destructive behaviors.
Interpersonal Conceptualization
Benjamin’s (2003a) posits that individuals with Borderline
Personality Disorder typically grew up in a family marked by a
chaotic, soap-opera lifestyle. Without these dilemmas, life was
experienced as hollow, boring, and empty.
The developmental histories of these individuals often included
traumatic abandonment experiences, marked by physical and/or
sexual abuse. These abuse experiences “taught” the individual to
shift from idealization to devaluation.
In short, there is a morbid fear of abandonment and a wish for
protective nurturance, particularly from a lover or caregiver.
Initially, friendly dependency on the nurturer gives way to hostile
control when the caregiver or lover fails to deliver enough.
Borderline individuals believe that significant others secretly like
dependency and neediness.
 • It is characterized by excessive
emotionality and attention seeking,
and by dramatic, colourful, and
extroverted behaviour.
• Egocentric, dependent, and
HISTRIONIC
demanding interpersonal relationships
PERSONALITY are typical of this disorder, which
DISORDER begins in early adulthood and is
present in a variety of contexts.
AETIOLOGY

• Some studies suggest that histrionic personality runs in

families, traits such as extraversion, emotional
expression, and reward dependence have a strong
genetic origin and might be constitutional.

• Biological findings associated with impulsivity, such as

serotonin deficiency, can be found in histrionic patients
with marked emotional instability and impulsive
behaviors.
• It has been proposed that histrionic personality in women
is genotypically linked to antisocial personality in men.

• From a development perspective, histrionic personality

is considered to be a result of abnormally intense
attachment with parental figures.
COURSE AND PROGNOSIS

• Depressive symptoms, suicide attempts, and frequent

use of medical ser vices are common.

• Histrionic personality may gradually improve with age,

as if a maturation of histrionic infantilism occurs over
the years.
TREATMENT
• Depressive and anxious symptoms are frequent in
histrionic personality disorder and can be alleviated
with the use of antidepressants and anxiolytic
medications.

• Supportive therapy is indicated for acutely distressed

histrionic patients, as well as for those at the sicker
end of the continuum.

Psychoanalysis and psychoanalytic psychotherapy are

the modes of treatment which are most successful.
Conceptualizations of the
Histrionic Personality Disorder
Psychodynamic Conceptualizations
Histrionic females typically lack maternal nurturance and turn
to their fathers for gratification of their dependence needs.
They learn that they can gain their father ’s attention through
flirtatious and exhibitionistic displays of emotion. As she
matures, she learns she must repress her genital sexuality to
remain “daddy ’s little girl".

Similarly, histrionic males will have also experienced maternal

deprivation and turned to their fathers for nurturance. If their
father is emotionally unavailable, they may develop a passive,
effeminate identification or hypermasculine one in reaction to
anxiety about effeminacy.
Biosocial Conceptualizations
Millon and Davis (1996) note that individuals with Histrionic
Personality Disorders often display a high degree of emotional
lability and responsiveness during infancy and early childhood,
which they attribute to low excitability thresholds for limbic
and posterior hypothalamic nucleus.

However, environmental factors seem to play the major role in

the development of this pathology. Millon and Everly (1985) list
three such factors: parental reinforcement of attention-
seeking behavior; histrionic parental role models; and
reinforcement of interpersonally manipulative behavior. In
effect, as children, these individuals learned to employ
cuteness, charm, attractiveness, and seduction to secure
parental reinforcement.
Cognitive-Behavioral Conceptualizations

Beck (2015) describes a cognitive therapy view of the

Histrionic Personality Disorder based on specific underlying
assumptions and cognitive distortions. Two underlying
assumptions are posited: “I am inadequate and unable to
handle life by myself” and “I must be loved by ever yone to be
worthwhile.”

Believing they are incapable of caring for themselves,

histrionic individuals actively seek the attention and approval
of others and expect others to take care of them and their
needs. Believing they must be loved and approved by others
promotes rejection sensitivity. Finally, feeling inadequate and
desperate for approval, they are under considerable pressure
to seek attention by “performing” for others.
Taking a more behavioral tack, Turkat (1990) differentiates the
Histrionic Personality Disorder into two types: the controlling type
in which the basic motivation is achieving total control through
the use of manipulative and dramatic ploys; and the reactive type
in which the basic motivation is seeking reassurance and approval.
Interpersonal Case
Conceptualizations
For Benjamin (2003a), persons with Histrionic Personality
Disorder were likely to be loved for their good looks and
entertainment value, rather than for competence or personal
strength. They learned that physical appearance and charm could
be used to control important others. The household of histrionic
personalities tended to be a shifting stage.
Unpredictable changes stemmed from parental instability,
possibly associated with alcohol or substance use. The chaos in
these families was more likely to be dramatic and interesting
rather than primitive and life-threatening, as with borderline
personalities.
 • Narcissistic personality disorder is
characterized by an exaggerated

sense of self-importance with a lack
of sustained positive regard for

NARCISSISTIC others.
PERSONALITY • Grandiosity (in fantasy or behaviour)
DISORDER and constant craving

for admiration and external gratifi
cation are additional features

of this disorder.
• They are present in a variety of
contexts and begin

by early adulthood.
 AETIOLOGY

• Some aspects of narcissism might be related with

inappropriate seeking for excitement and reward and
associated to monoamine function abnormalities at the
mesolimbic reward systems.

• Behind the compensator y grandiose self, a hungr y and

inferior real self- resides, as the core problem of
narcissistic personality disorder.

• Often, high parental expectations and harsh criticism of

the child is present in the family.
COURSE AND PROGNOSIS

• Patients often become depressed or defensively

hypomanic during middle age, when their internal life
gradually deteriorates owing to a vicious circle of
frustrations and disappointments and diminishing
narcissistic supplies.

• Hypochondriasis and anxiety disorders are frequent

complications.
 TREATMENT

• Anxiolytic agents and antidepressants may be helpful

for alleviating target episodes of mood and anxiety
symptoms.

• Psychotherapy Individual psychotherapy is aimed at

the analysis of idealizing transference and
interpretation of self-grandiosity.

• However, during the first stages only supportive

therapy is recommended with interpretations delayed
until confident and integrated attachment with the
therapist is achieved.
Conceptualizations of the
Narcissistic Personality
Disorder
Psychodynamic Conceptualizations

For Freud, parental overevaluation or erratic, unreliable

caretaking in early life were factors disrupting the
development of object love in the child providing. As a result of
this fixation or arrest at the narcissistic phase of development,
Freud posited that narcissists would be unable to form lasting
relationships. In other words, the etiology of the Narcissistic
Personality Disorder is that it is the outcome of insu cient
gratification of the normal narcissistic needs of infancy and
childhood.
The contrar y hypothesis is that the disorder stems from
narcissistic overgratification during childhood and, because of
this fixation, interferes with the normal maturation and
integration of the superego, leading to di culties in regulation
of self-esteem
Biosocial Conceptualizations
The principal environmental factors are parental indulgence and
over valuation, learned exploitive behavior, and only-child
status. Essentially then, children are pampered and given
special treatment by the parents such that they learn to
believe the world revolves around them. They become
egotistical in their perspectives and narcissistic in their
expressions of love and emotion.
Not surprisingly, they come to expect special treatment from
others outside the home. When special treatment is not
forthcoming, the children experiment with demanding and
exploitive tactics and subsequently develop considerable skill
in manipulating others so as to receive the special
consideration they believe they deser ve. At the same time,
they come to believe that most others are inferior, weak, and
exploitable.
Cognitive-Behavioral Conceptualizations

According to Beck (2015), the key feature of this disorder is self-

aggrandizement. Individuals with this disorder can be
characterized by specific core, conditional, and instrumental
beliefs.
Their core beliefs include deser ving special treatment and
dispensations because of their specialness. They also include
believing that they are not bound by the rules and social
conventions that govern others.
Their conditional beliefs are that others should be punished if
they do not recognize their special status, and that to maintain
their special status others must be subser vient to them.
Their instrumental belief is to continually strive to demonstrate
their superiority. Underlying these various beliefs are their
beliefs about self and the world.
Interpersonal Conceptualizations
For Benjamin (2003a), a person with Narcissistic Personality
Disorder typically was raised in an environment of selfless, non
-contingent love and adoration. Unfortunately, this adoration
was not accompanied by genuine self-disclosure. As a result,
the Narcissistic-Personality-Disorder-to-be learned to be
insensitive to others’ needs and views. The adoring parent is
likely to have been consistently differential and nurturant to
the narcissistic-in-training. As a result, the adult narcissist
held the arrogant expectation that others will continue to
provide these emotional supplies.
If support is withdrawn, or lack of perfection is evident, the
self-concept degrades into severe self-criticism. Totally
devoid of empathy, these individuals tend to treat others with
contempt and rage if their demand for entitlement fails.
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