Cluster B Personality Disorders

There are four Cluster B personality disorders: Antisocial, Borderline, Histrionic, and
Narcissistic. The antisocial personality demonstrates a pervasive pattern of irresponsible and
antisocial behavior. The borderline personality is characterized by a pervasive pattern of
instability of self-image, interpersonal relationships, and mood. The histrionic personality shows
a pervasive pattern of excessive emotionality and attention-seeking. Lastly, the narcissistic
personality is characterized by a pervasive pattern of grandiosity, hypersensitivity to evaluation
by others, and lack of empathy.
Antisocial Personality Disorder
One of the two Cluster B personality disorders that appear to have a genetic component, the
antisocial personality often begins with signs in childhood, including lying, stealing, truancy,
vandalism, fighting, running away from home, and cruelty. Adult signs are the failure to honor
obligations, failure to conform to norms, and repeated antisocial acts. The antisocial personality
appears unable to tolerate boredom and may be depressed. Individuals may also engage in
domestic violence or criminal acts. Their self-image is that of a rule-breaker where life is hostile,
and they thrive on defiance. Their fictitious goal is to successfully defy the world as their highest
obligation is to the self, and rules prevent getting their needs met. Their method is that “might
makes right,” and they have a total lack of empathy for others. Three to four times more common
in males, the impairments of the antisocial personality are dysphoria, substance abuse, and
inability to sustain lasting close, warm, responsible relationships.
Borderline Personality Disorder
The borderline personality is the other personality disorder that has genetic inheritability. With a
prevalence of 2% of the population, it accounts for 10% of patients seen in outpatient mental
health centers. It is also five times more common in first-degree relatives of those with
borderline personality disorder. The characteristics of the borderline personality include a
marked and persistent identity disturbance, chronic feelings of emptiness and boredom, and
intense unstable personal relationships. The borderline tends to have difficulty tolerating being
alone, and will fear abandonment. They are highly impulsive, and may engage in self-mutilating
behavior, have recurring suicidal threats, and manipulate others to meet their immediate needs.
The borderline also tends toward having an intense unstable affect mood, display inappropriate
anger, have perceptual distortions, and under great stress may depersonalize. They see the self as
justified; since they feel intolerably bad, they are entitled to go by impulse instead of common
sense, and entitled to soothe themselves. Their fictitious goal is to do whatever they want as they
cannot be happy by how others do it. Their methods are protean, and include splitting, primitive
idealization, projective identification, denial, and devaluation. The borderline personality is not a
cooperator. Their impairments include affective instability, anxiety and panic, and engaging in
self-harmful behaviors. These impairments may cause significant interference in social or
occupational functioning. Because the borderline uses others to meet their needs, they can often
be the “problematic patient” that medical offices dread.
Histrionic Personality Disorder
Those with histrionic personality want to be the center of attention, and are uncomfortable in
situations where they are not. They can display rapidly shifting and shallow expressions of
emotions, and their behavior is over-reactive and intensely expressed. They may crave novelty,
stimulation, and excitement, and may constantly demand reassurance due to feelings of
helplessness or dependence. The histrionic personality is over-concerned with physical
attractiveness, and has little or no tolerance for frustration or delayed gratification. Their manner
is seductive and flamboyant, though their expressionistic speech will most likely be devoid of
depth and lack detail. The self for the histrionic personality is that “I am sensitive and everyone
should admire and approve of me.” Their fictitious goal is to be the center of admiring attention
without really working for it, like a child. Their methods include hypersensitivity, covert
manipulation, emotional displays, and claims to be the center of attention. More common in
females and in first-degree relatives, the histrionic personality’s impairments include being
controlling or dependent in relationships, impressionable and easily influenced, and overly
trusting. Of note in our discussion here is that the histrionic personality may somaticize a great
deal as a means of gaining attention.
Narcissistic Personality Disorder
The last of the Cluster B personality disorders, the narcissistic personality is preoccupied with
fantasies of unlimited power, success, brilliance, and beauty. With fragile self-esteem, they have
chronic feelings of envy for those perceived as being more successful. Like the histrionic, there
is the exhibitionist need for constant attention and admiration, and they may constantly fish for
compliments. When criticized, the narcissistic personality may react with rage, shame, or
humiliation. In romantic relationships, the partner is often treated as an object to bolster their
own self-esteem. The narcissist is always measuring: “Am I better, or is this good for me?”
The self for the narcissist is special and unique, entitled to extraordinary privilege whether
earned or not. They have the fictitious goal of superiority, and are owed admiration and
privilege. The method is one of self-enhancement and deprecation of others.
Their impairments include anger and rage, often depression, disturbed relationships, and a lack
of empathy.
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Psychiatric management
P Rajan Thomas, in Headache, Orofacial Pain and Bruxism, 2009
Personality disorders
Undiagnosed personality disorders are common in those with chronic headaches. Common
personality disorders and personality traits observed are Cluster B personality
disorders (borderline personality, histrionic personality, anti social personality and narcissistic
personality) and Cluster C personality disorders (dependent personality, avoidant personality and
obsessive-compulsive personality). Patients with Cluster B and C personality disorders are more
prone to have co-morbid headache. These individuals develop maladaptive behavioral patterns to
cope with day to day stressors. Those who have a history of childhood physical or sexual abuse
have difficulty trusting others and have strained relationships. Such abuse can manifest as anger
and some exhibit self harming behavior when under stress. They are also prone to mood swings.
Among the Cluster C group, anxiety related symptoms predominate. Free floating anxiety and
their reaction to stress are seen with headache. The personality disorder group generally shows
changes in the manifestations of symptoms according to the environment.
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Alcohol and the Nervous System
J. Stephen Rich, Peter R. Martin*, in Handbook of Clinical Neurology, 2014
Differentiating mood from personality disorders
The personality disorders have many similarities to, and in some ways blend with and modify
expression of, primary Axis I disorders. Similar to BPAD, cluster B personality disorders present
with significant mood instability, impulsivity, and irritability, and may even have significant
anxiety that can sometimes be misinterpreted by patients as “racing thoughts” (a cardinal
symptom of BPAD) (Clark et al., 1994). However, in the context of personality disorders, racing
thoughts (although upsetting) are not as disorganized, nor are they associated with significant
pressured speech, decreased need for sleep, or episodic euphoria seen in BPAD. Personality
disorders can also be characterized by an enduring sense of emptiness and fractured sense of
identity (American Psychiatric Association, 2000). The stress these “existential” symptoms
generate may be greatly exacerbated by the presence of AUD, characterized by futile “self-
medication” of painful and seemingly immutable affects (Colder, 2001). Indeed, manifestations
of mood instability in externalizing personality disorders and BPAD, combined with shared
phenomenologic, developmental, and genetic features, may all reflect common neurobiologic
underpinnings, i.e., these conditions may represent different degrees of expression of a unified
underlying pathogenesis (Akiskal et al., 1985).
Comparable to the close relationship of BPAD to cluster B personality disorders, elements of
MDD are shared with cluster C personality disorders (Clark et al., 1994). Cluster C individuals
often have high levels of anxiety that can progress to worsening mood (Clark et al., 1994). A
“depressed” mood in this context, however, does not represent true MDD unless that depression
clearly extends beyond an acutely stressful event and is expressed with some consistency
throughout the entire depressive episode (American Psychiatric Association, 2000). Even so, as
with patients with other forms of anxiety/depression, the presence of stressful life events requires
close attention in the AUD patient, since such acute stresses represent a high risk for self-
medication (Colder, 2001). Furthermore, as with cluster B and BPAD, the nature of cluster C and
depression are pathophysiologically closely related and have been found to be mediated by
shared neurobiologic (impaired monoaminergic neurotransmission) and psychosocial
mechanisms (Cloninger et al., 1993).
Therefore, given the significant neurobiologic relationship between them, the presence of
personality traits or a disorder should not exclude the possibility of a related mood disorder, as
mood and personality are strongly intertwined (Skodol et al., 1999). Even so, the clinician must
clarify that patients with a personality disorder truly warrant an additional mood diagnosis,
especially if AUD is also present. This is because the appropriate treatment for personality
disorders is often different, with psychopharmacology playing much less of a role than
psychotherapy (Evershed, 2011).