Lecture 5.2: Cluster B Diagnoses

Cluster B Phrase

Emotional, dramatic, or erratic

Cluster B disorders

• Characterized by overly dramatic, flamboyant, emotional, and/or erratic behavior

  • Antisocial PD

  • Borderline PD

  • Histrionic PD

  • Narcissistic PD

Antisocial Personality Disorder

• A pervasive pattern of disregard for and violation of the rights of others

  • Repeatedly performing acts that are ground for arrest

  • Deceitfulness

  • Impulsivity

  • Consistent irresponsibility

  • Lack of remorse

• Requires:

  • Age 18 or older

  • Evidence of Conduct Disorder by age 15

Anti-social personality prevalence

• Prevalence

  • General Population: 4.1%

  • Forensic Populations: 60%

  • About 3x more common among men

Life course for anti-social personality

• Course

  • Tends to have a chronic course: delinquent behavior in childhood (e.g., conduct disorder) continues into adulthood

• Middle age (around their 40s), they “burn out”

Psychopathy

emphasizes both (1) personality traits (e.g., emotional deficits) and (2) behaviors (e.g., socially deviant behaviors)

• May or may not engage in criminal behavior

• The diagnosis of antisocial PD focuses more on observable behaviors

38% of people with Antisocial PD also have psychopathy.

Understanding psychopathy image

Antisocial PD vs. Psychopathy

• Earlier conceptualizations of Antisocial personality disorder had a greater overlap with psychopathy

• However, due to DSM-5’s focus on observable behaviors, Antisocial personality disorder is a distinct concept from psychopathy (there is still some overlap)

• Psychopathy is a better predictor of recidivism than ASPD

• 38% of people with Antisocial PD also have psychopathy.

(Recidivism is the rate at which an incarcerated person is released and later returns to prison)

Overlap between ASPD, Psychopathy, & Criminality

Individuals with psychopathy may or may not show criminal behavior.

38% of people with Antisocial PD also have psychopathy.

50-85% of criminals have anti-social personality disorder

15% of criminals are psychopaths

Does Psychopathy look the same in women as it does in men?

• The gender difference in psychopathy (and Antisocial PD) may be partly due to limitations of assessments

• Two Issues Created by Socialization

  • Socialization of Clinicians

  • Socialization of Clients

    • Physical aggression might be more common in men

• Women may be more likely to engage in relational aggression

Antisocial PD & Psychopathy: Etiology Psychological Factors

• Learning Deficits:

  • Hypothesis 1: Emotional deficits

They lack fear & anxiety, so they can ignore the effects of punishment

• Hypothesis 2: Impulsivity

They have trouble shifting their attention to consider the negative consequences of their behavior

• These etiological factors apply to people with psychopathic traits (with or without ASPD)

Antisocial PD & Psychopathy: Etiology Neurological Factors

• Abnormal brain structure & function

  • Evidence of smaller and hypoactive frontal lobes (i.e., the area which governs EF processes)

  • Deficits in EF: deficits in inhibition, planning

• Genetically predisposed temperament

  • High reward dependence: being highly motivated by the possibility of reward

  • Low harm avoidance: not being strongly motivated by the possibility of punishment

  • Low persistence: low frustration tolerance

Candoret et al study on criminal behavior of male adoptees

criminal behavior increased dramatically if the adoptee had BOTH a genetic predisposition to Antisocial PD and were being raised by a parent with antisocial PD. (interaction effect)

Antisocial PD & Psychopathy: Etiology Social Factors

• Inconsistent discipline (or complete lack of discipline) often seen in the prior family history of ASPD men

  • Kids with a "difficult temperament" are especially irritating to parents

  • Parents respond inappropriately by giving up or becoming severe in punishment

• Person selects friends who share antisocial interests and problems (‘skinheads’, gangs)

Antisocial PD & Psychopathy: Treatment

• Little research on treatments

  • Effectiveness depends on whether or not the individual has psychopathy

• Psychopathy has poor prognosis

  • Personality traits interfere with therapeutic alliance

  • Feasibility of managing behavior vs. treating personality traits

• Treatments for individuals with antisocial PD who are not psychopathic are more successful

  • Most likely to respond if they have a comorbid anxiety disorder (which indicates that they are not psychopathic)

  • Treatment that targets behavior change and behavior control (through CBT) is more effective than treatment that targets empathy training

Borderline Personality Disorder Symptoms

• A pervasive pattern of chaotic interpersonal relationships, unstable self-image, affective instability, and marked impulsivity

  • Frantic efforts to avoid abandonment

  • Recurrent suicidal behavior or self-mutilation

  • Marked reactivity of mood

  • Inappropriate, intense anger

  • Chronic feelings of emptiness

  • Impulsivity (e.g., binge eating, spending, seggs)

  • Chaotic interpersonal relationships that waver between extreme idealization and devaluation

• Requires 5 of the 9 possible criteria

Borderline prevalence

• Prevalence

  • General population: 5.9%

  • Treatment-seeking populations:

    • Inpatient: 20%

    • Outpatient: 10%

• According to the DSM, 75% of those diagnosed are women

  • Link to antisocial personality disorder: clinicians more likely to diagnose men with ASPD and women with BPD

  • Why? What are the similarities between the disorders?

    • Share symptoms of impulsivity, instability in relationships, and manipulation of others.

• High rate of suicide: 10% die by suicide

Borderline PD: Etiology Psychological Factors

• Core feature of the disorder is emotion dysregulation, meaning that they:

  • Have a lower threshold for emotional activation (i.e., their emotions shift quickly)

  • Experience emotions intensely

  • Experience slow return to emotional baseline (i.e., it takes them longer to self-soothe and come back down)

Borderline PD: Etiology Neurological Factors 

• Differences in brain activity

  • Hyperactivity of the amygdala

    • Brain structure that generates strong emotions

  • Hypoactivity of the frontal lobes

    • Brain structure that allows for self-control of emotional expression, as well as focusing attention and problem-solving

• Low serotonin levels

  • Associated with depression & impulsivity

  • Abnormal serotonin levels found more often

among women with the disorder

 

Borderline PD: Etiology Social Factors 

• Invalidating Environments

  • In childhood, family members and friends invalidated the child’s emotional experience (e.g., “You’re too sensitive)

  • Generates a learning history wherein the person views themselves as bad and punishable

• Childhood abuse

  • Especially sexual trauma

Treatment for Borderline Personality Disorder

• Among the most challenging personality disorder to treat

  • Medications

    • Used to treat comorbid Axis I disorders

    • May help with symptoms of emotional instability and impulsivity

• Dialectical Behavior Therapy (DBT)

  • Most well-validated treatment for BPD

Dialectical Behavior Therapy (Linehan, 1993)

• DBT falls under the umbrella of CBT, with an added emphasis on Zen- and meditation-related components

  • Developed for use with clients with BPD, particularly those with parasuicidal behavior

• What is “dialectics?”

  • Refers to synthesizing opposing elements. For example, accepting your current situation while at the same time recognizing that in order to feel better, change must occur

• Involves both individual therapy, as well as a skills training group

  • Skills training group involves 4 basic modules:

    • Core Mindfulness

    • Interpersonal Effectiveness

    • Emotion Dysregulation

    • Distress Tolerance

Histrionic Personality Disorder

• A pervasive pattern of excessive emotionality and attention seeking

  • Inappropriately seductive or provocative behavior

  • Uncomfortable in situations in which s/he is not the center of attention

  • Theatrical style of speech

  • Suggestible, easily influenced by others

  • Rapidly shifting and shallow expression of emotions

  • Considers relationships more intimate than they really are

• Requires 5 of the 8 possible criteria

Histrionic Personality Disorder Prevalence

• General Population: ~1.84%

• Treatment-Seeking Population: 10-15%

Histrionic PD Etiology

Retrospective reports suggests they feel they did not get enough attention from parents

• High in reward dependence: sensitive to negative evaluation

Histrionic PD Treatment

• CBT or psychodynamic therapy

• Get bored easily and continue to see other people as the primary problem

What do Histrionic PD vs. Borderline PD vs. Antisocial PD all have in common?

Cluster B is about manipulating others.

For Histrionic, it is manipulating to gain attention

For borderline personality, it is about gaining care/nurturance

For Antisocial PD, it is about gaining money, power, or sex

Narcissistic Personality disorder Symptoms

• A pervasive pattern of grandiosity, need for admiration, and lack of empathy

  • Preoccupied with fantasies

  • Associates only with high-status others

  • Has a strong sense of entitlement

  • Is interpersonally exploitative

  • Is envious and thinks others are envious of him/her

• Requires 5 out of 9 possible criteria

Narcissistic Personality disorder Prevalence

• Prevalence: 7.7% men, 4.8% women but hard to determine

• According to the DSM, between 50-75% of those diagnosed are male

• Hypothesized to have the same psychological and social factors that contribute to histrionic PD