Module IV: Concept, etiology and assessment strategies of cluster B personality disorders

Concept, causes and development of antisocial, borderline, histrionic and narcissistic personality

disorders

Specific evaluation strategies and intervention tools used in diagnosing and treating

the disorders

Co-morbid disorders

Recent researches in the associated field

ANTISOCIAL PERSONALITY DISORDER

CASE STUDY: ANTISOCIAL PERSONALITY DISORDER

● Individuals with antisocial personality disorder frequently lack empathy and tend to be

callous, cynical, and contemptuous of the feelings, rights, and sufferings of other

● They may have an inflated and arrogant self-appraisal (e.g., feel that ordinary work is

beneath them or lack a realistic concern about their current problems or their future) and

may be excessively opinionated, self-assured, or cocky

● They may display a glib, superficial charm and can be quite voluble and verbally

facile (e.g., using technical terms or jargon that might impress someone who is unfamiliar

with the topic)

 ● These individuals may also be irresponsible and exploitative in their sexual

relationships.

● They may have a history of many sexual partners and may never have sustained a

monogamous relationship

● They may be irresponsible as parents, as evidenced by malnutrition of a child, an

illness in the child resulting from a lack of minimal hygiene, a child's dependence on

neighbors or nonresident relatives for food or shelter, a failure to arrange for a

caretaker for a young child when the individual is away from home, or repeated

squandering of money required for household necessities

● Individuals with antisocial personality disorder are more likely than people in the general

population to die prematurely by violent means (e.g., suicide, accidents, homicides)

Comorbidities

● Individuals with antisocial personality disorder may also experience dysphoria,

including complaints of tension, inability to tolerate boredom, and depressed mood

● They may have associated anxiety disorders, depressive disorders, substance use

disorders, somatic symptom disorder, gambling disorder, and other disorders of

impulse control

● Individuals with antisocial personality disorder also often have personality features that

meet criteria for other personality disorders, particularly borderline, histrionic, and

narcissistic personality disorders

● The likelihood of developing antisocial personality disorder in adult life is increased if

the individual experienced childhood onset of conduct disorder (before age 10 years)

and accompanying attention- deficit/hyperactivity disorder

● Child abuse or neglect, unstable or erratic parenting, or inconsistent parental discipline

may increase the likelihood that conduct disorder will evolve into antisocial personality

disorder

● When antisocial behavior in an adult is associated with a substance use disorder, the

diagnosis of antisocial personality disorder is not made unless the signs of antisocial

personality disorder were also present in childhood and have continued into adulthood

● When substance use and antisocial behavior both began in childhood and continued

into adulthood, both a substance use disorder and antisocial personality disorder

should be diagnosed if the criteria for both are met, even though some antisocial acts

may be a consequence of the substance use disorder (e.g., illegal selling of drugs, thefts

to obtain money for drugs)

● Individuals with antisocial personality disorder and narcissistic personality disorder share

a tendency to be tough-minded, glib, superficial, exploitative, and lack empathy

● In addition, individuals with antisocial personality disorder may not be as needy of the

admiration and envy of others, and persons with narcissistic personality disorder usually

lack the history of conduct disorder in childhood or criminal behavior in adulthood

● Individuals with antisocial personality disorder and histrionic personality disorder share a

tendency to be impulsive, superficial, excitement seeking, reckless, seductive, and

manipulative, but persons with histrionic personality disorder tend to be more

exaggerated in their emotions and do not characteristically engage in antisocial behaviors

● Individuals with histrionic and borderline personality disorders are manipulative to gain

nurturance, whereas those with antisocial personality disorder are manipulative to gain

profit, power, or some other material gratification

 ● Individuals with antisocial personality disorder tend to be less emotionally unstable and

more aggressive than those with borderline personality disorder

Development & Course

● Antisocial personality disorder has a chronic course but may become less evident or

remit as the individual grows older, particularly by the fourth decade of life

● Although this remission tends to be particularly evident with respect to engaging in

criminal behavior, there is likely to be a decrease in the full spectrum of antisocial

behaviors and substance use

● By definition, antisocial personality cannot be diagnosed before age 18 years

Causes

Research suggests that genes play a role in antisocial personality disorder and criminality

● Many studies have compared concordance rates between monozygotic and dizygotic

twins

● Others have used the adoption method, comparing rates of criminal behavior in the

adopted-away children of criminals with rates of criminal behavior in the adopted-away

children of ordinary (noncriminal) parents

○ The results of both kinds of studies show a moderate heritability for antisocial

or criminal behavior (Carey & Goldman, 1997; Hare et al., 2012; Sutker &

Allain, 2001) and for ASPD (Waldman & Rhee, 2006)

● What is inherited, however, is far from clear – It could be impulsivity, low levels of

anxiousness, aggressive tendencies, or a combination of these and other dispositions

Many environmental factors have also been implicated in the development of antisocial

personality disorder

● These include low family income, inner-city living, poor supervision by parents,

having a young mother, being raised in a single-parent family, conflict between

parents, having a delinquent sibling, neglect, large family size, and also harsh

discipline from parents (Farrington, 2006; Granic & Patterson, 2006)

● Other nonshared environmental factors (nonshared because they are not necessarily

experienced by all children in the family) that are important are having delinquent peers,

physical or sexual abuse, and various academic or social experiences

Genotype-environment interaction

● Researchers also note that these environmental influences interact with genetic

predispositions (a genotype-environment interaction) to determine which individuals

become criminals or antisocial personalities (Carey & Goldman, 1997; Hare et al., 2012;

Moffitt, 2005)

● One study by Cadoret and colleagues (1995) found that adopted-away children of

biological parents with ASPD were more likely to develop antisocial personalities if

their adoptive parents exposed them to an adverse environment than if their adoptive

parents exposed them to a more normal environment

○ Adverse environments were characterized by some of the following: marital

conflict or divorce, legal problems, and parental psychopathology

● Similar findings of a gene-environment interaction were also found in twins who were at

high or low risk for conduct disorder (typically a childhood precursor of ASPD); in

this study, the environmental risk factor was physical maltreatment (Jaffee et al., 2005)
● This gene, known as the monoamine oxidase A gene (MAOA gene), is involved in the

breakdown of neurotransmitters like norepinephrine, dopamine, and serotonin – all

neurotransmitters affected by the stress of maltreatment that can lead to aggressive

behavior

Maoa - Neurotransmitter - Stress - Aggressive Behavior

● Researchers found that individuals with low MAOA activity were far more likely to

develop ASPD if they had experienced early maltreatment than were individuals with

high MAOA activity and early maltreatment and individuals with low levels of MAOA

activity without early maltreatment

● The basic finding of MAOA gene-environment interaction has now been replicated in a

large number studies

● The relationship between antisocial behavior and substance abuse is sufficiently strong

that some have questioned whether there may be a common factor leading to both

alcoholism and antisocial personality

● In support of this, research suggests that there is significant genetic involvement in their

high level of comorbidity

● Moreover, one study found that ASPD and other disorders (like alcohol and drug

dependence and conduct disorder) all share a strong common genetic vulnerability;

environmental factors were more important in determining which disorder a

particular person developed (Hicks et al., 2004; Krueger et al., 2007)

● Antisocial individuals may receive their genes from antisocial parents

 ○ In such cases, these parents will likely also expose the child to a home

environment that may provide a model for criminality, or contain risk factors

such as abuse, neglect, parental separations, violence, and a host of other factors

Biological Perspective

● Family inheritance studies provide strong evidence in favor of genetic explanations of

antisocial personality disorder, the personality trait of psychopathy, and antisocial

behavior, with heritability estimates as high as 80%

● Researchers also believe that dependence of the mother on substances such as alcohol

or drugs of abuse during pregnancy can lead to epigenetic influences

● Malnutrition in early life may serve as another risk factor for the development of

antisocial personality disorder

● In a study of children tested from ages 3 to 17, those who experienced poor nutrition at

age 3 showed more aggressiveness and motor activity as they grew older

● By age 17, they had a higher likelihood of conduct disorder, a precursor to antisocial

personality disorder (Liu, Raine, Venables, & Mednick, 2004)

● The hippocampus, the brain structure involved in short-term memory processing,

seems to function abnormally in individuals with psychopathy

● Although the volume of the hippocampus does not seem to differ between psychopath

and non-psychopath samples, these brain structures seem to have abnormal shapes in

people with psychopathy (Boccardi et al., 2010)

● Neuroimaging studies also suggest that people high in psychopathy have deficits in

frontal lobe functioning, meaning that they are less able to inhibit input from subcortical
 areas of the brain that are involved in aggression (Pridmore, Chambers, & McArthur,

2005)

Psychological Perspective

● Closely related to the biological perspective is the hypothesis that antisocial personality

disorder causes neuropsychological deficits reflected in abnormal patterns of learning and

attention

● Cleckley believed that psychopathic individuals lack emotional reactivity

● David Lykken (1957) took this idea into the lab and demonstrated that psychopathic

individuals exposed to aversive stimuli indeed failed to show the normal fear response

● Consequently, they do not learn from their negative experiences

● This deficit of classical conditioning is called passive avoidance, meaning that the

correct responses involve learning to avoid responding to a previously punished stimulus

● Poor passive avoidance learning in people high in the personality trait of

psychopathy may be related to deficits in the activation of limbic system circuits

responsible for emotional processing (Birbaumer et al., 2005)

● People high in psychopathy also have difficulty processing negative emotional stimuli

such as sad facial expressions (Sommer et al., 2006)

● Researchers believe that this emotional processing deficit could relate to the inability that

these individuals have to develop a sense of morality. Because they can’t empathize

with their victims, they do not feel remorse over harming them

● The response modulation hypothesis attempts to explain the failure of individuals high in

psychopathy to learn from negative experience and to process emotional information

(Glass & Newman, 2009)

● According to this explanation, people have a dominant and nondominant focus of their

attention in any given situation. For example, you may be focusing your attention now on

your reading, but at the same time, in the background, you are surrounded by noises such

as music, other students talking, or the sound of traffic

● Although your primary responses right now are to understand what you are reading, you

might switch over to the secondary cues if something changes to require your attention,

such as another student talking directly to you

● You need to pay enough attention to those secondary cues to switch if necessary, but not

so much that you are unable to carry out your primary task

● According to the response modulation hypothesis, individuals high on the trait of

psychopathy are unable to pay enough attention to secondary cues to switch (i.e.,

modulate) their attention when necessary

● Therefore, in a passive avoidance task, they pay attention only to the trials in which they

will receive a reward and do not learn from trials in which they incur punishment

● In their behavior in the outside world, this pattern would translate into a tendency to

focus only on what they can get from a situation (money, power, or other desired goals)

and not consider that if they pursue these rewards that punishment might result

● Similarly, they focus on their own pleasure, but not on the pain they may cause the

people they hurt

● The majority of research on psychopathy is focused on men and, in fact, researchers

primarily developed and tested the response modulation hypothesis on male populations
 ● Interestingly, when researchers examined both emotion processing and passive avoidance

learning in women, they did not find differences between women high and low in

psychopathy

● It is possible that women are better able to attend to nondominant responses compared to

men (Vitale, MacCoon, & Newman, 2011)

● Early life experiences can also serve as important influences on whether an

individual develops antisocial personality disorder.

● The parents of individuals with this disorder are more likely to have been overburdened,

lack parenting skills, and themselves exhibit antisocial behaviors (Lykken, 2000)

Developmental Perspective

● ASPD has its roots in childhood, especially for boys.

● The number of antisocial behaviors exhibited in childhood is the single best predictor of

who will develop an adult diagnosis of ASPD, and the younger the age at which problems

start, the higher the risk (Robins, 1978, 1991)

● Prospective studies have shown that it is children with an early history of oppositional

defiant disorder – characterized by a pattern of hostile and defiant behavior toward

authority figures that usually begins by the age of 6 years, followed by early-onset

conduct disorder around age 9 – who are most likely to develop ASPD as adults

● The second early diagnosis that is often a precursor to adult ASPD is

attention-deficit/hyperactivity disorder (ADHD)

● ADHD is characterized by restless, inattentive, and impulsive behavior, a short attention

span, and high distractibility

 ● When ADHD co-occurs with conduct disorder (which happens in at least 30 to 50

percent of cases), this leads to a high likelihood that the person will develop a severely

aggressive form of ASPD and possibly psychopathy

Assessment of Antisocial Personality Disorder

● Identification of comorbid treatable conditions such as depression or substance misuse

● Careful risk assessment, patient’s history of violence : Historical Clinical Risk- 20

(HCR-20) or the Violence Risk Appraisal Guide (VRAG)

● The severity of psychopathy is determined with the Psychopathy Checklist-Revised

(PCL-R) (Yakeley & Williams, 2014)

● Meloy (1988, 2010) recommends that therapy will be of no benefit and should not be

offered to patients with psychopathy who manifest any of the following features:

○ Sadistic

○ aggressive behaviour resulting in serious injury

○ Complete absence of remorse or justification for such behaviour

○ Very superior or mildly intellectually disabled intelligence

○ A historical absence of capacity to form emotional attachments

● The Personality Diagnostic Questionnaire 4+ (PDQ-4+)

● The Personality Assessment Inventory (PAI)

● The Millon Clinical Multiaxial Inventory-IV (MCMI-IV)

● The Minnesota Multiphasic Personality Inventory-3 (MMPI-3)

● The Wisconsin Personality Disorders Inventory (WISPI-IV)

● Personality Inventory for DSM-5 (PID-5)

● Structured Clinical Interview for DSM-5 Personality Disorders (SCID- PD-5)

 ● Diagnostic Interview for DSM-5 for Personality Disorders (DIPD-5)

● Structured Interview for DSM-5 Personality Disorders (SIDP-5)

Treatment of Antisocial Personality Disorder

● The accepted wisdom for many years in the field of abnormal psychology was that people

with antisocial personality disorder are untreatable, and current therapy effectiveness

studies unfortunately continue to support the difficulty of working with this population

(Wilson, 2014)

● A combination of being unable to learn from negative experiences along with an inability

to experience empathy would seem to make them resistant to approaches involving

either insight or behavioral interventions

● The problems of working with these individuals include the very characteristics of the

disorder itself: a seeming lack of motivation to change, a tendency toward deception

and manipulation, and a lack of deep or lasting emotion

● Reflecting these many difficulties both in working with the population and in defining

reasonable goals of therapy, at present there is no one accepted method of treatment

shown to be effective in reducing the core features of the disorder (Hatchett, 2015)

● Nevertheless therapists can take a pragmatic approach to helping clients satisfy their

needs through prosocial ways (Hooley et al., 2017)

● Motivational interviewing, focused on providing clients with opportunities to connect to

core values and the need for fulfillment, can also be of value as a means to help these

clients make better life decisions (Mitchell, Tafrate, & Freeman, 2015)

● Mentalization Therapy
 ○ If patients with antisocial personality disorder are immobilized, they often

become amenable to psychotherapy. When patients feel that they are among

peers, their lack of motivation for change disappears (Sadock, Sadock, & Ruiz,

2015)

● Pharmacotherapy is used to deal with symptoms such as anxiety, rage, and

depression, but because patients are often substance abusers, drugs must be used

judiciously (Sadock, Sadock, & Ruiz, 2015)

● If a patient shows evidence of attention-deficit/hyperactivity disorder,

psychostimulants such as Ritalin may be useful (Sadock, Sadock, & Ruiz, 2015)

BORDERLINE PERSONALITY DISORDER

CASE STUDY: BORDERLINE PERSONALITY DISORDER

● Individuals with borderline personality disorder may have a pattern of undermining

themselves at the moment a goal is about to be realized (e.g., dropping out of school

just before graduation; regressing severely after a discussion of how well therapy is

going; destroying a good relationship just when it is clear that the relationship could last)

● Some individuals develop psychotic-like symptoms (e.g., hallucinations, body-image

distortions, ideas of reference, hypnagogic phenomena) during times of stress

 ● Individuals with this disorder may feel more secure with transitional objects (i.e., a pet

or inanimate possession) than in interpersonal relationships

● Premature death from suicide may occur in individuals with this disorder, especially in

those with co-occurring depressive disorders or substance use disorders

● Physical handicaps may result from self-inflicted abuse behaviors or failed suicide

attempts

● Recurrent job losses, interrupted education, and separation or divorce are common

● Physical and sexual abuse, neglect, hostile conflict, and early parental loss are more

common in the childhood histories of those with borderline personality disorder

Comorbidities

● Common co-occurring disorders include depressive and bipolar disorders, substance

use disorders, eating disorders (notably bulimia nervosa), posttraumatic stress

disorder, and attention- deficit/hyperactivity disorder

● Borderline personality disorder also frequently co-occurs with the other personality

disorders

● Although histrionic personality disorder can also be characterized by attention seeking,

manipulative behavior, and rapidly shifting emotions, borderline personality disorder

is distinguished by self- destructiveness, angry disruptions in close relationships, and

chronic feelings of deep emptiness and loneliness

● Paranoid ideas or illusions may be present in both borderline personality disorder and

schizotypal personality disorder, but these symptoms are more transient, interpersonally

reactive, and responsive to external structuring in borderline personality disorder

 ● Although paranoid personality disorder and narcissistic personality disorder may also be

characterized by an angry reaction to minor stimuli, the relative stability of self-image, as

well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns,

distinguishes these disorders from borderline personality disorder

● Although antisocial personality disorder and borderline personality disorder are both

characterized by manipulative behavior, individuals with antisocial personality disorder

are manipulative to gain profit, power, or some other material gratification, whereas the

goal in borderline personality disorder is directed more toward gaining the concern of

caretakers

● Both dependent personality disorder and borderline personality disorder are characterized

by fear of abandonment; however, the individual with borderline personality disorder

reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas

the individual with dependent personality disorder reacts with increasing appeasement

and submissiveness and urgently seeks a replacement relationship to provide caregiving

and support

● Borderline personality disorder can further be distinguished from dependent personality

disorder by the typical pattern of unstable and intense relationships

Development & Course

● There is considerable variability in the course of borderline personality disorder

● The most common pattern is one of chronic instability in early adulthood, with episodes

of serious affective and impulsive dyscontrol and high levels of use of health and

mental health resources

 ● The impairment from the disorder and the risk of suicide are greatest in the young-

adult years and gradually wane with advancing age

● Although the tendency toward intense emotions, impulsivity, and intensity in

relationships is often lifelong, individuals who engage in therapeutic intervention

often show improvement beginning sometime during the first year

● During their 30s and 40s, the majority of individuals with this disorder attain greater

stability in their relationships and vocational functioning

● Follow-up studies of individuals identified through outpatient mental health clinics

indicate that after about 10 years, as many as half of the individuals no longer have a

pattern of behavior that meets full criteria for borderline personality disorder

Causes

● BPD appears to have high heritability (42 to 68%)

● BPD runs in families. The risk of having a BPD diagnosis was found to be four times

higher in the biological relatives of patients with BPD than it was in the relatives of

people who did not have a diagnosis of BPD (Gunderson et al., 2011)

● Genes result in heritability of certain personality traits – traits such as neuroticism or

impulsivity that are prominent aspects of BPD (Hooley et al., 2012; Paris, 2007)

● These inherited traits are also not specific to BPD but instead result in risk for a range of

other psychopathological conditions as well

● This helps explain why we see mood and anxiety disorders, impulse control disorders,

and other personality disorders in the family members of people diagnosed with BPD

(Zanarini et al., 2009)

Brain
 ● Areas of the brain that appear abnormal in individuals with BPD include the amygdala

and prefrontal cortex, regions involved in emotional processing and regulation

● Neuroimaging studies suggest that BPD is associated with increased amygdala

activation in emotion-inducing situations, as well as with reduced prefrontal

regulation (Leichsenring et al., 2011)

● Another problem is that BPD is a very complicated and may involve a very large number

of genes (Hooley et al., 2017)

● Yet another reason is that the influence of environmental factors is very rarely taken into

account (Hooley et al., 2017)

● Stressful early experiences may create long-term dysregulation of the hypothalamic-

pituitary-adrenal (HPA) and shape brain development, perhaps compromising key

brain circuits that are involved in emotion regulation (Hooley et al., 2017)

Psychological

● Although biological factors may certainly create a vulnerability to developing BPD, the

psychological perspective is more prominent in the approach taken by clinicians who

provide treatment

● Disturbances in emotional functioning form an important component of the diagnosis

of BPD and correspondingly, researchers have focused their efforts on identifying the

specific psychological processes that contribute to these emotional disturbances

● Cognitive theorists emphasize the importance of maladaptive schemas revolving around

the need for attention to validate self- worth

● Core dysfunctional beliefs might include “Unless I captivate people, I am nothing” and

“If I can’t entertain people, they will abandon me” (Beck et al., 1990)
 ● No systematic research has yet explored how these dysfunctional beliefs might develop

(Hooley et al., 2017)

Enivonmental

● This is important because environmental factors are thought to account for the largest

proportion (55%) of variance in borderline traits

● It is likely that environmental influences interact with genes to determine who will

develop problems at a later point

● Rather than looking for genes that are linked to specific disorders, we should perhaps be

looking for genes that might play a role in making us more or less susceptible to the

positive and negative aspects of our environments (Amad et al., 2014)

● Early life experiences have long been linked to BPD (Hooley et al., 2017

● Importantly, two prospective community-based studies have shown that childhood

adversity increases the risk of developing BPD in adulthood (Johnson et al., 1999;

Widom et al., 2009)

● These studies are consistent with a wealth of retrospective research showing that people

with this disorder usually report a large number of negative and sometimes traumatic

events in childhood (Hooley et al., 2017)

In one large study on abuse and neglect, Zanarini and colleagues (1997) reported on the results

of detailed interviews of over 350 patients with BPD and over 100 patients with other personality

disorders

● Patients with BPD reported significantly higher rates of abuse than did patients with

other personality disorders (which were also quite high): emotional abuse (73% vs. 51%),

physical abuse (59% vs. 34%), and sexual abuse (61% vs. 32%)
 ● Overall, about 90% of patients with BPD reported some type of childhood abuse or

neglect

Assessment of Borderline Personality Disorder

○ The McLean Screening Instrument for Borderline Personality Disorder (MSI-

BPD)

○ Personality Assessment Inventory-Borderline Features Scale (PAI-PD)

○ Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD)

○ Structured Clinical Interview for DSM-5 Personality Disorders (SCID- PD-5)

○ Diagnostic Interview for DSM Personality Disorders (DIPD)

○ Structured Interview for DSM Personality (SIDP)

○ Revised Diagnostic Interview for Borderlines (DIB-R)

Treatment of Borderline Personality Disorder

● Of all personality disorders, most clinical and research attention has been paid to the

treatment of BPD. This is due to the severity of this disorder and the high risk of suicide

that is associated with it (Hooley et al., 2017)

● Psychological treatment is considered essential. Medications are also used, although

most appropriately in a time-limited way and as an adjunct to psychological treatment

approaches (Bateman et al., 2015)

● Psychosocial Treatments – Clinical trials suggest that several types of psychotherapy

may be effective for BPD. However, these treatments share two common weaknesses:

their relative complexity and long duration, both of which make them challenging to

disseminate to the broader population (Paris, 2009)

● Patients act out their impulses, and show labile or fixed negative or positive

transferences, which are difficult to analyze (Sadock, Sadock, & Ruiz, 2015)

● Projective identification may also cause countertransference problems when therapists

are unaware that patients are unconsciously trying to coerce them to act out a particular

behavior (Sadock, Sadock, & Ruiz, 2015)

● The splitting defense mechanism causes patients to alternately love and hate therapists

and others in the environment (Sadock, Sadock, & Ruiz, 2015)

● Therapists have used behavior therapy to control patients' impulses and angry

outbursts and to reduce their sensitivity to criticism and rejection (Sadock, Sadock, &

Ruiz, 2015)

● Social skills training, especially with videotape playback, helps enable patients to see

how their actions affect others and thereby improve their interpersonal behavior (Sadock,

Sadock, & Ruiz, 2015)

● Patients with borderline personality disorder often do well in a hospital setting in which

they receive intensive psychotherapy on both an individual and a group basis (Sadock,

Sadock, & Ruiz, 2015)

● In a hospital, they can also interact with trained staff members from a variety of

disciplines and can be provided with occupational, recreational, and vocational therapy

(Sadock, Sadock, & Ruiz, 2015)

● Such programs are especially helpful when the home environment is detrimental to a

patient's rehabilitation because of intrafamilial conflicts or other stresses, such as parental

abuse (Sadock, Sadock, & Ruiz, 2015)

 ● Under ideal circumstances, patients remain in the hospital until they show marked

improvement, up to 1 year in some cases (Sadock, Sadock, & Ruiz, 2015)

● Patients can then be discharged to special support systems, such as day hospitals, night

hospitals, and halfway houses (Sadock, Sadock, & Ruiz, 2015)

Dialectical Behavior Therapy

● DBT was developed by Marsha Linehan, is a unique kind of cognitive and behavioral

therapy specifically adapted for BPD (Linehan, 1993; Lynch & Cuper, 2012; Neacsiu &

Linehan, 2014)

● Linehan (who once struggled with BPD herself) believes that patients’ inability to

tolerate strong states of negative affect is central to this disorder

● One of the primary goals of treatment is to encourage patients to accept this negative

affect without engaging in self-destructive or other maladaptive behaviors

● Accordingly, Linehan has developed a problem-focused treatment based on a clear

hierarchy of goals, which prioritizes decreasing suicidal and self-injurious behavior

and increasing coping skills

● The therapy combines individual and group components

● In the group setting, patients learn interpersonal effectiveness, emotion regulation, and

distress tolerance skills

● The individual therapist, in turn, uses therapy sessions to help the patient identify and

change problematic behavior patterns and apply newly learned skills effectively.

● Dialectical behavior therapy (DBT) appears to be an efficacious treatment for BPD

(Binks et al., 2006; Neacsiu & Linehan, 2014)

 ● However, there are still not enough randomized controlled trials to say whether it works

as well in men as in women (Lynch & Cuper, 2012)

● Patients receiving DBT show reductions in self-destructive and suicidal behaviors as

well as in levels of anger (Linehan et al., 2006; Lynch et al., 2007)

● Evidence also suggests that these gains are sustainable (Zanarini et al., 2005). As a

result of Linehan’s many efforts to help clinicians learn her methods, DBT is increasingly

available to patients

● Briefer versions of the treatment are also being developed (Hooley et al., 2017)

Transference-Focused Psychotherapy

● Another psychosocial treatment for BPD involves a variant of psychodynamic

psychotherapy

● Kernberg (1985, 1996) and his colleagues developed a form of psychodynamic

psychotherapy called transference-focused psychotherapy

● The primary goal is seen as strengthening the weak egos of these individuals, with a

particular focus on their defense mechanism of splitting

● This leads them to black-and-white, all-or-none thinking, as well as to rapid shifts in

their reactions to themselves and to other people (including the therapist) as “all good”

or “all bad”

● One major goal is to help patients see the shades of gray between these extremes and

integrate positive and negative views of themselves and others into more nuanced

views

● Although this treatment is often expensive and time consuming (often lasting a number

of years), it has been shown to be as effective as DBT (Clarkin et al., 2007)

Mentalization Therapy

● Bateman and Fonagy (2010) have developed a new therapeutic approach called

mentalization

● This uses the therapeutic relationship to help patients develop the skills they need to

accurately understand their own feelings and emotions, as well as the feelings and

emotions of others

● Moreover, many clinical improvements seem to be maintained even after an 8-year

follow-up (Bateman & Fonagy, 2008)

● Mentalization allows a person to be attentive to the mental states of oneself and of

others

● Mentalization Therapy is based on a theory that borderline personality symptoms, such as

difficulty regulating emotions and managing impulsivity, are a result of patients'

reduced capacities to mentalize (Sadock, Sadock, & Ruiz, 2015)

● Clients are helped to identify their feelings, can also help these individuals gain control

over their dysfunctional thoughts and corresponding emotions (Caligor, Levy, &

Yeomans, 2015)

1. In the early steps, the therapist provides support and empathy, an essential ingredient

of much psychotherapy

2. Moving to next steps, therapists then help clients clarify and elaborate on what they’re

feeling by putting their feelings at the moment into words (asked to put feelings into

words)

3. Now they can start to identify their own feelings and where those feelings originate
 4. Finally, clients learn how to use what they gained through putting feelings into words

with their therapist to the relationships with people in their lives outside of therapy

(Daubney & Bateman, 2015)

● Thus, it is believed that recovery of mentalization helps patients build relationship skills

as they learn to better regulate their thoughts and feelings (Sadock, Sadock, & Ruiz,

2015)

● Mentalization Therapy was found to be effective for borderline personality disorder in

several randomized, controlled research trials (Sadock, Sadock, & Ruiz, 2015)

Biological Treatments

● Many patients with BPD are taking multiple medications

● Yet there is little evidence to support their use (Bateman et al., 2015)

● Antidepressant medications (most often from the selective serotonin reuptake

inhibitors [SSRI] category) are widely used, although there is no compelling evidence

that they are effective (Hooley et al., 2017)

 ● They are most appropriate only when patients have a comorbid mood disorder (Silk &

Feurino, 2012)

● Some antipsychotic medications (risperidone) and mood stabilizers (lithium) may

slightly reduce symptoms over the short term

● Antipsychotics have been used to control anger, hostility, and brief psychotic episodes

(Sadock, Sadock, & Ruiz, 2015)

HISTRIONIC PERSONALITY DISORDER

CASE STUDY: HISTRIONIC PERSONALITY DISORDER

● Individuals with histrionic personality disorder may have difficulty achieving emotional

intimacy in romantic or sexual relationships

● Without being aware of it, they often act out a role (e.g., "victim" or "princess") in their

relationships to others

● They may seek to control their partner through emotional manipulation or

seductiveness on one level, while displaying a marked dependency on them at another

level

● Individuals with this disorder often have impaired relationships with same-sex friends

because their sexually provocative interpersonal style may seem a threat to their

friends' relationships

● These individuals may also alienate friends with demands for constant attention. They

often become depressed and upset when they are not the center of attention
 ● They may crave novelty, stimulation, and excitement and have a tendency to become

bored with their usual routine

● These individuals are often intolerant of, or frustrated by, situations that involve delayed

gratification, and their actions are often directed at obtaining immediate satisfaction

● Although they often initiate a job or project with great enthusiasm, their interest may lag

quickly

● Longer-term relationships may be neglected to make way for the excitement of new

relationships

● The actual risk of suicide is not known, but clinical experience suggests that individuals

with this disorder are at increased risk for suicidal gestures and threats to get attention

and coerce better caregiving

● Histrionic personality disorder has been associated with higher rates of somatic

symptom disorder, conversion disorder (functional neurological symptom disorder), and

major depressive disorder

Comorbities

● Borderline, narcissistic, antisocial, and dependent personality disorders often co-occur

● Although borderline personality disorder can also be characterized by attention seeking,

manipulative behavior, and rapidly shifting emotions, it is distinguished by self-

destructiveness, angry disruptions in close relationships, and chronic feelings of deep

emptiness and identity disturbance

● Individuals with antisocial personality disorder and histrionic personality disorder share a

tendency to be impulsive, superficial, excitement seeking, reckless, seductive, and

manipulative, but persons with histrionic personality disorder tend to be more

 exaggerated in their emotions and do not characteristically engage in antisocial

behaviors

● Individuals with histrionic personality disorder are manipulative to gain nurturance,

whereas those with antisocial personality disorder are manipulative to gain profit, power,

or some other material gratification

● Although individuals with narcissistic personality disorder also crave attention from

others, they usually want praise for their '"superiority," whereas individuals with

histrionic personality disorder are willing to be viewed as fragile or dependent if this is

instrumental in getting attention

● Individuals with narcissistic personality disorder may exaggerate the intimacy of their

relationships with other people, but they are more apt to emphasize the "VIP" status

or wealth of their friends

● In dependent personality disorder, the individual is excessively dependent on others for

praise and guidance, but is without the flamboyant, exaggerated, emotional features of

individuals with histrionic personality disorder

Causes

● There is some evidence for a genetic link with antisocial personality disorder, the idea

being that there may be some common underlying predisposition that is more likely to be

manifested in women as histrionic personality disorder and in men as antisocial

personality disorder

● The suggestion of some genetic propensity to develop this disorder is also supported by

findings that histrionic personality disorder may be characterized as involving extreme

versions of two common, normal personality traits, extraversion and, to a lesser extent,
 neuroticism – two normal personality traits known to have a partial genetic basis

(Widiger & Bornstein, 2001)

Assessment of Histrionic Personality Disorder

● Millon Clinical Multiaxial Inventory (MCMI-IV)

● Minnesota Multiphasic Personality Inventory-3 (MIMPI-3)

● Personality Diagnostic Questionnaire-Revised (PDQ-R)

● Brief Histrionic Personality Scale (BHPS)

● Temperament & Character Inventory (TCI)

● Personality Inventory for DSM-5 (PID-5)

● Structured Interview for DSM Personality Disorders-5 (SIDP-5)

Treatment of Histrionic Personality Disorder

Psychotherapy

● Patients with histrionic personality disorder are often unaware of their own real feelings;

clarification of their inner feelings is an important therapeutic process (Sadock,

Sadock, & Ruiz, 2015)

● Psychoanalytically oriented psychotherapy, whether group or individual, is probably

the treatment of choice for histrionic personality disorder (Sadock, Sadock, & Ruiz,

2015)

Pharmacotherapy

● Pharmacotherapy can be adjunctive when symptoms are targeted (e.g., the use of

antidepressants for depression and somatic complaints, antianxiety agents for

anxiety, and antipsychotics (Sadock, Sadock, & Ruiz, 2015)

NARCISSISTIC PERSONALITY DISORDER

CASE STUDY: NARCISSISTIC PERSONALITY DISORDER
● Interpersonal relations are typically impaired because of problems derived from

entitlement, the need for admiration, and the relative disregard for the sensitivities of

others

● Though overweening ambition and confidence may lead to high achievement,

performance may be disrupted because of intolerance of criticism or defeat

● Sometimes vocational functioning can be very low, reflecting an unwillingness to take

a risk in competitive or other situations in which defeat is possible

 ● Sustained feelings of shame or humiliation and the attendant self-criticism may be

associated with social withdrawal, depressed mood, and persistent depressive disorder

(dysthymia) or major depressive disorder

● In contrast, sustained periods of grandiosity may be associated with a hypomanic mood

● Narcissistic personality disorder is also associated with anorexia nervosa and substance

use disorders (especially related to cocaine)

● Histrionic, borderline, antisocial, and paranoid personality disorders may be associated

with narcissistic personality disorder

Development & Course

● Narcissistic traits may be particularly common in adolescents and do not necessarily

indicate that the individual will go on to have narcissistic personality disorder

● Individuals with narcissistic personality disorder may have special difficulties adjusting

to the onset of physical and occupational limitations that are inherent in the aging process

Causes

● For a long time there was a great deal of theory but precious little empirical data on the

environmental and genetic factors involved in the etiology of narcissistic personality

disorder (Kohut & Wolff, 1978; Millon & Davis, 1995; Widiger & Bornstein, 2001)

● Fortunately, a number of researchers are now actively trying to understand the causes of

this fascinating disorder

● A key finding has been that the grandiose and vulnerable forms of narcissism are

associated with different causal factors

 ● Grandiose narcissism has not generally been associated with childhood abuse,

neglect, or poor parenting. Indeed, there is some evidence that grandiose narcissism is

associated with parental overvaluation

● By contrast, vulnerable narcissism has been associated with emotional, physical, and

sexual abuse, as well parenting styles characterized as intrusive, controlling, and cold

(Horton et al., 2006; Miller, 2011; Miller & Campbell, 2008; Otway & Vignoles, 2006)

Assessment of Narcissistic Personality Disorder

● The Narcissistic Personality Inventory-16 (NPI-16)

● Five Factor Narcissism Inventory (FFNI)

● Narcissistic Admiration & Rivalry Questionnaire (NARQ)

● Pathological Narcissistic Inventory (PNI)

● Hypersensitive Narcissism Scale (HSNS)

● Personality Inventory for DSM-5 (PID-5)

● Personality Assessment Inventory (PAI)

● Personality Diagnostic Questionnaire-4+ (PDQ-4+)

● Structure Clinical Interview for DSM-5 Personality Disorders (SCID-PD-5)

Treatment of Narcissistic Personality Disorder

Psychotherapy

● Because patients must renounce their narcissism to make progress, the treatment of

narcissistic personality disorder is difficult (Sadock, Sadock, & Luiz, 2015)

● Psychiatrists such as Kerberg and Heinz Kohut have advocated using psychoanalytic

approaches to effect change, but much research is required to validate the diagnosis and

to determine the best treatment (Sadock, Sadock, & Luiz, 2015)

 ● Some clinicians advocate group therapy for their patients so they can learn how to

share with others and, under ideal circumstances, can develop an empathic response to

others (Sadock, Sadock, & Luiz, 2015)

● Unfortunately, people with ND are difficult to treat because they tend not to have

insight into their disorder (Whitbourne-Krauss, 2017)

● Moreover, the therapists who treat them may experience strong negative reactions to

them due to the very nature of their symptoms of grandiosity and entitlement, making

them critical and demeaning of their therapists (Dhawan, Kunik, Oldham, & Coverdale,

2010)

● Their extreme perfectionism can also obstruct treatment. Clients with ND have filled

their lives with success and accomplishments that preserve their self-esteem and ward

off their insecurities (Whitbourne-Krauss, 2017)

● As a result, it is particularly difficult for them to confront their anxieties and inner

securities (Ronningstam, 2011)

Pharmacotherapy

● Lithium (Eskalith) has been used with patients whose clinical picture includes mood

swings

● Because patients with narcissistic personality disorder tolerate rejection poorly and are

susceptible to depression, antidepressants, may also be of use (Sadock, Sadock, & Luiz,

2015)
 ASSESSMENT & TREATMENT

Characteristics and Management Strategies for Cluster B Personality Disorders

- They may attempt to create relationships that cross professional boundaries and to place

physicians in difficult positions

- Physicians often experience strong emotional reactions to these patients

- When dealing with such patients, physicians must be keenly aware of the issues of

manipulative behavior, professional boundaries, limit setting, and monitoring their own

emotional state

CAUSES

Biological Risk Factors for Dramatic Personality Disorders

● Dramatic personality disorders have moderate genetic predispositions, with heritability

estimates of 0.32 to 0.50 (Kendler et al., 2011)

● Impulsivity/aggression is most associated with borderline and antisocial personality

disorder
● People high on the impulsive/aggressive dimension, have a low threshold for action and

often act without deliberating

● They do not anticipate well the potential negative consequences of their actions and do

not profit from past experience or knowledge of negative consequences

● Impulsive aggression is associated with reduced serotonin (Coccaro, Fanning, Phan,

& Lee, 2015)

● Psychopathy in adults and conduct disorder in boys are also associated with reduced

brain size in areas that may be related to moral development→These areas include

the amygdala, frontal and temporal cortexes, superior temporal gyrus, and

hippocampus (Del Casale et al., 2015)

● Impulsivity in borderline personality disorder may relate as well to dysfunction of the

orbitofrontal cortex (Krause-Utz, Winter, Niedtfeld, & Schmahl, 2014)

● Another dimension important to dramatic personality disorders is affective instability

(Carpenter & Trull, 2013)

● People high on this trait are prone to rapid, intense mood shifts when frustrated,

criticized, or separated from others

● The noradrenergic neurotransmitter system is most closely associated with these

mood shifts

● People with significant mood shifts may be hypersensitive to fluctuations in the

noradrenergic neurotransmitter system

● Affective instability in borderline personality disorder may relate as well to poor

functioning in the frontal cortex and other areas important for emotion – hippocampus,
 amygdala, basal ganglia, & thalamus (Ruocco, Amirthavasagam, Choi-Kain, & McMain,

2013)

● Antisocial behavior and affective instability, which are large parts of the dramatic

personality disorders, also appear to have significant genetic predispositions (Broome,

He, Iftikhar, Eyden, & Marwaha, 2015)

● Antisocial behavior in particular demonstrates a strong family history (McCuish,

Lussier, & Corrado, 2015)

● These behaviors include anxiety, anhedonia (severe depression), disinhibition, and

oppositionality (Kendler, Aggen, & Patrick, 2012)

● Dramatic personality disorders are likely caused by genetic predispositions and family-

based stressors

● A family history of depressive, bipolar, substance use, or antisocial personality disorder

likely serves as a genetic diathesis

● This genetic diathesis directly influences family environmental (child maltreatment or

poor parental bonding) and neurobiological (impulsive aggression, affective instability)

factors related to dramatic personality disorders. Family environmental factors influence,

and are influenced by, cognitive beliefs such as “I need what I want now” and personality

traits such as emotional dysregulation that comprise dramatic personality disorders

● Neurobiological factors such as noradrenergic dysfunction also influence these cognitive

beliefs and personality traits

Environmental Risk Factors for Dramatic Personality Disorders

● Child maltreatment relates closely to dramatic personality disorders

 ● Antisocial personality disorder may develop because of traumatic childhood

experiences, such as physical or sexual maltreatment, aggressive parents, divorce, and

inconsistent parental discipline (Glenn et al., 2013; Shi, Bureau, Easterbrooks, Zhao, &

Lyons-Ruth, 2012)

● Borderline personality disorder relates to childhood sexual maltreatment and poor

parental bonding with a child due to perceived abandonment or actual separation (Trull,

2015)

● Various parent-child relationships likely influence histrionic personality disorder,

including one in which parental love and attention depends on a child’s attractiveness

and sexual provocativeness (Sperry, 2015)

● One result might be that a daughter’s self-worth depends primarily on how her father

relates to her, and this pattern may repeat itself in adulthood with other men

● Psychosocial theories of narcissistic personality disorder primarily focus on underlying

feelings of inadequacy that drive one to seek recognition from others (Roepke & Vater,

2014)

Several cognitive beliefs also underlie symptoms of dramatic personality disorders

● Some believe that deception, lying, cheating, and seductiveness are acceptable ways

of securing one’s needs

● These beliefs can lead to aggressive or provocative interpersonal styles and problems that

characterize antisocial and other dramatic personality disorders

Examples of Cognitions Associated with Dramatic Personality Disorders

1. I should be the center of attention (histrionic).

2. I cannot tolerate boredom (histrionic).

3. Other people should satisfy my needs (narcissistic).

4. Lying and cheating are okay as long as you don't get caught (antisocial).

5. fI Iwant something, Ishould do whatever is necessary to get ti (antisocial).

Reprinted from Beck et al. (1990), pp. 359-363.