Cluster B Personality Disorders

Question 1

Most common comorbidity of antisocial personality disorder

Answer 1

Any substance use disorder

Highly comorbid

Question 2

Acting out

Answer 2

Defense mechanism in which an individual directly expresses unconscious wishes or conflicts through action to avoid being conscious of uncomfortable accompanying ideas or affects

Question 3

Projective identification

Answer 3

A defense mechanism that helps an individual deal with emotional conflict or stressors by falsely attributing to another person the individual’s own unacceptable feelings, impulses, or thoughts.

Not infrequently, the individual induces in others the very feelings that he or she first mistakenly believed to be there, thus setting into motion a self-fulfilling prophecy.

Question 4

Antisocial personality “burn out”

Answer 4

The symptoms of antisocial personality disorder tend to burn out after age 30, but features of irritability, impulsivity, and detachment continue

Question 5

Major features of antisocial personality disorder

Answer 5

Pattern of pervasive disregard for and violation of the rights of others starting by age 15 and continuing into adulthood

No conscience or remorse regarding their activities

Reckless disregard for the safety of others

Question 6

In order to make a formal diagnosis of antisocial personality disorder, the individual must. . .

Answer 6

1. Be 18 years of age or older
2. Have had a diagnosis of conduct disorder in childhood with onset before age 15 OR have history consistent with this diagnosis without having been formally diagnosed

Question 7

Interviewing tips for patients with ASPD

Answer 7

Firm, no-nonsene approach. Clear limit setting.

Clinicians should be careful not to become punitive because of their anger over the patient’s lack of remorse.

If the interviewer feels genuinely frightened of the patient, they can simply leave if necessary.

Question 8

Antisocial should NOT be diagnosed, even when all criteria are met, when it occurs in the context of. . .

Answer 8

. . . a primary substance use disorder that appears to drive actions and effect emotional response/capacity

The two may coexist, so this can be tricky. A very careful history is necessary to untangle them.

Similarly, the diagnosis should not be made if antisocial behavior occurs only during the course of bipolar disorder or schizophrenia.

Question 9

Treatment of antisocial personality disorder

Answer 9

• Generally focused on reducing impulsive or aggressive behaviors rather than on a “cure”
• SSRIs, mood stabilizers, and antipsychotics all have value in reducing aggressive symptoms
• Beta blockers have also been shown to reduce aggression
• Group therapy is helpful as this reduces the amount of rationalization and evasion shown by others in the group because patterns are recognized

Question 10

The only diagnosis in the DSM system in which an individual must have had a preceding disorder in adolescence

Answer 10

Anti-social personality

In order to diagnose, a prior diagnosis of conduct disorder is required

Question 11

For patients older than 18, a diagnosis of conduct disorder is given only if. . .

Answer 11

. . . the criteria for ASPD are not met

Question 12

Defense mechanisms commonly seen in patients with ASPD

Answer 12

Acting out

Projective Identification

Question 13

Dissociation

Answer 13

Defense mechanism in which an individual deals with emotional conflict or stressors with a breakdown in the usually integrated functions of consciousness, memory, perception of the self or environment, or sensory/motor behavior

Question 14

Elements of a histrionic personality

Answer 14

Attention-seeking behavior

Dramatic exaggeration

Excessive, but shallow, emotionality (often with lability)

Seductive manner / inability to recognize inappropriate sexual behavior

Question 15

If a patient meets criteria for more than one personality disorder. . .

Answer 15

. . . then all can be diagnosed

They are not mutually exclusive.

Question 16

Top ddx for histrionic personality

Answer 16

Borderline personality

They can be quite hard to distinguish at times

It is useful to evaluate whether or not splitting is present when trying to differentiate them.

Question 17

Treatment of histrionic personality disorder

Answer 17

• Setting clear professional boundaries is important with these patients, as they often lack the insight to determine what behaviors are and are not appropriate
• Supportive psychotherapy to help improve defense mechanisms and understand emotions is the main therapy
  
  • They may also benefit from group or individual therapy
• Treat co-morbid psychiatric conditions with medication as indicated

Question 18

___ is a common comorbidity for all Cluster B personality disorders

Answer 18

Substance use disorder is a common comorbidity for all Cluster B personality disorders

Question 19

Defense mechanisms most associated with histrionic personality disorder

Answer 19

Dissociation

Repression

Question 20

Devaluation

Answer 20

A defense mechanism by which an individual deals with emotional conflict or stress by attributing exaggerated negative qualities to themselves or to others

This behavior can alternate with idealization.

Ex: A patient states that her therapist is “the worst clinician in the world”

Question 21

Treatment of narcissistic personality disorder

Answer 21

• Validation of the patient’s experience is key
• Appeals to the patient’s narcissism can actually aid the therapeutic relationship
• Psychotherapy is often challenging and terminates whenever confrontation is attempted
• Psychopharmacology is uesful in treating comorbid conditions and lability:
  
  • Lithium for affective lability
  • SSRIs for depressive symptoms

Question 22

Features of narcissistic personality disorder

Answer 22

Pervasive pattern of grandiosity

Need for admiration

Lack of empathy for others

Question 23

When narcissistic patients seek psychiatric help, it is usually not for their grandiosity (for which they have poor insight), but rather for. . .

Answer 23

. . . anger or depression

Question 24

Defense mechanisms most associated with narcissistic personality disorder

Answer 24

• Devaluation
• Idealization
• Denial

Question 25

Borderline personality and psychosis

Answer 25

Patients with BPD can become psychotic. It is a known possibility associated with this diagnosis, and should not rule it out.

These episodes are generally transient, but there is typically no signs of another thought disorder or schizophrenia.

Question 26

Simplified diagnostic criteria for borderline personality disorder

Answer 26

• A. Evidence of impaired personality functioning:
  
  • 1. Impairment in self functioning manifested as lack of identity or lack of self direction
  • AND
  • 2. Impairment in interpersonal functioning manifested as lack of empathy or unstable intimacy
• B.Pathologic personaity traits in the domains of negative or labile affect, disinhibition/impulsivity, antagonism/hostility
• C. Impairments are stable across time and situations

Question 27

Way to counteract the likely devaluation in working with a patient with borderline personality

Answer 27

Expectation setting

As in, “Although this is a great place to get better, it is a lot of work and it will be hard”

Decreasing the patient’s idealization can help to prevent future devaluation

Question 28

Histronic personality vs borderline personality

Answer 28

Lability is a common feature, and is very prominent in both disorders

However, patients with a histronic personality lack the chronic feelings of emptiness or loneliness and the constant angry disruptions in relationships seen in BPD.

Question 29

Defense mechanisms used by patients with borderline personality disorder

Answer 29

Splitting

Idealization and devaluation (often going together)

Projection

Projection identification

Distortion

Acting Out