Approach to antisocial, borderline, histrionic, and narcissistic (cluster B) personality disorders: Clinical sciences

Personality disorders represent an enduring and pervasive pattern of perceiving and relating to oneself, others, and the world in an atypical, and often detrimental, way.

Unlike most psychiatric conditions, personality disorders are frequently ego-syntonic, meaning many people with personality disorders do not perceive their behaviors as problematic. Consequently, these disorders typically do not cause direct distress to the individual but can lead to significant interpersonal and occupational difficulties.

There are ten personality disorders defined in the Diagnostic and Statistical Manual of Mental Disorders fifth edition, or DSM-5TR for short, and these are divided into clusters A, B, and C. Cluster B personality disorders include antisocial personality disorders, borderline personality disorders, narcissistic personality disorders, and histrionic personality disorders.

Now, when a patient presents with a chief concern suggesting a personality disorder, first obtain a focused history and physical exam. Symptoms might include significant interpersonal or occupational difficulties, patterns of hyper-dependence or hyper-independence with others, and a tendency to blame others for their own feelings and behaviors. Additionally, you might find frequent or extreme mood swings, angry outbursts, and attention seeking behaviors.

Keep in mind many of these traits might be reported by family, teachers, or friends. The physical exam is often unremarkable, but you might notice extremes of affect, ranging from flat to exaggerated facial expressions during your interaction with the patient. With these findings, consider a personality disorder.

Your next step is to assess your patient for a general personality disorder using the DSM-5 criteria. All personality disorders are characterized by an enduring pattern of thinking, feeling, and behaving in culturally atypical ways, and these traits are inflexible and maladaptive in multiple settings. The onset of this pattern must be during adolescence or early adulthood, although traits may be recognized at much younger ages. Additionally, the patient’s symptoms must cause clinically significant distress or impairment. If these criteria are met, you can diagnose a personality disorder.

After identifying a general personality disorder, you should assess for key personality traits to help you determine the cluster type. Here’s a high-yield fact! There are 3 major clusters of personality disorders: A, B, and C

You can remember them by the group name. Cluster A disorders include paranoid which is accusatory; schizoid is aloof; and schizotypal which can be described as atypical. With B disorders, think narcissistic is the best; histrionic boast; antisocial break laws; and borderline... well there is already a B in there. Lastly, for cluster C, avoidant can be described as cowardly; dependent as clingy; while obsessive-compulsive doesn’t need really additional descriptions.

If the patient exhibits dramatic, emotional, or erratic traits, consider cluster B personality disorders. Okay, once you suspect a cluster B personality disorder, assess for a history of criminal behavior.

If present, common behavior patterns include criminality, or repeated unlawful behavior, and deceitfulness like lying to and conning others. Individuals can also display a pattern of impulsivity, where they fail to plan ahead and have little regard for the consequences of their actions. Additionally, they are frequently irritable and prone to aggressive behavior, leading to physical fights or assaults, and display reckless disregard for the safety of themselves and others. Family and employers often report consistent irresponsibility with repeated failure to meet reasonable expectations. Finally, some individuals can have limited capacity for empathy and lack remorse for the pain they have caused others.

If many of these features are present, you should consider antisocial personality disorder, or ASPD, and assess using the DSM-5 criteria. This includes at least three of the behavior patterns from history. The onset must be by 15 years of age; however, diagnosis of ASPD cannot be made until the patient is 18 years or older. If these criteria are met, diagnose antisocial personality disorder.

Here’s a clinical pearl! Oppositional defiant disorder, or ODD, and conduct disorder are in the developmental pathway of antisocial personality disorder. ODD typically describes school-aged children who display a pattern of angry and irritable mood and argumentative and defiant behaviors. Children with ODD who are also aggressive and vindictive are more likely to develop conduct disorder, which describes a child or teen who repeatedly and persistently violates the rights of others. They may be physically aggressive towards people and animals, steal or destroy property, or repeatedly run away from home or school. An important takeaway is that all adults diagnosed with ASPD were either previously diagnosed with, or can be retrospectively diagnosed with, conduct disorder.