Cluster B Personality Disorders Flashcards
Most common comorbidity of antisocial personality disorder
Any substance use disorder
Highly comorbid
Acting out
Defense mechanism in which an individual directly expresses unconscious wishes or conflicts through action to avoid being conscious of uncomfortable accompanying ideas or affects
Projective identification
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.
Antisocial personality “burn out”
The symptoms of antisocial personality disorder tend to burn out after age 30, but features of irritability, impulsivity, and detachment continue
Major features of antisocial personality disorder
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
In order to make a formal diagnosis of antisocial personality disorder, the individual must. . .
- Be 18 years of age or older
- 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
Interviewing tips for patients with ASPD
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.
Antisocial should NOT be diagnosed, even when all criteria are met, when it occurs in the context of. . .
. . . 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.
Treatment of antisocial personality disorder
- 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
The only diagnosis in the DSM system in which an individual must have had a preceding disorder in adolescence
Anti-social personality
In order to diagnose, a prior diagnosis of conduct disorder is required
For patients older than 18, a diagnosis of conduct disorder is given only if. . .
. . . the criteria for ASPD are not met
Defense mechanisms commonly seen in patients with ASPD
Acting out
Projective Identification
Dissociation
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
Elements of a histrionic personality
Attention-seeking behavior
Dramatic exaggeration
Excessive, but shallow, emotionality (often with lability)
Seductive manner / inability to recognize inappropriate sexual behavior
If a patient meets criteria for more than one personality disorder. . .
. . . then all can be diagnosed
They are not mutually exclusive.
Top ddx for histrionic personality
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.
Treatment of histrionic personality disorder
- 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
___ is a common comorbidity for all Cluster B personality disorders
Substance use disorder is a common comorbidity for all Cluster B personality disorders
Defense mechanisms most associated with histrionic personality disorder
Dissociation
Repression
Devaluation
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”
Treatment of narcissistic personality disorder
- 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
Features of narcissistic personality disorder
Pervasive pattern of grandiosity
Need for admiration
Lack of empathy for others
When narcissistic patients seek psychiatric help, it is usually not for their grandiosity (for which they have poor insight), but rather for. . .
. . . anger or depression
Defense mechanisms most associated with narcissistic personality disorder
- Devaluation
- Idealization
- Denial
Borderline personality and psychosis
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.
Simplified diagnostic criteria for borderline personality disorder
-
A. Evidence of impaired personality functioning:
- Impairment in self functioning manifested as lack of identity or lack of self direction
- AND
- 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
Way to counteract the likely devaluation in working with a patient with borderline personality
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
Histronic personality vs borderline personality
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.
Defense mechanisms used by patients with borderline personality disorder
Splitting
Idealization and devaluation (often going together)
Projection
Projection identification
Distortion
Acting Out
