Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders

Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders

Cluster B personality disorders are characterized by personality styles that are impulsive, dramatic, highly emotional, and erratic.

Learning Objective

  • Summarize the similarities and differences in diagnostic criteria, etiology, and treatment options among the Cluster B personality disorders

Key Points

    • Cluster B disorders include antisocial, histrionic, narcissistic, and borderline personality disorders. People with these disorders usually are impulsive, overly dramatic, highly emotional, and erratic.
    • A person with antisocial personality disorder continuously violates the rights of others; often lies, fights, and has problems with the law; can be deceitful and manipulative in order to gain profit or pleasure; and lacks feelings for others and remorse over misdeeds.
    • Borderline personality disorder is characterized by instability in self-image, mood, and behavior. The person cannot tolerate being alone; has unstable and intense relationships with others; and exhibits behavior that is impulsive, unpredictable, and sometimes self-damaging.
    • A person with histrionic personality disorder is excessively overdramatic, emotional, and theatrical; feels uncomfortable when not the center of others’ attention; exhibits inappropriately seductive or provocative behavior; and may alienate friends with demands for constant attention.
    • People with narcissistic personality disorder have an overinflated and unjustified sense of self-importance and are preoccupied with fantasies of success. They believe they are entitled to special treatment from others, take advantage of others, and lack empathy.


  • egocentrismThe constant following of one’s egotistical desires to an extreme.
  • serotoninAn indoleamine neurotransmitter (5-hydroxytryptamine) that is involved in depression and is crucial in maintaining a sense of well-being and security.
  • conduct disorderA psychological disorder diagnosed in childhood that presents itself through a persistent pattern of behavior in which the basic rights of others or major age-appropriate norms are violated.

Full Text

The DSM-5 recognizes 10 personality disorders, organized into 3 different clusters. Cluster B disorders include antisocial personality disorder, histrionic personality disorder, narcissistic personality disorder, and borderline personality disorder. People with these disorders usually are impulsive, overly dramatic, highly emotional, and erratic.

Antisocial Personality Disorder

Defining Antisocial Personality Disorder

Antisocial personality disorder (ASPD) is characterized by a pervasive pattern of disregard for (or violation of) the rights of others. There may be a poor moral sense or conscience and a history of crime, legal problems, impulsivity, and aggressive behavior. One of the most important features of ASPD is the individual’s lack of remorse or guilt for the acts they have committed. While many individuals break the law and engage in antisocial behavior, it is not appropriate to assume that antisocial behaviors indicate the antisocial personality disorder. Individuals with ASPD do not feel as though they are doing anything wrong, necessarily, and are able to internally justify all of their behaviors and actions.

Though the word “antisocial” is often used to indicate someone who does not like interacting with others, or may be shy or reserved, these characteristics have little to nothing to do with ASPD, and should not necessarily be associated. ASPD is sometimes referred to as psychopathy or sociopathy, though the criteria might be slightly different depending on the method of diagnosis.

DSM-5 Diagnostic Criteria for Antisocial Personality Disorder

The DSM-5 describes ASPD as a pervasive pattern of disregard for, and violation of, the rights of others occurring since age 15, as indicated by three (or more) of the following:

  • Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest;
  • Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure;
  • Impulsivity or failure to plan ahead;
  • Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
  • Reckless disregard for safety of one’s self or others;
  • Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations; and
  • Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

The individual must be at least 18 years old; there must be evidence of conduct disorder with onset before age 15; and the occurrence of antisocial behavior must not exclusively be during the course of schizophrenia or a bipolar manic episode.

Conduct Disorder

Features of conduct disorder (CD) are necessary for a diagnosis of ASPD. CD is childhood behavior disorder characterized by aggressive and destructive activities that violate social norms and the rights of others.

Etiology of Antisocial Personality Disorder

ASPD seems to be caused by a combination of both genetic and environmental influences. Genetic influences draw on the temperament and the kind of personality a person is born with, and environmental influences include the way in which a person grows up and the experiences they have had. Traumatic events can lead to a disruption of the standard development of the central nervous system, which can generate a release of hormones that can change normal patterns of development. One of the neurotransmitters that have been discussed in individuals with ASPD is serotonin.

ASPD is seen in up to 30% of psychiatric outpatients. The prevalence of the disorder is even higher in selected populations, such as prisons, where there is a preponderance of violent offenders. Approximately 47% of male prisoners and 21% of female prisoners have ASPD. Similarly, the prevalence of ASPD is higher among patients in alcohol or other drug abuse treatment programs than in the general population. Furthermore, ASPD is diagnosed three times more frequently in men than in women.

Treatment of Antisocial Personality Disorder

ASPD is considered to be a difficult personality disorder to treat. Because of their very low or absent capacity for remorse, individuals with ASPD often lack sufficient motivation and fail to see the costs associated with antisocial acts. Those with ASPD may stay in treatment only as required by an external source, such as a parole. Residential programs that provide a carefully controlled environment of structure and supervision along with peer confrontation have been recommended. Various therapeutic approaches such as schema therapy and multisystemic therapy (MST) have been indicated as potential avenues for treatment.

No medications have been approved by the FDA to treat ASPD, although certain psychiatric medications (such as antipsychotic, antidepressant, or mood-stabilizing medications) may alleviate conditions sometimes associated with the disorder.

Borderline Personality Disorder

Defining Borderline Personality Disorder

The central features of borderline personality disorder (BPD) are a pattern of impulsivity and instability in mood, interpersonal relationships, and self-image. These patterns emerge in early adulthood and persist throughout the lifetime, though they can improve with treatment. One tell-tale symptom is intense fear of abandonment, which underlies the unstable relationships characteristic of BPD. People with BPD often engage in idealization and devaluation of others, alternating between high positive regard and great disappointment. If they sense any indication of negative emotion, criticism, or abandonment, they will completely devalue that once-idealized person and may even seek to hurt them. Other symptoms may include intense anger and irritability, self-mutilation, and suicidal behavior.

DSM-5 Diagnostic Criteria for Borderline Personality Disorder

According to the DSM-5, a diagnosis of borderline personality disorder needs to meet at least five of the following criteria, and can only be diagnosed after the age of 18:

  • Frantic efforts to avoid real or imagined abandonment (not including suicidal behavior);
  • A pattern of unstable and intense interpersonal relationships that alternate between extremes of idealization and devaluation;
  • Identity disturbance: markedly and persistently unstable self-image or sense of self;
  • Impulsivity in at least two areas that are potentially self-damaging (not including suicidal behavior), such as excessive spending, unprotected sex, substance abuse, reckless driving, and/or binge eating;
  • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior;
  • Affective instability due to a marked reactivity of mood, such as intense episodic dysphoria, irritability, or anxiety lasting between a few hours and a few days;
  • Chronic feelings of emptiness;
  • Inappropriate, intense anger or difficulty controlling anger; and
  • Transient, stress-related paranoid ideation or severe dissociative symptoms.

Etiology of Borderline Personality Disorder

The causes of BPD are complex and not fully agreed upon. Most researchers agree that a history of childhood trauma can be a contributing factor. Recently, more attention has been given to investigating the role played by congenital brain abnormalities, genetics, neurobiological factors, and environmental factors other than trauma.

Sixty-five percent of the variability in symptoms among different individuals with BPD can be explained by genetic differences. There are also some brain abnormalities associated with BPD. The hippocampus tends to be smaller in those who suffer from this disorder, as it is in people with post-traumatic stress disorder (PTSD). However in BPD, unlike PTSD, the amygdala also tends to be smaller. Since the amygdala is a major structure involved in managing negative emotions, this may explain the intense fear, sadness, anger, and shame experienced by people with BPD. The prefrontal cortex tends to be less active in people with BPD, especially when recalling memories of abandonment.

Treatment of Borderline Personality Disorder

Psychotherapy is the primary treatment for borderline personality disorder. Treatments should be based on the needs of the individual, rather than upon the general diagnosis of BPD. Various forms of therapeutic treatments include dynamic deconstructive psychotherapy (DDP), mentalization-based treatment (MBT), transference-focused psychotherapy, dialectical behavior therapy (DBT), general psychiatric management, and schema-focused therapy. While DBT is the therapy that has been studied the most, empirical research and case studies have shown that most of these treatments are effective for treating BPD.

Medications are useful for treating comorbid (co-occurring) disorders such as depression and anxiety. Short-term hospitalization has not been found to be more effective than community care for improving outcomes or long-term prevention of suicidal behavior in those with BPD.

Stigma and Controversy Surrounding Borderline Personality Disorder

There is an ongoing debate about the terminology of this disorder, especially the word “borderline”. The concern is that the diagnosis of BPD stigmatizes people and supports discriminatory practices by suggesting that the personality of the individual is flawed.

There are many stigmatizing features of BPD, including emotional instability, intense unstable interpersonal relationships, a need for intimacy, and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them. Pejorative terms are often used to describe people with BPD (such as difficult, treatment resistant, manipulative, demanding, and attention-seeking) and may become a self-fulfilling prophecy, as the negative treatment of these individuals triggers further self-destructive behavior.

Women are three times more likely to be diagnosed with BPD, corroborating the false stereotype of the “hyper-emotional, unstable woman” that will not conform to traditional female roles. In fact, a large criticism of BPD from a feminist perspective is that the diagnosis forces women into traditional gender roles for fear of being stereotyped. Many survivors of childhood abuse who are diagnosed with BPD are re-traumatized by negative responses from healthcare providers. Some argue that people diagnosed with BPD should instead be diagnosed with PTSD, as this would acknowledge the impact of abuse on the person’s behavior. Others argue that that a diagnosis of PTSD does not encompass all aspects of the disorder and is neurologically and characteristically different than BPD.

Instability in Emotions and Relationships

A central feature of BPD is markedly unstable relationships and sense of self, as well as an intense fear of abandonment.

Histrionic Personality Disorder

Defining Histrionic Personality Disorder

Histrionic personality disorder (HPD) is a personality disorder characterized by a pattern of excessive attention-seeking emotions, usually beginning in early adulthood, including inappropriately seductive behavior and an excessive need for approval. Histrionic people are lively, dramatic, vivacious, enthusiastic, and flirtatious. People with HPD have a high need for attention, make loud and inappropriate appearances, exaggerate their behaviors and emotions, and crave stimulation. They may exhibit sexually provocative behavior, express strong emotions with an impressionistic style, and can be easily influenced by others. HPD is diagnosed four times more often in women as it is in men, which critics argue suggests a culturally-based gender bias.

DSM-5 Diagnostic Criteria for Histrionic Personality Disorder

According to the DSM-5, a diagnosis of histrionic personality disorder is indicated by at least five of the following:

  • The person is uncomfortable in situations in which he or she is not the center of attention;
  • Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior;
  • The person displays rapidly shifting and shallow expression of emotions;
  • The person consistently uses physical appearance to draw attention to self;
  • The person has a style of speech that is excessively impressionistic and lacking in detail;
  • The person shows self-dramatization, theatricality, and exaggerated expression of emotion;
  • The person is suggestible, i.e., easily influenced by others or circumstances;
  • The person considers relationships to be more intimate than they actually are.

Etiology of Histrionic Personality Disorder

Little research has been done to find evidence as to what causes histrionic personality disorder and where it stems from. There are a few theories, however, that relate to the lineage of its diagnosis. Psychoanalytic theories incriminate authoritarian or distant attitudes by one (mainly the mother) or both parents, along with conditional love based on expectations the child can never fully meet.

Another theory suggests that histrionic personality disorder and antisocial personality disorder could have a possible relationship to one another. Research has found two-thirds of patients diagnosed with histrionic personality disorder also meet criteria similar to that of the antisocial personality disorder. Some family history studies have found that histrionic personality disorder, as well as borderline and antisocial personality disorders, tends to run in families, but it is not clear if this is due to genetic or environmental factors.

Treatment of Histrionic Personality Disorder

Treatment is often prompted by depression associated with dissolved romantic relationships. Medication does little to affect the personality disorder, but may be helpful with symptoms such as depression. The primary forms of treatment for HPD itself involve psychotherapy, including cognitive therapy.

Narcissistic Personality Disorder

Defining Narcissistic Personality Disorder

Narcissistic personality disorder (NPD) is a personality disorder in which a person is excessively preoccupied with personal adequacy, power, prestige, and vanity, and is mentally unable to see the destructive damage they are causing to themselves and others. People with NPD are characterized by exaggerated feelings of self-importance. They have a sense of entitlement and demonstrate grandiosity in their beliefs and behavior. They have a strong need for admiration, but lack feelings of empathy.

It is estimated that this condition affects one percent of the population, with rates greater for men. First formulated in 1968, NPD was historically called megalomania and is a form of severe egocentrism.

DSM-5 Diagnostic Criteria for Narcissistic Personality Disorder

Symptoms of this disorder, as defined by the DSM-5, include significant impairments in self functioning (such as excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal; goal-setting based on gaining approval from others; personal standards that are unreasonably high; etc.) along with impairments in interpersonal functioning (such as lack of empathy; over- or underestimating one’s own effect on others; superficial relationships that exist to serve self-esteem regulation; etc.). They must also experience feelings of grandiosity (including entitlement or self-centeredness) and attention seeking behavior.

Etiology of Narcissistic Personality Disorder

The cause of this disorder is unknown; however, Groopman and Cooper (2006) listed the following factors identified by various researchers as possibilities:

  • An oversensitive temperament (personality traits) at birth.
  • Excessive admiration that is never balanced with realistic feedback.
  • Excessive praise for good behaviors or excessive criticism for bad behaviors in childhood.
  • Overindulgence and overvaluation by parents, other family members, or peers.
  • Being praised for perceived exceptional looks or abilities by adults.
  • Severe emotional abuse in childhood.
  • Unpredictable or unreliable caregiving from parents.
  • Learning manipulative behaviors from parents or peers.
  • Valued by parents as a means to regulate their own self-esteem.

Recent research has identified a structural abnormality in the brains of those with NPD, specifically noting less volume of gray matter in the left anterior insula. This brain region relates to empathy, compassion, emotional regulation, and cognitive functioning.

Treatment of Narcissistic Personality Disorder

People rarely seek therapy for NPD, partly because many NPD sufferers deny they have a problem. Most, if not all, cannot see the destructive damage they cause to themselves and to others and usually only seek treatment at the insistence of relatives and friends.

Psychotherapy is generally used to treat NPD. Schema therapy, a form of therapy developed by Jeffrey Young that integrates several therapeutic approaches (psychodynamic, cognitive, behavioral etc.), also offers an approach for the treatment of NPD. Anger, rage, impulsivity, and impatience can be worked on with skill training. Group treatment has its benefits as the effectiveness of receiving peer feedback rather than the clinician’s may be more accepted.

Source: Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders

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