Is bipolar a cluster b personality disorder

Antisocial Personality Disorder

The key features ofantisocial personality disorder are repetitive unlawful acts, socially irresponsible behaviors, and a pervasive disregard for the rights of others. Antisocial behaviors develop early in adolescence, before age 15. These individuals are so unconcerned with the feelings and rights of others that they are morally bankrupt and lack a sense of remorse. Such people seem completely unable to project themselves into the feelings of others and they are bereft of empathy. Superficially, they can be charming and engaging, yet beneath the facade lie individuals who live in a world filled with illegal activity, deceit, promiscuity, substance abuse, and assaultive behavior. Because patients with this disorder are so indifferent to how their actions affect others, antisocial personality disorder is the personality disorder most resistant to treatment.

The differential diagnosis for antisocial personality disorder includes antisocial behavior, other cluster B personality disorders, impulse control disorders, mania, psychosis, substance abuse disorders, mental retardation, and personality changes caused by general medical conditions. Patients with borderline personality disorder may perform illegal acts, yet they tend to demonstrate more repetitive suicidal and parasuicidal behaviors, as well as intense affect and self-loathing. When patients with narcissistic personality disorder violate the law, it is typically motivated by a need to maintain their sense of entitlement rather than to meet an instrumental desire (i.e., narcissistic personality disorder is associated with “white collar crime,” whereas antisocial personality disorder is associated with “blue collar crime”). Bipolar mania can be difficult to separate from antisocial personality disorder, because patients with antisocial personalities can also have co-morbid bipolar disorders. For the most part, however, patients with bipolar disorder lack a significant degree of childhood conduct problems, and the antisocial behavior is usually limited to manic episodes. Patients with psychotic disorders may also perform criminal acts, but these acts are usually in response to delusions or hallucinations. Substance abuse disorders can be especially difficult to differentiate from antisocial personality disorder, because patients with antisocial personality disorder almost invariably engage in substance use. However, criminal behaviors associated with substance abuse disorders generally center around using and obtaining the drugs.

Antisocial personality disorder affects 3% of men and less than 1% of women. Given the prominence of illegal activity in the diagnostic criteria of this personality disorder, it is not surprising that at least 75% of the prison population carries the diagnosis. Patients with this disorder have an onset of conduct disorder before the age of 15 years, and frequently suffer from co-morbid attention-deficit/hyperactivity disorders, polysubstance disorders, and somatization disorder. The exact etiology is unknown, but this disorder occurs five times more commonly in first-degree relatives of men with the disorder. While the natural history of antisocial personality disorder is variable, some improvement can occur during middle age.

Occupational performance deficits

Occupational performance deficits vary by cluster of personality disorder and may affect social participation, emotional modulation, and coping skills.71 Persons with a Cluster A personality disorder may be seen as odd or eccentric. In general they are suspicious and distrusting of others, resulting in decreased interest in social relationships. Older adults with Cluster A personality disorders may have difficulty maintaining interpersonal relationships. Persons with Cluster B personality disorders experience a lack of empathy and unpredictable behaviors and may seem aggressive and narcissistic. Older adults with Cluster B personality disorders may have unstable relationships and desire to be the center of attention. Persons with Cluster C personality disorders often have trouble coping and may feel unable to function without the help of others. This may cause persons with Cluster C personality disorders to be dependent on others to care for their daily activities. Personality disorders often result from negative interactions or environments and may result in decreased trust in others. Issues can also be seen with modulating emotions, impulsivity, and coping. Together, these symptoms increase the risk of self-harming behaviors, such as cutting, and substance abuse. Persons with personality disorders may need assistance in developing positive coping strategies and learning to control their emotions and impulses.

Personality disorders

It has commonly been hypothesised that certain personality disorders such as Borderline Personality Disorder have their developmental origins in early childhood traumas, including CSA (Ball & Links, 2009). As personality is typically partially formed by early emotional experiences with caregivers, it is possible that early adversities such as CSA influence the development of a normal personality structure.

Several studies have utilised robust methodologies (including the use of representative community samples, official diagnostic data and appropriate comparison groups) to examine the development of personality disorder in CSA survivors. Research has found significant relationships between CSA and the development of personality disorders, including higher rates of diagnoses of Cluster B personality disorders (i.e. narcissistic, histrionic, borderline, and antisocial personality disorders) and schizotypal personality disorder, as well as increased severity of problematic personality traits (Afifi et al., 2011; Calvete et al., 2011; Cutajar et al., 2010a; Kuo, Khoury, Metcalfe, Fitzpatrick, & Goodwill, 2015; Putnam, 2003; Zhang, Chow, Wang, Dai, & Xiao, 2012). Afifi et al. (2011) utilised a nationally representative sample from the United States to study relationships between all forms of adverse childhood experiences and diagnoses of personality disorders. They found that all types of childhood adversity (including CSA) were significantly correlated with increased odds of being diagnosed with a cluster A or B personality disorder. Among the Cluster A disorders, the strongest association was found for schizotypal personality disorder. However, this study was unable to assess whether CSA was causally associated with the development of personality disorders. While evidence for a CSA–personality disorder relationship is the most compelling for Cluster B personality disorders, this may be an artefact of the comparatively greater research attention paid to the links between CSA and Cluster B personality disorders. Therefore, firm conclusions cannot yet be drawn about the relationship between CSA and other forms of personality disorder.

Histrionic Personality Disorder

The most notable features of histrionic personality disorder (HPD) are excessive emotionality and an almost insatiable need for attention. These individuals are overly concerned with their physical appearance, they have poor frustration tolerance (with emotional outbursts), and their speech is impressionistic and vague. They view physical attractiveness as the core of their existence, and as such, are often provocative in dress, flamboyant in mannerisms, and inappropriately seductive in behavior. While they appear superficially charming, others tend to view them as vain and lacking in genuineness. Histrionic and narcissistic personality disorders are closely associated.

The differential diagnosis for HPD includes other cluster B personality disorders and somatization disorder. BPD differs from HPD in that the borderline patient displays more despair and suicidal/parasuicidal behaviors. The narcissistic patient is more preoccupied with grandiosity and envy than is the histrionic individual. The person with dependent personality disorder, while sharing the need for acceptance and reassurance, lacks the degree of emotionality seen in histrionic individuals. Somatization disorder can co-exist with HPD, but it is distinguished by the greater emphasis on physical complaints.

This disorder occurs in 2% to 3% of the general population. While women receive the diagnosis more often than do men, many clinicians believe that men are underdiagnosed. This disorder is more common in first-degree relatives of people with this disorder. Like most personality disorders, the course is variable. Some individuals experience an attenuation or softening of the core symptoms during middle age. Others may experience a complicated course, including co-morbid somatization, conversion, pain, and dissociative, sexual, and mood disorders. Two major caveats pertain to this diagnosis. The first is that emotional displays can vary from culture to culture, and what is histrionic in one culture may be identified as normal emotional expression in another. The other concerns the great co-morbidity this disorder has with BPD. Some believe that while not all borderline patents are histrionic, most HPD patients have sufficient borderline traits to merit a diagnosis of BPD.

Borderline Personality Disorder (BPD)

Borderline personality disorder dates back more than 60 years and is traced to the clinical observations of Adolph Stern who had a subgroup of patients that eluded diagnosis as either having psychoses or neuroses (Gunderson & Links, 2008). These patients were therefore deemed to occupy the diagnostic landscape between psychosis and neurosis, and thus were on the borderline of both diagnoses. BPD first entered the DSM-III (Diagnostic and Statistical Manual of Mental Disorders—3rd edition) in 1980 and was adopted in 1992 by the World Health Organization in their ICD (International Classification of Diseases) (Gunderson & Links, 2008). Those with BPD may be more disposed toward violence when an overwhelming predominance of aggression interferes with sensuality, where there may also be weaknesses in ego control, a lack of anxiety tolerance, and impulse control problems (Kernberg, 2004).

Borderline PD is common in forensic samples, and is the second most common disorder found in men and often the first in women (Esbec & Echeburúa, 2010). For women, self-harm may be a greater risk and this is not only common in forensic samples, but also in clinical sample (Paris, 2005). Suicide and suicidal ideation is in fact one of the diagnostic criteria, discussed later. BPD most recently falls under the Cluster B Personality Disorders in DSM-5 (American Psychiatric Association, 2013) after discarding the Axis system found in DSM-IV-TR (American Psychiatric Association, 2000) and previous versions. The diagnostic criteria for BPD are (American Psychiatric Association, 2013, p. 663):

A pervasive pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity, beginning in early adulthood and present in a variety of contexts, as indicated by five or more of the following:

1.

Frantic efforts to avoid real or imagined abandonment (Note: Do not include suicidal or self mutilating behaviour covered in Criterion 5).

2.

A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation.

3.

Identity disturbance: markedly and persistently unstable self-image or sense of self.

4.

Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5).

5.

Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.

6.

Affective instability due to marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

7.

Chronic feelings of emptiness.

8.

Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

9.

Transient, stress-related paranoid ideation or severe dissociative symptoms.

While individuals with BPD are often characterized by self-harm, they can display externalized aggression also, and on rare occasions may commit murder (Sansone & Sansone, 2012). The diagnostic criteria above would in many ways be linked to acts of aggression and crimes of violence, especially when faced with rejection or abandonment and includes at least a pattern of unstable relationships, identity disturbance, impulsivity, affective instability, inappropriate and intense anger, and paranoid ideation.

BPD shares many features with posttraumatic stress disorder, which is an anxiety disorder caused by major physical or emotional trauma (Martin, 2015). The relationship between the two disorders is well established, where it has been found to be common but not ubiquitous (Zanarini et al., 1998), with posttraumatic stress disorder (PTSD) being twice as likely to be found in borderline patients (Golier et al., 2003). It is suggested that one is an extreme version of the other, and data from the Collaborative Longitudinal Personality Disorder Study (CLIPS) shows that BPD was often comorbid with PTSD and substance abuse (which is also one of the diagnostic criteria), and suggest a shift from Axis 2 to Axis 1 under the old DSM-IV-TR classification system (New, Triebwasser, & Charney, 2008).

Borderline Personality Disorder

Closely related to the concept of multi-impulsivity is the diagnosis of BPD. One of the diagnostic criteria for BPD is impulsivity in at least two areas that are potentially self-damaging, such as spending, sex, substance abuse, reckless driving, and binge eating, while another is recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior (American Psychological Association, 1994). Clearly, there is overlap by definition between being diagnosed as multi-impulsive or as having BPD; however, the question remains as to which better captures the etiological base of the co-occurrence of ED and alcohol abuse. Grilo et al. (1995) compared inpatients who had EDs with and without substance abuse with a comparison group who had substance abuse, but not EDs. They found that cluster B personality disorders (i.e. erratic and unstable), which includes BPD, were more likely to occur in the group with both ED and substance abuse, whereas cluster C personality disorders (i.e. anxious and fearful) occurred more often in patients with only ED. This study provides evidence that BPD is an important feature of this clinical subgroup.

Further support for the importance of BPD is found in a study by Bulik et al. (1997), where they compared BN patients with and without alcohol dependence and found substantial differences between these groups. The co-morbid group had higher rates of suicide attempts, anxiety disorders, conduct disorder, and problems with other substances as well as higher rates of personality disorders, particularly borderline and histrionic personality disorder. This study also replicated the earlier finding by Bulik et al. (1994) that women with ED and alcohol abuse score higher on measures of novelty seeking. In this study, Bulik et al. (1994) found that among hospitalized women with BN, those who also abused alcohol did not differ from those who did not in terms of their specific symptoms of BN, depression, or general psychiatric symptoms. They did, however, score higher on measures of novelty seeking, disorderliness, and being socially detached. The authors suggest that the combination of high novelty seeking and harm avoidance may predispose someone to develop BN, and within that group, higher novelty seeking may then predispose them to co-morbid alcohol abuse.

Assertive-Driven PD and Criminality

PD offenders who are assertive-driven are similarly motivated by the need to obtain or restore self-esteem through other people (just like the reassurance-driven PD types). The two groups, however, differ in the emotional content that drives their motivation. Rather than fear driving motivation and subsequent behavior, the assertive-driven PD persons are primarily motivated by anger. PD persons with this orientation tend to have an underlying belief that they are superior to others and therefore deserve more than they already have and, further, are owed something by others (or society).

This group are angry because they believe that they, whether clear or unclear to them, are not getting everything they deserve. Paradoxically, this group tends to have very low self-esteem or a high self-esteem that is very fragile. Motivation, therefore, comes from the desire to restore their self-esteem through obtaining accolades from others. Alternatively, they will attempt to restore self-esteem by emotionally dominating others. They do this by deliberately setting out to make other people feel inferior and in turn make themselves feel more superior. This type of personality is hyperemotional, melodramatic, and extremely intense and is characteristic of the cluster B PDs, such as the antisocial, borderline, histrionic, and narcissistic personality types. Narcissism and histrionic are likely to be the primary personality characteristics associated with this group.

Narcissistic and histrionic PD offenders express these flamboyancies in a highly aggressive and dominating “look at me” manner that is ultimately compensatory in nature. The attitude and behaviorally expressed belief that they are superior are not underpinned by substance but are constantly undermined by their low or high but fragile self-esteem. In this way, their behaviors are motivated by the need to repair the incongruence. They do this through a variety of mechanics including fantasies about success, power, and their attractiveness in the eyes of others. The result is a blurred reality in which exaggerations of personal achievements, successes, and talents are made, resulting in increased need for external praise and recognition to “prop-up” their assertions. The self-absorption means that they usually make ongoing, high-maintenance demands, without the ability to recognize or acknowledge the feelings of those around them.

In the histrionic PD person, behaviors can be overly sexualized or provocative and flirtatious, and these individuals are most commonly egocentric, self-indulgent, and manipulative. The need for continuous appreciation from others means that this group of individuals are also easily manipulated and influenced by others.

The selfish, aggressive, and “I deserve more” personal agenda–driven attitudes of narcissistic PD persons often results in criminal behaviors aimed at obtaining what is believed to be rightfully theirs (for example, financial gain through fraud, theft, or embezzlement in an attempt to obtain material items that they perceive will make them more respected by others). Often the criminal behavior will be purposefully directed at specific individuals in an attempt to take what is theirs as both a means of gaining material possessions and as an act of domination over a rival (whether or not that person is aware of an existing rivalry or even aware of the offender in any personal sense). This could be an employer, sibling, teammate, neighbor, or other person whom the offender has identified as a rival. Further, the aggressive and volatile elements of their personality can lead to violence if their fragile self-esteem is threatened (for example, someone belittles them or embarrasses them in some way, particularly if there is an audience). Any perceived threat to their need for dominance can result in retaliatory aggression. Table 1.7 shows how the narcissistic PD person can be described by using the mnemonic “SPEEECIAL,” while histrionic PD persons are represented in Table 1.4 (Pinkofsky, 1997).

Table 1.7. Mnemonic for Narcissistic Personality Disorder

S(3)Special (believes he or she is special and unique)P(2)Preoccupied with fantasies (of unlimited success, power, brilliance, beauty, or ideal love)E(8)Envious (of others, or believes others are envious of him or her)E(5)EntitlementE(4)Excess admiration requiredC(1)Conceited (grandiose sense of self-importance)I(6)Interpersonal exploitationA(9)Arrogant (haughty)L(7)Lacks empathy

Notes: 1. Numbers in brackets correspond to the diagnostic criteria set out in the DSM5 (American Psychiatric Association, 2013); 2. Diagnosis requires the presence of any five of the nine diagnostic criteria.

Pinkofsky, H. B. (1997). Mnemonics for DSM-IV personality disorders. Psychiatric Services, 48(9), 1197–1198.

Clinical Features

While Münchausen syndrome is the most dramatic form of factitious illness, common factitious disorder is more frequently encountered.1 As opposed to those with Münchausen syndrome, these patients do not typically use aliases or travel from hospital to hospital, but rather frequent the same physician. They are well known in their health care system due to numerous hospitalizations. They still misrepresent symptoms and feign illness, but are not as prone to pseudologia fantastica. Although conflicting data exist with regard to whether factitious disorders are more common in males or females, some suggest that common factitious disorder is more prevalent in women. Other risk factors include being unmarried, an age in the thirties, experience in the health care profession, and having a cluster B personality disorder. Münchausen syndrome, on the other hand, may be more frequently seen in men in their forties who are single and have antisocial traits.1 The co-morbidity with personality disorders may be a result of rigid defensive structure, poor identity formation, and prominent dependency needs.8

A typical hospitalization for those who feign medical illness has a number of common characteristics. First, the patient often comes to the emergency department after hours (at night or on the weekend) when it is less likely that medical staff who know him or her are available. The patient uses medical jargon and generally knows what diagnoses or conditions will merit hospitalization. The history is often quite dramatic and convincing, and the patient persuades the physician to provide care by appealing to narcissistic qualities, such as omnipotence. Once hospitalized, the treatment is marked by demands for specific interventions (e.g., surgery or particular medications) and by an increasing need for attention. When these are not delivered, the patient becomes angry and may accuse staff of mistreatment or misdiagnosis. If medical personnel uncover the deception, strong countertransference feelings of hatred ensue—the patient is then rapidly discharged or elopes from the hospital only to seek “treatment” at another facility soon thereafter.

The types of physical symptoms and diseases that have been faked are limited only by the imagination of those who feign them. Table 25-2 lists some common categories. Modern-day laboratory tests and diagnostic modalities may be particularly useful in distinguishing factitious symptoms from true medical illness. For example, in the case of suspicious infection, polymicrobial culture results that indicate an uncommon source (e.g., from urine or feces) is highly suggestive. Those who inject insulin to produce hypoglycemia will have a low C-peptide on laboratory analysis, while glyburide can be measured in the urine of those suspected of taking oral hypoglycemics. Laxative abuse to cause ongoing diarrhea is confirmed by testing for phenolphthalein in the stool.9 Finally, diagnostic studies in cases of suspected thyrotoxicosis (from surreptitious ingestion of thyroid hormone) reveal elevated serum total or free thyroid hormone levels, undetectable serum thyrotropin levels, low serum thyroglobulin concentration, normal urinary iodine excretion, suppressed thyroidal radioactive iodine uptake (RAIU), absence of goiter, and absence of circulating antithyroid antibodies.10

Detection of other types of physical factitious illness may require more astute physical examination or observational skills (not to mention catching the patient “in the act”). For example, fever of unknown etiology may be caused by warming thermometers on light bulbs, radiators, or with a flame (though this is more difficult with the advent of the electronic thermometer). Hematuria may be produced by bloodletting from another body area (commonly from a finger prick) into the urine sample. While finding suspicious cuts may be suggestive, direct observation may be the only way to prove factitious disorder in this instance. Likewise, with nonhealing wounds where self-excoriation or “picking” behavior is suspected, witnessing the act either directly or with the use of video monitoring is diagnostic. Of note, the latter brings up ethical considerations unless done with the consent of the patient. Finally, among the numerous other possible physical manifestations, those that rely on more subjective report (including joint or muscle pain, headache, renal colic, or abdominal pain) may be present for months or years before a factitious etiology is even considered, much less proven.

6 ED psychopathology associated with PDs

Across all ED types, high rates of binge eating and purging are often associated with Cluster B PDs (e.g., Spindler & Milos, 2007), whereas high rates of dieting, fasting, and excessive exercise are more common among those with Cluster C PDs, especially obsessive–compulsive PD (e.g. Anderluh, Tchanturia, Rabe-Hesketh, Collier, & Treasure, 2009; Spindler & Milos, 2007). The effect of a comorbid PD on treatment outcome appears to vary depending upon the specific ED diagnosis. Those with AN and a comorbid PD were more likely to drop out of treatment (e.g., Pham-Scottez et al., 2012) and those with AN and avoidant PD were less likely to recover relative to those without a comorbid PD (Zerwas et al., 2013); however, research has consistently shown that the presence of a PD does not adversely affect treatment outcome in women with BN (e.g. Grilo et al., 2012; Rowe et al., 2010). Research on how comorbid PDs relate to treatment outcome among those with BED is mixed: one study found that cluster C PDs were associated with more severe post-treatment psychopathology and negative affect (Masheb & Grilo, 2008), whereas another study found that those with avoidant PD responded just as well to dialectical behavior therapy for BED as those without avoidant PD (Robinson & Safer, 2012).