General
Cluster B personality disorders behaviours are described as:
- Dramatic
- Emotional
- Erratic
What essential pattern is observed in anti-social personality disorder?
Which of the following is NOT a feature of histrionic PD?
Which of the following is NOT a feature of narcissistic PD?
Deceitful / manipulative for personal gain, hostile if needs are blocked, high risk for harm, no responsibility, impulsiveness if what PD?
Anti-social personality disorder
Why is it difficult to care for the social domain of those with anti-social PD?
Their social supports are minimal at best as they have usually taken advantage of friends or relatives and they no longer trust them
What is the ultimate treatment goal for someone with histrionic PD?
Change the tendency to fulfill all their needs by focusing on others to the exclusion of themselves
What are significant predictors of narcissistic PD?
(a) making multiple suicide attempts
(b) using lethal means to attempt suicide
(c) making suicide attempts in proximal relationship to being fired or experiencing domestic, financial, or health-related problem
Mr Brown is 52y, referred to the local Crisis Team following attempted suicide by taking an overdose, cutting his wrists and jumping off a car park. He was found unconscious, bleeding next to his car (did not jump). He reported deterioration in his mood following the breakdown of his marriage (separation from his wife and children) a couple of months ago.
He talked in detail about his life prior to the separation, describing “a perfect marriage”. He doesn’t understand why his wife has left him when he feels he has offered her everything a woman could want. He tells you that money has never been an issue. He owns a 4-bedroom house in the South, where his wife and children still live. He is currently staying at a 5-star hotel. He talks with exceptional pride about his job – he is a businessman and tells you how no one can do his job as well as him which is why he is paid “big money”. He is always called when not at work to come and solve problems that others can’t. He is annoyed at his boss though, as he went with the younger colleague’s idea over his own. He then developed this further and stated his boss is envious of him but that he is not bothered as he knows his boss will eventually come to his senses when things go undoubtably wrong.
He is very upset with his children as they have made no contact with him since he left. He finds it offensive that they are not coming to see him knowing how tough it has been on him. He has a 15y daughter and a 19y son. When asked about his relationship with the children, he says “it’s fine”. Then, he adds they are spoilt – he always worked so hard and made sure that they could attend all their extracurriculars. He feels they are ungrateful – his son has commented that he was “never there” to which Mr Brown took offence as he had to work. He says that his daughter is struggling with GCSEs, but that it is not an excuse for her lack of contact and support as he is her only father.
In relation to his suicide attempt, he said that he wanted to do something that would “be noticed”. He was angry with his wife and children and wanted them to “feel sorry for what they have put him through”.
Mr Brown is very open to talking about what happened, but most topics end up with him talking about the others in a derogatory way and in excessive detail. He is often late to his appointments with the team and offers only a vague, if any, explanation. Once a clinician comments on his tardiness he complains of being discriminated. He doesn’t present with symptoms of depression and when this is pointed out to him, he becomes increasingly irritable. He repeatedly refers to the assessment from the “esteemed” Liaison Psychiatry Consultant Psychiatrist who saw him in the A&E and stated that he has severe depression. As a result, he remains on treatment for depression (even though clinicians agree it is unnecessary) mostly due to fear of a complaint.
Narcissistic PD
DSM V – pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy – as indicated by 5 or more:
grandiose sense of self-importance
fantasies of unlimited power or importance
believes that they are “special” and can only be understood by/associate with other special of high-status people (or institutions)
requires excessive admiration
sense of entitlement
lack empathy
often envious of others or believes that others are envious of them
arrogant, haughty behaviours and attitudes
Narcissistic injuries to pride lead to rage reactions.
Management – limited evidence-base – psychoanalytic therapy (although high rates of self-termination due to feeling criticised)
What is the connection between childhood and anti-social PD?
Conduct disorder is the childhood precursor to ASPD
Symptoms of conduct disorder prior to 15 required for diagnosis
Antisocial behaviour of biological mothers predicts callous, unemotional behaviours in children
ICD-10 defines histrionic PD as:
Personality disorder characterized by shallow and labile affectivity, self-dramatization, theatricality, exaggerated expression of emotions, suggestibility, egocentricity, self-indulgence, lack of consideration for others, easily hurt feelings, and continuous seeking for appreciation, excitement and attention.
Narcissistic PD mnemonic “SPECIAL” stands for?
Superiority (grandiosity – views self as superior to others)
Preoccupied with fantasies
Entitled/egocentrism/exhibitionism
Criticism (sensitive to criticism from others)
Interpersonal exploitation
Arrogant
Lacks empathy
Marsha is 34-year-old who has been attending therapy with a male therapist for the past 6 months. Her therapist has documented the following from their appointments:
Marsha visibly resents the fact that I have had to pay attention to another patient (an emergency) "at her expense" as she puts it. She pouts and bats suspiciously her eyelashes at me: "Has any of your female patients fallen in love with you?" – suddenly changing her approach.
I maintain boundaries by asking her about her marriage. She sighs and her face contort, on the verge of tears: "I hate what's been happening to Doug and me. He has had such a stretch of bad luck - my heart goes out to him. I really love him, you know. I miss what we used to be. But his rage attacks and jealousy are driving me away. I feel that I am suffocating."
Why do you think he is jealous? She shifts uneasily in her seat: "I like to flirt. A little flirting never hurt nobody is what I say." Does Doug share those views? You mentioned he accuses you of being too provocative and seductive. Do you think he has a point? “Well… A woman can never be too much of either" - she protests mockingly.
Have you ever been unfaithful? Never. So, what is he so upset about? She explained she has been pretty direct with men she fancied, told them what she would do with them and to them if circumstances were different. When I ask her if she believes it to be a common approach in public, she stated it was not the wisest, but it sure was fun, she laughs.
When asked about how men responded to her advances, she stated with no hesitation "Usually, with an enormous erection." - she chuckled, and then she added "How did you react, Doctor?“. I admitted I was embarrassed, even annoyed. She stated she did not believe me and added that “No red-blooded male has ever been put off by the lure of an attractive female and from where I sit, you sure look as red-blooded as they come."
I mention Doug has been her fourth serious relationship this year and challenge how can such a short-lived liaison have such an impact. "Depth and intimacy can be created overnight" - she assures me, it is not a matter of the duration of the acquaintance.
She sighs theatrically and shields her eyes with her hand: "I wish it was all over." Does she mean her relationship with Doug? "No, silly", she was referring to her tumultuous life and its vagaries. I attempt to clarify her statement and she admits she did not mean it. She rolls to one side, leaning on her elbow, face supported by an open palm: "I just wish people were more light-hearted, you know? I wish they knew how to enjoy life to the maximum, give and take with joy.”
Histrionic PD
ICD 10 – characterised by:
Self-dramatization, theatricality, exaggerated expression of emotions
Suggestibility, easily influenced by others of by circumstances
Shallow and labile affectivity
Continual seeking for excitement and activities in which the patient is the centre of attention
Inappropriate seductiveness in appearance and behaviour
Over-concern with physical attractiveness
Management: psychoanalytic psychotherapy, limited evidence base
Features of anti-social PD described in ICD-10:
ICD-10 (at least 4 of the following):
Callous unconcern for the feelings of others
Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations
Incapacity to maintain enduring relationships, though having no difficulties in establishing them
Very low tolerance to frustration and a low threshold for discharge of aggression, including violence
Incapacity to experience guilt or to profit from experience, particularly punishment
Marked proneness to blame others, or to offer plausible rationalisations, for the behaviour that has brought the patient into conflict with the society
TOP TIP! Think of the H's for histrionic:
Hey, look at me: attention-seeking with the need to be the center of attention, overly emotional, dramatic, seductive.
Hissy fits: temper tantrums, self-absorbed.
Come hither: often inappropriate, sexually provocative, seductive.
Hype me up: seeks reassurance and praise often. Can be easily influenced by others.
Hyper-inflated: may believe their relationships are more intimate than they really are.
DSM V describes narcissistic PD features as:
DSM V – pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy – as indicated by 5 or more:
grandiose sense of self-importance
fantasies of unlimited power or importance
believes that they are “special” and can only be understood by/associate with other special of high-status people (or institutions)
requires excessive admiration
sense of entitlement
lack empathy
often envious of others or believes that others are envious of them
arrogant, haughty behaviours and attitudes
Narcissistic injuries to pride lead to rage reactions.