DSM-5: The Ten Personality Disorders: Cluster B

What Are Cluster B Personality Disorders?

Cluster B personality disorders are a group of personality disorders characterized by dramatic, emotional, and erratic behavior. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has grouped these personality disorders in Cluster B due to shared features and tendencies. Cluster B personality disorders can significantly affect a person’s relationships, well-being, and overall functioning.[1]

Cluster B is called the dramatic, emotional, and erratic cluster. These disorders include:[1]

• Borderline Personality Disorder (BPD)
• Narcissistic Personality Disorder (NPD)
• Histrionic Personality Disorder (HPD)
• Antisocial Personality Disorder (ASPD)

Disorders in this cluster share problems with impulse control and emotional regulation.

Prevalence of Cluster B Personality Disorders

Prevalence rates for Cluster B personality disorders can vary depending on the specific disorder, population, and study. Prevalence rates for Cluster B personality disorders include:[1,3,4,5,6]

• Narcissistic personality disorder: Between .5% and 5% in community samples and up to 15% in clinical settings
• Antisocial personality disorder: Between 1% and 4% in the general population
• Histrionic personality disorder: Research is lacking, but studies estimate prevalence to be as high as 3%
• Borderline personality disorder: About 1.6% in community samples and 20% of psychiatric inpatient settings

Antisocial Personality Disorder

Antisocial Personality Disorder* is characterized by a pervasive pattern of disregard for the rights of other people that often manifests as hostility and/or aggression. Deceit and manipulation are also central features. Many people confuse the disorder with asocial personalities (learn more about asocial vs. antisocial disorders), but they have distinct differences.[1],[2],[3]

In many cases, hostile-aggressive and deceitful behaviors may first appear during childhood:[1,2,3]

• These children may hurt or torment animals or people.
• They may engage in hostile acts such as bullying or intimidating others.
• They may have a reckless disregard for property, such as setting fires.
• They often engage in deceit, theft, and other serious violations of standard rules of conduct.

• When this is the case, Conduct Disorder (a juvenile form of Antisocial Personality Disorder) may be an appropriate diagnosis.
• Conduct Disorder is often considered the precursor to an Antisocial Personality Disorder.

In addition to demonstrating reckless disregard for others, they often place themselves in dangerous or risky situations. They frequently act on impulsive urges without considering the consequences. This difficulty with impulse control results in loss of employment, accidents, legal difficulties, and incarceration.

People with Antisocial Personality Disorder typically do not experience genuine remorse for the harm they cause others. However, they can become quite adept at feigning remorse when it is in their best interest to do so, such as when standing before a judge.[1,2,3]

They take little to no responsibility for their actions. In fact, they will often blame their victims for “causing” their wrong actions or deserving their fate. The aggressive features of this personality disorder make it stand out among other personality disorders, as individuals with this disorder take a unique toll on society.

Histrionic Personality Disorder

People with Histrionic Personality Disorder* are characterized by a pattern of excessive emotionality and attention-seeking. Their lives are full of drama (so-called “drama queens”). They are uncomfortable in situations where they are not the center of attention.[1,4]

• People with this disorder are often quite flirtatious or seductive and may like to dress in a manner that draws attention to them.
• They can be flamboyant and theatrical, exhibiting an exaggerated degree of emotional expression.
• Yet simultaneously, their emotional expression may appear vague, shallow, and lacking in detail. This can give them the appearance of being disingenuous and insincere.
• Moreover, the drama and exaggerated emotional expression often embarrass friends and acquaintances, as they may embrace even casual acquaintances with excessive ardor or sob uncontrollably over a minor sentimentality.

People with Histrionic Personality Disorder can appear flighty and fickle. Their behavioral style often gets in the way of truly intimate relationships, but it is also the case that they are uncomfortable being alone.[1,4]

They tend to feel depressed when they are not the center of attention. When they are in relationships, they often imagine relationships to be more intimate than they are.

People with Histrionic Personality Disorder tend to be suggestible; that is, they can be easily influenced by other people’s suggestions and opinions. A literary character that exemplifies Histrionic Personality Disorder is the character of Blanche DuBois in Tennessee William’s classic play, Streetcar Named Desire.

To help manage the symptoms, a person with Histrionic Personality Disorder can use medications along with psychotherapy. [1,4]

Narcissistic Personality Disorder

People with Narcissistic Personality Disorder* have significant problems with their sense of self-worth, stemming from a powerful sense of entitlement. This leads them to believe they deserve special treatment and to assume they have special powers, are uniquely talented, or that they are especially brilliant or attractive. Their sense of entitlement can lead them to act in ways that fundamentally disregard and disrespect the worth of those around them.[1,5]

• People with Narcissistic Personality Disorder are preoccupied with fantasies of unlimited success and power, so much so that they might end up getting lost in their daydreams while they fantasize about their superior intelligence or stunning beauty.
• Those who have this disorder can get so caught up in their fantasies that they don’t put effort into their daily life and don’t direct their energies toward accomplishing their goals.
• They may believe they are special and deserve special treatment, and they may display an attitude that is arrogant and haughty.
• This can create a lot of conflict with other people who feel exploited and who dislike being treated condescendingly.
• People with Narcissistic Personality Disorder often feel devastated when they realize they have normal, average human limitations, that they are not as special as they think, or that others don’t admire them as much as they would like.
• Feelings of intense anger or shame often accompany these realizations that they sometimes take out on other people.
• Their need to be powerful and admired, coupled with a lack of empathy for others, makes for conflict-laden relationships that are often superficial and devoid of real intimacy and caring.

Status is very important to people with Narcissistic Personality Disorder. Associating with famous and special people provides them with a sense of importance. Individuals with Narcissistic Personality Disorder can quickly shift from idealizing others to devaluing them.[1,5]

However, the same is true of their self-judgments. They tend to fluctuate between feeling like they have unlimited abilities and feeling deflated, worthless, and devastated when they encounter their normal, average human limitations. Despite their bravado, people with Narcissistic Personality Disorder require a lot of admiration from other people to bolster their fragile self-esteem. They can be quite manipulative in extracting the necessary attention from people around them.[1,5]

Borderline Personality Disorder

Borderline Personality Disorder* is one of the most widely studied personality disorders. People with Borderline Personality Disorder tend to experience intense, unstable emotions and moods that can shift fairly quickly. They generally have a hard time calming down once they have become upset. As a result, they frequently have angry outbursts and engage in impulsive behaviors such as substance use, risky sexual liaisons, self-injury, overspending, or binge eating. These behaviors often function to soothe them in the short term but harm them in the longer term.[1,6]

• People with Borderline Personality Disorder tend to see the world in polarized, oversimplified, all-or-nothing terms.
• They apply harsh either/or judgments to others and themselves, and their perceptions of themselves and others may quickly vacillate between “all good” and “all bad.”
• This tendency leads to an unstable sense of self, so people with this disorder tend to have a hard time being consistent.
• They can frequently change careers, relationships, life goals, or residences. Quite often, these radical changes occur without any warning or preparation.

Black-and-White Thinking and Emotion Dysregulation in Borderline Personality Disorder

People with Borderline Personality Disorder tend to view the world in terms of black-and-white or all-or-nothing thinking. Their tendency to see the world in polarized terms makes it easy for them to misinterpret the actions and motivations of others.[1,6]

• These polarized thoughts about their relationships with others lead them to experience intense emotional reactions, which in turn exacerbates their ability to regulate intense emotions.
• The result is that they will characteristically experience great distress that they cannot easily control and may subsequently engage in self-destructive behaviors as they do their best to cope.
• The intensity of their emotions, coupled with difficulty regulating these emotions, leads them to act impulsively.

To illustrate the way black-and-white thinking, emotional dysregulation, and poor impulse regulation culminate to create interpersonal conflict and distress, let’s use an example:

• Suppose the partner of a woman with Borderline Personality Disorder fails to remember their anniversary. Black-and-white thinking causes her to conclude, “He doesn’t love me anymore,” and all-or-nothing thinking leads her to (falsely) conclude, “If he does not love me, then he must hate me.”
• Such thoughts would easily lead to intense emotions, such as feeling rejected, abandoned, sad, and angry. She has a hard time tolerating and dealing with these intense feelings and consequently becomes highly upset and overwhelmed. The intensity of her negative feelings seems unbearable.
• Next, she has a powerful impulse to “do something” just so that these feelings will go away. She might angrily accuse her partner of having an affair, and she might plead with her partner not to leave her.
• Meanwhile, her partner is baffled by this extreme reaction, particularly because he is not having an affair, and he readily recalls recent loving gestures he has made. Her partner might become angry at these wild accusations of infidelity, so the conflict escalates and becomes more intense.
• Alone after the fight, the woman feels overwhelming self-loathing or numbness. She goes on to intentionally injure herself (by cutting or burning herself) as a way to cope with her emotions.
• When her partner learns about this self-harming behavior, he can’t understand it and concludes he is being manipulated. He expresses his strong concern for her well-being and his anger. In turn, she feels misunderstood.

Borderline Personality Disorder, with its combination of distorted thought patterns, intense and under-regulated emotions, and poor impulse control, is practically designed to wreak havoc on interpersonal relationships.[1,6]

As Dr.Brindusa Vanta, MD, says, “Emotional dysregulation is an important feature in many mental health conditions, including Borderline Personality Disorder, Bipolar Disorder, ADHD, PTSD, and Autism Spectrum Disorder.”

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Dialectical Behavior Therapy (DBT)

*It is important to remember that everyone can exhibit some of these personality traits from time to time. To meet the diagnostic requirement of a personality disorder, however, these traits must be inflexible and regularly observed without regard to time, place, or circumstance.

Furthermore, these traits must cause functional impairment and/or subjective distress. Functional impairment means these traits interfere with a person’s ability to function well in society. The symptoms cause problems in interpersonal relationships or at work, school, or home. Subjective distress means the person with a personality disorder may experience their symptoms as unwanted, harmful, painful, embarrassing, or otherwise distressing. The above list only briefly summarizes these individual Cluster B personality disorders. Richer, more detailed descriptions of these disorders are in the section describing the four core features of personality disorders.

Cluster B Personality Disorders vs. Other Personality Disorders

Cluster B personality disorders are characterized by dramatic, emotional, and erratic behaviors. Individuals with Cluster B disorders often struggle with impulse control, emotional dysregulation, and difficulties in interpersonal relationships.[1]

In contrast, Cluster A personality disorders, such as Paranoid Personality Disorder (PPD) and Schizoid Personality Disorder (SPD), are characterized by eccentric or odd behaviors and social detachment.

Cluster C disorders, including Avoidant Personality Disorder (AvPD) and Obsessive-Compulsive Personality Disorder (OCPD), are characterized by anxiety and fearfulness.[1]

One significant distinction between Cluster B personality disorders and other personality disorders lies in interpersonal functioning and emotional expression. People with Cluster B disorders often exhibit intense and unstable relationships, marked by idealization and devaluation, as seen in Borderline Personality Disorder.[1]

Additionally, those with Cluster B disorders may engage in impulsive and reckless behaviors, such as substance use or self-harming behaviors, further complicating their relationships and functioning.[1]

Conversely, people with other personality disorders, such as Avoidant Personality Disorder (AvPD) or Obsessive-Compulsive Personality Disorder (OCPD), may struggle with social withdrawal or perfectionism, respectively, but typically do not display the same level of emotional volatility or interpersonal chaos as those with Cluster B disorders.[1]

Causes of Cluster B Personality Disorders

Cluster B personality disorders are complex and multifaceted conditions that don’t have a single cause—rather, they are caused by many interrelated and intersecting risk factors. The risk factors for the development of Cluster B personality disorders include:[1,7,8]

• Genetics
• Childhood abuse, including emotional or verbal abuse
• History of sexual trauma
• Childhood neglect
• Parents with substance use disorder
• Parents with a personality disorder

Again, there is no one cause or reason someone has a Cluster B personality disorder like borderline personality disorder. Typically, people have environmental risk factors and in some cases, genetic vulnerabilities are also identified.

As Dr.Brindusa Vanta, MD, says, “According to Freud, being stuck at various developmental stages early in life leads to certain personality disorders. For example, dependent, obsessive-compulsive, and histrionic personality disorders correspond to being stuck (having a fixation) at oral, anal, and phallic stages, respectively.”

Treatment for Cluster B Personality Disorders

Treatment for Cluster B personality disorders typically involves a comprehensive approach tailored to the individual’s specific needs and symptoms, including psychotherapy, behavioral therapy, and medication. Here’s an overview:[9,10,11,12,13]

• Dialectical Behavior Therapy (DBT): Originally created as a treatment for Borderline Personality Disorder, DBT focuses on enhancing distress tolerance, emotional regulation, interpersonal effectiveness, and mindfulness skills.
• Cognitive Behavioral Therapy (CBT): This therapy analyzes the connection between thoughts, feelings, and behaviors and can help rectify maladaptive behaviors and build coping skills.
• Psychodynamic Therapy: This type of therapy helps people with Cluster B personality disorders by exploring underlying unconscious conflicts, early life experiences, and relational patterns that contribute to maladaptive behaviors and emotional distress.
• Schema Therapy: Schema therapy helps people identify and challenge deeply ingrained maladaptive beliefs that drive dysfunctional patterns of behavior, feeling, and thinking. It can help promote emotional regulation, develop adaptive coping skills, and cultivate fulfilling relationships.
• Group Therapy: Group counseling can provide people with a safe and validating environment to explore interpersonal dynamics, practice new skills, and receive support from peers.
• Family Therapy: Family therapy can address relational conflicts and improve communication and boundaries within interpersonal relationships.
• Selective Serotonin Reuptake Inhibitors (SSRIs): These medications, such as Zoloft and Lexapro, can relieve symptoms of depression and anxiety, which often co-occur with personality disorders.
• Mood Stabilizers: Mood stabilizers, such as Lithium, may be prescribed to address mood dysregulation and impulsivity.

While many of these therapeutic interventions can be beneficial, one disadvantage of a Cluster B personality disorder is that many people with one of these conditions don’t seek professional treatment. Moreover, many individuals, especially those with Narcissistic Personality Disorder and Antisocial Personality Disorder, may feel that nothing is wrong with them and won’t seek help.