Realm of Abnormal Psychology: Cluster B Personality Disorder

Cluster B Personality Disorder

In this article some of the latest research regarding the Cluster B personality disorders has been given along with their etiology, diagnosis and treatment. Further some research related to the causes, preventive measures and treatments of such disorders has been discussed here as well. The article also presents biblical and cultural points-of-views regarding the disorder. Lastly, various viewpoints associated with the counter transference related to the treatment of the patients with these personality disorders have been addressed as well (Kraus & Reynolds, 2001).

According to the definition of personality disorder it is 'a continuing pattern of behavior and inner experience which is a lot different from the culture that an individual lives in, this sort of behavior or experience is inflexible and pervasive, starts either during the initial years of childhood or adolescence and although it is generally stable but can become stressful over the years. It has been seen through various neuro-imaging, endocrine and electrophysiological measures that the various personality components like aggressiveness and impulsivity have neurobiological correlates. Personality and even more the personality disorder is anticipated to have an effect on an individual's functioning and in some of the cases this might actually result in others reacting to the individuals with personality disorder. Therefore, it is logical to expect the individuals with personality disorders to react to their medical illness, treatments and doctors in different manner (Douzenis, Tsopelas, & Tzeferakos, 2012).

The DSM-IV-TR views the Cluster B personality disorders such as borderline narcissism, antisocial andistrionic personality as the subdivision of the personality disorders which are known to be emotional, dramatic and show erratic behavior. Cluster B is the most frequently studied personality disorder and the reason for this is that it contains antisocial as well as borderline personality disorder (BPD). It is significant to note here that the medical co-morbidity of histrionic and narcissistic personality disorders is lacking according to the knowledge of the author. On the other hand the most studied personality disorders in the field of psychiatry are BPD and antisocial. (Douzenis, Tsopelas, & Tzeferakos, 2012).

There is an associated of the cluster B personality disorders with lifestyle and behavior because of which they can prove to be quite problematic not only for the patient but also the people around him. Even though a lot of attention is being given to cluster B personality disorders however, their link with the medical problems hasn't been studied that much. There is a great need for the relationship between medical illness and personality disorders to be studied (Douzenis, Tsopelas, & Tzeferakos, 2012).

Historical Context

The metaphor of a pendulum has mostly been used to describe the history of psychiatry with the opinions of the psychiatrists regarding the mental disorders swinging back and forth among the biological and psychological understandings. Within the clinical and historical literature as well as various other scholarly groups like sociologists, the pendulum is considered to be a very dominant motif. However, the use of pendulum as a metaphor has recently been challenged by Jonathan Sadowsay (2005) in one of his studies as he argues that the use of this metaphor exaggerates the differences as well as conceals the continuities among the psychological and biological traditions.

Sadosky's ideas have been drawn upon by Nicolas Rasmussen (2006) and he has applied them to depression's history between the years of 1940s and 1950s, this was a time when psychoanalysis was at its top. It was suggested by him that the extended use of amphetamine as anti-depressant shows that there is a need to revise the categorical divide which exists between the psychoanalyst and their psychiatrist colleagues (Pickersgill, 2010).

More and more expansion of the psychiatric comorbidity can be seen with every consecutive DSM-I to DSM-IV revision. It is the diagnostic system's design that the reason lies within as the DSM-IV is a categorical, descriptive system which separates the psychiatric symptoms and behaviors into a number of diagnoses and makes use of some of the exclusionary hierarchies in order to get rid of the numerous diagnoses. In the DSM's original version there were many concepts and Emil Kraepelin's structure of mental disorders' classifications was used. In comparison to the previous revisions, a 'one disease-one diagnosis' model was used by the DSM-I and DSM-II according to which the clinician made use of the qualifying phases in order to try and assign one all-encompassing diagnosis like "with psychotic reaction" and "with neurotic reaction" (Pincus, 2004).

However, a different approach was taken by DSM-III according to which big number of comparatively psychiatric diagnosis were used which were defined rather narrowly and gave operationalized diagnostic criteria. For instance, the single DSM-II category 'phobic neurosis' was split into 5 DSM-III categories which are social phobia, agoraphobia with panic, separation anxiety disorder, simple phobia and agoraphobia without panic. It is not surprising at all that the amounts of distinctive psychiatric diagnoses which are described by the DSM-IV are almost double as that of DSM-II (Pincus, 2004).

Cause of the Illness

In the light of this argument, the present diagnostic criteria for DSM, it is not possible to identify the Cluster B Personality Disorders without the proper use of moral notions and terms (Charland 2006, 119). Therefore, these disorders are moral instead of mental (Reimer, 2013)

The patients who suffer from the personality disorders have deep seated pathological patterns of behavior, thought and feeling which can be traced all the way back to early adulthood or adolescence. Other than the actions that are found in majority of the people, these people who suffer from personality disorders make a subjective distress or they suffer from functional impairment due to their maladaptive, inflexible and pervasive ways with which they interact with other people (DSM-IV; American Psychiatric Association. 1994).

Mostly the personality disordered patients aren't aware of their pathology (Millon & Davis, 1996). A very common condition through which the issues related to the comprehension of neurobiology get exemplified is the antisocial personality disorder. Conflicting results have been demonstrated by the postmortem studies that have been conducted on the antisocial personality disorders. In the serial killers who underwent the postmortem examination some abnormalities were found in their amygdala. Although it is also possible that these individuals might have suffered from various other disorders such as depression or substance abuse that can change the structure of brain. There aren't any reliable neuropathological studies that can show particular association between pathology and antisocial behavior. In case of majority of personality disorders, failure of insight is a major clinical feature. Irrespective of the symptoms the people who suffer from the personality disorders show different amounts of inability when it comes to understanding the affect that their behavior might have on other people. The capacity of an individual to monitor and examine himself gets diminished because of the insight failure (The Neurobiology of Personality Disorders).

Treatment

Psychotherapy has been observed to be the preferred treatment for the Cluster B personality disorders (Gabbard, 1994, 1995a), even though there are still discussion being conducted regarding pharmacotherapy (e.g., Kapfhammer&Hippius, 1998). It is the case methods that the literature which guides us about the suitable approach to psychotherapy is based upon instead of the clinical methods. According to the latest reviews regarding the treatment methods, more importance is being given to interpersonal/psychodynamic and cognitive-behavioral perspectives with regards to the treatment of such disorders (Gabbard, 1994, 1995a; Rosenbluth & Yalom, 1997). Discussions have also been conducted regarding the integrative approaches which deal with blending cognitive and psychodynamic perspectives (e.g., Horowitz, 1997). (Kraus & Reynolds, 2001).

The treatment for these disorders with regards to the cognitive-behavioral approaches is based upon the identification of the illogical beliefs, describing and easing the expression about such beliefs through the strengthening of healthy choices and behaviors that are made by the patient. The way that the interpersonal psychodynamic treatment approaches work is that they are based on the management and understanding of transferential and unconscious features of the therapeutic relationship, recognizing as well as working through the resistance mechanisms and by harmonizing the ability of a patient to not just experience but also think about their feelings and emotions (Kraus & Reynolds, 2001).

Generally speaking it is very difficult to diagnose and treat the people who have cluster B personality disorders. The patients who have antisocial or narcissistic personality disorder might challenge the group leader for the group's control whereas those who have borderline personality disorder might try to 'provoke' the group into saving them. Group therapy however, can prove to be very helpful as, it can help the patients in learning about autonomy, community, intimacy, relationships and individuation within the proper limits and setting (Rutan & Stone, 1993). With the help of covert and over role identification (Gemmill & Kraus, 1988) and various other methods of framing and conceptualizing the group life it is possible for the Cluster B patients to comprehend the ways in which their individual symptoms as well as interpersonal world affects each other (Kraus & Reynolds, 2001).

Prevention

About 9% of the U.S. population has been documented to have personality disorders. There are a number of methods through which the health of these patients can be improved by the family physicians. Some of these methods are pharmacotherapy, brief interventions and psychotherapy. There are three clusters that the personality disorders are divided into, these are A, B and C. Schizoid, paranoid and schizotypal personality disorders are included in cluster A; antisocial, borderline, narcissistic and histrionic personality disorders are included in cluster B; whereas, avoidant, obsessive-compulsive and dependent personality disorders are included in cluster C and this cluster has been noticed to be a lot more prevalent than the rest of the two clusters. Family physicians can treat majority of the patients who suffer from these disorders. Omega-3 fatty acids, mood stabilizer as well as 2nd generation antipsychotics will probably benefit the patients who suffer from the borderline personality disorder. Those who suffer from the antisocial personality disorder can benefit a lot from the antidepressants, mood stabilizer as well as antipsychotics. Problem solving on the basis of solution as well as motivational interviewing are some other forms of therapeutic interventions (Angstman & Rasmussen, 2011).

Intervention which is based on mindfulness, active listening and improving the connection to those values of the patients that he/she cherishes the most tend to be most successful for the family physicians. Interventions of this sort were mainly designed for the family physicians and the concerns regarding job satisfaction and emotional endurance are addressed by these interventions while at the same time they allow the physicians to care for the patients who suffer from the personality disorders as well. A collaboratively created safety and crisis plan should be considered by the physicians when the personality disordered patients are being treated by them, especially for the ones who have borderline personality disorder (Angstman & Rasmussen, 2011).

Cross-Cultural Issues

According to DSM it is a manual that can help in diagnosing the mental disorders. The American Psychiatric Association (APA) published it. Someone who knows that the manual has been published by a medical association might find it very surprising that the latest edition of this manual has a portion on 'Personality Disorders,' in which a few of the disorders have been defined completely in form of aberration from the moral norms. The question is if it is possible that in fact the cluster B personality disorders are moral instead of mental? Is their addition to the DSM merely a coincidence of 'medicalization of morals'? (Reimer, 2013)(Alarcon & Foulks, 1995)

The formation of a cultural axis has been advocated by a few of the authors to be an independent factor when it comes to diagnosing these psychiatric condition generally as well as the personality disorder (PDs) specifically. It is the powerful cultural influence regarding the idea of self-formation, its independence as well as the instant socio environmental happenings that their views are based upon psychopathology (Hallowell, 1934; Hamilton, 1971; Dohrenwend & Dohrenwend, 1974; Mezzich & Goode, 1994). The most important problem which is often faced by a diagnostician who works across the cultures is the necessity to separate the typical personality, ideal personality as well as the atypical personality from cultural functionality's standpoint. The most common way through which the ideal personality kind is revealed is when the people are questioned about how they would like to live and raise their children (Alarcon & Foulks, 1995).