Portrait of a Personality Disorder, Part 2: What Are Cluster B Personalities?

So, we have ten standard personality disorders and they are grouped into three clusters, A, B, and C.  Here, we are going to focus on cluster B, arguably the most difficult and controversial of the three clusters, but before we dive in, lets take a quick glance at A and C, and get that out of the way.

Cluster A is the "odd duck" cluster of personality types.  These are clustered together because they share certain attributes and characteristics.  To a layperson, seeing someone with a Cluster A personality on the street, you might assume that person is seriously mentally ill.  They might keep to themselves, they might be dirty and unbathed with an unkempt look, they might be wearing a heavy coat in the middle of a warm summer, they might act paranoid.  Basically, they look mentally ill.  The only thing is, they aren't.  There are no delusions, no auditory hallucinations, no manic episodes.  This is a person who has separated themselves from society and from normative social standards.  They have made themselves social isolates, and there they stay (unless there is a dramatic change to their personality at some point).  The specific Cluster A disorders are Paranoid Personality, Schizoid Personality, and Schizotypal Personality Disorders.

Cluster C is the anxious and fearful cluster of personalities.  These are people whose personalities and habits have been shaped by lifelong anxiety and fear, resulting in avoidance, dependence on others, obsessiveness and compulsive behaviors.  These are personalities that could be associated with the popularized version of neurosis--bundles of worries with irrational behaviors.  The specific disorders are Avoidant Personality, Dependent Personality, and Obsessive-Compulsive Personality Disorders.  Please note that Obsessive-Compulsive Personality Disorder is distinct from Obsessive-Compulsive Disorder per se, which was categorized as an anxiety disorder in DSM IV but in the 5th edition was placed in the new category of Obsessive Compulsive and Related Disorders.  The very brief explanation of the difference is that OCD per se is more severe and has a higher subjective experience of distress, whereas the personality disorder is characterized by a person who finds comfort in the OCD type behaviors and therefore is not usually motivated to change.

And, now, what we are really here for, Cluster B personalities.  These are your worst nightmares, as a therapist.  These are people for whom everyone else is wrong.  Everyone else is at fault.  They are blind to their own role in the making of their misery.  Their behaviors are motivated to manipulate and use others while seemingly unaware of what they are doing.  They have deep seated defense mechanism and are rarely motivated to change.  After all, why should they change when they're never at fault?  It's your fault.  You made me this way.  You change.

Cluster B personalities are familiar to everyone, but they are notoriously difficult to define and understand.  The characteristics that make up these personalities are somewhat disparate, and yet they appear together as a pattern again and again.  You will rarely find Cluster B defined or described as a whole, because it is so difficult for people to get a conceptual grip on it.  The APA's diagnostic manual, keeping it simple, describes Cluster B thus, "Individuals with these disorders often appear dramatic, emotional, or erratic."  That's it.  That's what the DSM has to say on the subject.  The UK's NHA describes Cluster B thus, "Someone with a cluster B personality disorder struggles to relate to others. As a result, they show patterns of behaviour (sic) most would regard as dramatic, erratic and threatening or disturbing."

I'm sure I can't expect to do better than the APA or the NHA, but here's my best shot . . . (1) thinking is characterized by cognitive distortions in the form of strongly developed defense mechanisms in which the individual fails to recognize the negative impact to them from their own actions and behaviors (more on this next time), (2) excessive use of out and out dishonesty and subterfuge, (3) actions and interactions frequently tied to secondary gains (i.e., attention seeking behavior), (4) excessive emotional reactions, and (5) apparent lack of substantive empathy (but superficial empathy may be expressed).  These personality disorders, besides having some common characteristics, are conceptually tied because there is a fair degree of co-morbidity.  In other words, it is not uncommon to find someone, for example, who has a combination of narcissistic and anti-social traits.  And this holds true for all four Cluster B disorders.

In this cluster, we have Anti-Social Personality Disorder.  This is very broadly defined disorder that accurately describes just about anyone who has found themselves up against the criminal justice system more than once.  It is more widely known by the older term of psychopathic personality.  It's characteristics include lack of empathy, lack of stress reaction to violence, dishonesty, disregard for the safety of self and others (but, especially others), lack of remorse, impulsivity, consistent irresponsibility, etc.  One point I would like to emphasize is that anti-social types often fail to plan or think ahead.  This, of course, is tied to impulsive behaviors, lack of ability to get one's needs met through normative behaviors (e.g., holding a job and budgeting your money to pay rent), and lack of concern about consequences (because cognitively the individual is trapped in the moment, they seem blithely unaware that tomorrow is going to happen).

Then there is Borderline Personality Disorder.  This is the most difficult to understand and relate to, but we see this pattern of behavior quite frequently in the mental health system.  With this personality profile, you often see intense emotional reactions, misunderstandings, the individual frequently attributes negative motivations to others, self harm behaviors (e.g., cutting), suicidal gestures, suicide attempts, intense anger (but often masked), and highly unstable relationships.  Being in any kind of relationship with such an individual can be very difficult due to the constant manipulation and polar emotional swings between clinging and anger.

Histrionic Personality Disorder is the least often diagnosed of this cluster.  Many clinicians and researchers have questioned the validity of this diagnosis, but I think it is more accurate to say it is an anachronism in the sense that it is an idiom of emotional distress that was common in the cultural context of the past but is much less common now.  To give you a sense of the flavor, criteria include (1) Is uncomfortable in situations in which he or she is not the center of attention, (2) . . . inappropriate sexually seductive or provocative behavior, (4) . . . uses physical appearance to draw attention to self, (6) shows self-dramatization, theatricality, and exaggerated expression of emotion.  Et cetera.

And, lastly, we have Narcissistic Personality Disorder.  It's been splashed all over the news, of late.  Most people already have a sense of what narcissism is, but that concept is not necessarily the same as the personality disorder.  Anyway, I'll save this one for a later, dedicated, blog post.

In our next installment we'll try to get a grip on those pesky Cluster B cognitive distortions that are so damn crazy making.

Portrait of a Personality Disorder, Part 1: What Is a Personality Disorder?

Can a personality be an illness?

Well, not exactly.  Everyone has a unique personality.  And, some are more likable than others, I suppose, but when and how is it appropriate to slap the "disorder" label on someone's personality?

In answering this question, it is important to understand that all mental disorders, including severe disorders such as schizophrenia, are defined by behaviors and/or inner states that cause distress or dysfunction for the individual or for people around them.  This concept is true of the larger medical field, as well.  Take for instance the individual with six digits on each hand.  It is an unusual condition, yes, but do we consider it an illness?  No, nor should we (unless of course, having six fingers is excessively distressing and dysfunctional or you simply want to say it is so the insurance will pay for surgical "correction," but that's a wholly different blog post, for another day).  On the other hand, being born with the inability to produce blood clotting components is considered a disease for the simple fact that it will lead to a quick demise unless treated.

Biologically, every individual is unique, and the human population presents a vast range of phenotypes.  Disease cannot be defined by deviation from the norm, alone, but must be defined by impact, dysfunction, pain and death.  This is even more true with mental disorders.  We cannot pathologize based on what looks different or anormative, alone.  We have to limit our determination of disorder to the impact of behaviors and inner states, i.e., distress and dysfunction.  And, this is even more important when discussing the pathology of personalities.  Why?  Because, it is far too tempting for us to label people we don't like or don't understand as disordered.

According to the American Psychiatric Association (APA) in the latest diagnostic manual (DSM 5), "A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment" (emphasis mine).

This definition attempts to limit the idea of personality disorder within strict parameters, but let's face it, it's still wide open.  The DSM 5, like its predecessor, the DSM IV TR, then goes on to list 10 specific personality disorders grouped into three clusters, A, B, and C, and an eleventh, "unspecified" personality disorder for personalities that meet the general definition but do not meet criteria for any one of the 10 specific disorders.  Lastly, there is a disorder for personality change due to a medical condition.

Personality disorders carry some controversy in the field and some clinicians simply refuse to acknowledge them or diagnose them, but this is the minority of clinicians, I think.  I too was very skeptical as a new clinician, but over two decades of working with a wide variety of clients, I have come to recognize there really are some distinct patterns of personality dysfunction and pathology, and it does us no good to pretend it does not exist.

Personality disorders are categorically distinguished from major mental illness.  This idea goes back a ways, well before Freud, even.  The personality disorder idea is the intellectual descendant of the concept of moral insanity.  This was a diagnostic category proposed in 1835 by a certain Dr. Prichard.  He defined it as "madness consisting in a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions, and natural impulses, without any remarkable disorder or defect of the interest or knowing and reasoning faculties, and particularly without any insane illusion [delusions] or hallucinations."  It remains an important distinction that personality disorders are defined by cognitive distortions and aberrant behaviors and emotions as opposed to cognitive impairment or delusions or hallucinations as these are indicative of major mental illness.

Well, there's a nice little overview.  Not too boring I hope.  In the next installment, we will take a big bite into Cluster B types and figure out why they leave such a bad taste in your mouth.  Then, we'll examine what we mean by cognitive distortions and why it leaves you wondering if you're the crazy one.  Finally, we will narrow our focus on narcissists and what you can do when your family member, or your boss, or your president has this personality disorder.

Autism's Tipping Point

Besides being an expert at neuroscience, to the benefit of the greater good neuroskeptic also dabbles in cultural criticism of science and healthcare with an eye toward empirical observation of the ethnocultural processes of those areas.  A bit of armchair social science, but well done.

His latest piece on the phenomenal growth of autism:

Are We Headed For "Peak Autism"?

Many have observed the unnatural increase in autism over recent years.  In the midst of this apparent epidemic, news stories push "autism awareness" and "promising findings" about the cause(s) of autism.

Among practitioners, among psychiatric naysayers, among the small community of social scientists who make medicine, psychiatry and science their field of study, there has been much conjecture about the sociocultural factors behind the growth.  The usual conclusion based on observation and/or conjecture, is that the incidence of the underlying condition has probably not changed dramatically, but instead we are seeing an expanding practical definition of autism as interpreted by clinicians in the field.  You can add to this the fact of heightened awareness of the diagnosis resulting in people (clinicians, parents, teachers, etc.) seeing it where they didn't see it before (rightly or wrongly).  This, in the context of a loosely defined spectrum disorder that (like all mental health diagnoses) is determined by a check list of behavioral signs and indicators allowing for broad differences of interpretation and understanding.

Sadly the places and people with money to pay for research don't seem particularly interested in putting resources into resolving this question.

Lucky for us we have a guerrilla social science researcher in neuroskeptic who counted the number of research papers (via PubMed) on the subject of autism, relative to several other disorders.  He found that autism research has increased eight fold in 12 years, about twice the rate of ADHD (the next highest growth disorder) and maybe 4x (about) the growth of schizophrenia research.  It is hugely out of proportion to the 4% growth in science (as a whole) per year.

I might take it a step further and just state what has been clear over the last 150 years or so of psychology and psychiatry--the field, popular and professional, is driven by fads.

A Buffet of Childhood Diagnoses

I just want to promote this very good post on Neuroskeptic on the North American epidemic of diagnosing young children with the adult disorder of Bipolar and the American Psychiatric Association's attempt to fight this problem by writing yet another childhood disorder into the DSM-V.

Psychiatrists: Does Fire Put Out Fire?

What is it about North America that we want to believe all our children are mentally sick?

Why Does Norway Want Breivik to Be Insane?

Anders Breivik bombed downtown Oslo and went about methodically murdering 77 people and injuring many more.  In his recent trial that came to a close last month he calmly described how he did it and discussed with detached curiosity the victims' various reactions or lack of reactions to his attacks.  Throughout, he taunted family members, survivors and the world with what can only be described as a psychopathic sneer.

A sneer, micro or macro, is the universal expression of contempt

Is he insane?  This was the central question the recent trial revolved around.  Prosecutors want him to be insane, even though they now admit their doubt on the subject.  Prosecutor, Svein Holden, is quoted by the BBC as stating, "We are not convinced or certain that Breivik is insane but we are in doubt."  And yet, they continue to argue he should not be imprisoned but should instead be committed to a psychiatric institution.

Here, insane is more or less defined as psychotic.  Is he psychotic (insane) or psychopathic (sane but very very bad)?  That is the question.  Technically the defense is on a fool's mission to explain his actions as justified, but that is beyond absurd.  One wonders if the defense attorneys have undergone cognitive deficiency testing themselves--if not, perhaps they should.  While there is little if any evidence of actual psychosis there is a strong desire to place Breivik in that category, or maybe more to the point, to place him outside the categories of normal or sane.

Other than the fact that Norway has one of the most lenient and forgiving criminal justice systems on the planet, I know too little of that place and culture to fully understand their reasoning.  I can only surmise it gives some comfort to hold a belief that a man capable of doing what Breivik did cannot be normal or sane.  In a lay sense, what Breivik did makes him, by definition, insane.  This creates a safe psychological boundary between him and us.

It is an understandable sentiment, I'm sure.  But what does it say about a criminal justice system where prosecutors are not motivated by truth but by the outcome that makes them the most comfortable?

Can a man like Breivik be helped by psychiatric care?  If he were in fact psychotic, there are drugs that may (or may not) help.  Add some cognitive-behavioral whatnot and sometimes we see improvement, even dramatic improvement at times.  Conversely, if he is a straight up psychopath (as is likely the case), there is very little help possible if we want to be honest about it.

The Norwegian prosecutors fail to recognize the collateral impact of their strategy is to add more fear and stigma to the actual insane, the 1% or so of the world's population with a form of psychosis at some point in their lives.  Granted there have been plenty of psychotic shooters and killers over the years, and we may very well have experienced another one in Colorado just this month, but the vast majority of people with psychotic experiences, 1% of the world's population, are as non-violent as anyone else.  Some psychotic individuals can be dangerous, but lets not pin everything too horrific to comprehend on them just to make us feel a little more removed from the human potential for evil.

They Want Us to Believe

There is a ubiquitous use of tense in mental health treatment, and curiously, it highlights an interesting contrast with the evangelists of multiple personalities.

In working with people on the more severe end of the spectrum of mental health disease (or "disease" in quotations if you prefer) we usually find that we cannot directly challenge beliefs we believe are delusive without threatening to lose the relationship, the precious rapport, that is often our only hope of helping, and yet we don't want to reinforce the delusion just in order to maintain rapport as that would also be counterproductive, so we try to ease our way through the dilemma with a little play of tense.  The client speaks in the indicative, "I have an implant in my neck that Richard Nixon speaks to me though." It is a solid fact.  Meanwhile, we clinicians reflect in the subjunctive, "You believe . . .", "You said . . .", or you might even risk a "I believe you believe . . ."  We leave it in an open and conjectural mood to show understanding, and thereby avoiding conflict, but without reinforcing.

Changes in tense are also important in the strictly professional side of mental health when we take our professionally sanctioned beliefs and apply them in the real world.  The ultimate document of professional belief, the Diagnostic and Statistical Manual, The DSM, is written entirely in the indicative tense.  Every mental health diagnosis is a fact and every criterion of every diagnosis is a fact.  These facts are immutable immobile objects with crisp edges.  The DSM is seemingly free from conjecture or uncertainty, much less fantasy and make believe.  Here we find ourselves in another dilemma because most clinicians (and researchers too I would guess) do not believe the diagnostic categories handed down from on high are factual at all.  Most of us handle these interesting but crude objects with healthy skepticism.  They are all works in progress that may or may not hold up long enough for the next edition.  The clients we work with are individual people who do not always so easily fit these models.  We are well aware they are just that, models.  Is Schizophrenia really a single disease entity or several that happen to look similar?  No one really knows for the time being.  So, we think and talk about these things in the subjunctive manner even though Medicaid forces us to write out our final diagnoses in the indicative.

It has recently struck me, however, when it comes to therapists who are wont to diagnose and promote Dissociative Identity Disorder (or Multiple Personality Disorder), the above outlined patterns do not hold.

Firstly, there is no distance between the belief of the clinician and the belief of the client.  They become fused in a shared belief.  A shared fantasy.  A shared dramatic enactment.  Between clinician and client, the belief system is spoken of in the indicative.  Changes of mood are distinct personages inhabiting a single body.  The clinician pronounces it.  The client reflects it and gradually comes to act it and be it.  The reality that DID becomes depends on the indicative mood.  The clinician and client must truly believe and always speak of it in the most confident and unwavering language.  Any doubt may cause the mirage to waver and blow away in the wind.  The clinician is on stage also, enacting the role of professional therapist, but it is an "as if" that only looks like therapy.  In fact, it is therapy in reverse, rather than curing or ameliorating, with this therapy the symptoms of the client strangely increase in strength and definition over time and eventually become cemented facts.

Secondly, there is no healthy skepticism on the part of the clinician in the professional realm.  Always these therapists use the same indicative tense used in the DSM whenever discussing their one cherished true diagnosis of DID.  They are believers who want us to believe in it too.  To convince themselves and us, they don't use the language of belief, they use the language of hard facts.  There are no maybes or uncertainties.  The facts of DID are proven and true.  Professionals who doubt run the risk of being called closed-minded or ignorant of the facts, or finally when we fail to align we are told we are invalidating toward their clients--spoken as if it is the worst possible insult.  It always strikes me that the selfsame therapists who want so hard to believe in the fact of DID are often the most doubtful of just about any other diagnosis in the DSM.  I have been told by a straight faced bearded therapist that many cases of Schizophrenia are actually DID.  There are many many people out there with mood fluctuations who have DID and don't even know it.  Or so I'm told.  I suppose the right therapist can skillfully draw out the symptoms and turn annoying mood fluctuations into a disabling condition and Medicaid will reward the therapist for many years to come.

It may be no coincidence the only other people I have experienced such a hard sell from, miraculously turning uncertainties into facts, are car salesmen and preachers.  I can't say that I've ever knowingly been part of a cult, but I imagine cult leaders also are inclined toward an indicative mood.

Two New Mental Disorders?

Researchers are forever trying to link existing mental disorders with some kind, any kind, of brain structure “abnormality.”  Even the weakest of links send people into hysterical excitement and soon we see flashy headlines claiming Researchers Find Neurological Cause . . .” for, well, just fill in the blank yourself with your favorite mental disorder.

So, this is just what I was thinking about when I came across this flashy brain structure study, published in Current Biology, which found a significant link between anatomical brain differences and certain identifiable behaviors.  It’s a headline grabber for sure.

Of course, any researcher who has an actual college degree and took Statistics 101, would never, never assume that correlation equals causation, but this doesn’t stop people from doing endless correlational studies that grab headlines and are statistically significant but are of no use diagnostically.

If you don’t know what I’m talking about, you can see for yourself.  Go to Google and do a search for:  “brain structure” +adhd

ADHD happens to be a favorite target for useless correlational brain structure studies that might be interesting but give us no immediately useful knowledge because the differences they find can never be clearly separated out from the background noise of human variation.

But, back to the topic at hand . . . this write-up from Current Biology, found a strong link between brain structure and behavior that gives us a greater neurological understanding of this behavior than we have of many mental disorders.  What I don’t understand is why the authors didn’t make that leap and suggest a couple new diagnoses.  Does it make any difference that the behavior they looked at was political identification?  Honestly, I don’t know why it should make any difference; it seems to me we have two new perfectly good mental illness labels with some statistically significant data to back it all up.  All we need to do now is develop some psychopharmacological interventions and some evidence based psychotherapies.  Then we’re in business.

Kanai, et al., found that people who say they are liberal (gee, does anyone really do that anymore?) have thicker anterior cingulated cortexes.  On the other hand, people who go around using the word conservative in reference to themselves have inflated right (wing) amygdalas.  So, the authors interpret this to mean that liberals are able to cope with conflicting information (in other words, they’re spineless elitist smarty-pants who can’t make decisions) while conservatives are more able to recognize threats (which I interpret just a little further as meaning they are neurologically closer to highland gorillas than they are to homo sapiens sapiens).

Well, that’s all very cute, but let’s turn this into a real money maker.  It’s simple.  All we have to do is turn the glass-half-full language into glass-half-empty language.  Like this:

Liberalism Not Otherwise Specified is linked to smaller than average amygdalas resulting in impaired ability to recognize threats leading to being taken advantage of by freeloaders and traumatized by bullies and obstinate foreign powers.

Conservatism With or Without Paranoid Delusions is linked to withered anterior cingulates resulting in impaired ability to process complex information leading to reactive, bellicose and sometimes violent behaviors when confronted with multifaceted ideas and situations.

See? That wasn’t so hard, was it now?  Is it too late to get them added to the DSM-5?

Reference:  Ryota Kanai, Tom Feilden, Colin Firth, Geraint Rees.  Political Orientations Are Correlated with Brain Structure in Young Adults.  Current Biology, 07 April 2011 DOI: 10.1016/j.cub.2011.03.017

There are Psychiatric Diagnoses and Then There is Reality

Reality is a hard thing to pin down sometimes.  Why do the stars spin in a circle overhead?  Why are the people born under the constellation of Scorpio always such jerks?

I suppose the scientific method comes in there somewhere.  But let’s face it, our empirically grounded bodies of knowledge have their limits.  We can be hopeful that we will continue to expand our horizons of knowledge, but knowing what we really know and how we know it is probably a good thing.  I mean, isn’t that part of the whole scientific endeavor?

Well, I know you agree with me, but can someone help me understand how this message got so mixed up in the field of psychology?  In psychology, “scientific findings” and diagnostic labels seem to be thrown around with about as much critical scrutiny as a gibbering glossolalic soliloquy might receive in the midst of a writhing Pentecostal congregation.

Among practitioners, it seems to me, that the diagnostic categories of the DSM are typically taken with several cobblestone-sized grains of salt.  Not so among journalists or among the ubiquitous faceless internet-based free-advice-givers with their pop-up ad business models.  Doubly not so among purveyors of “evidence-based” therapies who use flashy headlines from the world of scientific research to prove their wares (acupuncture, Blood-LettingÒ, Eye Movement Desensitization Reprogramming, etc.).

It bothers me, not a little, that DSM labels are thrown around the way they are and it troubles me that so many researchers build their research designs as if these committee-written categories are unquestionable real-world phenomena.  Does anyone really believe that there is a discrete Major Depressive Disorder that is a distinct and separate process from Dysthymia?  Even that most archetypal of mental disorders, Schizophrenia, is quite fuzzy around the edges, and there continues to be some question as to whether we are dealing with a single disease process or multiple phenomena with similar and overlapping symptoms.

It is a truism that, in young disciplines, where there is a dearth of causal understanding, we tend to fall back on simple categorization of observable phenomena.  That, in fact, accounts for every single mental health diagnosis now in use.  These are loose categories based on our sad attempts to group complex human behaviors into digestible and palatable portions that we can pretend to understand and try to get the insurance companies to swallow without puking all over us.

With the upcoming DSM-V we are going to realign our categories by shifting our bullet-item-symptoms from one list to another and rebranding our labels, but still we will end up with somewhat arbitrary diagnostic descriptions authored by compromising, wordsmithing  committees and deeply confounded by cultural assumptions, political correctness and insurance driven language games.

Some day, maybe, we will have our grand synthesis of psychology, neurology and genetics, but we are not there yet people.  Please let’s stop playing pretend.