C H A P T E R 18

Cluster B Personality Disorders

Jessica Dotson  ■  Christian Gerwe

A 21-year-old female presents to the emergency department with arm lacerations. She reports a long
history of psychiatric illness and says she has been diagnosed with bipolar disorder, posttraumatic
stress disorder, attention-deficit hyperactivity disorder (ADHD), depression, and anxiety. She has
tried numerous psychotropic medications, all of which have been unsuccessful in treating her symp-
toms. She feels unable to function in society and recently dropped out of college and moved back
home to live with her mother. She constantly worries about how others perceive her and worries that
the people closest to her will abandon her or hurt her. She states, “People are always out to get me.”
She also experiences frequent nightmares and an increased startle response. The arm lacerations did
not require suturing, routine laboratory studies are ordered, and a psychiatry consult is placed.

What is the first step in evaluating this patient?

Initial steps of a full psychiatric evaluation include obtaining a thorough history from the patient,
obtaining information from collateral individuals (such as family, friends, or outpatient providers),
and review of basic laboratory studies to rule out medical causes for presenting symptoms. This
patient’s medical workup was within normal limits. Given the patient presented with concerns of
people being out to get her, abandon her, or hurt her, it is important to determine whether she is
acutely psychotic and responding to internal stimuli during the evaluation. Her mental status ex-
amination revealed a linear thought process, she was able to respond to questions appropriately, and
she did not endorse auditory or visual hallucinations, illusions, or delusions. Given she is not dem-
onstrating overt paranoia, it is likely that she is exhibiting a defense mechanism known as projection,
which is common in patients with personality disorders (particularly borderline personality disorder
and narcissistic personality disorder). Projection occurs when an individual’s unwanted feelings, or
characteristics that the individual finds unacceptable in his/herself, are displaced onto someone else.
Patients with borderline personality disorder often fear abandonment from loved ones and project
this fear by accusing those close to them of planning to abandon them or hurt them in some manner.
Projection is often a component of paranoia in patients with psychotic disorders and contributes to
the delusions associated with paranoia. Paranoia itself is composed of multiple other characteristics,
including reality distortion and disorders of reasoning, which this patient does not demonstrate.

Upon further discussion with the patient, she reports a long history of interpersonal conflicts, most
recently with her significant other and her mother’s boyfriend. The patient has been feeling very
alone and unable to care for herself, and she has felt depressed off and on for many years, which has
worsened since going to college. During her first semester of college, she started cutting herself during
periods of stress. This provided a sense of relief. She states, “I have mood swings all the time,” elaborat-
ing that she feels sad one minute, angry the next, and then becomes hyperactive. She cycles through
these emotions numerous times a day. She states further, “No one understands my bipolar disorder.”

131
132 PSYCHIATRY MORNING REPORT: BEYOND THE PEARLS

What is the differential diagnosis?

The differential diagnosis includes anxiety disorders, depressive disorders, psychotic disorders,
posttraumatic stress disorder, substance use disorders, borderline personality disorder, and symp-
toms related to another medical condition. Patients with borderline personality disorder are fre-
quently misdiagnosed with bipolar disorder. They often have a history of numerous psychiatric
diagnoses, which is evident with this patient. They typically have symptoms that are characteristic
of many psychiatric illnesses, but may not meet full diagnostic criteria for each individual condi-
tion. It is also common for patients to have other comorbid psychiatric illness.
The most likely diagnosis for this patient is borderline personality disorder. According to the
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a person must have
a long history of unstable interpersonal relationships, fluctuating self-image, and volatile changes
in affect. These individuals are also impulsive. The symptoms start in early adulthood and occur in
a variety of settings. For the diagnosis, the patient must experience five or more of the following:
■ Extreme efforts to avoid feeling abandoned, whether real or imagined
■ History of intense close relationships that are not stable, marked by alternations between

extremes of idealizing the other person and devaluing them (splitting)

■ Persistent instability of self-image or sense of self (identity disturbance)
■ Being impulsive in at least two areas that are potentially harmful to self (e.g., sexual indis-

cretions, substance use, overspending)

■ Recurrent suicidal behaviors and/or threatening suicide, which can also include self-harm-

ing behavior, such as cutting or burning

■ Affective instability (severe mood swings)
■ Feeling empty
■ Trouble controlling anger (short-tempered)
■ Brief paranoid ideation (caused by stressful situations) or severe dissociation (feeling dis-

connected from reality)

CLINICAL PEARL STEP 1/2/3

It is important to distinguish mood lability, which is a characteristic of mood disorders
(such as bipolar disorder), from affective instability, which is a trait often seen in personality
disorders (particularly borderline personality disorder). Mood lability is described as a rapid
oscillation of mood that fluctuates between euthymia (normal mood), depression, and elation.
The mood states occur over a period of days to weeks. This mood shifting results in the char-
acteristic depressive and/or manic episodes seen in bipolar disorder. Affective instability is
defined as rapid (moment-to-moment) affect shifting with random patterns and dysregulation
of emotions. These changes can occur multiple times per day, as seen in this case. Affective
instability is often misattributed to the common sign of mood lability seen in bipolar disorder.

What are additional considerations for this patient?

It is imperative to discuss medical history and presenting symptoms as well as her current emo-
tional state. There may be medical comorbidities that could be missed if the evaluation is too
focused on the psychiatric presentation. In addition, medical illnesses or physical ailments may
influence psychiatric symptoms and vice versa.

The patient’s medical history includes migraines, heartburn, and vague diffuse muscle pain. Cur-
rent medications are topiramate, venlafaxine, aripiprazole, trazodone, prazosin, omeprazole, and
ibuprofen. Prior medications included hydroxyzine, buspirone, clonazepam, melatonin, fluoxetine,
citalopram, quetiapine, and an unspecified stimulant.
18—Cluster B Personality Disorders 133

CLINICAL PEARL STEP 1/2/3

In addition to having numerous psychiatric diagnoses, patients with borderline personality
disorder will often have numerous medical conditions as well. At times the conditions will
interfere with seeking treatment or with adhering to a psychiatric treatment regimen. This can
often lead to polypharmacy. As seen with this case, individuals with cluster B personality dis-
orders are often prescribed psychotropic medications from a variety of classes (such as mood
stabilizers, antidepressants, anxiolytics, or antipsychotics). The reasons for this are multifacto-
rial in nature but in part arise from diagnostic uncertainty (particularly in the initial stages of
treatment) and attempting to target the wide array of symptoms that a patient with borderline
personality disorder will often present with. Pharmacotherapy is particularly useful in manag-
ing the features of the personality disorder that interfere with functioning.

The patient has had two inpatient psychiatric admissions (at age 16, after an overdose on Tylenol,
and at age 18, after self-inflicted arm lacerations). She reports that these hospitalizations were not
particularly helpful to her. She sees a psychiatrist every 1 to 2 months and does not have a current
therapist. She tells you that psychotherapy has been of minimal benefit in the past and says, “I
know you will be great, because I know you’ll really be able to understand me and all that I’ve been
through.” She reports prior conflicts with every therapist she has met because “no one understands
me.” Family history reveals that her mother has migraines, fibromyalgia, anxiety, and a history of
multiple suicide attempts. She does not know her biological father. She uses marijuana daily for
her anxiety and denies other illicit substance use. She is an only child and reports that her mother
drank alcohol a lot and had numerous boyfriends when she was growing up. One of her mother’s
boyfriends sexually abused the patient from ages 5 to 12. When she told her mother about the abuse,
her mother blamed the patient. They have subsequently had a tumultuous relationship.

CLINICAL PEARL STEP 1/2/3

Ego defenses are conscious or unconscious mental processes used during periods of
conflict to prevent unwanted emotions. Individuals with personality disorders typically exhibit
maladaptive or immature defenses. The patient in this case is using the defense mechanism
known as splitting in an attempt to resolve the current conflict and unwanted thoughts and
emotions. This defense mechanism is frequently used and is the belief that someone is either
all good or all bad (that same person may vary between the two extremes depending on the
circumstance). There is rarely a gray area or ambiguity. Another mechanism frequently used in
those with borderline personality disorder is reaction formation. This occurs when a thought or
emotion is replaced by the opposite thought or emotion and is an unconsciously derived pro-
cess. Some of the other frequently used defense mechanisms include fantasy, dissociation,
isolation, projection, passive aggression, acting out, and projective identification. Personality
disorders are ego-syntonic (acceptable to the ego) and alloplastic (try to alter external factors
instead of themselves; external locus of control).

The term personality refers to an individual’s traits, both emotional and behavioral, that adapt
to one’s environment. Personality disorders develop when these traits become maladaptive. In
general, personality disorders are inflexible and pervasive, lead to impairment or distress, are long-
standing, have a pattern of behavior that deviates from cultural norms, and manifest in a variety of
ways (cognition, affectivity, interpersonal functioning, and impulse control).
The personality disorders are divided into clusters, each with typical characteristics. Cluster
A personality types are also known as eccentric or weird, whereas cluster C personality types are
134 PSYCHIATRY MORNING REPORT: BEYOND THE PEARLS

TABLE 18.1  ■  Cluster B Personality Types

Disorder Key Features
Borderline personality Mood instability, unstable relationships, identity instability, impulsivity,
disorder feelings of emptiness, often a history of self-harm and suicidal ideation.
Use splitting as defense mechanism. Females > males
Histrionic personality Attention seeking, emotional, sexual provocativeness, overly concerned
disorder with appearance. Females > males
Narcissistic personality Grandiosity, require admiration, lack empathy, sense of entitlement, react
disorder poorly to criticism
Antisocial personality Impulsive, lack remorse, violate rights of others. There must be evidence of
disorder conduct disorder symptoms before age 15. Males > females

described as worried. Borderline personality disorder is within cluster B, which is considered

the wild group. Other disorders within this cluster division include narcissistic personality dis-
order, histrionic personality disorder, and antisocial personality disorder. Collectively individu-
als with one of the cluster B personality disorders may be described as dramatic, emotional, or
erratic (see Table 18.1).

The patient denies current suicidal ideation and denies that the self-inflicted arm lacerations
were performed with intent to die. Rather, she elaborates that she cut herself after an argument
with her significant other out of anger. She states that she has a job interview in 2 days and does
not want to be admitted to the hospital. Her mother corroborates the patient’s description of
events leading up to admission and does not think the patient was attempting to kill herself.
She does not think the patient needs to be admitted to the hospital. There are no firearms in
the home. Voluntary psychiatric admission is offered, but she declines. A safety plan is discussed
with both the patient and mother, and she is subsequently discharged from the emergency room
with a follow-up appointment scheduled with her psychiatrist. She is encouraged to resume
therapy.

Personality disorders are typically diagnosed in early adulthood, but traits may be seen as
early as adolescence. If a diagnosis is made before age 18, the traits should be present for at
least 1 year (with the exception of antisocial personality disorder, which can only be diag-
nosed after age 18). An individual with a personality disorder will typically have fluctuations
in the level of impairment that will likely persist throughout life. In those with borderline
personality disorder or antisocial personality disorder, the traits may be less evident (or even
remit) with age if there are stabilizing factors that arise, such as a stable relationship or job
stability. The personality traits should be persistent over time and be evident across different
settings in order for a diagnosis of a personality disorder to be made. It may require many
observations by a clinician to accurately make the diagnosis. The primary treatment approach
is psychotherapy; however, pharmacotherapy is often used for comorbid mood, anxiety, or
psychotic symptoms. Often patients will have comorbid psychiatric illnesses, and the person-
ality disorder may interfere with appropriate treatment for them. There is a particularly high
incidence of comorbid major depressive disorder. The mainstay of treatment for borderline
personality disorder is dialectical behavior therapy (DBT). However, other forms of therapeu-
tic interventions include transference-focused psychotherapy, psychodynamic psychotherapy,
and supportive psychotherapy. These therapies show varying levels of success in this patient
population.
18—Cluster B Personality Disorders 135

Individuals with borderline personality disorder will often be evaluated in an emergency room
setting in an acute crisis or as a result of an impulsive act. It is then imperative to perform a thor-
ough risk assessment to determine an appropriate disposition. Both risk factors and protective
factors should be considered. With the patient in the case, primary risk factors include impulsiv-
ity, a prior suicide attempt, family history of suicide attempt, and access to means of harm by
knives or medications. Protective factors were lack of current suicidal ideation, future-oriented
thought process with identifiable goals, presenting symptoms without potential lethality (did not
require sutures), and a collateral person who felt the patient would be safe. Although this patient
declined admission, it is common for patients with borderline personality disorder to be admit-
ted to psychiatric units for crisis stabilization. The prevalence of borderline personality disorder
is estimated to be 20% of all psychiatric hospitalized patients. Hospitalization can be beneficial,
especially in the initial stages of observation and treatment, but can also evolve into a maladaptive
coping strategy over time.

BEYOND THE PEARLS:

• Studies have evaluated the clinical benefit of lamotrigine for borderline personality disorder, with
results that have not shown a significant benefit. However, more studies need to be performed.
• Some patients with borderline personality disorder may have shortened REM latency,
disturbance of sleep maintenance, abnormal dexamethasone suppression test (DST), and
abnormal thyrotropin-releasing hormone test results. Similar findings are found in depres-
sive disorders.
• Mentalization-based treatment (MBT) focuses on an individual being attentive to his/her
mental states and the states of others, which is a key component of interpersonal interac-
tions. It is believed that if a patient with borderline personality disorder can improve mental-
ization, then the person will be better able to regulate thoughts and emotions. There have
been randomized, controlled research trials that have shown this treatment to be effective
for borderline personality disorder.
• Studies have demonstrated an association between cannabis use and borderline personal-
ity traits in young adults. In addition, it has been shown that cannabis use in adolescence
is related to depressive and anxious symptom development and chronicity.

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