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Definition
The term personality disorder refers to a set pattern of characteristics and maladaptive behaviours that cause people to think, feel and relate to others in ways that are not in keeping with social norms (World Health Organization, 2019). The International Classification of Diseases (ICD-10) lists 10 types of personality disorders which are commonly grouped into clusters – A, B and C – depending on their shared characteristics and aetiology.
Cluster B personality disorders include:
People with cluster B personality disorders experience dramatic, unpredictable and extreme emotional responses, which they find difficult to regulate. Emotionally unstable personality disorder is one of the most common personality disorder subtypes (Chapman et al, 2023), and histrionic personality disorder is the least (Winsper et al, 2019).
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Symptoms
Symptoms of personality disorders often manifest from childhood, but are not diagnosed before the age of 18 years as the personality is still developing until that point (World Health Organization, 2019). People with cluster B personality disorders have usually experienced significant childhood trauma and adversities, which affect the development and course of their symptoms.
The ICD-10 uses the term ‘dissocial personality disorder’, but this article will refer to ‘antisocial personality disorder’ in line with the National Institute for Health and Care Excellence (NICE, 2013a) guidelines.
Common symptoms of antisocial personality disorder include:
- lacking concern for social norms
- lacking empathy
- low tolerance for frustration
- low threshold for violent and aggressive behaviour
- blaming others
- dishonesty
- behaviour that is not modified by punishment (Wong, 2023)
People with antisocial personality disorder often disregard the societal norms and other people’s rights. People with antisocial personality disorder are commonly found in prisons and forensic psychiatric settings,
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Aetiology
Contemporary views on the aetiology of personality disorders highlight the influence of genetic, neurobiological and environmental factors (Maass, 2019). A lack of research into histrionic personality disorder means that the influence of genetics, neurochemistry and neurobiology is poorly understood.
Genetics
Research highlights a strong genetic links in both antisocial and narcissistic personality disorders (Luo and Cai, 2018; Wong, 2023) and limited evidence of genetic associations in histrionic personality disorder (Torgersen et al, 2012).
Neurochemical
Differences in the serotonin transportation system are seen in people with antisocial and narcissistic personality disorders, which is linked to aggression and antisocial behaviours (Konrath and Bonadonna, 2014; Wong, 2023).
People with antisocial personality disorder tend to have higher dopamine levels (linked to mood and reward systems) and differences in oxytocin levels (plays a role in social behaviours and bonding). Additional neurochemical changes that mediate impulsivity and aggression have also been found
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Diagnosis
Diagnosis of cluster B personality disorders is based on the clinical symptoms described above. Assessment tools can aid a robust diagnosis, but no specific recommendations are made in the literature or guidelines (NICE, 2013a). A thorough assessment of the presenting symptoms, behaviours, comorbidities and risk profile is paramount (NICE, 2013a), along with an understanding of the person’s upbringing and childhood experiences (Maass, 2019).
Differential diagnoses and comorbidities must be considered, as they can affect treatment outcomes (Wong, 2023). The symptoms of cluster B personality disorders are often similar and can overlap. Differential diagnoses for histrionic personality disorder include dependant personality disorder, somatic and anxiety disorders. Antisocial personality disorder is highly comorbid with harmful substance use, depression and anxiety (NICE, 2009). Differential diagnoses include schizophrenia and mania (Wong, 2023). Narcissistic personality disorder is comorbid with depression and anxiety, and common differential diagnoses include bipolar affective disorder and harmful substance use (Yaxley,
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Management
The evidence base for treatment interventions is poor. People with cluster B personality disorders do not often independently seek treatment, but can be encouraged to by family, friends or mandated by the courts. However, this can limit treatment adherence and effectiveness (NICE, 2013a; Maass, 2019).
There are no pharmacological treatments licenced for cluster B personality disorders, but it is important to carefully assess and treat any comorbid psychiatric conditions. Psychological therapy is recommended, but no single approach has been found to be superior.
Histrionic personality disorder
Psychodynamic therapy can support people with histrionic personality disorder to understand how past experiences unconsciously affect their current behaviours. Since they often excessively seek validation, group therapies are not recommended. Additionally, people can struggle with treatment endings, so these must be carefully managed (Maass, 2019).
Narcissistic personality disorder
People with this disorder commonly present to primary care or psychological
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NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 1: Procedures for assessing people’s needs for person-centred care
1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages
Part 2: Procedures for the planning, provision and management of person-centred nursing care
3. Use evidence-based, best practice approaches for meeting needs for care and support with rest, sleep, comfort and the maintenance of dignity, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions
11. Procedural competencies required for best practice, evidence-based medicines administration and optimisation
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Resources
Blashfield R, Reynolds S, Stennett B. The death of histrionic personality disorder. In: Widiger T (ed). The Oxford handbook of personality disorders. Oxford: Oxford University Press; 2012: 603-627
Chapman J, Jamil RT, Fleisher C. Borderline personality disorder. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023
Khalifa NR, Gibbon S, Völlm BA, Cheung NH, McCarthy L. Pharmacological interventions for antisocial personality disorder. Cochrane Database Syst Rev. 2020;9(9):CD007667. https://doi.org/10.1002/14651858.CD007667.pub3
Konrath S, Bonadonna JP. Physiological and health-related correlates of the narcissistic personality. In: Besser A (ed). Psychology of narcissism. New York: Nova Science Publishers; 2014
Luo YLL, Cai H. The etiology of narcissism: a review of behavioral genetic studies. In: Hermann A, Brunell A, Foster J (eds). Handbook of trait narcissism. Cham: Springer Cham; 2018
Ma G, Fan H, Shen C, Wang W. Genetic and neuroimaging features of personality disorders: state of the art. Neurosci Bull. 2016;32(3):286-306. https://doi.org/10.1007/s12264-016-0027-8
Maass V. Personality disorders:
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