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Clinical Psychology Review, Vol. 21, No. 3, pp. 345–373, 2001
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THE “A-B-C’S” OF THE CLUSTER B’S:
IDENTIFYING, UNDERSTANDING,
AND TREATING CLUSTER B
PERSONALITY DISORDERS
George Kraus and David J. Reynolds
University of Cincinnati
ABSTRACT. This article is a summary of some of the more recent research on the diagnosis, etiology, and treatment of Cluster B personality disorders (antisocial, histrionic, borderline, and
narcissistic). Research on psychological, psychosocial, and biological perspectives of these disorders is presented. Individual psychotherapy, group psychotherapy, and other forms of multiperson
therapies are also discussed. Finally, perspectives on issues of countertransference when treating
these personality-disordered patients are addressed. © 2001 Elsevier Science Ltd.
KEY WORDS. Antisocial, Histrionic, Borderline, Narcissistic.
THIS ARTICLE SUMMARIZES some of the more recent research and clinical findings on the diagnosis, etiology, and preferred treatment approaches for treating antisocial, histrionic, borderline, and narcissistic personality disorders—the Cluster B Personality Disorders of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV;
American Psychiatric Association, 1994). Over the years, much has been written about
these personality disorders, and this article is designed, not as an exhaustive review of
the topic, but rather as a general overview of current thinking and trends in this area
of practice.
Understanding Cluster B disorders is essential to every clinician whether their practice focuses on this area of treatment or not, because almost all psychiatric symptomatology has characterological treatment implications both for the patient and the clinician. The person in the clinician must treat the person in the patient. Therefore,
whether treating patients with acute Axis I disorders or the more pervasive psychological and behavioral patterns of Axis II disorders, clinicians must develop effective clinical formulations and make decisions on how to work with patients within the context
of their particular personality organization and style. A better understanding of the
Correspondence should be addressed to George Kraus, 376 Probasco Street, Apt. 6, Cincinnati,
OH 45220. E-mail: [email protected]
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Cluster B disorders offers clinicians the potential benefit of understanding the whole
patient and not simply his or her symptoms.
A WORD ABOUT PERSONALITY DISORDERS AND THE CLUSTER B GROUP
Patients experiencing personality disorders have deeply ingrained and pathological
patterns of thought, feeling, and behavior that can be traced back to adolescence or
early adulthood. Outside the range of actions found in most people, those persons
with a personality disorder create subjective distress and/or experience functional impairment because of their pervasive, maladaptive, and inflexible ways of interacting
with others (DSM-IV; American Psychiatric Association. 1994) The pathology of the
personality-disordered patient is, for the most part, out of their awareness (Millon &
Davis, 1996). Quick cures for these disorders are unavailable.
Estimates are that approximately 10–15% of the U.S. population suffers from a personality disorder (Zimmerman & Coryell, 1989). Although children are sometimes diagnosed with personality disorders, the diagnosis is typically used with adults. Contrasted with Axis I disorders, which can have periods of remission, untreated
personality disorders (classified as Axis II disorders) remain stable across time, and as
a result, they are extremely resistant to intervention. Although the DSM-IV (American
Psychiatric Association, 1994) provides the latest and most widely accepted standard
for diagnosing personality disorders, significant criticism of and revision to this categorical assessment model has also been presented (e.g., Westen & Shedler, 1999a,
1999b). Accurate diagnosis is essential. Basing the diagnosis of a personality disorder
on initial test or interview data, however, is ill-advised, and clinicians often defer drawing early conclusions until such time has passed that enduring patterns of behavior
become evident.
Disorders of personality can be conceptualized along a continuum of severity (e.g.,
Horowitz, 1995). At one end of the spectrum the configuration of symptoms can be
understood as having a “neurotic feel”: sufficient symptoms are present to warrant the
diagnosis but social or occupational functioning, while impaired, is not severe. When
psychic distress is extreme, psychotic personality disorganization is usually present.
The person’s sense of identity is fragmented and chaotic, and reality testing is impaired. Although a treatment plan for personality disorders seldom stems from categorizing the patient’s diagnosis (Horowitz, 1997), the level of severity is prescriptive of
appropriate treatment approaches. Severe disorganization generally demands supportive techniques coupled with self-challenging information administered in small
but palatable doses.
The treatment of choice for Cluster B personality disorders seems to be psychotherapy (Gabbard, 1994, 1995a), although pharmacotherapy continues to be discussed
(e.g., Kapfhammer & Hippius, 1998). The literature guiding the appropriate approach to psychotherapy is based almost entirely on case methods and not clinical
methods. Recent reviews of treatment approaches place emphasis on cognitive-behavioral and interpersonal/psychodynamic perspectives in treating these disorders (Gabbard, 1994, 1995a; Rosenbluth & Yalom, 1997). Integrative approaches blending psychodynamic and cognitive perspectives have also been discussed (e.g., Horowitz,
1997).
Cognitive-behavioral approaches to treating these disorders formulate treatment
around identifying irrational beliefs, clarifying and facilitating the expression of those
Understanding Cluster B
347
beliefs, and by reinforcing healthy behaviors and choices made by the patient. Interpersonal/psychodynamic treatment approaches center around understanding and
managing unconscious and transferential elements of the therapeutic relationship,
identifying and working through mechanisms of defense, and by balancing the patient’s ability to both experience and reflect on their feelings.
The Cluster B personality disorders have remained unchanged from the DSM-III-R
(1987) to DSM-IV (American Psychiatric Association, 1994). While Cluster A personality disorders are described as odd or eccentric and Cluster C disorders are deemed
anxious or fearful, Cluster B personality disorders have been characterized as dramatic, emotional, or erratic.
The underlying theme for persons with Cluster B personality disorders is a general
lack of empathy for others, albeit for different reasons (Hamilton, 1988; Ruegg,
Haynes, & Frances, 1997). Persons with narcissistic personality disorder—by definition—do not see others as important enough to warrant empathy. Those with borderline personality disorder typically find themselves too much a victim to have any empathy to spare, and patients with antisocial personality disorder usually cannot even
conceptualize empathy.
THE ANTISOCIAL PERSONALITY
Diagnostic Picture
Because of the enormous implications on public safety and the economic well-being
of our society, research on the antisocial personality has been more prevalent than on
any other personality disorder. Prior to more careful differentiation among these
terms, the antisocial personality had been referred to as the psychopathic, sociopathic, dyssocial, and criminal personality. This disorder is typified by a wanton disregard for and violation of the rights of others. Such eye-popping cinematic roles as
Woody Harrelson’s in Natural Born Killers or Anthony Hopkin’s Hannibal “The Cannibal” Lecter in The Silence of the Lambs highlight the most extreme and severe forms of
this disorder.
Perhaps first described in Psalms 10:7, “His mouth is full of curses and lies and
threats; trouble and evil are under his tongue,” psychopathy (or what is now labeled
antisocial personality disorder) was the first disorder identified in psychiatry. The basic belief or attitude held by antisocials is that they are entitled to break the rules. Patients with antisocial personality disorder are typically seen as having overdeveloped
combativeness, exploitiveness, and predation, at the expense of empathy, reciprocity,
and social sensitivity.
Hallmarks of the disorder are repeated criminal offenses, manipulation and mistreatment of others for personal gain, amusement, or in the throes of passion, and little or no
remorse for misdeeds (Hare, Hart, & Harper, 1991). According to the DSM-IV (American Psychiatric Association, 1994), when accompanied by subjective distress or functional impairment, antisocial personality disorder is the appropriate diagnosis when (a)
the person is at least 18 years of age; (b) there is evidence of conduct disorder with onset
before age 15 years; and (c) at least three of the following pervasive symptom criteria are
present—(1) unlawful behavior, (2) deceitfulness, (3) impulsivity, (4) assault, (5) reckless disregard for the safety of self or others (6) consistent irresponsibility, and (7) lack of
remorse. Deceitfulness is reported to have the highest predictive value for an accurate diagnosis (Links, 1996; Westen & Shedler, 1999a, 1999b). Patients with antisocial personal-
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ity disorder have been reliably differentiated from those with either borderline or narcissistic personality disorders based on Criterion 1 (unlawful behaviors), Criterion 2
(deceitfulness), Criterion 3 (impulsivity), Criterion 6 (consistent irresponsibility), and
Criterion 7 (lack of remorse) of DSM-IV (American Psychiatric Association, 1994). Antisocial patients could not be reliably differentiated from borderline and narcissistic patients on the basis of Criterion 4 (irritability and aggressiveness) and Criterion 5 (reckless
disregard for safety of self or others) (Holdwick, Hilsenroth, Castlebury, & Blais, 1998).
Paradoxically, it is the deceitfulness of the antisocial patient that may make early diagnosis difficult. Therefore, collateral information can be especially useful in diagnosing
this disorder. The impulsiveness of the antisocial patient may emerge in social or occupational dysfunction, or in suicidal or homicidal behavior. Therefore, a careful differential diagnosis should be made to distinguish antisocial personality disorder from similar
symptoms of a variety of Axis I disorders—for example, from the rageful attacks characteristic of intermittent-explosive disorder, the grandiosity and impulsivity of bipolar disorder, or the aggressiveness and recklessness associated with substance abuse.
Three types of antisocial personality disorder have been distinguished: the impulsive type, the psychopathic type, and the psychopathic psychotic type (Hare, 1993).
Psychopathic literally means “psychologically damaged” and was the first label used in
psychiatry to identify a personality disorder (Millon, Simonsen, Birket-Smith, & Davis,
1998). Most antisocials are of the impulsive type, around 10–30% are within the psychopathic range with less remorse and more deliberate violations of others’ rights
(Hare, 1993), and about 1–2% belong to the psychopathic psychotic category (Srna,
1995). Slovenly in appearance, this last type of psychopath is maligned even by other
psychopaths and acts out his hallucinations of murder and mutilation. Millon and
Davis (1998) have further delineated 10 subtypes of psychopathy.
Currently, the DSM-IV (American Psychiatric Association, 1994) requires that a diagnosis of antisocial personality disorder be made only with presence of a prior conduct disorder before age 15. Recent research, however, is calling this requirement
into question. For example, Tweed, George, Blazer, Swartz, and MacMillan (1994) recently explored whether or not adult onset of Severe and Pervasive Antisocial Behavior (currently a V Code in the DSM-IV) was a syndrome distinct from antisocial personality disorder. They found that only about half of the 502 people in their prison
sample who were reporting a pattern of severe adult antisocial behavior reported a
history of antisocial behavior in childhood. Although the V Code is intended for those
persons whose behavior is limited to criminal activity, it is not clear whether a diagnosis of antisocial personality disorder should be ruled out solely on the basis of the absence of a childhood history of antisocial behavior. Despite the statistic that 50–80%
of the criminal population in prison today can be diagnosed with antisocial personality disorder (Hare, 1983; Ruegg, et al., 1997), there remains a basic distinction between criminal behavior (a specific set of actions) and antisocial personality disorder
(a pervasive and rigid way of thinking, feeling, and interacting with others).
Compared to the general population, patients with antisocial personality disorder are
more likely to have a comorbid Axis I disorder, including major depression, bipolar illness, panic disorder, posttraumatic stress disorder, attention-deficit disorder, or substance-use disorder. The accuracy of a differential diagnosis is at issue. Estimates are that
as many as 80% of antisocial patients may be substance abusers (Cottler, Compton,
Ridenour, Ben Abdallah, & Gallagher, 1998; Dahl, 1998; Wenar, 1994). Ruegg et al.
(1997) report that 30% of antisocial patients over the age of 30–35 develop major depression as a comorbid condition, and that 5–10% of antisocial patients are at a lifetime
Understanding Cluster B
349
risk of suicide (see also Dahl, 1998; Corruble, Ginestet, & Guelfi, 1996). Further, it has
been estimated that nearly one third of suicide victims carry a personality disorder diagnosis, and that antisocial personality disorder is common among this group (Bronisch,
1996). A subtype of unipolar depression that involves a sudden onset of periods of anger
and irritability can also be misdiagnosed as antisocial personality disorder (Fava, 1998).
Etiology
Estimates are that approximately 3% of men and 1% of women within the general
U.S. population exhibit the criterion features of antisocial personality disorder (Millon, 1987; Robins et al., 1984). However, these percentages are reported to be on the
rise, particularly for women (Mulder, Wells, Joyce, & Bushnell, 1994; Robins, Tipp, &
Pszybeck, 1991). Because antisocial personality disorder seems to have a higher prevalence within the same family constellation, both hereditary and psychosocial factors
are implicated in its etiology (Kaplan, Sadock, & Grebb, 1994).
Organic factors that have been reported to be linked with antisocial personality disorder are the presence of the XYY chromosome, lower resting heart rate, higher
plasma testosterone, limbic stimulation, neurological soft-signs, EEG patterns, impaired ability to concentrate, and motor and hand-eye coordination problems (Kaplan
et al., 1994). More recent research, however, has found these biogenic factors to be of
only minor importance (Cloninger & Gottesman, 1987; Links, 1996; Millon & Everly,
1985; Wenar, 1994). Sociocultural factors, on the other hand, seem to be highly predictive. For example, Norwegian populations report only a 0.1% incidence of antisocial
personality disorder (Torgersen, 1995). For the psychopathic subtype of this disorder,
however, more recent reviews highlight the neurobiological system (e.g., Sewer, 1998).
Conduct disorder is still considered a requisite criterion in the diagnosis of antisocial
personality disorder, and as such, is heuristic of possible causes of the disorder. The risk
factors for conduct disorder are being male, having low socioeconomic status, a difficult
temperament in infancy, antisocial parents, stress, living in a high-crime neighborhood,
and having unskilled grandparents (Patterson, Reid, & Dishion, 1992). These risk factors seem to be mediated by family discord and divorce (Emery, 1982; Pakiz, Reinherz,
& Giaconia, 1997), parental rejection and negativity (Loeber & Stouthamer-Loeber,
1986) and modeling of antisocial behavior (Lahey et al., 1988). Upon entering school,
poor academic performance, peer rejection, and later substance use all increase the
likelihood of developing a conduct disorder and ultimately increase the likelihood of
developing antisocial personality disorder (Patterson et al., 1992).
Evidence suggests that symptoms may decrease or “burn out” after age 40; between
30% and 40% of patients become less impulsive, less violent, or adopt new value systems in midlife (Kaplan et al., 1994; Ruegg et al., 1997). The course of antisocial personality disorder, however, is generally regarded as unremitting. For Kernberg (1975,
1998), the antisocial personality represents the most severe form of pathological narcissism and is viewed as an aggressive form of narcissistic personality disorder.
Individual Psychotherapy with the Antisocial Patient
Antisocial personality disorder is extremely difficult to treat. While several therapies
have been suggested, few controlled studies have been conducted. Individual psychotherapy, however, seems to be the treatment of choice.
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Treatment success rates can be improved through early intervention during childhood and adolescence—particularly through parent training (Kazdin, 1987). Once
patients reach adult age, change depends on the patient’s willingness to participate in
treatment. This is made more difficult by the ego-syntonic nature of the symptoms
and the antisocial patient’s intense mistrust of others.
It is generally believed that individual psychotherapy with the antisocial patient
should avoid insight-oriented approaches. Instead, emphasis should be placed on positive reinforcement, a reality-based approach, concrete interventions, an educationoriented anger management or impulse-control program, and other cognitive-behavioral techniques (Melroy, 1995). A prudent first course of action may be a brief phase
of therapy focusing on the specific issues that led the patient into therapy. Ruegg et al.
(1997) encourage therapists to focus on the reality of the patient’s life situation and
de-emphasize the relationship with the therapist. An initial focus of treatment might
be the patient’s aggressive behavior.
Using a cognitive-behavioral approach, the patient may be asked to consider what
might motivate or reinforce such behavior—for example, the use of aggression to create safety for themselves, to relieve tension, or as a defense against other feelings. The
patient’s awareness of their primary defense mechanism (acting out) is believed to
constitute a major breakthrough in treatment (Millon & Everly, 1985). The patient
may then be able to weigh the pros and cons of changing their behavior. Internal and
external triggers or warning signs for these behaviors can also be identified and constructive actions can be practiced as the patient learns to intervene early by directing
pent-up anger at inanimate objects, employing relaxation techniques, learning to
walk away from arguments, cathartic physical exercise, or complaining to a third party
(Ruegg et al., 1997).
Patients with antisocial personality disorder also benefit by focusing on their alcohol and drug use, which increases the likelihood of aggressive and acting-out behaviors (Cottler et al., 1998). Teaching patients to understand the consequences of their
drinking or drug use and how it exacerbates symptoms can be very useful.
Helping the antisocial patient understand how others are affected by their behaviors has also been shown to be effective. For example, Hare (1993) has shown that for
prisoners with the impulsive type of antisocial personality disorder, empathy training
can be successful in reducing recidivism. Caution is advised, however; empathy training for psychopathic antisocials can turn them into better predators (Hare, 1993).
Prognostic markers have been identified both in the social environment and in the
therapeutic setting. Social/environmental predictors of poor treatment outcome include (a) trouble in elementary school, (b) misconduct while alone (as opposed to
with a peer group), (c) lack of external structure for framing and monitoring the patient’s behavior such as is found in a prison or other institutional setting, and (d) negative relationships with parents or siblings (Ruegg et al., 1997).
Factors within the therapeutic setting that seem to bode well for treatment are (a)
the patient’s ability to form an alliance with the therapist, (b) the patient’s ability
when feeling devalued to avoid aggressively acting out, (c) the patient’s capacity to
avoid using primitive defenses such as splitting or projective identification, (d) a
greater level of psychic distress about their actions, (e) the patient’s capacity for empathy, and (f) the presence of remorse (Melroy, 1995).
With the antisocial patient, boundaries and limit setting are essential. These patients will oftentimes threaten therapists, demand money or prescriptions, proposition
them, or violate other rules (Ruegg et al., 1997). As such, therapists who contemplate
Understanding Cluster B
351
treating patients with antisocial personality disorder should prepare themselves for
how they will deal with these and other boundary violations when, not if, they occur.
Group Treatments with the Antisocial Patient
In general, patients diagnosed with Cluster B personality disorders are well known as
difficult to treat. Those with narcissistic or antisocial personality disorder may challenge the leader for control of the group, while borderline personality-disordered patients may try to incite the group to “save” them. As relational beings, however, group
psychotherapy offers a unique opportunity for community, autonomy, intimacy, individuation, and a setting in which to learn about relationships tempered by appropriate limits (Rutan & Stone, 1993). Through overt and covert role identification (Gemmill & Kraus, 1988) and other ways of conceptualizing and framing group life, Cluster
B patients can begin to understand how their interpersonal world and their individual
symptoms mutually affect one another.
Rutan and Stone (1993) offer important issues to consider before recommending
that a Cluster B patient enter group therapy. Will the patient likely commit to the
group? Will the patient be able to follow group rules? Can the patient manage their
impulses in the group and appropriately interact with other group members? Might
the patient be better served in a homogeneous group? Given the group’s composition, can the therapist manage the emotions of the patient in the group? Can the
group handle the role the patient is likely to play? Does the age, gender, race, and
level of ego development of the patient fit the group? Regardless of whether or not a
Cluster B patient is appropriate for group therapy, concurrent individual therapy is
advised (Bardikoff, 1997; Leszcz, 1989; Rutan & Stone, 1993).
Moving from a discussion of group therapy in general, to group therapy with the
antisocial patient, Yalom (1985), MacKenzie (1997), and others have suggested that
the antisocial patient most likely should not be involved in group psychotherapy.
Yalom (1985) explains that while the antisocial patient may initially be an active and
important group member, their characteristic manner of relating will place them in
an interpersonal role that will likely be destructive to the group and therapeutically
contraindicated for themselves. The success of specialized forms of group therapy for
the antisocial patient, however, have been discussed (Cox, 1998).
Various other forms of group treatments have demonstrated some effectiveness.
For example, family and marital therapy have been shown to be effective with antisocial patients (Melroy, 1995; Ruegg et al., 1997). Because the patient’s relationships
with significant others is a stronger motivator for change than is their relationship
with the therapist, the patient is more likely to accept confrontation from them. Family members can also learn how to better use assertiveness for their own protection
(Ruegg et al., 1997). Although family therapy with adult psychopathic patients is ill-advised (Melroy, 1995), reductions in criminal recidivism have been found in nonpsychopathic adults as a consequence of family intervention (Gendreau & Ross, 1987).
Milieu and residential therapy programs, such as token economies (Rice, Harris,
Quinsey, & Cyr, 1990) and therapeutic communities (Dolan, 1998; Harris & Rice,
1994) have also shown some success with the antisocial patient. Group treatments
such as these may work because patients are able to see the flaws in others that are
more like them, they may be more likely than therapists to confront other patients’
behaviors, and as they gain the support from other similar patients they may be more
accepting of confrontations from them. Milieu and residential group programs may
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also be particularly helpful for antisocial patients by diffusing the intense feelings often developed in the individual therapy relationship (Dolan, 1998).
Although much of the treatment in a therapeutic community is conducted in
smaller subgroups, therapeutic communities may be effective because they utilize a
psychoeducational model of treatment that tends to elicit less disturbing affect in patients than does the intimate examination of intrapsychic and interpersonal issues typical of an intensive small group psychotherapy.
Medicines and the Antisocial Patient
No data are available on medicines designed to treat antisocial personality disorder.
Prognosis for treatment is improved, however, with medication (Gabbard & Coyne,
1987; Melroy, 1992). Several forms of medication have been found to alleviate aggressive behavior sometimes associated with antisocial personality disorder. These include
antisympathetics (beta-blockers and neuroleptics), selective serotonin reuptake inhibitors (SSRIs), and Depo-Provera for sexually violent offenders (Ruegg et al., 1997).
Aggression and irritability have also been ameliorated by the antipsychotic medications chlorpromazine and haloperidol (Extein, 1980) but at higher doses than those
given for psychosis (McEvoy, Hogarty, & Steingard, 1991).
Ries (1974) found it useful to make the distinction between aggression which is “affective” (or laden with significant emotion and arousal) and aggression which is
“predatory” (which is devoid of affective arousal). Serotonin agonists (such as fluoxetine) and anticonvulsants (such as lithium) have been found to inhibit both types of
aggression (Eichelman, 1988). Fluoxetine has also been found to decrease mood
swings and impulsiveness (Coccaro, Astill, Herbert, & Schut, 1990). Benzodiazapines
have also been found to inhibit affective aggression (Eichelman, 1988).
A major concern with antisocial patients is the likelihood of medication abuse, either by taking more than prescribed or by selling the medicines. This is especially true
of benzodiazapines, which are addictive. Because most patients with antisocial personality disorder are likely to be substance abusers, addictive medicines like benzodiazapines should be avoided. For some patients, benzodiazapines have even been shown
to have a paradoxical disinhibiting effect that causes increased agitation (Gardner &
Cowdry, 1985).
THE BORDERLINE PERSONALITY
Diagnostic Picture
Among all those diagnosed with a Cluster B personality disorder, patients with borderline personality disorder are believed to experience the greatest suffering. Almost always in a state of crisis, borderlines are so named because they were believed to stand
on the border of a number of diagnoses, perhaps most poignantly on the border between a neurotic and psychotic personality organization (Hoch & Polatin, 1949). Patients with borderline personality disorder have significant impairments in tolerating
affect, controlling impulses, and coping with feelings of aloneness. Perhaps no more
apt an example of the borderline personality is Glenn Close’s character in the film,
Fatal Attraction. Depressed and lonely, severely dependent, uncontrollably angry, and
impoverished in her self-identity, she “would not be ignored!”
Understanding Cluster B
353
According to the DSM-IV (American Psychiatric Association, 1994), borderlines are
characterized by at least five of the following pervasive symptom patterns: frantic efforts to avoid real or imagined abandonment (highest positive predictive value; Links,
1996), recurrent suicidal behavior, gestures, or threats (second highest positive predictive value), impulsivity, unstable interpersonal relationships, identity disturbance,
affective instability, chronic feelings of emptiness, inappropriate anger, transient and
stress-related paranoid ideation, or severe dissociative symptoms. Three clusters of
borderline personality disorder symptoms have been identified: (a) identity disturbance; (b) unstable relationships and affect (especially involving anger); and (c) selfdestructive and impulsive behavior (Hurt, Clarkin, Munroe-Blum, & Marziali, 1992).
With similar findings, Blais, Hilsenroth, and Castlebury (1997) identified three symptom domains in a factor analysis of 91 patients with personality disorders based on
DSM-IV (1994) criteria: (a) interpersonal and identity instability, (b) impulsivity, and
(c) affective instability.
For many clinicians, a history of self-harming or self-destructive behavior is the defining feature of borderline personality disorder (Gunderson, Davis, & Youngren, 1997)—
the most obvious and lethal form of which is suicide. Approximately 10% of borderline
personality disordered patients commit suicide (Stone, 1990). Gunderson, Kolb, and
Austin (1981) noted that of a group of 57 inpatients diagnosed with borderline personality disorder, 75% had previous suicide attempts—70% via overdose and 65% by mutilation (e.g., cutting, banging, burning, or puncturing; see also Bronisch, 1996). Less obvious forms of self-abusive behavior also were found: 67% of the sample abused drugs
and/or alcohol, 67% were involved in promiscuous sexual behavior, and 25% were generally reckless. Swartz, Blazer, George, Winfield, Zakris, and Dye (1989) found that one in
five borderline patients had been hospitalized on an inpatient unit in the preceding year.
In more dynamic terms, borderline personality disorder can be recognized by the presence of extraordinarily disturbed object relations. One predominant defense used by
borderline patients is splitting, the expression of contradictory beliefs, feelings, and behaviors that alternate in a seemingly haphazard fashion. For example, the patient may alternate their representations of either themselves or others as exclusively “good” or exclusively “bad.” The therapist may be idealized and soon later devalued. The rapidity with
which these expressions fluctuate can be surprising and shocking to others and are typically treated by the patient with outright denial or a lack of concern (Kernberg, 1975).
Projective identification, another defense commonly employed by borderline patients, involves the patient attributing to others the compartmentalized aspects of
themselves (good or bad) that they have disavowed, which the other person then begins to act out. In therapy, this can alternate between moment-to-moment idealization
and denigration of the therapist. Borderline patients may act in such a way as to overstep the boundaries of therapy and to exert pressure on the therapist to behave in
what the patient perceives as a critical manner. For example, the patient may continually ask for longer sessions, less expensive sessions, or excessive contact with the therapist outside the session. When the therapist sets appropriate limits, the patient may exhibit significant angry or hurt feelings followed by denigration and disparagement of
the once-idealized therapist.
Etiology
Prevalence estimates of borderline personality disorder are about 1–2% for the general population, 10% in outpatient populations, and from 20–25% in inpatient popu-
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lations (Frances & Widiger, 1986; Gunderson, 1984; Park & Park, 1997; Swartz et al.,
1989). Approximately 75% of people diagnosed with borderline personality disorder
are women, and up to 90% of all patients diagnosed with the disorder meet the criteria for at least one other personality disorder (Links, 1996; Swartz et al., 1989).
The overlap of borderline personality disorder with Axis I disorders has been estimated at between 40% and 60% (Marziali & Munroe-Blum, 1994). Depression and bipolar disorder are common and can overshadow accurate diagnosis of borderline personality disorder (Fava, 1998; Goodwin & Jamison, 1990; Rosenbluth & Silver, 1997).
As many as 87% of borderlines have been found to exhibit symptoms of depression
(Corruble et al., 1996; Hudziak et al., 1996), 51% with symptoms of panic disorder
(Hudziak et al., 1996), and 75% with symptoms of anxiety disorder (Swartz et al.,
1989).
Family links of borderline personality disorder with Axis I disorders have been
found (Loranger, Oldham, & Tulis, 1982). Supported by a link between antisocial
personality disorder and serotonergic abnormalities, (Silk, 1994) also implicates organic causes. A history of developmental or acquired brain injury, ADHD, and EEG
abnormalities has also been associated with the disorder (Links, 1996). In addition, at
least two neurological soft-signs (the fist-palm-side test and alternating sequence completion) have been found in about 60% of borderline patients (Links, 1996).
Perhaps the most insidious cause implicated in the development of borderline personality disorder, however, is childhood sexual abuse (Kroll, 1997; Ogata et al., 1990).
In some studies, well over half of borderline patients report such trauma (Zanarini,
1996). Herman, Perry, and van der Kolk (1989) found that 80% of their sample of
borderline patients had been physically or sexually abused. Because girls are at
greater risk for sexual abuse than are boys and because women are more often diagnosed with the disorder, many clinicians believe that child sexual abuse is a primary
cause of this personality disorder (Kroll, 1988).
From a psychodynamic formulation borderline patients have a deficit in integrating
and maintaining self and object representations (Kernberg, 1967; Kohut, 1971). Kernberg (1967) has argued that it is the disturbed infant-parent relationship and the
child’s subsequent failure to develop an adequate sense of self-esteem that is at the
core of the development of borderline personality disorder. Without a soothing parent-child bond, borderlines may develop a “fragmented self” that crumbles easily under pressure (Kernberg, 1975; Wexler, 1991). Their sense of themselves is weak and
the boundary between themselves and others is highly permeable.
Individual Psychotherapy with the Borderline Patient
As with other Cluster B disorders, borderline personality disorder is extremely difficult to treat. Although success has been reported with focused and time-limited therapies (Stone, 1990), it is generally recognized that long-term treatment is required.
Hospital readmission should be viewed as a predictable part of the course of treatment.
Among all the treatment issues with the borderline patient, the most serious is suicidality. About 75% of patients make a suicide attempt and approximately 8–10%
eventually kill themselves (Paris, Howles, & Brown, 1987; Stone, Hurt, & Stone, 1987).
A risk assessment for self-harm and a distinction between suicidal intent and the
search for caretaking from others is essential in weighing the risks and benefits of hospitalization (Gunderson, 1984). Clear limit-setting of boundaries, expectations, and
Understanding Cluster B
355
responsibilities for both therapist and patient are essential (Gunderson et al., 1997;
Rosenbluth & Silver, 1997). Rosenbluth and Silver also advocate documentation of
the degree of suicidality at each session. In a 5-year follow-up study with borderlines,
Sabo, Gunderson, Najavits, Chauncey, and Kisiel (1995) found that while suicidal ideation remained unchanged, suicidal behavior was greatly decreased.
Individual therapy with a borderline patient will likely end with the patient dropping out of treatment. Essential components of effective treatment, however, have
been identified (Gabbard, 1994; Waldinger & Gunderson, 1987): (a) development of
a stable treatment frame (e.g., developing consistent appointment times, ending sessions on time, voicing expectations about payment of fees, discussing the consequences of missed appointments); (b) active involvement of the therapist; (c) connections made between the patient’s actions and feelings; (d) identification of the
negative consequences of self-destructive behaviors; and (e) active monitoring of the
therapist’s countertransference issues. Gabbard (1994) also suggests that the therapist
focus on (f) containing the patient’s anger; (g) setting appropriate limits; and (h)
maintaining the focus of interventions on the here-and-now. More recently, Gunderson and Links (1995) recommend that clinicians: (i) identify and actively treat comorbid substance abuse disorders and major depression; (j) develop a means of differentiating lethally and non-lethally motivated self-harm; (k) collaborate with the patient
in the therapy process; and (l) be sensitive to their own need to seek consultation.
Clinical conceptualization of borderline personality disorder evolved from object
relations perspectives on key mechanisms of psychic defense (Kernberg, 1967). Kernberg reformulated clinical thinking on this disorder by illustrating the patient’s use of
primitive defenses such as splitting, projection, and projective identification. Using
Kernberg’s analysis of primitive defense mechanisms in borderline pathology, Soltzm,
Budman, Demby, and Merry (1995) found that acting out, projection, and splitting
were more highly correlated with the borderline, histrionic, and narcissistic personality disorders than with any other personality disorder. There is general agreement,
however, that these defensive processes are extremely unlikely to be available for direct interpretation because they are outside the patient’s awareness.
Although there have been recent theoretical revisions to Kernberg’s (1967, 1975)
approach, based on a sizable body of literature it is now believed that early “here-andnow” confrontation and interpretation of sadistic, controlling, and manipulative behavior is not advisable (and possibly even harmful to the patient). Instead, it is suggested to intervene in a manner that conveys understanding and empathy of the patient’s legitimate anger stemming from their childhood victimizing experiences
(Gunderson & Links, 1995). MacKenzie (1997) calls this “reflective validation”
whereby the patient’s ambivalent or “split” feelings are clarified and contained.
Kernberg (1967) believed, however, that therapists should utilize a combination of
support, advice, and cognitive exploration based on the psychodynamic concepts of
splitting and projective identification in conjunction with an object-relations conceptualization of the patient’s distress. Using a cognitive therapy approach, Beck and
Freeman (1990) identify three extremely maladaptive “basic assumptions” held by
borderline patients: (a) “The world is dangerous and malevolent;” (b) “I am powerless
and vulnerable;” and (c) “I am inherently unacceptable.” In the context of a trusting
alliance the goal of therapy is then to reduce these types of all-or-none thinking patterns.
Blending dynamic and cognitive perspectives, other clinicians (Fonagy, Steele, &
Steele, 1994; Kroll, 1997; Turner, 1994), have recommended that therapists assist bor-
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derline patients in developing a “reflective self function” whereby the patient can invoke or call up their internal representations of others, including their feelings and
motivations about them, and to conceive of their own fantasies and feelings in relation to their behavior with them. By doing so, borderline patients can begin to understand how actions are influenced by such constructs as expectations, feelings, fantasies, and beliefs.
Based on a more behavioral approach, Linehan (1993) recommends teaching the
patient how to regulate emotional distress in an effort to undo unrelenting crisis and
to decrease suicidal and avoidant behavior. Derksen (1995) echoes this treatment philosophy by arguing that treatment initially must be directed at the ego, thereby avoiding exploration of deeply rooted feelings from early childhood. Treatment, therefore,
is designed to highlight reality testing, the development of social support, and the
presence of defense mechanisms. For example, acting-out behavior is quickly pointed
out to the patient and clear arrangements regarding the therapeutic frame are established.
Using what she calls Dialectical Behavior Therapy, Linehan (1993) focuses more on
behavior than on cognition to (a) reduce suicidal and parasuicidal behaviors, (b) reduce behavior that interferes with therapy, and (c) reduce behavior that undermines
the quality of life. Empirical support for her approach is developing (Gunderson &
Links, 1995; Turner, 1994). For example, Linehan, Armstrong, and Suarez (1991)
found that patients who remained in treatment for 1 year averaged 8.5 hospital days
and 1.5 self-mutilation acts, while a control group averaged 39 hospital days per year
and 9 destructive acts. The cost savings for such therapy has been estimated at roughly
$10,000 per patient per year (Heard, 1994).
Therapists who have treated individuals with borderline personality disorder will attest to these patient’s frequent verbal barrages of contempt and hatred at others,
themselves, and the therapist. The therapist is encouraged to empathize with the borderline patient who must split off the “bad” parts they feel within themselves so as not
to destroy the internalized “good” parts (Gabbard, 1994). Empathizing with a patient’s rage and manipulative behaviors has been found to facilitate the development
of a trust (Gabbard, Horwitz, & Allen, 1994; Horwitz, Gabbard, & Allen, 1996). Here,
the therapist recognizes the patient’s feelings and actions as adaptive within the context of childhood trauma. Voicing this recognition to the patient changes the therapy
from a debate over whether the patient’s perceptions are “real” or not to a common
goal of reducing the influence these events have on present behaviors.
Patients with borderline personality disorder will often make extravagant requests
from therapists, such as asking for hugs, extended sessions, decreased fees, and
around-the-clock availability. When the patient’s behavior jeopardizes therapy, interpretations of those behaviors without appropriate limit-setting has been shown to result in negative therapeutic outcome (Colson, Lewis, & Horwitz, 1985). Many cases of
therapist-patient sex involve patients diagnosed with borderline personality disorder.
In one tragic case, two therapists indulged a patient’s demand that nothing short of
an orgasm brought on by her therapist would cure her (Gabbard & Lester, 1995). She
eventually killed herself. Limits should be made in the first session of therapy and
might include (a) no non-emergency phone calls between sessions, (b) verbalizing
suicidal thoughts before acting on them, and (c) agreeing to hospitalization when suicidal impulses are out of control.
With this personality disorder, more so than any other, it is necessary that clinicians
work at two levels (Rockland, 1992): first, to establish what is believed to be the sine
Understanding Cluster B
357
quo non of successful treatment—that is, to foster the subtle, soothing aspects of a secure and trusting alliance that creates early-on a sense of safety for the patient (Herman, 1992) and second, to focus on the patient’s daily life problems as a means of reducing self-destructive behaviors.
Group Treatments with the Borderline Patient
Although entering and remaining in group psychotherapy can be particularly difficult
for the borderline patient, it is generally believed that these patients can benefit from
group treatment (Budman, 1993; Marziali & Munroe-Blum, 1994). Group psychotherapy, family therapy, social skills training, day treatment programs, and job-training
programs have all been recommended for the patient with borderline personality disorder (Bardikoff, 1997). Both homogeneous and heterogeneous groups have been
shown to be effective with these patients (Rutan & Stone, 1993).
Peer feedback from others in the group, identification of dependent and manipulative behaviors, feeling safe around other people, the reward of working through feelings, and being in a place where new behavior, new perspectives, and new relationships can be the focus of experimentation all can make group treatment a viable
alternative for the borderline patient. Gabbard (1994) suggests that borderline patients may benefit from group psychotherapy because their symptoms emerge out of
various relational problems, such as facing authority figures, sibling rivalries, and onlychild issues.
Horwitz (1980) suggests that group therapy for borderlines is advantageous because
there are more objects to contain the borderline patient’s negative transferences. The
patient can also regulate in group how close or distant they want to be with members
other than the therapist. How the borderline patient sees the therapist and other members can be “reality checked” with how the remaining members view these people. Scapegoated for their exhibitionistic needs, however, borderlines can often polarize the group.
Transferences can be intensified and regulating emotional closeness can become more
difficult in a group with borderline patients (Rutan & Stone, 1993). While endorsing the
effectiveness of group therapy for the borderline patient, MacKenzie (1997) advises that
patients are informed that the therapist will not be reliably available 24 hours a day, and
that the appropriate emergency services should be used when needed.
Although borderline patients are often extremely reluctant to participate, family
therapy that utilizes a supportive and educational approach has been shown to be effective, particularly with families who show a pattern of over-involvement or neglect
(Perry, Herman, & van der Kolk, 1990). Honest communication among family members coupled with the hope and positive feelings accompanying achievement of reconciliation can have very powerful effects.
Medicines and the Borderline Patient
Although there is little empirical evidence on the effectiveness of psychopharmacological agents in relieving specific personality disorders, clinicians are using a symptom-specific pharmacotherapy to treat borderline patients. Rosenbluth and Silver
(1997) note that clinicians should treat patients with borderline personality disorder
with medication when they have a diagnosable Axis I disorder, and if not, should look
for subthreshold symptom clusters such as cognitive-perceptual and affective symptom domains to guide pharmacotherapy interventions.
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As examples, antipsychotics have been used to control anger and brief psychotic episodes (Kroll, 1988), while aggression has been found to decrease when treated with
lithium (Links, 1996). Mood stabilization has been successful with antidepressants,
low-dose neuroleptics and lithium carbonate (Links, 1996; Turner, 1994). Cowdry
and Gardner (1988) have also reported that carbamazepine has been underutilized in
the treatment of severe behavioral problems. Monoamine-oxidase inhibitors (MAOIs)
have been used to treat impulsivity (Cowdry & Gardner, 1988). Benzodiazapines like
Xanax also have been used for the treatment of anxiety with borderlines. Anticonvulsants such as tegretol and SSRIs like fluoxetine (Prozac) have been used to improve
global functioning (Kaplan et al., 1994). In a double-blind study of fluoxetine with 31
borderline patients, 80% showed a significant improvement in their level of depression, anxiety, paranoia, psychoticism, interpersonal sensitivity, and hostility (Markovitz, Trevidi, & Wagner, 1991).
Although pharmacotherapy carries the risk for intentional overdose, it is often recommended in conjunction with psychotherapy with borderline patients. Several caveats should be noted, however, First, consideration must be made for the potential for
suicide when using medications with a high potential for overdose, such as tricyclics
(Gunderson et al., 1997; Rosenbluth & Silver, 1997). Second, borderline patients may
resort to “splitting” mental health professionals (e.g., social worker vs. psychiatrist)
and multimodal treatments (therapy vs. medication) by alternately idealizing one and
devaluing the other (Rosenbluth & Silver, 1997). Borderline patients may alternate
between believing they are influenced entirely by biochemical factors for which medication is the only solution, or entirely by thoughts and feelings for which supportive
psychotherapy is the only answer (Koenigsberg, 1994). Gunderson et al. (1997) advocate discussing with the patient the harmful effects of overdose, realistic expectations
for medication, and the meaning the patient attributes to the medication. The goal is
to have the patient accept as much responsibility as possible when taking medication.
THE HISTRIONIC PERSONALITY
Diagnostic Picture
Derived from the Latin word for actor, the histrionic patient has a style of presentation that is excessively dramatic and emotionally exhibitionistic. Driven by an intense
need for affection, histrionics are self-centered, seductive, and blatantly conspicuous
in their shallow manipulation of others. Previously referred to as the hysterical personality, histrionic personality disorder is typified by a need to be the center of attention and an almost desperate kind of gregariousness in which the person appears to
others as if they are always performing. Vivien Leigh’s portrayal of Scarlet O’Hara in
Gone With the Wind is a good example of this disorder. Despite the fairly consistent descriptions of the histrionic patient in the psychiatric literature, of all the personality
disorders in the Cluster B group, the least amount of research has been devoted to the
histrionic personality.
According to the DSM-IV (American Psychiatric Association, 1994), histrionic personality disorder is a pervasive, persistent, and inflexible pattern of behavior characterizing a person who is uncomfortable when not the center of attention (highest predictive value; Links, 1996), is inappropriately sexually seductive or provocative
(second highest positive predictive value), shows shallow expression of emotion,
draws attention through his or her physical appearance, has excessively impressionis-
Understanding Cluster B
359
tic speech, shows self-dramatization, is suggestible, and considers relationships to be
more intimate than they actually are. Five or more of these symptom patterns must be
present to make the diagnosis.
MacKenzie (1997) identifies persons with histrionic personality disorder as having
the belief that other people exist only to serve and admire them. They have overdeveloped the strategies of exhibitionism, expressiveness, and impressionism at the expense of reflectiveness, control, and systematization. Persons with histrionic personality disorder are impressionable, often enmeshed in fads, and often complain of and
exaggerate their health problems.
Three hierarchical clusters of the disorder have been identified (Turner, 1994): (a)
seductiveness, self-centeredness, and excessive concern with attractiveness; (b) unstable and exaggerated shifts in emotion; and (c) excessive need for attention and approval, exaggerated use of colorful speech, and excessive display of emotions. Research on Roschach Structural Summaries by Blais, Hilsenroth, and Fowler (1998)
found that T (or Pure texture responses) and the sum of FC (form-color) ⫹ CF
(color-form) ⫹ C (pure color) responses were significantly correlated with the number of DSM-IV criteria for histrionic personality disorder in their sample.
Because symptoms more typical of the personality fragmentation of borderlines
may be present, clinicians should take note of the degree of self-coherence of identity
and the capacity to form close relationships in order to guide accurate diagnoses
(Horowitz, 1995, 1997). The co-occurrence of borderline, narcissistic, and antisocial
personality disorder is common (Pfohl, 1991).
As with other Cluster B disorders, there is high comorbidity between Axis I disorders and histrionic personality disorder, including depression, anxiety (especially
around separation), bipolar disorder, impaired interpersonal functioning, substance
abuse, and self-mutilation (Fruensgaard & Flindt-Hansen, 1988). Depressive episodes
“tend to be expressed in current, fashionable, or intellectual terms (such as “existential anxiety” or “estrangement from mass society” [Millon, 1996, p. 185]). Corruble et
al., (1996) found that between 2% and 20% of persons with histrionic personality disorder had concomitant depression.
The emotional reaction of histrionics tends to be overblown and labile, and their
tolerance for frustration is very low. They crave excitement, are easily bored, and they
often have difficulty with concentration and directed thinking (Millon, 1996). Dimensional models of the disorder support the description that histrionics tend to be overly
needy, dependent, and require excessive reassurance and approval (Westen & Shedler, 1999a, 1999b).
Horowitz (1997) identified several very descriptive roles of histrionic theatrics, including “the sexy star,” “the wounded hero,” and “the worthy invalid” complemented by relationships with others prototypically described as “the interested suitor,” “the devoted rescuer,” and “the responsible caretaker.” While more active histrionic behaviors have been
given the most attention in the literature, a more passive style of histrionics (shy and inhibited) has also been discussed (Horowitz, 1997). In this style the patient may wish to
gain attention but may fear the consequences of excessive and theatrical display of themselves to be too exciting, too difficult to manage, or result in rebukes from others.
Etiology
The prevalence of histrionic personality disorder is 2–3% in the general population
and about 10–15% in mental health settings, according to the DSM-IV (American Psy-
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chiatric Association, 1994). Approximately 85% of individuals diagnosed with this disorder have been women (Millon, 1986). More recent research, however, suggests that
the prevalence rates among women and men are equivalent (Nestadt, Romanoski,
Chalel, & Merchant, 1990), especially when more structured interviews are used to
evaluate for the disorder (DSM IV). It appears that the influence of sex-role stereotypes on the diagnosis of this disorder is not as much at play as has been previously assumed (Belitsky et al., 1998).
Although it can be argued that people with histrionic personality disorder are extroverts and as extroverts their temperaments are partially genetically determined
(Wilson, O’Leary, & Nathan, 1992), there is no empirical support for an organic link
to histrionic personality disorder. Guided by almost no empirical research, histrionic
personality disorder is believed to be primarily developmental in origin, arising out of
a childhood inability to legitimately get parental attention. It is believed that an excessive, unmet need for attention and an inability to successfully compete with others in
getting these needs met leads to inappropriate pursuits to garner attention, often in a
dramatic fashion. Environmental factors and their interaction with developmental issues are also assumed to play a role (Turner, 1994).
Histrionic patients are often preoccupied with erotically pleasing others to compensate for feeling unlovable (Gunderson, 1988). Histrionic personality disorder has also
been viewed as a form of an “overstimulated self” developing when parents’ interactions with a child have been excessively intense or overwhelming. As an adult, the person feels as if normal life pleasures are insufficient (Wexler, 1991).
Individual Psychotherapy with the Histrionic Patient
Although cognitive and behavioral approaches to treatment are gaining support
(Beck & Freeman, 1990; Linehan, 1993), psychodynamically oriented individual therapy has been the most common mode of treatment for histrionic personality disorder,
and long-term supportive work is currently considered optimal (Turner, 1994). Initially, a high frequency of sessions is often advisable (Derksen, 1995). Although understandable in the light of the high comorbidity with Axis-I disorders, complaint-specific
approaches to treating histrionic personality disorder are often misapplied. Treating
frequently reported but vague anxiety and depressive complaints often results in
failed treatment (Millon, 1996).
Horowitz (1995, 1997) has written extensively on the treatment of histrionics and
recommends a three-phase approach based on a clinical formulation whereby (a) the
patient’s problems are stipulated, (b) states of mind are defined, and (c) topics of
concern and defensive obstacles are clarified. The emphasis is placed on integrating
psychodynamic and cognitive conceptualizations. Phase 1 consists of clarifying symptoms, establishing an alliance based on supportive techniques, and clarifying temporal
sequencing of outside events, internal mental states, and symptoms. Here, the patient
is encouraged to engage in behavioral restraint from harmful but immediately gratifying actions. They are also encouraged to increase self-regulation of affect by reflecting
on and planning for uncomfortable events.
Once safety in the therapy process is achieved, Phase 2 begins, consisting of clarifying “cloudy” verbal communication and modifying defensive processes used to control unmanageable effect. Horowitz believes this is achieved by identifying defenses as
they arise, by encouraging exploration of these defenses until more rational choices
can be reached, and by modeling contemplation and reinforcing cooperation in this
Understanding Cluster B
361
process. For example, the undermodulated flooding of emotion common in histrionics can be viewed as a defense against anticipated rebukes if the patient were to authentically express his or her needs. Highlighting this process and encouraging genuine expression of feeling can be helpful.
Phase 3 encourages the patient to modify interpersonal behavior and integrate
their sense of identity with their relationships with others. In this phase of treatment,
emphasis is placed on modifying the meaning of internal events: irrational beliefs
about self and others are transmuted into more healthy patterns of thought, feeling,
and action. These beliefs may include excessive fears of abandonment, dependence,
idealization, and other scripts based on dysfunctional and inappropriate role-relationships from the past. These behaviors can be changed through rehearsal and repetition.
An important issue in successful treatment of histrionics focuses on conceptualizing
and managing the patient’s seductiveness (Wilson et al., 1992)—both physically (with
their tendency to erotically act out) and psychologically (with their inclination to seduce the therapist into providing more treatment time or through their overdramatization of insights). Raising awareness of the patient’s primary defense mechanism is a
critical step in treatment. Millon and Everly (1985) believe the primary defense of histrionic patients is the dissociation of their “real” selves from their “public” selves.
Group Treatments with the Histrionic Patient
Very little research has been reported on histrionic patients in group psychotherapy.
Because of the overlap in symptomatology, the reader can begin to extrapolate and
apply to the histrionic patient some of the group findings for other Cluster B disorders reported elsewhere in this article. Two citations are worth noting.
Sperry and Maniacci (1998) applied a dynamic-systems approach in examining relational dynamics with a personality-disordered couple. They showed how individual
partner dynamics in a histrionic-obsessive couple can be modified through couples
treatment. Significant symptom reduction was also reported for histrionic patients
within a therapeutic community (Hafner & Holme, 1996).
THE NARCISSISTIC PERSONALITY
Diagnostic Picture
The term narcissism is derived from the Greek myth of Narcissus. In this story, a handsome young man disobeyed his mother’s warning never to look upon his own reflection. Gazing into a pool of water, he fell in love with himself and died vainly, unable to
release his compelling stare.
According to the DSM-IV (American Psychiatric Association, 1994), persons with
narcissistic personality disorder are interpersonally exploitative, exhibit a grandiose
sense of their own self-importance, are preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love, and believe themselves to be “special”
such that they should only associate with others of high status. They require excessive
admiration, have a sense of entitlement, lack empathy, are envious of others or believe others are envious of them, and show arrogance and disdainful pride. Five of
these symptom patterns are needed to qualify for the diagnosis. A factor analysis of
these criteria in a group of 91 patients identified with personality disorders revealed
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three symptom domains: (a) grandiosity; (b) lack of empathy; and (c) need for admiration (Blais et al., 1997). Other diagnostic propositions for this disorder have been
offered (Morey & Jones, 1998).
Screen characters such as those portrayed by Shirley MacLaine in Terms of Endearment and Debbie Reynolds in Postcards From the Edge capture many of the traits held by
narcissistic people, but perhaps the clearest depictions of narcissistic personality disorder have been presented by Nicole Kidman in To Die For and the “Mr. Hyde” personality of Buddy Love, portrayed by Jerry Lewis and later by Eddie Murphy in The Nutty
Professor. Although the chemically produced traits of Buddy Love eventually dissipated, Nicole Kidman’s overly entitled and ruthless drive for media power and fame
left a wake of victims in her path which in the end included herself.
The trait of interpersonal exploitation carries the highest predictive value for the
disorder; grandiosity has the second highest predictive value (Links, 1996). For
Groopman and Cooper (1995), the need for admiration, grandiosity, and a lack of
empathy represent the core features of the disorder. Having to use people to support
their sense of self-esteem, the narcissist is unlikely to have many close relationships.
Indeed, they are more likely to have a pattern of short-term, superficial relationships
where the narcissist exists when asked to give of themselves (Gabbard, 1994).
Patients with narcissistic personality disorder are often identified by the precarious
nature of their sense of self, which can be shattered by the objective or subjective loss
of gratifying sources such as important relationships, jobs, or physical appearance
(Rodin & Izenberg, 1997). Within this context, patients with narcissistic personality
disorder continually seek out ways to feel special about themselves. One way of doing
this is through high performance, and the elusive attainment of perfection. Because
they are so preoccupied with their own grandiosity, they have difficulty feeling empathy for others (Hamilton, 1988). This is what makes their capacity for self understanding so poor.
Although DSM-IV (American Psychiatric Association, 1994) emphasizes the more
grandiose, exhibitionistic, and unempathic aspects of the disorder, there is empirical
support for a more passive form of narcissism (Hibbard, 1992; Rathvon & Holmstrom,
1996; Wink, 1991). In this passive form, the person is embarrassed or ashamed of his
grandiose or exhibitionistic wishes, is self-degrading, excessively shies away from attention, and can be overly inhibited. For this subgroup of patients, feeling special paradoxically comes from self-denigration and self-effacement, which may elicit countervailing statements from others. Narcissistic patients have also been classified along a
continuum of self-doubt versus self-sufficiency (Rodin & Izenberg, 1997). They may
seek out others for answers to their life’s problems or remain detached from suggestions made by others. Gabbard (1994) referred to similar subtypes of the disorder as
hypervigilant narcissists and oblivious narcissists, respectively.
As with other Cluster B personality disorders, comorbid substance use, mood disorders, and other Axis I conditions can occur, complicating an accurate assessment of
narcissistic personality disorder (Ronningstam, 1998). Bipolar disorder is one of the
most common comorbid conditions among narcissistic patients (Stormber, Ronningsham, Gunerson, & Tohen, 1998). Ronningstam (1996) reviewed the available empirical studies on concomitant narcissistic personality disorder and Axis I disorders and
found that between 12% and 38% of patients with a substance use disorder, and between 4% and 47% of those with bipolar disorder could be diagnosed with narcissistic
personality disorder. No single Axis I disorder, however, was most often associated
with narcissistic personality disorder (Ronningstam, 1996). Corruble et al. (1996),
Understanding Cluster B
363
found, however, that less than 5% of persons with narcissistic personality disorder had
major depressive disorder. A subtype of unipolar depression with sudden episodes of
anger and irritability can be misdiagnosed as narcissistic personality disorder (Fava,
1998).
Comorbidity among other Cluster B disorders is not uncommon. Although at a
higher level of personality organization with less likelihood of psychotic episodes, narcissists can have many features in common with persons experiencing borderline personality disorder (Hamilton, 1988).
Etiology
The prevalence of narcissistic personality is estimated at less than 1% in the general
population but as high as 16% in the clinical population (Kaplan et al., 1994). The cooccurrence of narcissistic personality disorder with antisocial, borderline, and histrionic personality disorders is common. No biogenic characteristics have been associated with narcissistic personality disorder, and therefore, an organic cause for this disorder is especially unclear (Millon & Everly, 1985).
Freud (1914) wrote the first definitive paper on narcissism and described it as a normal developmental stage in which the child is believed to be loved for almost everything they do and feel. As children grow they learn they are not the center of the universe and that to love others is important. If, however, healthy parenting is unreliable
the child regresses or is arrested in his or her development.
Like Freud, Otto Kernberg (1970) believed in a structural model of the egoid-superego but placed emphasis on good and bad self and object relations. He believed that operating within the narcissist is a set of characterological polarities: (a) selfaggrandizement coupled with an insatiable need for praise; (b) a charming exterior
hiding a ruthless interior; and (c) a presentation of independence and self-sufficiency
masking intense envy. For Kernberg, devaluation of others and a sense of omnipotence are used to maintain self-esteem and keep feelings of rage and envy in check.
Like Freud and Kernberg, Heinz Kohut (1971) suggested that narcissistic personality develops as a particular response to parental empathic failures and subsequent
feelings of being unlovable. Kohut proposed, however, that in order to save the lost
perfection of the mother-infant relationship the narcissist develops a perfectly lovable
“grandiose self” which embarks on a lifelong search for the praise and adulation from
which he or she had been deprived. As Ornstein (1974) put it, narcissists have an “insufficient consolidation of the self” (p. 137). Since Kohut (1971), narcissism has taken
a position at the centerpiece of psychoanalytic thinking (Gabbard, 1994; Groopman &
Cooper, 1995; Watson, Little, Sawrie, & Biderman, 1992).
In stark contrast to these psychoanalytic perspectives, Millon (1986, 1998) believes
that children become narcissists because their parents are too positive or permissive
with them. Based on false premises, these children overvalue their self-worth. For Millon, parents of narcissists dote over them, overrate them, and when older and when
facing the world outside their family these children discover that they are not “the
greatest” nor the “most beautiful.”
Ramsey, Watson, Biderman, and Reeves (1996) tested the idea that some type of inadequate parenting was involved in the development of narcissism. While these authors did not assess persons with narcissistic personality disorder per se, college students who scored high on a measure of narcissism perceived both parents as
authoritarian and/or permissive.
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Individual Psychotherapy with the Narcissistic Patient
For Freud (1914), narcissists fail to form attachments and are not amenable to psychotherapy because of their inability to form a requisite therapeutic relationship with the
therapist. Kohut (1971) believed, however, that narcissists form attachments through
aloofness and desperately need the therapist as a means of defining themselves. There
have been no empirical studies, however, comparing treatments for narcissistic personality disorder. Clinical findings form the basis for treatment evaluation.
Although the debate over competing theoretical positions continues, clinicians can
develop treatment prescriptions from many approaches and an integrative model is
recommended (Groopman & Cooper, 1995). The choice of therapy depends on the
patient’s capacity to tolerate anxiety, control impulses, and to develop meaningful social and personal relationships (Kernberg, 1970). When these factors are insufficiently maintained, improving the patient’s level of functional adaptation, not altering underlying character structure, is a more realistic goal.
For both practical and clinical reasons, restructuring the personality is not generally
considered the goal of therapy. With many narcissistic patients, therapy should focus
on impulse-control issues and the development of greater empathy. Patients who are
ruthless in their need to manipulate and manage their impression of what others
think are believed not to be amenable to personality change (Turkat, 1990).
When more fundamental personality change is a goal of therapy or when a more
thorough understanding of the underlying character dynamics is sought in an effort
to guide any type of intervention, a more complete model of personality is needed.
Gabbard (1994), Groopman and Cooper (1995), and others have contrasted Kohut’s
and Kernberg’s treatment of the narcissistic patient. Both psychodynamic approaches
have found clinical support. One principal issue in the debate centers on aggression;
Kernberg believed unmodulated aggression plays a major role in child development
whereas Kohut did not. Kohut believed that the narcissistic patient may need to maintain an idealized view of the therapist for a long time until the patient can internalize
the therapist’s empathic stance.
For Kohut, the therapist should not attempt to undue the patient’s glowing admiration by confronting the patient’s underlying hostility too early. Kernberg, however,
believed that the idealizing transference was a thin disguise for the patient’s feelings
of envy and devaluation for the therapist and suggested these need to be confronted
in a systematic way. For example, if the patient were to dismiss a comment by the therapist Kohut might focus on the patient’s difficulty to hear the comment because it
may have rekindled old psychological injuries of the patient, whereas Kernberg might
focus on how the narcissist may need to dismiss the therapist’s comments to avoid
painful feelings of envy of the therapist.
Those who advocate Kernberg’s object relations approach would decidedly emphasize negative transferential issues of anger, envy, and devaluation of others, whereas
those clinicians favoring the self psychological view of Kohut would emphasize the
positive transferences of mirroring, idealizing, and twinship—that is, the patient’s
need for the therapist to act as (a) an admiring mirror to the patient, (b) an ideal object of the patient’s control and through whom the patient can merge to procure
strength and peace of mind, and (c) as a source for the patient’s unfulfilled sense of
belonging (Kohut, 1984).
From a more Kohutian point of view, Rodin and Izenberg (1997) note that patients
with narcissistic personality disorder typically enter treatment due to the experience
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of losses that affect their self-esteem, or because they feel unable to form deep attachments. They report that successful therapists are predictable, reliable, and nonjudgmental towards their patients. Patients with narcissistic personality disorder may initially approach the therapeutic relationship in a superficial way, or may focus on goals
that are related to their need to be admired and impress others. Eventually their goal
may change to feeling closer with others.
Concomitantly, narcissistic patients have a need to express their anger as well as
their admiration at therapists, and when apparent, therapists should focus on the patient’s underlying need to do so. Narcissistic rage can be seen as being brought on by
feeling injured, helpless, or overwhelmed (Wexler, 1991). When the narcissist feels
dependent on others or when it is perceived that others want to control them, their
reaction is often to lash out. In the logic of the narcissist, what cannot be controlled
must be destroyed. The patient may be aided in understanding their narcissistic rage
and aggression as attempts to actively protect themselves from further emotional or
psychic injury.
Group Treatments with the Narcissistic Patient
Yalom (1985) has long argued the problematic nature of having a narcissist in a psychotherapy group—scapegoating and devaluation by others seems to stem naturally
from the narcissist’s lack of empathy, sense of entitlement, and intense need for admiration. While acknowledging the problematic potential of the narcissist in group, Rutan and Stone (1993) argue that a reassessment of such difficulties in light of self psychology can be extremely helpful. For example, the narcissistic monopolizer may be
viewed not as a problem group member, but as someone both wishing and fearing
recognition and admiration. Their verbal outpourings protect the narcissist from real
intimacy while maintaining their fantasy that they are the idealized center of attention. Empathy and the sufficient maintenance of the idealizing transference are recommended until such time when empathic failure by group members can be interpreted in terms of the injury inherent in the narcissist’s inner world and their painful
but characteristic relationships with others. Groopman and Cooper (1995) argue that
if the group is sufficiently cohesive and self-supporting the narcissist can find a safe
holding environment within which to learn and grow. As Leszcz (1989) points out,
however, group therapy for the narcissist without concurrent individual therapy is almost never sufficient treatment.
For MacKenzie (1997), the goals of treatment for narcissistic personality disorder
are the development of a norm of sharing with others and the identification with the
group. In earlier phases of treatment the alliance can be built with empathy and support; when greater patient frustration and anxiety can be tolerated later phases of
treatment can be devoted to confronting more guarded defenses of envy and devaluation (Groopman & Cooper, 1995).
Conjoint marital therapy with concomitant individual therapy has also been found
to be effective with the narcissistic patient. Bird, Martin, and Schuman (1983) interviewed prominent, successful men who suffered decompensation into childlike crises of helplessness and confusion. Only during marital therapy did it become apparent to these men that the true precipitant to their crisis was the instability of their
marriages and how faultless and strong they perceived they needed to be in their
marital role.
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A Word About Countertransference and the Cluster B Disorders
Because the goal of therapy is not simply to achieve insight but to experience successfully working through unsettling emotions, the therapist’s office is continually
charged with affect—much of which may not be in the awareness of either the therapist or the patient. As Book (1997) has so aptly pointed out, when personality-disordered patients are “difficult” they are difficult for two reasons, their behavior and our
response. Cluster B patients unknowingly try to recreate and work through in the
therapeutic relationship troublesome aspects from their own relationships with significant others. Separating out the unconscious issues of the clinician from those of the
patient can be difficult. This issue was first discussed by Freud in his work with Dora,
who terminated therapy prematurely because of their conflicted interactions (Meissner, 1984).
Cluster B patients stir up a host of feelings; hatred, rage, despair, impotence, apathy, helplessness, feelings of sexuality, the illusion of omnipotence, omniscience,
and love. As clinicians, we often try to cope with this affect by disparaging our patient, questioning our own competence, or feeling guilty over what we may have said
or done.
Although therapists may bring in unresolved dynamic issues—unconscious memories triggered by the patient’s characteristics or the treatment process—the patient
also puts into, or evokes in the therapist unconscious emotional conflicts and deprivations that are the patient’s. Kernberg (1975) refers to this latter process as the “totalistic transference”. For example, one of us (G.K.) recently had an antisocial patient
whose manipulativeness and deceitfulness was evoking irritation and disparagement
of the patient by staff members. When the staff’s anger was viewed from the perspective of being influenced by the patient’s projection of his own frustration with treatment and with his treatment relationships, staff members were better able to let go of
the patient’s anger, undo taking ownership for it, and react in a less defensive way.
Cluster B patients are repeatedly compelled to act out these issues (a) to “test” the
therapist’s loyalty or competence, (b) by compelling the therapist to contain the patient’s intolerable feelings for safe keeping, (c) to recreate what is familiar to them,
and (d) as a means of communicating in the patient’s own way difficult, confusing,
and complex feelings (Book, 1997).
Feeling threatened is one of the most telling signs for therapists working with antisocial patients. If a therapist feels threatened, the patient should either be referred to
another provider or steps should be taken by the therapist to understand why the patient is evoking such a reaction (Ruegg et al., 1997). Therapists may alternate between
fear and anger with antisocial patients. They may also be made to feel humiliated.
Countertransference feelings of fascination and envy for the antisocial patient have
also recently been discussed (Weiss, 1998).
Melroy (1995) cautions clinicians to be mindful of the following pitfalls: condemnation of all patients with an antisocial diagnosis, an illusory treatment alliance with
these patients, unrealistic fears of harm, denial of the potential for harm, helplessness, guilt and devaluation when change does not occur, and an identification with
the patient’s hatred and wish to destroy. Oftentimes, the therapist is unaware of these
powerful feelings and may act them out possibly through retaliation or withdrawal.
Therapists are encouraged to acknowledge these feelings as well as the patient’s need
to act in ways that elicit such feelings. Support and consultation in treating such patients is advised.
Understanding Cluster B
367
A host of transferential and countertransferential characteristics have been attributed to working with borderline personality disorder. Kroll (1997), Gabbard (1995b),
and others have discussed how patients with borderline personality disorder can become dependent on the therapist for extrication from harmful or potentially damaging situations (i.e., “rescuer fantasy”). Borderline patients wrestle with their unconscious disavowal of internalized abusers which may then get attributed to the
therapist. Late-night phone calls from the patient, requests for extension of therapy
hours, and forgoing of payment are common acting-out patterns. Therapists themselves can feel victimized.
Bardikoff (1997) suggests that consultation with another therapist serves the purpose of reviewing the therapy, the treatment goals, identifying additional therapeutic
resources to help the patient, exploring the therapist’s feelings about the therapy, and
the reasons for the impasse. Borderlines, as with other Cluster B patients, act out, often in dramatic fashion, whatever feelings can’t be verbalized. Understanding the
therapist’s reaction to the patient as a manifestation of these feelings is essential
(Rosenbluth & Silver, 1997). For example, therapists must be willing to examine their
own disavowal of aggressive impulses and then to set limits with borderline patients
(Davies & Frawley, 1992). Such limits should address the therapist’s boundaries as well
as the patient’s. Patients should be encouraged to process their feelings about imposed boundaries.
Horowitz (1997) points out that with their dramatic and often entertaining stories,
histrionics can evoke powerful rescue fantasies as well. A honeymoon period of mutual idealization of the therapeutic relationship is likely followed by disappointment
and emotional turbulence. Clinicians who get caught up in this drama may be left
feeling angry and rejecting towards histrionic patients who are not grateful for the clinician’s efforts. The pattern is often repetitious with previous and subsequent therapists.
Like the histrionic, one of the most common countertransferential relationship patterns with the narcissistic patient is where the patient idealizes the therapist and the
therapist basks in that glow of affection (Gabbard, 1994). What is avoided are feelings
of rage or hostility the patient may have for the therapist and the overidealized view of
himself the therapist may need to maintain. Idealization can also take the form of devaluing former therapists. Clinicians who buy into their patient’s idealization of them
may themselves be vulnerable to the patient’s primitive defense of splitting service
providers (Kernberg, 1998).
CONCLUDING COMMENTS
The line between normal and abnormal or disordered personalities lacks a sharp divide (Millon, 1986). Although the authors of the DSM-IV (American Psychiatric Association, 1994) deemed a categorical system of clustering personality disorders to be
the most appropriate at this time, they acknowledge the absence of distinct boundaries between the various personality disorders. Many of the personality disorders
have been found to be strongly correlated with one another (Bell & Jackson, 1992),
and in some studies as few as 7 of the 11 personality disorders fit into their corresponding clusters (Dowson & Berrios, 1991).
Much of the current criticism for assessing personality disorders stems from the
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menu-driven categories which predominate the field (Gabbard, 1997), and other
models of personality diagnosis have been offered (Costa & Widiger, 1994; Derksen,
1995; Westen & Shedler, 1999a, 1999b). For example, Derksen proposes that Axis II
should be comprised of five interaction disturbances, referred to as such because they
represent relational rather than intrapsychic difficulties. He points out that Axis II disorders usually come to the attention of clinicians when problems have emerged in the
patient’s interactions with others, and therefore, an Axis II diagnosis should be less
dependent on abstract and non-empirically derived conceptualizations of personality
than on behavioral descriptions of the patient’s recurring and maladaptive interactions with others.
Regardless of the system used, all treatment must begin with an accurate assessment
of the patient’s condition. Weiner (1975) suggests the clinician should arrive at a working formulation which includes a description of the nature and severity of the patient’s
symptoms as well as clinical impressions of the patient and how the patient got that
way. Clinical impressions of the patient’s personality should include the patient’s conflicts, defenses, styles of coping, attitudes towards self and others, and how the patient
relates his past and present life to his current distress and reasons for seeking help.
Westen (1997) has found that clinicians approach the diagnosis of personality disorders
differently from researchers who have tended to base their work on standard research instruments formulated from the DSM-IV (American Psychiatric Association, 1994). He has
questioned the validity of evaluation and outcome research based solely on the DSM-IV
and suggests that the clinician should develop treatment plans not only from the diagnosis
but also from a clinical formulation as to the causes of the patient’s problems.
Diagnosis and treatment of Cluster B disorders requires careful and continued assessment—assessment of the patient’s behavioral patterns and a keen assessment of
the clinician’s own reaction to the patient. It is our hope that greater emphasis in the
literature on the nature of personality development and personality organization—
particularly which may underlie Cluster B disorders—can be helpful to clinicians
treating a wide variety of conditions.
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