Cluster B Personality Disorders: Types, Causes, & Treatments

What Are Cluster Personality Disorders?

A personality disorder is a persistent, long-term, unhealthy pattern of thinking, feeling, and relating to others. The symptoms are chronic and severe enough to interfere with the person’s daily functioning at home, school or work. There are 10 specific personality disorders which are organized into 3 clusters (A, B, and C), based upon similarity of the traits that characterize them.

Cluster B Personality Disorders Types & Traits

The four personality disorders in cluster B are all characterized by dramatic, unpredictable and erratic behavior. Emotions are expressed with intensity and are often inappropriate to the situation. Thinking tends to be self-focused with relatively little concern for the well-being of others. Behavior is often manipulative or deceitful, treating others as a means to an end. There is typically a difficulty respecting authority or a lack of concern for cultural norms.

Personality disorders characterized as cluster B are:¹

Antisocial Personality Disorder (ASPD)

A person with Antisocial Personality Disorder demonstrates a blatant disregard for the rights, feelings and safety of others. They are known to frequently lie, act impulsively and act violently. Although a person cannot be diagnosed with ASPD until age 18, a history of aggressive and cruel behavior is often present as early as age eight.² As children, people with antisocial personality disorder often have a history of bullying others and being cruel to animals. When the most severe symptoms are present, an adult with ASPD may be a psychopath.

Among the cluster B personality disorders, the evidence for genetic factors is strongest with ASPD.³ Environmental factors, such as childhood neglect, abuse, or other trauma also play an important role in the development of ASPD.⁴ Up to 5% of the population meets the criteria for ASPD, with men more often diagnosed than women.¹

Common symptoms of ASPD include:

• Disregard for rules, laws, and norms
• Lying, cheating, stealing out of habit, including pathological lying (lying with no purpose)
• Physical aggression
• Lack of empathy, remorse, or sense of guilt
• Taking advantage of others
• Putting others in danger without regard for their safety
• Chronic irresponsible behavior, or recklessness
• Constant striving for power or control, such as in business or government
• Manipulative behavior
• Superficial charm or flattery

Borderline Personality Disorder (BPD)

A person with Borderline Personality Disorder demonstrates extreme emotional instability, with sudden, unpredictable and dramatic shifts in mood. They tend to be very impulsive, and are at high risk of self-harming behavior. There may be frequent suicidal ideation with a risk of suicide attempts. Feelings of emptiness and fear of abandonment are both characteristic of BPD. Due to these traits, those with BPD have difficulty maintaining stable relationships.

Childhood experiences are particularly important in the development of BPD, although there may also be some genetic influences. Circumstances which increase the likelihood of BPD being triggered in someone with a biological disposition include: high conflict home environments, neglect, physical or sexual abuse, traumatic losses, and unhealthy attachment with caregivers.⁵ BPD does improve with treatment, particularly Dialectical Behavior Therapy, although it may take two years to see major improvements.

Common symptoms of BPD include:

• Intense and quickly changing emotions
• Feelings of emptiness
• Unstable relationships
• Impulsiveness, including impulsive self-harming behaviors
• Fear of abandonment
• Strong need for attention
• Efforts to avoid loss of relationships
• Cycles of valuing and devaluing others
• Low self-image, feeling worthless or purposeless
• Suicidal ideation or suicide attempts
• Temporary paranoia

Histrionic Personality Disorder (HPD)

A person with Histrionic Personality Disorder appears highly dramatic, and is frequently seeking attention and approval. While they can be lively and entertaining, their behavior can also become embarrassing with public displays of love, crying, or temper outbursts. Their interactions are often seductive or provocative in an attempt to manipulate others. While emotions are expressed in a theatrical way, they tend to be superficial and may quickly shift to indifference.

Common symptoms of HPD include:

• Excessive need for attention
• Discomfort or anxiety when not the center of attention
• Sexually seductive or provocative behavior
• Expressing quickly shifting and shallow emotions
• Using appearance to draw attention to self
• Using speech which is lacking any detail
• Dramatic or theatrical speech and behavior
• Being easily influenced by others, or being gullible
• Misperception of relationships as closer than they actually are
• Efforts to appear helpless in order to attract attention

Narcissistic Personality Disorder (NPD)

A person with Narcissistic Personality Disorder demonstrates a strong need for admiration and attention, a sense of entitlement, and a feeling of superiority. Although they do not completely lack empathy as does the antisocial personality, their capacity for empathy is low. As is true with the other cluster B personality types, they tend to have poor control of their emotions. As a result, they are prone to either narcissistic rage, or withdrawal and detachment, when offended. A person with NPD has no hesitation about exploiting others for personal gain.

Common symptoms of NPD include:

• Having a grandiose sense of self-importance
• Preoccupation with fantasies of success, power, beauty or ideal love
• Believing that one is special or unique and can only be understood by other special persons
• Needing excessive admiration
• Having a sense of entitlement or expecting favorable treatment due to being important
• Manipulating or exploiting others
• Lacking in empathy, unwilling to identify with the feelings or needs of others
• Believing others are envious of them
• Acting arrogant or superior

What Causes a Cluster B Personality Disorder?

While the exact causes of cluster B personality disorders are unknown, there are several possible causes. These include environmental factors such as parenting styles and attitudes passed on to children. Childhood trauma might also have a significant effect on the development of a cluster B personality disorder, particularly BPD and HPD. Some evidence has shown links between genetics and/or brain structure and certain cluster B personality disorders.

According to Dr. Stephanie Steinman, PhD, CSAC, “The biggest environmental trigger that can influence the onset of a cluster B personality disorders is a history of trauma, particularly physical neglect and emotional abuse. Complex trauma, where a person has been exposed to multiple traumatic events is a major risk factor for the development of these traits. However, a person can have cluster b symptoms without a trauma history. Attachment difficulties, chronic invalidation, and having family members with mental health struggles can also contribute to development. It is important to know that even with a complex trauma history, treatment is still effective.”¹⁵

Possible causes of cluster B personality disorders include:

• Environmental factors: Studies have shown that certain parenting styles increase the risk that a child will later be diagnosed with a personality disorder. One such style is parents being over-indulgent, giving excessive praise and believing their child to be more special and entitled than others. Studies have suggested that this might lead to that child growing up with a sense of entitlement or superiority, two of the core traits of NPD.⁶
• Trauma: Childhood abuse or neglect has been associated with higher risk for a number of adult symptoms. The risk of developing BPD, HPD, or ASPD is higher among children who experienced severe physical, emotional, or sexual abuse. Trauma in the form of physical or emotional neglect also raises the risk of developing HPD.^5,7
• Genetics: Population studies have suggested that having at least one immediate family member with a cluster B disorder increases the chances of being diagnosed with the same disorder.⁸ It should be kept in mind that these studies show correlation and not necessarily genetic causation. Ways of relating to others, including emotional expression and impulse control, are learned within families and might explain the presence of more than one family member with the same personality disorder.
• Brain Structure: Differences in brain structure may play a role in the development of ASPD. Neuroimaging studies have shown differences in the prefrontal cortex in many people with ASPD. The ASPD individuals had a thinner cortex and larger surface area in several specific brain regions. These differences may explain the lack of self control and the aggressiveness of persons with ASPD.⁹

Cluster A, B, & C Personality Disorders Differences

All three categories of personality disorders center on a person’s behavior, emotional stability, and ways of thinking. They all describe patterns of behavior which are consistent across time and circumstances, causing impairments for that person.

There are basic differences among the three clusters of personality disorders, including:¹

Cluster A Vs. Cluster B Personality Disorders

Cluster A personality disorders are characterized by thinking which is odd or eccentric. Cluster A personalities tend to be detached and distrustful, with reluctance to form close trusting relationships.

The three personality disorders within cluster A are Paranoid, Schizoid, and Schizotypal. Paranoid personality is marked by suspicion and mistrust of others, resulting in avoidance of close relationships. Schizoid personality is marked by aloofness and indifference, such that close relationships are neither desired or enjoyed. Schizotypal personality is characterized by the most extreme degree of odd thinking and behavior. Their perceptions of reality tend to be distorted; this can be noticed in their speech as well as their limited range of emotional expression.

In contrast to cluster B personalities, those in cluster A are less likely to be at ease in a social environment. Their unusual thinking and behavior is apparent. They are either detached and isolated or present yet appearing and sounding very odd. They are much less expressive of their emotions than cluster B types, and less likely to be manipulative, deceitful or impulsive. Although the cluster A personality might draw attention to themselves due to their eccentricity, they are not purposefully seeking attention and would rather avoid it.

Cluster C Vs. Cluster B Personality Disorders

Cluster C personality disorders are characterized by feelings of anxiety and fearfulness. They experience fears of confrontation, rejection, ridicule, or being seen as not good enough. Their behavior is chronic and causes problems at work, at home, or in social circumstances.

The three personality disorders within cluster C are Obsessive-Compulsive, Dependent, and Avoidant. Obsessive-Compulsive Personality Disorder (OCPD) is marked by thoughts and behaviors focused upon details, rules, lists, and organization. Those who have OCPD typically take pride in their perfectionism, even though that perfectionism often interferes with completing tasks. With OCPD, the thoughts and behaviors interfere with relationships, work, and peace of mind.

Dependent personality is marked by a need for others to take responsibility for them, along with a fear of being alone and having to take care of themself. They fear and avoid confrontation, due to the risk of losing relationships of importance to them. Avoidant personality is characterized by the fear of rejection or ridicule, due to their chronic feelings of inadequacy. They avoid both social situations and intimate relationships.

In contrast to cluster B personalities, those in cluster C are more often anxious and fearful. Their behavior is less erratic, less impulsive and typically not dramatic. They tend to be less expressive of emotions and not inclined to deceive or manipulate others. They can be very difficult to live with or work with, due to strict adherence to rules and routines.

How Are Cluster B Personality Disorders Diagnosed?

A personality disorder diagnosis must be made by a qualified mental health provider who has experience in identifying personality disorders and the differences among them. It might include personality questionnaires, such as the MMPI, but often doesn’t due to the level of skill required to interpret these tests. A detailed personal history of work experiences, interpersonal functioning and any long-term problems would be obtained in a clinical interview.

If you’re seeking a diagnosis for yourself, it may be helpful for your mental health provider to also talk with your spouse, family members, or others of your choice. They might be able to provide insights into longer-term patterns of behavior, and they may have observed behavior that you’ve overlooked. This would only be done with your permission.

Four criteria must be met in order for a personality disorder to be diagnosed, according to the DSM-5. First, there must be an enduring pattern of thoughts and behaviors that deviates from the norms or expectations of the person’s culture. Second, this pattern must be inflexible and observed along a wide range of personal and social situations. Third, this pattern must cause significant distress or impairment in important aspects of the person’s life, such as work or relationships at home. Fourth, the pattern is stable and can be traced back to adolescence or early adulthood.

Cluster B Personality Disorders Treatment

The primary treatment for personality disorders is psychotherapy, with medications used as needed to treat symptoms of related problems such as anxiety or depression. It’s not unusual for the person with a personality disorder to lack the self-awareness to realize that they have a problem that requires help. Since their pattern of behavior has been chronic and long-term, they have typically not questioned its normalcy. They may need encouragement from concerned family members or other loved ones to seek treatment.

Psychotherapy

The major forms of psychotherapy used to treat personality disorders are Cognitive-Behavior Therapy, Dialectical Behavior Therapy, Psychodynamic Therapy, and Psychoeducation. Couples or family counseling may also help to reduce conflict at home and improve family relationships. In order for therapy to be effective, the person with the cluster B personality needs to be genuine in their desire for change and improvement in their quality of life.

Here are therapy methods used in treating cluster B personality disorders:

• Cognitive behavioral therapy (CBT): CBT works by helping people become aware of how their thoughts affect their actions and feelings so that they might change maladaptive thoughts and the related behaviors. A specific benefit for those with HPD or NPD is better management of their need for attention.¹
• Dialectical behavior therapy (DBT): DBT works toward reducing emotional instability, self-harm, and suicidal impulses. DBT for borderline personality disorder is particularly effective in treating impulsive behavior and self-harming tendencies.¹⁰
• Psychodynamic therapy: Psychodynamic therapy creates a relationship between the therapist and patient which is non-confrontational, validating, and empathic. This approach is particularly helpful in treating the person with NPD, whose typical defensiveness and manipulative behavior might block the interventions used in behavioral therapies.^10,11
• Psychoeducation: By improving a person’s understanding of their condition, psychoeducation can help reduce harmful use of drugs or alcohol which are known to increase the chances of aggressive behavior. In this way, psychoeducation may be particularly helpful for those with ASPD.¹²

Medications

There are no FDA-approved medications for the specific treatment of personality disorders. Medication can help treat the symptoms of cluster B disorders, such as tendency to self-harm or to be aggressive toward others. Medication may also be prescribed to help manage the symptoms of co-occurring mental health problems. For example, medications used to treat BPD typically target coexisting depression, anxiety, mood shifts or impulsivity. Medication is also particularly helpful in ASPD treatment to reduce the tendency toward aggressive behavior.¹⁰

Medications prescribed to treat symptoms for people with cluster B personality disorders include:

• Mood stabilizers: When depressed mood occurs along with a personality disorder, one of the mood stabilizers might be prescribed to treat the symptoms of low mood and suicidal ideation. Studies have shown that lithium, an effective mood stabilizer, may reduce suicide risk when used as a long term treatment.¹³
• Antidepressants: When symptoms of depression include disrupted sleep, changes in appetite, low energy, or low mood, antidepressants might be prescribed. The most commonly prescribed of these are the SSRI’s, SNRI’s, and NDRI’s.¹³
• Antipsychotics: When severe depression and distorted thinking co-occurs with a personality disorder, antipsychotics might be prescribed to treat symptoms such as hallucinations or delusions.¹³ Antipsychotics have also been used to manage aggressive behavior in ASPD,¹⁰ and the temporary paranoia that might occur with BPD.
• Anti-anxiety medications: Anxiety can often co-occur with a cluster B personality, and can be treated with anti-anxiety medications. Most commonly prescribed are the short-acting benzodiazepines; these are often tapered off over time to reduce the risk of drug tolerance or dependence.¹³
• Anticonvulsants: Anticonvulsants may be prescribed to help suppress impulsive and aggressive behavior, both of which are characteristic of the cluster B personality disorders. Studies have shown that Topiramate (Topamax) may be safe and effective in controlling anger and aggression.¹⁴

9 Tips for Living With a Diagnosed Loved One

Living with a loved one who has cluster B traits can be very challenging, frustrating, and disruptive. While it can be very difficult to interact with them, there are some ways to respond effectively to maintain your own well-being. How to deal with cluster B personality disorders depends on the specific disorder. Tips for disarming a narcissist will be somewhat different from tips for dealing with BPD relationships. However, some general guidelines are useful for any type of cluster B relationship.

Dr. Steinman continues, “If you know someone who has been diagnosed with cluster b personality traits, relationships can be difficult to manage. Educating yourself and understanding these disorders can help separate the symptoms from the person. Telling a person they have to get help is often not effective. Instead, you can offer support when they say they need help. Validation is another effective skill in navigating these relationships. Validation is different from agreement. You are not saying that you believe everything they are saying or doing is true. You are instead communicating that you hear them and can understand their point of view.”¹⁵

Here are 9 tips for interacting with loved ones who have difficult symptoms of personality disorders:

• Set boundaries: Know your needs and be ready to assert them. Know the limits of what you can live with, including physical, emotional and financial conditions.
• Be the person you want to be. Rather than being reactive to their provocations, remind yourself of your own values or priorities. This might look like being patient with someone who is clearly trying to improve their own behavior by responding to your boundaries and/or cooperating in therapy.
• Practice saying no. This is particularly important when living with attention seeking individuals and those who are chronically unaware of your needs.
• Avoid over-explaining or excessive apologizing. This is especially important when responding to requests that violate your stated limits or house rules.
• Take care of yourself emotionally and physically. In addition to getting enough sleep, eating well, and getting exercise, practice kindness toward yourself.
• Maintain social support Extended family or friends can provide critical emotional or practical support if/when your circumstances become overwhelming.
• Don’t engage in emotional drama. The drama which characterizes cluster B personalities can be exhausting. Learn to self-calm as needed or to walk away.
• Seek therapy for yourself if you’re struggling to cope. Mental health providers understand how challenging those with personality disorders can be. They can help you find ways to cope with your particular circumstances.
• Have an exit strategy. These personality types are usually manipulative and/or deceitful. If they repeatedly ignore your boundaries, you may need to be physically separated from them. Know when you need to have that separation and be prepared to follow your plan.

In My Experience

In my experience as a therapist, working with individuals who have a personality disorder is extremely challenging because they are typically not self-aware enough to realize how their behavior is harming themselves or others. Cluster B personalities tend to assume that any problems in their lives are due to the actions of others. As a result, they are usually not genuinely motivated to make changes. If you are living with someone who has been diagnosed with a cluster B personality disorder, it’s important to realize that you cannot convince them to change. The motivation must come from them.

However, if you are the person with one of these personality types and genuinely wish to make the changes to improve your life at work or at home, there is hope for you. Treatment in the form of therapy and medication can help with your symptoms and your daily struggles. Seek professional help and be patient with yourself.