Understanding Cluster B Personality Disorders in the DSM-5

The American Psychiatric Association uses the Diagnostic and Statistical Manual of Mental Illnesses, 5th Edition (DSM-5) to accurately diagnose mental health-related conditions and disorders. To diagnose personality disorders, the DSM-5 groups them into “clusters” with other conditions that share similar symptoms and characteristics. Of these, Cluster B personality disorders are defined by their erraticness and theatricality, causing individuals to engage in excessive or impulsive behaviors.

The DSM-5 classification system is incredibly significant to researchers and medical professionals because it helps them recognize signs and symptoms of cluster B and make an accurate personality disorder diagnosis.

What are Cluster B Personality Disorders?

According to the DSM-5, cluster B personality disorders are characterized by issues with emotional regulation and an inability to effectively manage personal conflicts. Individuals with cluster B personality traits are more likely to become involved in litigation than those with other traits, though not always. This is due to the impulsive or reckless behaviors that these personality disorders often trigger. There are four main subsets grouped into cluster B: antisocial, borderline, histrionic, and narcissistic. ^[1]

People with cluster B personality disorders are usually manipulative, excessively emotional, dramatic, and demanding. They may construct unhealthy interpersonal relationships or inappropriate relationships with colleagues or other professionals, particularly medical staff. Some individuals may struggle to deal with the effects of a cluster B disorder, resulting in a higher risk of impaired everyday functionality, suicidal tendencies, and being hospitalized. There is also an increased risk of comorbidity in those diagnosed with a cluster B disorder, particularly a dual-diagnosed personality disorder or substance use disorder. ^[2]

The DSM-5 classification system is important because it helps clinicians accurately diagnose those with cluster B personality disorders and differentiate their symptoms from those of cluster A or C. Cluster A personality disorders are characterized by eccentric or outlandish behavior, and cluster C types often appear to be anxious, stubborn, and meek. Cluster B personality disorders, on the other hand, are often more distinguishable because the signs are more dramatic, uncontrolled, and emotional. ^[3]

Antisocial Personality Disorder

Antisocial personality disorder (ASPD) is one of the more potentially dangerous cluster B personality disorders. The signs often begin during an individual’s childhood and persist throughout their life, impacting their personal and professional relationships and making them more susceptible to dangerous or criminal behaviors. Common diagnostic criteria for ASPD include disregarding other people’s thoughts, feelings, and rights, manipulative behavior, irresponsibility, and a lack of remorse. As a result, they may cause harm to themselves but also pose a threat to others. ^[4]

ASPD is a spectrum, with conduct disorder (CD) being one of the biggest signifiers that a person may develop ASPD. Conduct disorder is diagnosed in children and characterized by unusual aggression, violent or destructive treatment of people, pets, and property, and theft. Not every child diagnosed with conduct disorder will develop ASPD in adulthood, but it increases their risk, especially if they don’t receive professional help for their CD. The DSM-5 tracks persistent signs of ASPD from childhood to adulthood, with a particular focus on behaviors that display an overt disregard for other people’s rights and safety. ^[4]

Borderline Personality Disorder

Like ASPD, borderline personality disorder (BPD) is also signified by a lack of care, but unlike those with ASPD, BPD sufferers are more of a risk to themselves than others. They experience very intense and fluctuating emotions, which can lead to impulsive behavior as a coping mechanism.

People with BPD struggle to regulate these big emotions and become easily overwhelmed by their thoughts, which can lead them to believe that their closest friends and relatives are going to abandon them. This impacts how they maintain personal relationships, as do their distorted perceptions of themselves and others. ^[5]

It’s very common for those suffering from BPD to have a dual diagnosis with another type of disorder, including mood disorders, anxiety disorders, substance abuse disorders, and other personality disorders. These comorbid disorders often make the symptoms of BPD worse.

The feelings of self-loathing and loneliness expressed by individuals with BPD can trigger reckless acts, including overspending, dangerous driving, risky sexual behavior, and binge eating or drinking. There is also an increased risk of self-harm, with cutting and hitting oneself being two common methods and possible suicidal behavior. ^[5]

Histrionic Personality Disorder

Histrionic personality disorder (HPD) is one of the most excessive of the cluster B personality disorders, usually identifiable by excessive emotional displays and chronic attention-seeking behaviors. It’s also the hardest cluster B personality to treat because individuals may exaggerate their symptoms or struggle with therapies that make them feel exposed outside of the front they put on.

Individuals with HPD stand out because they want to, with common symptoms including theatrical speech and behavior, a hunger for the spotlight, and a bad reaction to feeling sidelined or unappreciated. This disorder is usually life-long. ^[6]

Some people may describe those with HPD as being very charismatic, flirtatious, excitable, extroverted, and self-indulgent. DSM-5 histrionic personality disorder also recognizes emotional instability and difficulties maintaining relationships as a result of excessive attention-seeking and low persistence when making an effort with other people. Research suggests that those diagnosed with HPD as adults may have been neglected or abused as children, though not always. Findings are more limited for HPD because it’s such a rare disorder. ^[6]

Narcissistic Personality Disorder

Narcissistic personality disorder (NPD) is typically characterized by a startling lack of empathy and thoughts and behaviors that show chronic entitlement and arrogance. While those with HPD desperately crave and seek attention to improve their self-esteem, individuals with NPD believe that they are automatically worthy of other people’s respect and admiration because they have a lofty sense of self-importance. They behave in grandiose ways and treat people poorly; as a result, they often brag and put others down to inflate their egos. ^[7]

NPD persists for a long time, impairing the individual’s abilities to create and maintain interpersonal relationships, although it does begin to decrease in adulthood compared to adolescence. People with narcissistic tendencies often use others for their own gain, so many of their social interactions are shallow and short-lived.

The DSM-5 also lists a demand for admiration, conceitedness, a lack of empathy, and a preoccupation with an idealized existence among the diagnostic criteria for NPD. Individuals with NPD usually don’t realize it, so they rarely seek professional help. ^[7]

Diagnosing Personality Disorders in the DSM-5

Despite their distinguishing features, DSM-5 cluster B personality disorders can be difficult to diagnose. Personality disorders from all three clusters regularly go undiagnosed because individuals who seek help often complain of anxious and depressive symptoms, which lead professionals away from the more intrinsic signs of a personality disorder. Many people also write off the dramatic and overly emotional characteristics of cluster B disorders as personality traits rather than symptoms of something more. ^[3]

A personality disorder diagnosis requires the symptoms to be persistent, unwavering, and have a negative influence on areas of the individual’s life. The diagnostic criteria outlined in the DSM-5 necessitates that the individual show signs of impaired self-perception, poor impulse control, difficulties maintaining social and occupational relationships, and a long-term track record of affected behavior.

However, many individuals don’t know that they have a personality disorder, so they cannot share enough insight into their traits or symptoms to achieve an easy diagnosis. As a result, more thorough diagnostic tools will utilized to provide the individual with help and support. ^[3]

The DSM-5 is one of these tools; however, it received a mixed response from clinicians and researchers when it was first published. The controversy stems from the fact that the changes between the 4th and 5th editions had expanded the terms of psychiatric diagnosis. Some felt that over-labeling signs of normal emotion as personality disorder traits risked misdiagnosing patients, and there were worries that new medications might be pushed as treatments for disorders that could be treated in other ways. Not only would needless treatment be harmful to patients without mental disorders, but those who were suffering may not receive the help they needed. ^[8]

As a result, while the DSM-5 is an incredibly useful source of information when diagnosing personality disorders, its classification system should be used alongside other resources and tools to ensure a rigorous and accurate diagnosis.

Physicians and therapists must take additional care when diagnosing individuals with cluster B personality disorders because of the manipulative and emotionally unstable traits associated with ASPD, BPD, HPD, and NPD. Histories of familial mental illness, self-harm or suicide attempts, and substance abuse must also be taken into account, as they are significantly prevalent among those with cluster B personality disorders. ^[2]

But even with these diagnostic difficulties, tools like the DSM-5 remain essential for clinicians diagnosing personality disorders because the signs are often so difficult to identify fully. The DSM-5 clearly outlines the characteristics of an individual with a cluster B disorder, then narrows traits and behaviors into four similar yet distinctive disorders. The intricacies of ASPD, BPD, HPD, and NPD mean that different treatment approaches may be required, so understanding how to recognize, differentiate, and diagnose each disorder is vital to the recovery process. ^[3]