Understanding Borderline Personality Disorder (BPD) and Cluster B Personality Types

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Cluster B Personality Types, the
Dramatic-Erratic Group:  Overview
and Focus on Borderline Personality
 
WHAT IS BORDERLINE PERSONALITY DISORDER (BPD)?
WHAT APPROACHES AND INTERVENTIONS WORK WITH BPD?
SELF CARE WORKING WITH BPD.
 
What is Cluster B: Dramatic-erratic
group?
 
Four distinct personality types organized by descriptive similarities.
These similarities separate this group from Cluster A (odd-
eccentric) and Cluster C (anxious-avoidant)
General requirements for all personality subtypes to meet criteria
for disorder:
Cultural-norm deviation (cognition, affectivity, interpersonal,
impulse control)
Pattern is inflexible and pervasive
Clinically significant distress
Stable, long duration
Not accounted for by other (medical, substance, mental health)
 
Cluster B
 
Antisocial Personality Disorder
 
Histrionic Personality Disorder
 
Narcissistic Personality Disorder
 
Borderline Personality Disorder
 
Antisocial Personality
 
General population:  3% male, 1% female
Clinical population: 3% to 30%  (setting dependent)
Core feature: disregard for, and violation of, the rights of others
At least 18 years old
Evidence of Conduct Disorder onset before age 15
Does not occur exclusively during the course of schizophrenia or
manic episode
 
Antisocial Personality, p.2
 
Failure to conform to social norms: law
Deceitfulness
Impulsivity
Irritable/aggressive
Reckless disregard
Irresponsibility
Lack of remorse: indifferent or rationalizing
 
Histrionic Personality
 
General population:  2% - 3%
Clinical population:  10% - 15%
Core feature: pervasive and excessive emotionality and attention-
seeking
Uncomfortable when not the center
Inappropriately seductive, provocative
Rapid and shallow emotion
Uses physical appearance
 
Histrionic Personality, p.2
 
Excessively impressionistic, lacking detail (shallow)
Self dramatization
Easily suggestible
Considers relationships to be more intimate than they actually are
 
Narcissistic Personality
 
General population:  less than 1%
Clinical population:  2% - 16%
Core feature:  grandiosity, need for admiration, lack of empathy
Self-important
Preoccupied with fantasy
Believes self to be special
Requires excessive admiration
Entitlement
 
Narcissistic Personality, p.2
 
Interpersonally exploitive
Lacks empathy
Envious of others; believes others are envious of him/her
Arrogant, haughty
 
Borderline Personality
 
General population:  2%
Clinical population:  10% - 20%
Core feature:  instability of relationships, self image, and emotional
expressivity, marked impulsivity
Frantic efforts to avoid real or imagined abandonment
Intense, unstable relationships (idealization 
 devaluation)
Identity disturbance
Impulsivity in 2: spending, sex, use, reckless driving, binge eating
 
Borderline Personality, p.2
 
Recurrent suicidal behaviors (acts with or without intent, threats) or
self-mutilation
Affective instability due to marked reactivity of mood
Feelings of emptiness
Inappropriate, intense anger or inability to control anger
Transient stress-related paranoia or severe dissociative experiences
 
Getting more specific
 
Millon, Disorders of Personality DSM-IV and Beyond
BPD is one of 3 “structurally defective” personality types
(schizotypal, paranoid)
Adaptive inflexibility
Self-perpetuating vicious circles
Tenuous emotional balance
 
BPD:  The Unstable Pattern
 
Argues for the lack of utility of the term “borderline” as it does not
describe the clinical presentation
Ambivalent personality
Erratic personality
Impulsive personality
Quixotic personality
 
Millon’s diagnostic domains
 
Expressive behavior:  spasmodic
Interpersonal conduct:  paradoxical
Cognitive style:  capricious
Self-image:  uncertain
Object-representations:  incompatible
Regulatory mechanisms:  regressed
Morphologic organization:  split
Mood/temperament:  labile
 
Millon’s subtypes
 
Discouraged
:  
sad, depressed, submissive, fear-based, insecure,
helpless/hopeless alternates with brief periods of cheer, anger
outbursts, resentment, fury
 
Impulsive:  
capricious, superficial,  seductive, evasive, worry turns to
agitation, turns to gloom, hypomanic, what was once exciting is
now bleak
 
Subtypes, p.2
 
Petulant
:  extreme unpredictability, defiant, disgruntled, discontent,
sullen, pessimistic, resentful of the love they feel for others, swing
from rage to pleading for forgiveness
 
Self-destructive
:  perpetual vacillation, vent anger intropunitively
(not externally), fear of autonomy, tries to please others
(deferential, ingratiating) but do not perceive reciprocity, feel
incapable, self harm and suicide
 
BPD:  Common co-morbidities
 
Substance use
Mood disorders
Eating disorders
PTSD
AD/HD spectrum
Other PDs
 
 
Approaches to working with BPD
 
Assess for co-morbid conditions with plan to treat
Integrated care is optimal
Individual, group, psychiatry, case management
Assess risk and prioritize safety planning when needed
Encourage family engagement
DBT
Manipulation?
Schema Therapy
 
 
What is manipulation?
 
Preplanned or cunning attempt to get someone to do something
they ordinarily would not do, often with nefarious intent.
 
It is a logical fallacy to assume that because you feel a certain
way, the other person intended for you to feel that way.
 
Dialectical Behavioral Therapy
 
Marsha Linehan
Chief dialectic:  validate and hold out the expectation for change
Mindfulness:  wise mind, emotion mind, rational mind
Distress tolerance skills
Interpersonal effectiveness skills
Emotion regulation skills
Formal, informal/modified, inpatient, outpatient
 
Goals
 
Supportive, empathic stance with validation of past traumas, help
the person connect present to the past when tolerable.
Poor self-image aggravates the problem.  Clearly establish the
goal – independent functioning (“responsible autonomy” –
Linehan) at the beginning of treatment, maintain firm boundaries.
Therapy starts with short term achievable goals
(increase/decrease) followed by mid- to long-term process goals
(family of origin, cognitive restructuring, trauma recapitulation
(remembrance and mourning – Herman).
 
Goals
 
Help the person identify their paradoxical interpersonal conduct
and how it leads to what they fear the most (eg rage at separation
creates the abandonment that they are trying to avoid) which is
driven by splitting with a nonintegrated emotional functioning &
black-white cognitive style.
Group is an excellent opportunity to offer rich interpersonal
learning to try new skills, observe others, and not over-focus on a
primary therapist as in the typical individual therapy session.
 
Self Care
 
Caseload management
Risk assessment and management
Stay out of the drama (G. Lester)
Rescuer
Victim
Persecutor
Be the Scientific Observer:  observe, describe, observe, describe,
do not become part of the experiment you are watching.  Have a
hypothesis and plan to be wrong and figure out how to use the new
information
 
 
Self care
 
Use supervision
Learn more about BPD and about flyfishing
Do not personalize:  stay cognitively loose, flexible, resist like/dislike
Your feelings are natural, normal, and a tool for you, learn how to use
them
Be prepared for requests for self disclosure
Be consistent
Be a role model
Find the funny
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Borderline Personality Disorder (BPD) is part of the Cluster B Personality Types characterized by emotional instability, impulsivity, and strained relationships. Approaches for BPD include dialectical behavior therapy (DBT) and cognitive-behavioral therapy (CBT), while interventions involve emotion regulation techniques and boundary setting. Self-care when working with BPD individuals is essential to maintain boundaries, manage stress, and seek support.


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  1. Cluster B Personality Types, the Dramatic-Erratic Group: Overview and Focus on Borderline Personality WHAT IS BORDERLINE PERSONALITY DISORDER (BPD)? WHAT APPROACHES AND INTERVENTIONS WORK WITH BPD? SELF CARE WORKING WITH BPD.

  2. What is Cluster B: Dramatic-erratic group? Four distinct personality types organized by descriptive similarities. These similarities separate this group from Cluster A (odd- eccentric) and Cluster C (anxious-avoidant) General requirements for all personality subtypes to meet criteria for disorder: Cultural-norm deviation (cognition, affectivity, interpersonal, impulse control) Pattern is inflexible and pervasive Clinically significant distress Stable, long duration Not accounted for by other (medical, substance, mental health)

  3. Cluster B Antisocial Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Borderline Personality Disorder

  4. Antisocial Personality General population: 3% male, 1% female Clinical population: 3% to 30% (setting dependent) Core feature: disregard for, and violation of, the rights of others At least 18 years old Evidence of Conduct Disorder onset before age 15 Does not occur exclusively during the course of schizophrenia or manic episode

  5. Antisocial Personality, p.2 Failure to conform to social norms: law Deceitfulness Impulsivity Irritable/aggressive Reckless disregard Irresponsibility Lack of remorse: indifferent or rationalizing

  6. Histrionic Personality General population: 2% - 3% Clinical population: 10% - 15% Core feature: pervasive and excessive emotionality and attention- seeking Uncomfortable when not the center Inappropriately seductive, provocative Rapid and shallow emotion Uses physical appearance

  7. Histrionic Personality, p.2 Excessively impressionistic, lacking detail (shallow) Self dramatization Easily suggestible Considers relationships to be more intimate than they actually are

  8. Narcissistic Personality General population: less than 1% Clinical population: 2% - 16% Core feature: grandiosity, need for admiration, lack of empathy Self-important Preoccupied with fantasy Believes self to be special Requires excessive admiration Entitlement

  9. Narcissistic Personality, p.2 Interpersonally exploitive Lacks empathy Envious of others; believes others are envious of him/her Arrogant, haughty

  10. Borderline Personality General population: 2% Clinical population: 10% - 20% Core feature: instability of relationships, self image, and emotional expressivity, marked impulsivity Frantic efforts to avoid real or imagined abandonment Intense, unstable relationships (idealization devaluation) Identity disturbance Impulsivity in 2: spending, sex, use, reckless driving, binge eating

  11. Borderline Personality, p.2 Recurrent suicidal behaviors (acts with or without intent, threats) or self-mutilation Affective instability due to marked reactivity of mood Feelings of emptiness Inappropriate, intense anger or inability to control anger Transient stress-related paranoia or severe dissociative experiences

  12. Getting more specific Millon, Disorders of Personality DSM-IV and Beyond BPD is one of 3 structurally defective personality types (schizotypal, paranoid) Adaptive inflexibility Self-perpetuating vicious circles Tenuous emotional balance

  13. BPD: The Unstable Pattern Argues for the lack of utility of the term borderline as it does not describe the clinical presentation Ambivalent personality Erratic personality Impulsive personality Quixotic personality

  14. Millons diagnostic domains Expressive behavior: spasmodic Interpersonal conduct: paradoxical Cognitive style: capricious Self-image: uncertain Object-representations: incompatible Regulatory mechanisms: regressed Morphologic organization: split Mood/temperament: labile

  15. Millons subtypes Discouraged: sad, depressed, submissive, fear-based, insecure, helpless/hopeless alternates with brief periods of cheer, anger outbursts, resentment, fury Impulsive: capricious, superficial, seductive, evasive, worry turns to agitation, turns to gloom, hypomanic, what was once exciting is now bleak

  16. Subtypes, p.2 Petulant: extreme unpredictability, defiant, disgruntled, discontent, sullen, pessimistic, resentful of the love they feel for others, swing from rage to pleading for forgiveness Self-destructive: perpetual vacillation, vent anger intropunitively (not externally), fear of autonomy, tries to please others (deferential, ingratiating) but do not perceive reciprocity, feel incapable, self harm and suicide

  17. BPD: Common co-morbidities Substance use Mood disorders Eating disorders PTSD AD/HD spectrum Other PDs

  18. Approaches to working with BPD Assess for co-morbid conditions with plan to treat Integrated care is optimal Individual, group, psychiatry, case management Assess risk and prioritize safety planning when needed Encourage family engagement DBT Manipulation? Schema Therapy

  19. What is manipulation? Preplanned or cunning attempt to get someone to do something they ordinarily would not do, often with nefarious intent. It is a logical fallacy to assume that because you feel a certain way, the other person intended for you to feel that way.

  20. Dialectical Behavioral Therapy Marsha Linehan Chief dialectic: validate and hold out the expectation for change Mindfulness: wise mind, emotion mind, rational mind Distress tolerance skills Interpersonal effectiveness skills Emotion regulation skills Formal, informal/modified, inpatient, outpatient

  21. Goals Supportive, empathic stance with validation of past traumas, help the person connect present to the past when tolerable. Poor self-image aggravates the problem. Clearly establish the goal independent functioning ( responsible autonomy Linehan) at the beginning of treatment, maintain firm boundaries. Therapy starts with short term achievable goals (increase/decrease) followed by mid- to long-term process goals (family of origin, cognitive restructuring, trauma recapitulation (remembrance and mourning Herman).

  22. Goals Help the person identify their paradoxical interpersonal conduct and how it leads to what they fear the most (eg rage at separation creates the abandonment that they are trying to avoid) which is driven by splitting with a nonintegrated emotional functioning & black-white cognitive style. Group is an excellent opportunity to offer rich interpersonal learning to try new skills, observe others, and not over-focus on a primary therapist as in the typical individual therapy session.

  23. Self Care Caseload management Risk assessment and management Stay out of the drama (G. Lester) Rescuer Victim Persecutor Be the Scientific Observer: observe, describe, observe, describe, do not become part of the experiment you are watching. Have a hypothesis and plan to be wrong and figure out how to use the new information

  24. Self care Use supervision Learn more about BPD and about flyfishing Do not personalize: stay cognitively loose, flexible, resist like/dislike Your feelings are natural, normal, and a tool for you, learn how to use them Be prepared for requests for self disclosure Be consistent Be a role model Find the funny

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