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What dimensions underlie cluster B personality disorders?
What Dimensions Underlie Cluster B Personality Disorders? Karl J. Looper and Joel Paris This report presents a conceptual model of the relationships between personality dimensions and the four personality disorders listed in the B cluster on axis II. The hypothesis will be developed that while impulsivity is the common dimension underlying all four disorders, differences between the categories reflect
the severity of impulsive traits, interactions with other personality dimensions, the effects of gender, and the influence of culture. Clinical and research implications of the model are then described. Copyright r 2000 by W.B. Saunders Company
A
egorical system of classification with a dimensional system.15-18 This approach is supported by the lack of any sharp cutoff between personality traits and personality disorders,19 and by findings that the dimensions are more closely linked to the genetic and biological underpinnings of personality structure.18,20 Several of these schema, drawn either from factor-analytic methods16,21 or from biologically driven theories,17,22,23 describe personality in terms of a limited number of traits. Livesley et al.19,24 describe a larger number of ‘‘lower-order’’ traits, with more specific relationships to pathology that may only be found in a few disorders. However, these traits can be factor-analyzed into a small number of ‘‘higher-order dimensions,’’ broad traits that cut across many diagnoses. In this model, therefore, the structure of personality and personality disorders may be thought of as hierarchical. However much they seem to compete with each other, all of these dimensional models have striking overlaps. Since the broadest dimensions correspond approximately to the clusters of axis II, categorical and dimensional systems seem to overlap at the highest level of the hierarchy, i.e., the cluster. The present report will suggest that impulsivity is the dimension most consistently characterizing cluster B personality disorders, and that this trait can be a point of convergence between dimensional and categorical systems. However, any model of these disorders must also account for the striking phenomenologic differences between the categories within cluster B. We will further hypothesize that these differences can be explained by (1) the severity of impulsivity, (2) interactions with other personality dimensions, (3) the influence of gender, and (4) the influence of the sociocultural environment.
LTHOUGH the 10 categories of personality disorders on axis II are listed as three clusters, this method of classification came close to being eliminated in the latest revision of the DSM-IV.1 In the end, the three clusters originally termed odd, dramatic, and anxious were retained, but are now termed simply A, B, and C. However, there is some evidence for the validity of these clusters. Family history studies, as well as studies of biological markers,2 suggest that cluster A disorders share common diatheses within the schizophrenic spectrum. Similarly, family history studies3 and longitudinal studies of impulsive disorders in children4 indicate that cluster B disorders lie on a spectrum, along with substance abuse, bulimia nervosa, and other conditions associated with poor impulse control. In addition, family history studies5 and longitudinal studies of behaviorally inhibited children6 suggest that cluster C disorders share a diathesis with anxiety disorders derived from anxious traits. However, a good deal of controversy remains concerning the validity of the clusters. While some factor-analytic and cluster-analytic studies using symptoms derived from self-report questionnaires7,8 have failed to confirm their validity, studies derived from structured interviews, which may be more sensitive to phenomena of psychopathological import,9 have often yielded factors similar to the axis II clusters.10-14 Several authors have proposed replacing a catFrom the Department of Psychiatry, McGill University, Montreal; and Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Quebec, Canada. Address reprint requests to Karl J. Looper, M.D., Institute of Community and Family Psychiatry, Sir Mortimer B. DavisJewish General Hospital, 4333 Chemin de la Coˆte SteCatherine, Montreal, Quebec, H3T 1E4 Canada. Copyright r 2000 by W.B. Saunders Company 0010-440X/00/4106-0006$10.00/0 doi:10.1053/comp.2000.16563 432
Comprehensive Psychiatry, Vol. 41, No. 6 (November/December), 2000: pp 432-437
WHAT DIMENSIONS UNDERLIE CLUSTER B PDs?
IMPULSIVITY AS THE COMMON FACTOR IN CLUSTER B
Phenomenology Impulsivity is the tendency to act on a thought or feeling without consideration of the alternatives and consequences.25 This trait is found in major psychiatric diagnoses such as impulse-control disorders and bulimia nervosa, as well as in personality disorders. Thus, Zanarini’s3 concept of an ‘‘impulsive spectrum’’ spans both axis I and axis II. Impulsivity dominates the clinical picture in both antisocial personality disorder (ASPD) and borderline personality disorder (BPD). ASPD patients have impulsive behaviors directed against others, while BPD patients have impulsive behaviors directed against themselves. On the other hand, the impulsivity observed in histrionic personality disorder (HPD) is more often expressed in interpersonal contexts such as attention-seeking, selfdramatization, and theatricality. The impulsivity found in narcissistic personality disorder (NPD) is also expressed in interpersonal contexts, including rapid escalation of anger in response to empathic failures, or angry responses when denied entitlements. As well, the DSM specifically notes common comorbidities of NPD with other disorders in the impulse spectrum, most particularly substance abuse. Outcome and Prognosis Impulsivity has important implications for outcome in cluster B disorders. In ASPD, impulsivity predisposes to high mortality rates including accidents, violent deaths, and suicides,26,27 with almost one quarter of the subjects dying prematurely.28 In BPD, there is good evidence that measures of impulsivity such as comorbid antisocial traits29 and substance abuse30,31 are strongly predictive of both poor outcome and completed suicide. In fact, in prospective studies of BPD patients, Links et al.32 demonstrated that initial impulsivity accounts for nearly 25% of the variance in scores of functional status on outcome. With remission as an outcome variable, follow-up studies of both ASPD28 and BPD33,34 show that over time, patients no longer meet diagnostic criteria and this is part of the natural evolution of the disorder. Similar clinical observations have been made for NPD35 and HPD.36 This change is typically due to a decrease in
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‘‘acting out’’ behaviors associated with impulsivity. Consequently, impulsivity is central to the cluster B diagnoses, not only in predicting negative outcomes but also as a primary determinant of the natural history of the illness. FACTORS DIFFERENTIATING CLUSTER B DISORDERS
Severity of Impulsivity Impulsivity dominates the clinical picture in the two most severe disorders of cluster B. The DSM criteria of both ASPD and BPD have several criteria related to this trait, with behaviors ranging from violence toward others to self-harm. Although the criteria for NPD and HPD mainly describe interpersonal problems, some clinical observers have considered HPD and BPD to be on a continuum, differing mainly in the severity of impulsivity,37,38 and others have suggested a parallel relationship between NPD and ASPD.38 These hypothesized relationships among the four categories in cluster B are summarized in Fig 1, in which impulsivity is presented as a common dimension of the cluster, with ASPD and BPD showing considerably greater levels of severity compared with NPD and HPD. Interactions With Other Dimensions While impulsivity best defines the cluster, interactions with other traits account for the unique characteristics of specific disorders. Thus, affective instability is particularly important in shaping symptoms in BPD and, to a lesser extent, in HPD. For example, Livesley’s system describes two higherorder factors in cluster B personality disorders, dissocial behavior and emotional dysregulation, while Siever and Davis propose two similar dimensions, impulsivity and affective instability. BPD patients have an unusually high level of affective instability that produces mood reactivity, dysphoria, irritability, and feelings of abandonment and emptiness. Empirical studies showing unusually high levels of neuroticism in BPD39-41 support the centrality of affective instability in this disorder. Cluster-analytic and factor-analytic studies of BPD patients42,43 also support a central importance for both impulsivity and affective instability. Other dimensions may also contribute to the clinical picture of BPD. Interestingly, Zanarini et al.44 found that a cognitive or micropsychotic
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LOOPER AND PARIS
Fig 1. Model of cluster B personality disorders.
dimension (paranoid thinking, hallucinatory phenomena, and depersonalization) is the most useful feature for discriminating BPD from other axis II disorders. Much less is known about the traits underlying HPD. The clinical features described in the DSM suggest that affective instability is less severe, yet this dimension is apparent in rapidly shifting and exaggerated expression of emotions and may also play a role in impressionistic speech. In one of the few empirical studies of HPD, Livesley and Schroeder43 factor-analyzed symptoms into four trait dimensions: interpersonal exploitation, dependency behaviors, hysterical thinking, and sensation seeking. ASPD and NPD may also share common traits. Cleckley45 originally described the exploitative behaviors and lack of empathy for others common to these groups as part of a larger construct of ‘‘psychopathy.’’ Hare et al.46 have presented strong arguments for retaining this construct, while dividing it into two factors (termed socially deviant and affective/interpersonal). In ASPD, this latter trait is associated with irresponsibility, deceitfulness, disregard for the rights of others, and lack of remorse. Although less severe in NPD, some of the same features (poor empathy and interpersonal exploitation) can be found in the diagnostic criteria. Thus, the broader construct of psychopathy accounts for some of the most characteristic features of narcissism. On the other hand, NPD is differentiated from ASPD by a core dimension of grandiosity which Gunderson et al.47 identify as the crucial element of the construct of narcissistic personality. This trait
presently accounts for the majority of the diagnostic criteria of NPD such as self-importance, selfperception of being unique and special, entitlement, and arrogance. Figure 1 shows how impulsivity might interact with affective instability, demonstrating that higher levels of this trait in BPD and HPD could differentiate them from ASPD and NPD. Not shown in the Figure are traits that are prominent in only one disorder, such as cognitive dysfunction in BPD and grandiosity in NPD. Interaction With Gender Dramatic gender differences are observed between cluster B disorders. While BPD is four times more common in women in both community48 and clinical49 samples, ASPD is similarly more common in men.49-53 Thus, ASPD and BPD have a mirror-image prevalence in relation to gender. NPD is also more commonly diagnosed in men,54,55 with one study49 showing a threefold difference. On the other hand, the difference in HPD rates between the sexes remains unclear. While a community study found similar rates in men and women,56 clinical populations show a much greater prevalence of women.49 Gender differences mask intrinsic commonalities. Impulsivity not only expresses itself differently in antisocial men and borderline women, but also cuts across all four diagnoses in cluster B. For example, in one community study, psychopathy as a dimension was found to be common to antisocial traits in men and histrionic traits in women.57 Biological factors may help to explain these gender
WHAT DIMENSIONS UNDERLIE CLUSTER B PDs?
differences in the expression of cluster B traits. For example, gender differences in serotonin levels58 and in the responsiveness of the serotonin receptor system59,60 may be linked to the differential expression of impulsivity in specific disorders. Women are known to be at greater risk of major depression,61 which could be related to the affective instability found in women with BPD or HPD. Social factors may also play a role in these differences. For example, differences in the socialization of men and women may shape the expression of personality traits. Social factors may also influence differences in impulsivity, with women expressing aggression in verbal and indirect ways62 and men expressing these emotions in more physical and direct ways.63 Socialization may influence whether the need for attention is focused on sexual attractiveness, as in females with HPD, or on achievement and power, as in males with NPD. Figure 1 illustrates these hypothesized links between traits, gender, and cluster B diagnosis. Interaction With Culture Large cross-cultural differences in the prevalence of ASPD have been documented. Significantly lower rates of ASPD have been found in East Asian countries such as Taiwan,64,65 Japan,66 and possibly China.67 Indirect evidence derived from increases in the symptoms associated with borderline pathology (i.e., parasuicide and substance abuse) suggests that BPD may also be increasing.68 A few studies have dealt with the transcultural aspects of narcissism, suggesting that culture may influence the prevalence69 and expression70 of this trait. It has also been suggested that culture is a factor influencing histrionic behavior in women.71 One explanation could be that societies with high social cohesion contain impulsive behavior. In contrast, a rapid rate of social change and the breakdown of cohesive social structures have been proposed to account for the increasing prevalence of impulsive personality disorders in recent decades.72,73 RESEARCH AND CLINICAL IMPLICATIONS
The hierarchical model of cluster B disorders presented here could help to integrate dimensional and categorical approaches to personality disorder. We hypothesize that all cluster B diagnoses share
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the trait of impulsivity, although each diagnosis has unique criteria rooted in other interacting traits. The model presented herein is researchable. Trait dimensions, as well as the biological correlates of these dimensions, need to be measured in each cluster B disorder to determine if there is a consistent pattern of commonalities and differences. The study by Livesley et al.43 was an important step in this direction. The hypothesized relationship of gender to the four disorders in cluster B is also researchable. Thus, the prevalence rates of BPD, HPD, and NPD in community samples have yet to be firmly established. These data could help to determine whether there are true gender effects on phenomenology, or whether clinicians’ diagnoses are influenced by gender stereotypes.74 Moreover, the influence of culture on personality development requires investigation. In particular, we need to determine the comparative rates of personality disorders in different cultures, as well as the variations in prevalence within cultures that could be explained by social factors. Finally, the model could also have clinical relevance. More specific treatments, both pharmacologic and cognitive-behavioral, are being developed to target impulsivity. If this dimension is common to many diagnoses, then treatments found to be effective in controlling behaviors in one disorder may also be useful in others. For example, there may be value in applying Linehan’s dialectic therapy75 or pharmacologic treatments76-78 designed for BPD to other cluster B diagnoses. LIMITATIONS OF THE MODEL
We wish to acknowledge a number of important limitations for this model. To begin with, it follows the existing structure of the present DSM classification, which will undergo revisions as new research findings emerge. Another limitation is the lack of consensus concerning the definitions of personality traits arising from competing (even if ultimately similar) dimensional models. A further limitation is the serious lack of research on NPD and HPD, resulting in our model’s being largely based on research concerning ASPD and BPD. Finally, the literature we have cited here on the effects of gender and culture is highly inferential, not securely based in hard data.
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WHAT DIMENSIONS UNDERLIE CLUSTER B PDs?
Borderline Personality Disorder: Clinical and Empirical Perspectives. New York, NY: Guilford, 1992:199-219. 43. Livesley WJ, Schroeder ML. Dimensions of personality disorder: the DSM-III-R cluster B diagnoses. J Nerv Ment Dis 1991;179:320-328. 44. Zanarini MC, Gunderson JG, Frankenburg FR, Chauncey DL. The Revised Diagnostic Interview for Borderlines: discriminating BPD from other axis II disorders. J Pers Disord 1998;3: 10-18. 45. Cleckley H (ed). The Mask of Sanity. Ed 4. St Louis, MO: Mosby, 1964. 46. Hare RD, Hart SD, Harpur TJ. Psychopathy and the DSM-IV criteria for antisocial personality disorder. J Abnorm Psychol 1991;100:391-398. 47. Gunderson JG, Ronningstam E, Bodkin A. The Diagnostic Interview for Narcissistic Patients. Arch Gen Psychiatry 1990;47:676-680. 48. Swartz M, Blazer D, George L, Winfield I. Estimating the prevalence of borderline personality disorder in the community. J Pers Disord 1990;4:257-272. 49. Fabrega H, Ulrich R, Pilkonis P, Mezzich J. On the homogeneity of personality disorder clusters. Compr Psychiatry 1991;32:373-386. 50. Robins LN, Regier DA (eds). Psychiatric Disorders in America. New York, NY: Free Press, 1991. 51. Kessler RC, McGonagle KA, Nelson CB, Hughes M, Eshelman S, Wittchen HU, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Arch Gen Psychiatry 1994;51:8-19. 52. Bland RC, Newman SC, Orn H. Lifetime prevalence of psychiatric disorders in Edmonton. Acta Psychiatr Scand 1988; 77:24-32. 53. Oakley-Browne MA, Joyce PA, Welss E, Bushnell JA, Hornblow AR. Christchurch Psychiatric Epidemiology Study: six month and other period prevalences of specific psychiatric disorders. Aust N Z J Psychiatry 1989;23:327-340. 54. Grilo CM, Becker DF, Fehon DC, Walker ML, Edell WS, McGlashan TH. Gender differences in personality disorders in psychiatrically hospitalized adolescents. Am J Psychiatry 1996; 153:1089-1091. 55. Golomb M, Fava M, Abraham M, Rosenbaum JF. Gender differences in personality disorders. Am J Psychiatry 1995;152: 579-582. 56. Nestadt G, Romanovski AJ, Brown CH, Chahal R, Merchant A, Folstein MF, et al. DSM-III compulsive personality disorder: an epidemiological survey. Psychol Med 1991;21:461471. 57. Hamburger ME, Lilienfeld SO, Hogben M. Psychopathy, gender, and gender roles: Implications for antisocial and histrionic personality disorders. J Pers Disord 1996;10:41-55. 58. Carlsson M, Carlsson M. A regional study of sex differences in rat brain serotonin. Prog Neuropsychopharmacol Biol Psychiatry 1988;12:53-61. 59. Heinsbroek RP, van Haaren F, Feenstra MG, van Galen H, Boer G, van de Poll NE. Sex differences in the effects of inescapable footshock on central catecholaminergic and serotonergic activity. Pharmacol Biochem Behav 1990;37:539-550.
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60. O’Connor LH, Feder HH. Estradiol and progesterone influence L-5-hydroxytryptophan-induced myoclonus in male guinea pigs: sex differences in serotonin-steroid interactions. Brain Res 1985;330:121-125. 61. Weissman MM, Klerman G. Gender and depression. Trends Neurosci 1985;8:416-420. 62. Buss AH, Durkee A. An inventory for assessing different kinds of hostility. J Consult Psychol 1957;21:343-349. 63. Kellerman AL, Mercy JA. Men, women, and murder: gender-specific differences in rates of fatal violence and victimization. J Trauma 1992;33:1-5. 64. Hwu HG, Yeh EK, Change LY. Prevalence of psychiatric disorders in Taiwan defined by the Chinese Diagnostic Interview Schedule. Acta Psychiatr Scand 1989;79:136-147. 65. Compton WW, Helzer JE, Hwu H-G, Yeh E-K, McEvoy L, Tipp JE, et al. New methods in cross-cultural psychiatry: psychiatric illness in Taiwan and the United States. Am J Psychiatry 1991;148:1697-1704. 66. Sato T, Takeichi M. Lifetime prevalence of specific psychiatric disorders in a general medicine clinic. Gen Hosp Psychiatry 1993;15:224-233. 67. Cheung P. Adult psychiatric epidemiology in China in the 1980’s. Cult Med Psychiatry 1991;15:479-496. 68. Paris J (ed). Social Factors in the Personality Disorders. New York, NY: Cambridge University Press, 1996. 69. Smith BM. The measurement of narcissism in Asian, Caucasian and Hispanic American women. Psychol Rep 1990; 67:779-785. 70. Warren MP, Capponi A. The role of culture in the development of narcissistic personality disorders in America, Japan and Denmark. J Appl Soc Sci 1996;20:77-82. 71. Nuckolls CW. Toward a cultural history of the personality disorders. Soc Sci Med 1992;35:37-47. 72. Millon T. Borderline personality disorder: a psychosocial epidemic. In: Paris J (ed): Borderline Personality Disorder: Etiology and Treatment. Washington, DC: American Psychiatric Press, 1993:197-210. 73. Paris J. Social risk factors for borderline personality disorder: a review and hypothesis. Can J Psychiatry 1992;37:510515. 74. Rienzi BM, Scrams DJ. Gender stereotypes for paranoid, antisocial, compulsive, dependent, and histrionic personality disorders. Psychol Rep 1991;69:976-978. 75. Linehan MM. Cognitive Behavioral Treatment of Borderline Personality Disorder. New York, NY: Guilford, 1993. 76. Gardner DL, Cowdry RW. Positive effects of carbamazepine on behavioral dyscontrol in borderline personality disorder. Am J Psychiatry 1986;143:519-522. 77. Stein DJ, Simeon D, Frenkel M, Islam MN, Hollander E. An open trial of valproate in borderline personality disorder. J Clin Psychiatry 1995;56:506-510. 78. Coccaro EF, Kavoussi RJ. Fluoxetine and impulsive aggressive behavior in personality-disordered subjects. Arch Gen Psychiatry 1997;54:1081-1088.
the severity of impulsive traits, interactions with other personality dimensions, the effects of gender, and the influence of culture. Clinical and research implications of the model are then described. Copyright r 2000 by W.B. Saunders Company
A
egorical system of classification with a dimensional system.15-18 This approach is supported by the lack of any sharp cutoff between personality traits and personality disorders,19 and by findings that the dimensions are more closely linked to the genetic and biological underpinnings of personality structure.18,20 Several of these schema, drawn either from factor-analytic methods16,21 or from biologically driven theories,17,22,23 describe personality in terms of a limited number of traits. Livesley et al.19,24 describe a larger number of ‘‘lower-order’’ traits, with more specific relationships to pathology that may only be found in a few disorders. However, these traits can be factor-analyzed into a small number of ‘‘higher-order dimensions,’’ broad traits that cut across many diagnoses. In this model, therefore, the structure of personality and personality disorders may be thought of as hierarchical. However much they seem to compete with each other, all of these dimensional models have striking overlaps. Since the broadest dimensions correspond approximately to the clusters of axis II, categorical and dimensional systems seem to overlap at the highest level of the hierarchy, i.e., the cluster. The present report will suggest that impulsivity is the dimension most consistently characterizing cluster B personality disorders, and that this trait can be a point of convergence between dimensional and categorical systems. However, any model of these disorders must also account for the striking phenomenologic differences between the categories within cluster B. We will further hypothesize that these differences can be explained by (1) the severity of impulsivity, (2) interactions with other personality dimensions, (3) the influence of gender, and (4) the influence of the sociocultural environment.
LTHOUGH the 10 categories of personality disorders on axis II are listed as three clusters, this method of classification came close to being eliminated in the latest revision of the DSM-IV.1 In the end, the three clusters originally termed odd, dramatic, and anxious were retained, but are now termed simply A, B, and C. However, there is some evidence for the validity of these clusters. Family history studies, as well as studies of biological markers,2 suggest that cluster A disorders share common diatheses within the schizophrenic spectrum. Similarly, family history studies3 and longitudinal studies of impulsive disorders in children4 indicate that cluster B disorders lie on a spectrum, along with substance abuse, bulimia nervosa, and other conditions associated with poor impulse control. In addition, family history studies5 and longitudinal studies of behaviorally inhibited children6 suggest that cluster C disorders share a diathesis with anxiety disorders derived from anxious traits. However, a good deal of controversy remains concerning the validity of the clusters. While some factor-analytic and cluster-analytic studies using symptoms derived from self-report questionnaires7,8 have failed to confirm their validity, studies derived from structured interviews, which may be more sensitive to phenomena of psychopathological import,9 have often yielded factors similar to the axis II clusters.10-14 Several authors have proposed replacing a catFrom the Department of Psychiatry, McGill University, Montreal; and Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Quebec, Canada. Address reprint requests to Karl J. Looper, M.D., Institute of Community and Family Psychiatry, Sir Mortimer B. DavisJewish General Hospital, 4333 Chemin de la Coˆte SteCatherine, Montreal, Quebec, H3T 1E4 Canada. Copyright r 2000 by W.B. Saunders Company 0010-440X/00/4106-0006$10.00/0 doi:10.1053/comp.2000.16563 432
Comprehensive Psychiatry, Vol. 41, No. 6 (November/December), 2000: pp 432-437
WHAT DIMENSIONS UNDERLIE CLUSTER B PDs?
IMPULSIVITY AS THE COMMON FACTOR IN CLUSTER B
Phenomenology Impulsivity is the tendency to act on a thought or feeling without consideration of the alternatives and consequences.25 This trait is found in major psychiatric diagnoses such as impulse-control disorders and bulimia nervosa, as well as in personality disorders. Thus, Zanarini’s3 concept of an ‘‘impulsive spectrum’’ spans both axis I and axis II. Impulsivity dominates the clinical picture in both antisocial personality disorder (ASPD) and borderline personality disorder (BPD). ASPD patients have impulsive behaviors directed against others, while BPD patients have impulsive behaviors directed against themselves. On the other hand, the impulsivity observed in histrionic personality disorder (HPD) is more often expressed in interpersonal contexts such as attention-seeking, selfdramatization, and theatricality. The impulsivity found in narcissistic personality disorder (NPD) is also expressed in interpersonal contexts, including rapid escalation of anger in response to empathic failures, or angry responses when denied entitlements. As well, the DSM specifically notes common comorbidities of NPD with other disorders in the impulse spectrum, most particularly substance abuse. Outcome and Prognosis Impulsivity has important implications for outcome in cluster B disorders. In ASPD, impulsivity predisposes to high mortality rates including accidents, violent deaths, and suicides,26,27 with almost one quarter of the subjects dying prematurely.28 In BPD, there is good evidence that measures of impulsivity such as comorbid antisocial traits29 and substance abuse30,31 are strongly predictive of both poor outcome and completed suicide. In fact, in prospective studies of BPD patients, Links et al.32 demonstrated that initial impulsivity accounts for nearly 25% of the variance in scores of functional status on outcome. With remission as an outcome variable, follow-up studies of both ASPD28 and BPD33,34 show that over time, patients no longer meet diagnostic criteria and this is part of the natural evolution of the disorder. Similar clinical observations have been made for NPD35 and HPD.36 This change is typically due to a decrease in
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‘‘acting out’’ behaviors associated with impulsivity. Consequently, impulsivity is central to the cluster B diagnoses, not only in predicting negative outcomes but also as a primary determinant of the natural history of the illness. FACTORS DIFFERENTIATING CLUSTER B DISORDERS
Severity of Impulsivity Impulsivity dominates the clinical picture in the two most severe disorders of cluster B. The DSM criteria of both ASPD and BPD have several criteria related to this trait, with behaviors ranging from violence toward others to self-harm. Although the criteria for NPD and HPD mainly describe interpersonal problems, some clinical observers have considered HPD and BPD to be on a continuum, differing mainly in the severity of impulsivity,37,38 and others have suggested a parallel relationship between NPD and ASPD.38 These hypothesized relationships among the four categories in cluster B are summarized in Fig 1, in which impulsivity is presented as a common dimension of the cluster, with ASPD and BPD showing considerably greater levels of severity compared with NPD and HPD. Interactions With Other Dimensions While impulsivity best defines the cluster, interactions with other traits account for the unique characteristics of specific disorders. Thus, affective instability is particularly important in shaping symptoms in BPD and, to a lesser extent, in HPD. For example, Livesley’s system describes two higherorder factors in cluster B personality disorders, dissocial behavior and emotional dysregulation, while Siever and Davis propose two similar dimensions, impulsivity and affective instability. BPD patients have an unusually high level of affective instability that produces mood reactivity, dysphoria, irritability, and feelings of abandonment and emptiness. Empirical studies showing unusually high levels of neuroticism in BPD39-41 support the centrality of affective instability in this disorder. Cluster-analytic and factor-analytic studies of BPD patients42,43 also support a central importance for both impulsivity and affective instability. Other dimensions may also contribute to the clinical picture of BPD. Interestingly, Zanarini et al.44 found that a cognitive or micropsychotic
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Fig 1. Model of cluster B personality disorders.
dimension (paranoid thinking, hallucinatory phenomena, and depersonalization) is the most useful feature for discriminating BPD from other axis II disorders. Much less is known about the traits underlying HPD. The clinical features described in the DSM suggest that affective instability is less severe, yet this dimension is apparent in rapidly shifting and exaggerated expression of emotions and may also play a role in impressionistic speech. In one of the few empirical studies of HPD, Livesley and Schroeder43 factor-analyzed symptoms into four trait dimensions: interpersonal exploitation, dependency behaviors, hysterical thinking, and sensation seeking. ASPD and NPD may also share common traits. Cleckley45 originally described the exploitative behaviors and lack of empathy for others common to these groups as part of a larger construct of ‘‘psychopathy.’’ Hare et al.46 have presented strong arguments for retaining this construct, while dividing it into two factors (termed socially deviant and affective/interpersonal). In ASPD, this latter trait is associated with irresponsibility, deceitfulness, disregard for the rights of others, and lack of remorse. Although less severe in NPD, some of the same features (poor empathy and interpersonal exploitation) can be found in the diagnostic criteria. Thus, the broader construct of psychopathy accounts for some of the most characteristic features of narcissism. On the other hand, NPD is differentiated from ASPD by a core dimension of grandiosity which Gunderson et al.47 identify as the crucial element of the construct of narcissistic personality. This trait
presently accounts for the majority of the diagnostic criteria of NPD such as self-importance, selfperception of being unique and special, entitlement, and arrogance. Figure 1 shows how impulsivity might interact with affective instability, demonstrating that higher levels of this trait in BPD and HPD could differentiate them from ASPD and NPD. Not shown in the Figure are traits that are prominent in only one disorder, such as cognitive dysfunction in BPD and grandiosity in NPD. Interaction With Gender Dramatic gender differences are observed between cluster B disorders. While BPD is four times more common in women in both community48 and clinical49 samples, ASPD is similarly more common in men.49-53 Thus, ASPD and BPD have a mirror-image prevalence in relation to gender. NPD is also more commonly diagnosed in men,54,55 with one study49 showing a threefold difference. On the other hand, the difference in HPD rates between the sexes remains unclear. While a community study found similar rates in men and women,56 clinical populations show a much greater prevalence of women.49 Gender differences mask intrinsic commonalities. Impulsivity not only expresses itself differently in antisocial men and borderline women, but also cuts across all four diagnoses in cluster B. For example, in one community study, psychopathy as a dimension was found to be common to antisocial traits in men and histrionic traits in women.57 Biological factors may help to explain these gender
WHAT DIMENSIONS UNDERLIE CLUSTER B PDs?
differences in the expression of cluster B traits. For example, gender differences in serotonin levels58 and in the responsiveness of the serotonin receptor system59,60 may be linked to the differential expression of impulsivity in specific disorders. Women are known to be at greater risk of major depression,61 which could be related to the affective instability found in women with BPD or HPD. Social factors may also play a role in these differences. For example, differences in the socialization of men and women may shape the expression of personality traits. Social factors may also influence differences in impulsivity, with women expressing aggression in verbal and indirect ways62 and men expressing these emotions in more physical and direct ways.63 Socialization may influence whether the need for attention is focused on sexual attractiveness, as in females with HPD, or on achievement and power, as in males with NPD. Figure 1 illustrates these hypothesized links between traits, gender, and cluster B diagnosis. Interaction With Culture Large cross-cultural differences in the prevalence of ASPD have been documented. Significantly lower rates of ASPD have been found in East Asian countries such as Taiwan,64,65 Japan,66 and possibly China.67 Indirect evidence derived from increases in the symptoms associated with borderline pathology (i.e., parasuicide and substance abuse) suggests that BPD may also be increasing.68 A few studies have dealt with the transcultural aspects of narcissism, suggesting that culture may influence the prevalence69 and expression70 of this trait. It has also been suggested that culture is a factor influencing histrionic behavior in women.71 One explanation could be that societies with high social cohesion contain impulsive behavior. In contrast, a rapid rate of social change and the breakdown of cohesive social structures have been proposed to account for the increasing prevalence of impulsive personality disorders in recent decades.72,73 RESEARCH AND CLINICAL IMPLICATIONS
The hierarchical model of cluster B disorders presented here could help to integrate dimensional and categorical approaches to personality disorder. We hypothesize that all cluster B diagnoses share
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the trait of impulsivity, although each diagnosis has unique criteria rooted in other interacting traits. The model presented herein is researchable. Trait dimensions, as well as the biological correlates of these dimensions, need to be measured in each cluster B disorder to determine if there is a consistent pattern of commonalities and differences. The study by Livesley et al.43 was an important step in this direction. The hypothesized relationship of gender to the four disorders in cluster B is also researchable. Thus, the prevalence rates of BPD, HPD, and NPD in community samples have yet to be firmly established. These data could help to determine whether there are true gender effects on phenomenology, or whether clinicians’ diagnoses are influenced by gender stereotypes.74 Moreover, the influence of culture on personality development requires investigation. In particular, we need to determine the comparative rates of personality disorders in different cultures, as well as the variations in prevalence within cultures that could be explained by social factors. Finally, the model could also have clinical relevance. More specific treatments, both pharmacologic and cognitive-behavioral, are being developed to target impulsivity. If this dimension is common to many diagnoses, then treatments found to be effective in controlling behaviors in one disorder may also be useful in others. For example, there may be value in applying Linehan’s dialectic therapy75 or pharmacologic treatments76-78 designed for BPD to other cluster B diagnoses. LIMITATIONS OF THE MODEL
We wish to acknowledge a number of important limitations for this model. To begin with, it follows the existing structure of the present DSM classification, which will undergo revisions as new research findings emerge. Another limitation is the lack of consensus concerning the definitions of personality traits arising from competing (even if ultimately similar) dimensional models. A further limitation is the serious lack of research on NPD and HPD, resulting in our model’s being largely based on research concerning ASPD and BPD. Finally, the literature we have cited here on the effects of gender and culture is highly inferential, not securely based in hard data.
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