Cluster B

Patients with Cluster B disorders have as their major shared style a pattern of high arousal. When their arousal needs are not met, they often become frustrated, angry, and disappointed, which then manifest as depression or depressive-like symptoms. We may term this depressive reaction as "deprivation depression." When they have their arousal needs met, they do not experience the same disappointment and subsequent depressive reaction. An alternative reaction is the more commonly described frustration-aggression hypothesis. If they do not receive the arousal that they believe that they need, they may become aggressive, either verbally or behaviorally, to create the needed arousal.

Patients diagnosed with Cluster B disorders have more of a chance for change than do patients in the Cluster A category (Magnavita, 1997). Although therapeutic growth is slow at times, change can and does happen, generally over a longer period of time. Interestingly enough, the therapeutic challenge lies in the complexity of Cluster B disorders, because patients with each disorder seem to respond differently to treatment interventions (Magnavita, 1997). When others do not meet their needs, demands, or expectations, individuals with Cluster B disorders may feel empty, cheated, misunderstood, or depressed. When their needs are met, they may temporarily feel good, but when that feeling wanes, they are back to needing another "fix" of attention or arousal.

Histrionic PD

People with histrionic PD (HPD) typically experience symptoms of low-grade depression as opposed to major depressive episodes (Millon & Davis, 2000). Generally speaking, individuals with HPD experience difficulty in relationships and typically feel empty and bored, but conceal their negative feelings with dramatic outbursts/behaviors in an attempt to divert the spectator's attention. Most times individuals with HPD do not seek therapy; however, when they do, it is for immediate relief from typical Axis I disorders (Beck et al., 2004; Millon, 1999; Millon & Davis, 2000).

Angela dressed very carefully for her date with her new beau, Fred. They were going to a party at Fred's boss's home, and Angela was determined to be a "knockout." Fred worked as an associate at a prestigious and conservative law firm. Angela knew that he was being considered as a partner. She knew that she could help him in his quest for a partnership by how she would look. She described her dress as very revealing, but "if you've got it, flaunt it." She stated that her intent was to "dazzle them," which would positively impact on Fred's goal. When Fred came to pick her up, his first question was, "Is that what you are wearing?" The answer was all too obvious. Yes, it was what she planned to wear, and it caused Fred great concern. He then asked if she could wear a shawl to "cover herself." Angela reacted, in her words, "as if he had hit me with a club." She brought a shawl spent the evening in a corner. She described the other women at the party as "unattractive, dowdy, drab, gross, and matronly." She could not understand why Fred would not want her to "liven the place up." She decided that there was something wrong with Fred if he wanted to be a law partner in such a conservative law firm. She felt "down, way down." When Fred did not call for another date, then refused to meet with her to discuss their relationship, Angela reported being "crushed." It was as if he ran her over with a truck, had a plane crash onto the truck, and then blew it all up."

Antisocial PD

Many patients with ASPD experience depression related to issues of rejection, abandonment, or remorse for past actions (Beck et al., 2004; Millon, 1999; Millon & Davis, 2000). Most times the depression manifests itself in hopelessness and triviality, in that patients with ASPD experience consequences of their actions and believe that there is no hope for change for the future. Depression becomes cyclical, in that the patient with ASPD is not able to see a way out. The perpetual cycle is manifested in the actions of the antisocial personality, followed by depression, which may spur on more antisocial activities. Depression co-occurring with ASPD perpetuates the cycle, which makes it difficult to motivate patients to change.

Ken, age 24, was interviewed in a county jail. He had been arrested for drug possession with intent to sell. The first part of the interview was filled with his bravado that he would beat the charge. After all, it was a small amount of drugs, it was only his second arrest, there were larger dealers, and he had a good lawyer who could beat the system. Based on all of these factors, Ken stated that he would easily be acquitted. He then shifted to justification and rationalization. After all, he claimed, "There are many places in the world where drug possession and sales are legal," and he would not have been bothered. His next strategy in the interview was to be challenging and angry. Who did these people think they were, messing with him? When asked about the possibility of his going to jail and not being able to be with his girlfriend and their two children, ages 2 and 3, Ken spoke of his children and the possibility of being in jail for 5-7 years. He became sad and a far more depressed affect emerged. The depressive reaction was not simply a passing sad ness, but a far more pervasive sorrow that he would likely be separated from his girlfriend and their children.

Borderline PD

Borderline PD (BPD), the most commonly diagnosed personality disorder, affects about 3% of the population, and is mostly comprised of women (Robinson, 2003). However, for cultural reasons, men with BPD characteristics and traits are most likely to be diagnosed with ASPD. Depression is usually seen as a comorbid disorder among patients diagnosed with BPD. According to Akiskal (1981), depression is so commonly associated with BPD that it is difficult to distinguish whether it is a lifestyle consequence or rather more genetically based. Typically, issues of depression center on the patient's low self-esteem, feelings of inadequacy, helplessness, and marked difficulties in maintaining appropriate and long-term relationships. Many times patients with BPD seek therapy due to relationship difficulties and the negative consequences of failed relationships attempts or the interpersonal feelings generated by them (Fusco & Freeman, 2004; Millon & Davis, 2000).

Carrie, age 36, sought therapy because of what she described as her chronic depression. She had been married three times for periods of 1, 4, and 6 years, respectively. Each marriage ended in divorce and was accompanied by Carrie's expressions of anger. She accused her husbands of cheating in their hearts when they looked at other women in a mall, on television, or in a magazine. She would walk behind her husband in a mall, so that she could see who he was looking at. Carries used each and every charge and denial as further evidence that she would soon be abandoned. The fact that each marriage had ended substantiated her view. In all three marriages, she and her spouse went for couple therapy. In every case, Carrie believed that the therapist was siding with her husband when he/she pointed out anything that Carrie was doing to help to create the problem. Carrie saw no outcome other than spending the rest of her life alone. This was enough to create an ongoing depressive mood.

Narcissistic PD

Patients diagnosed with narcissistic PD (NPD) typically are resistant to therapeutic interventions because of the characteristics and traits associated with their PD (Beck et al., 2003; Millon & Davis, 2000). They often end up in power struggles with the therapist to prove that they are indeed special. Their pattern is, however, more a low-grade depression, or a series of depressive episodes, as opposed to major depressive episodes. Basically, patients with NPD tend to use their defense mechanisms and distorted thinking as a means to resist treatment needs or attempts, complicating the process of treating symptoms of comorbid depression. Usually the strain of repeated attempts at presenting a false, presumptuous demeanor and failing to reap the benefits eventually takes its toll on the individual with NPD, perhaps contributing to low-grade depression, usually hidden from others and based on fear, anger, and envy (Beck et al., 2004; Millon & Davis, 2000).

Shelly, a 45-year-old accountant, came to therapy at the demand of his wife. She was concerned by his behavior over the years and had recently become more concerned inasmuch as she saw their two sons emulating Shelly's pattern. Shelly sought to regale the therapist with stories of his accounting legerdemain: how he had cheated the IRS out of millions of dollars over the years, and how his clients were so dumb that he could cheat them, too. Each "victory" would help Shelly soar, but soon afterward he fell to earth. Therapy focused on helping him get more of what he wanted (the highs) without the depressive crashes.

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