(logo chiming) - (gentle music) Personality
disorders are considered by many professionals to be
some of the most difficult to diagnose. Luckily, Dr. Ramani is the go-to expert when it comes to this class of conditions, she sat down with MedCircle to dive into cluster B
personality disorders, which are known to be the
most unpredictable type. It's just so great to sit down with you. - I love talking with you. - Sometimes we talk about some topics that I think are really really dreadful and hurtful. - And I think this series
is going to be more in that lane. - Yes, it is. Yeah, you brought up the cluster B? - Personality disorders. I think it's so, I'm so
glad we're doing this having this conversation because a lot of folks out there are trying to make sense of these difficult patterns and they put in all kinds of words into search engines online. Cluster B is a something that comes out and a lot of people don't
know how to make sense of it. So let me give you some
historical background this word, cluster B. It comes from how the
personality disorders were traditionally organized
in the diagnostic manual of psychiatry and
psychology called the DSM. The DSM organize a personality disorders. There were 10 of them into three groups, cluster A, cluster B and cluster C and they organized the disorders based on their manifestations. Now, back in graduate school we would remember these three clusters by calling them mad, bad and sad. That's how we sort of memorized them. And by mad, it was sort of
that traditional like madman, like, you know a person
who's just really off and almost like you know, very disturbed, bad, almost badly behaved and that's our cluster
B is inside where people are more anxious and avoidant. The cluster B disorders are also termed dramatic and erratic. Now, these disorders again are grouped by sort of how they affect a person. And today we're gonna focus on cluster B. The cluster B disorders are
the difficult disorders. They're antagonistic, they're
interpersonally challenging. These are folks who, as a rule,
almost always lack empathy. They tend to be entitled. So it's almost like narcissism
becomes a nice sort of like the mid point of a
lot of these disorders. Like most of them have qualities of narcissism in different ways. And as you said, the four
disorders that hangout in cluster B are anti-social
personality disorder, borderline personality disorder, narcissistic personality disorder and something called histrionic
personality disorder. These are probably the most clinically vexing patterns we see in
psychology and psychiatry because they can make for
very difficult clients. These patterns can interfere
with us treating other issues the person may have like substance abuse, bipolar disorder, major depression, anxiety
disorders, eating disorders the list goes on. If you have a cluster B
disorder and these other things you're constantly sort of like, it's like you're trying to like
fight two different battles at the same time. And it's really one big
kind of war if you will. So it is a challenge. And it's a challenge for people not only living with
the cluster B patterns but also a challenge for the people living with those people who
have cluster B patterns. So that's what cluster B is
dramatic, erratic, emotional, antagonistic, combative, lacking empathy. Oftentimes internally, very chaotic. They can't regulate their
emotions very easily. And some of these are
really clinically demanding borderline personality for example, is very clinically challenging condition narcissistic, histrionic clients. They don't even tend to end
up in therapy that often and anti-social personality disorder. Those folks often end up in prison. - We've talked about specific
personality disorders but what is a personality
disorder in general? - A personality disorder
is a maladaptive pattern of behavior and relating that
cuts across all situations in the person's life; relationships, work, social functioning, and
even their sense of self. It's the long-standing
stability that makes these be called personality disorders because personality is
considered to be a stable trait but their personality
styles cause the person problems in all areas of their life. But it's the maladaptive,
consistent and stable nature of these problematic
personality patterns that lead to them being called
personality disorders. - Can someone be diagnosed
as having cluster B disorder? No, you just have one of them. And then that's. - What would end up happening
is like, for example, I, you know, I do research
on psychopathology and mental illness and mental health. So when we analyze our data, because these disorders are common, sometimes we'll combine these patterns to see if we see any patterns there. So partly it serves as sort of a research kind of an approach. It becomes a shorthand for clinicians, but we as clinicians have
to be really, really careful about using that term because cluster B is code
for difficult patient. And there's a chance. - Wait that's really big. Cluster B is code for difficult patient. Now I can already hear
people that are saying, well I'm watching that. My therapist said, I have cluster B. Now that's rude. Why would you say I'm difficult? - That's what I'm saying. We have to be very
careful with these labels. It's really meant. It's almost like, again, it's
an organizational scheme. If we see, because what may happen, Kyle as a person may not meet
the full diagnostic criteria for any one pattern of those disorders we test for disorders. They may have a little bit of
this, a little bit of that. And we might call it this
sort of as a cluster B pattern to it. It means that we might use very specific kinds of therapeutic techniques or realize that these patterns may interfere with the treatment of other
disorders, if you will. But it does imply typically somebody who's interpersonally difficult. I'll honest with you. I mean, those of us in mental health will sometimes even use that
as shorthand in our own lives. Like I'm going to Thanksgiving, it's going to be difficult to have cluster B relatives there. You know, anyone in the
business will know like, ah she's got some really
difficult family members, but it's beyond difficult. It's antagonistic. And almost like they often don't get it. - Is it almost often that
they don't want the help? - Not necessarily. I think, you know because cluster B disorder's
taken so much territory. I work with many clients who have borderline personality disorder. They desperately want help. They desperately want help. In fact, sometimes need
more help than even they can get in sort of like one or two weekly therapy sessions and many clients with
borderline personality disorder are very invested in getting that help. But it's difficult for them. They feel so internally chaotic and frightened that
therapy can be challenging not only for them, but for the therapist. Who's trying to sort of sew this patient. Obviously when you're
dealing with somebody with narcissistic personality you don't think anything's wrong. So they're often gonna think
I don't even need help. And then, you know histrionic
personality disorder, actually, they're
thinking of removing that from the diagnostic manual. These are people who are dramatic and attention seeking and seductive. And look at me, how come I'm not getting all
the attention kind of thing. They almost also never end
up seeking out treatment for that particular pattern. The folks with antisocial
personality disorder also almost never seek out treatment. They get in trouble for something. And then they're sometimes
forced into treatment. - Briefly, describe what
antisocial personality disorder is because that name is so misleading. - Antisocial personality disorder is one of the most important and one of the most unfortunately
named diagnoses out there it throws my students off. It throws off trainees. It throws off lay people. Antisocial personality disorder
is actually quite dangerous. It can be quite dangerous. It doesn't mean what we think. A lot of people take
the antisocial domain. Oh, these are people who don't
wanna be with other people almost as though they're socially anxious. Not at all. The unfortunate term
historically came from this idea that these were people
who were anti society. They were anti the norms of society. They would break the rules of society. That was where the anti social came from. Like I said, such an unfortunate name. Cause we use anti
antisocial to mean someone who doesn't wanna socialize. - What would you call it? - I would call it psychopathic
personality disorder. That's what I would term it. And antisocial personality
disorder is the diagnostic term for things that are called
psychopathy and sociopathy in the popular literature,
in the media at large in all kinds of other writing,
in criminology writing but not, it's not a diagnostic. Those are not diagnostic terms. But those two terms
definitely ascribe more to anti-social personality disorder. Now, what is it? Antisocial personality
disorder is a pattern whereby a person not only lacks empathy,
but they think the rules do not apply to them. They do not adhere to them. They break moral codes,
social codes, legal codes. They have a failure to take
any kind of responsibility. They're very deceitful. They exploit other people
to achieve their ends. They will take risks that will
put other people in danger. So they're dangerous. They're dangerous. And here's the ringer. Here's the ringer. I personally think that, to really call it antisocial
personality disorder. You're talking about
someone who lacks remorse for the bad things they do. And that's where it gets scary. That's where it gets scary. I'm sorry. - Can they fake it? - Can a person fake - Remorse. - Remorse, oh absolutely. You can fake anything. You can fake empathy. You can fake remorse. You can fake anything. And they do. They will. When they're finally hauled in front of the press conference, they'll cry crocodile tears and a year later, they'll do it again. That's antisocial personality disorder. - Which clusters of disorders
do you think are most common? - In terms of the personality
disorders overall? I actually think that
the cluster B disorders may be more common. And the only reason I
think I'm gonna say that is because when we do
research on these disorders they're the ones that are
more clinically compelling. So we may see more clients
with these patterns because especially in the
case of borderline personality they're more likely to get help and the case of anti-social
personality disorder, they're more likely to end up in prison. So there are these two groups of folks. We study a lot because of
the sort of the distress we see in borderline
personality and the danger that can be created by
antisocial personality. So and there's four
disorders in that group too so it's gonna up your
number up a little bit. I think that the cluster
B disorders probably are the ones that are, have
the highest prevalence rates across the three groups overall, yeah. - Oh yeah, more disorders
and people are having to go get help. - They're more disruptive that's who you're gonna see, I'd say, if you were working
in the mental health business you'll see that a lot. In cluster C there's things like avoidant personality disorder, which is it almost looks like
a social anxiety disorder. So you will see that
sometimes, but sometimes we don't even know which variant
we're seeing social anxiety or avoidant personality. And with the cluster A disorders the schizoids, the schizotypal,
the paranoid personalities. These are people who
actually look quite severely mentally ill. They're incredibly
either socially withdrawn or they appear as so odd. They almost look psychotic. They're sometimes overrepresented
in residentially, unstable like homeless populations
or people who are in and out of long-term
psychiatric facilities. - Is there hope for people
who are in the cluster B camp. - In terms of hope for
cluster B clients, it varies. It varies. - Now hold on, we don't
hear that answer a lot. - Oh, it varies. Yeah, and that's the problem that speaks to how heterogeneous the disorders that make
up this cluster are. - If I talk about bipolar disorder if I talk about anxiety, depression, ADHD the doctor across from me will
say, there's so much hope. - No, very variable. I would say that the most good research on treatment outcomes and
best practices can be found for borderline personality disorder. I believe firmly that if you have a client with
borderline personality disorder and you can give them trauma focused care, dialectical behavioral therapy, whatever psychiatric medications they may need to manage other
sorts of conditions they have and other kinds of adjunctive
therapies that will help them with their symptoms. The treatment literature can really show some good long-term outcomes but the treatment has to be consistent. And long-term, and that's often passed beyond the financial
ability of a lot of people. That's, what's so unfortunate because I think there is
tremendous hope for people with borderline personality if they get the kinds of treatment. And if the client won't
cooperate with the treatment and then all bets are off. With narcissistic personality disorder you know what I say about that. You're not gonna see much change. And when you do it's glacial and the amount of change
you see is often not enough for the people around them to
feel like things are better but with antisocial personality disorder that disorder might be
the most hopeless of all. These are folks who will
try to outwit and outfox a therapist who will fake it and are often court
ordered to go to therapy as a condition of parole or probation or something like that. And so they'll sit there for 10 sessions and say I don't need to say anything. I just need you to sign that document so that I came here for 10 sessions. So you can get a lot of resistance and they can often try to
intimidate a therapist. You have to be a very specially
trained therapist to work with that population,
particularly those who have very very difficult criminal histories. And if you're dealing with sort of the more neat and tied up
antisocial personality, sort of like the CEO variant, there they're very manipulative. They can be very exploitative that again they will often
try to outwit the therapist. They're really not
motivated to change because they really truly don't think
there's anything to change. So if anything, that just
really out to game the system that's not progress. So I would say definitely
for them of all groups they'll have the worst outcomes. - What percentage of your clients do you think fall in
the cluster B category? - Oh with some cluster B symptomatology. Well, I mean, well, over 50%. Maybe, yeah. Maybe even a little less. - Actually I thought you gonna say 5%. - Oh, heck no, no, no, no. I actually, that's what
I choose to focus in but maybe 40%, 40%. - You know, that is good though because then at least
people are getting help or in the space to get help. - And there are people out
there who specialize in this like people who specialize in
dialectical behavioral therapy is called DBT. I'd say they see 90%
because they're working with clients who have a lot
of borderline personality, sorts of symptoms. People who work in prisons
are probably seeing antisocial personality
at the level of 60, 70%. But I'd say almost half of
the clients I work with. I choose to do that though. Because like I said, although
I would say maybe even all right, I'll be 35% because the majority
of clients I work with are trying to negotiate a family or other relationship with a person with a cluster B disorder, a solid 30 of them are
struggling with these, with these issues. - Well, that leads perfectly
into my next question, knowing that if somebody has
watched this video this far they have been likely given
a diagnosis of a disorder in the cluster B family, or
they know somebody who has. What could I do I ask them on their behalf that you would think
would be most beneficial for them to hear? - I would, you know, I think that the big question people
have is from the person, there's two sides of it, from the side of the person
who's experiencing it is what do I do? I'm not only always miserable. I feel like I'm making
people miserable, you know? And then from the other side I think the question
would be, what do I do? I feel like nothing I say to this person ever makes things better. In fact, all I do is feel
like things get worse. And I feel like I'm always
walking on eggshells. What do I do? What do I do? - Yeah what is the answer to that? - I mean for the people who are experiencing this symptomatology. You got to get therapy. You're not gonna think
your way out of this one. You're not gonna meditate
your way out of this one. You got to get therapy. And with somebody who is trained in things like DBT and working with
these kinds of patterns, okay? That's an have to. - You know, Dr. Yip is one of the nation's
leading experts on OCD. And I interviewed her for OCD series. She really drove home the point of don't just go get therapy because the therapist
said, yeah, I treat OCD go find the person who
that's, what they do. They are OCD, right? So with these people I feel bad for someone who might've gone to a therapist who said
they could treat it but they did it once, 10 years ago. And they had a bad experience. - Yeah, I think that
you, especially with now, again with something like
narcissistic personality disorder if you actually do get them to therapy you can use a combination
of some DBT techniques but also some cognitive behavioral work, some humanistic work, rapport building it's a lot of it's relationship building. You need a strong therapist
to work with those clients because they will try to outfox you. And so you've got to be almost have to be one step ahead of them. Like you can't fall for the charm. You have to be almost charm
immune or charm proof to work with the narcissistic clients. With the anti so. You know, so it's all about expertise. But the borderline clients are the ones who are most likely to
actually seek out therapy. And for them to say, like
I said, you do it right. What do you do? You need to get help from somebody who knows
what they're doing. And it might even be a team of people who know what they're doing. In fact, DBT is best
delivered in a team approach with a combination of group
therapy and individual therapy and some medication management. On the other side of it. If somebody in your life is experiencing these cluster B patterns it's gonna be difficult. I'm telling you that right now. And you're not a bad person
for thinking it's difficult because a lot of people say I feel guilty. There's actually something
happening to them. How do I think that this
is difficult because it is. Because the nature these patterns
is somewhat antagonistic. That again, it may be that they're feeling
insecure or chaotic inside. And that's why they're lashing
out at the end of the day it doesn't matter when somebody lashes out it doesn't feel good,
regardless of the reason. And so I will tell people, if you are in, you are with somebody who is
experiencing cluster B patterns definitely seek out individual therapy. You may need to manage your
expectations of that person and then ask yourself,
what would the landscape of a relationship look
like with this person if things don't change because in many cases,
yeah, it may not change. - Those are really good three takeaways. Real quick for people watching, explain briefly what DBT is? - Yeah, DBT is dialectical
behavioral therapy. Dialectical behavior therapy was developed by someone named Dr. Marsha Linehan. And she developed DBT
actually specifically to address the crisis of suicidality in people who had borderline
personality disorder because that's the dangerous issue. People with borderline
personality are experiencing so much inner pain and turmoil that they
wanna silence that pain. They truly do believe often
they're a burden to others that they don't, they're
not worthy to live. It's really agonizing for them and for the people around
them who care for them. And so DBT was initially
really developed as a way for the person living with
borderline personality disorder to see how they life always
feels like a crisis to them how everything is black or white. And so the dialectic is really
to bring those two sides those two perspectives together and find that gray in the middle. The other thing that Dr.
Linehan brought into this work was a real focus on mindfulness. People with borderline
personality disorder tend to react instead of responding,
responding is a more thoughtful approach reacting
as like you jump right in through DBT using mindfulness
and sort of catching yourself. You help people construct more responsive rather than reactive kinds of approaches when they're faced with a stressor. You know cause the reacting often means people's feelings get hurt. People get angry, but to help them deal with that crisis and the
fears that overtake a person with borderline personality disorder such as things like that they're going to be left, that they're going to be alone that they can't take care of themselves. Many people with borderline
personality disorder engage in a lot of negative self-talk. Dialectical behavioral therapy also draws from cognitive
behavioral therapy where you push back and say, you know, it's interesting you say
all these terrible things about yourself cause my experience. And you really do point out to them the good things and the strengths and you do some resilience
building with them. So, and you have them
do homework assignments between sessions. So they do a lot more monitoring so they can help. They can start seeing their own patterns. DBT has been shown to reduce the rate of suicidal
thoughts, suicidal actions in people with borderline
personality disorder. And it's really the only
evidence-based treatment we know of right now that has any
consistently good outcomes in persons with borderline. - I just wanna touch
on two things you said that really struck a chord with me. The first one is mindfulness. It is becoming a reoccurring theme in all of my conversations
about mental health. Which makes me think if there's one thing we all could do to make our lives better it would be to be conscious
of what we're doing mindful of what we're doing. And then the second
thing is that difference between reacting and responding. - Yeah. - That's huge. - We live in a very reactive world. Especially when you think
about tweeting and texting. - And responding to
those tweets and texts. - But that's reacting to
these tweets and texts. Responding means you stop. You think, what's meaningful. Well, how do I write this
so I don't hurt people. You know, that it's actually beneficial to either the receiver or other people who will
be seeing this message. You go through a series of cognitive steps but unfortunately technology doesn't, I mean I wish all technology made you like are you sure, are you sure, are you sure. Like, you know, - That's an app idea. - And honestly they
made you wait 60 seconds and then another, are you sure? And then another 60 seconds
and then are you sure? Because by then a lot of
reacting would have come down and you're like, forget about it. It's not that important. - Think about emails
that you write in a rage and hopefully you don't
send them and you save it. And then the next morning
you read it and go, thank goodness I didn't send that. - Never ever put a name in a subject line of an email until you're ready to send it. That's sort of a bit of advice. But it's that react, respond,
and mindfulness are linked. And because everything these
days is so quick, quick, quick and we're judged on speed. And everything's designed
not only for speed but not to catch ourselves
before we go off the edge that we can send things without, you know back in the day, you'd have to like write the letter fold the letter, put the
letter in the envelope find the stamp, write the
address, go the mailbox. That was nine times you could have said, maybe I shouldn't send this. You know and so we, that
that's where that mindful. (gentle music) Mindfulness is a stop. It's a feel. It's a think, but that does
mean awareness of other people. And if you don't have empathy, all the mindfulness in the world may not necessarily pay out. (logo chiming)
