September 04, 2008

The DSM, Axis II & Cluster B

La Primavera by Sandro Botticelli 

“15% of Americans have one or more personality disorders.” ~Mayo Clinic 

“Up to 30 percent of people who require mental health services have at least one personality disorder (PD)--characterized by abnormal and maladaptive inner experience and behavior.”~Sadie Dingfelder

“PDs are present in 10 to 15 percent of the adult population, with Cluster B accounting for approximately 9 percent based on research…a failure to identify them may create significant risk.” ~Joe Carver

The DSM, Axis II and Cluster B

The Diagnostic and Statistical Manual of Mental Disorders (DSM) categorizes psychological disorders on a multiaxial system comprised of five levels: Axis I, Axis II, Axis III, IV & V.

If you've been learning about Narcissistic Personality Disorder, it's highly likely you've heard NPD referred to as an Axis II disorder.

Now most likely, you're wondering why personality disorders are not grouped in with Axis I disorders like depression, schizophrenia, and substance dependence. Well, that’s because a personality disorder is a long-standing condition preceding a psychological crisis. A crisis big enough to force someone with a personality disorder into a psychologist's office. As most of us know however, it's usually the narcissist's family and friends who insist he or she get help.

It's important to know that insurance covers treatment for Axis I disorders since intervening treatments are considered to be cost-effective. Axis I disorders can be ameliorated with medical & psychological intervention, unlike personality disorders requiring intensive, long-term treatment.

Because of a poor prognosis for curing personality disorders, insurance companies have refused to pay for long-term treatment. Curing Narcissistic Personality Disorder is still uncertain which is why insurance companies are reluctant to throw money at treatment if treatment is not cost-effective.

The perception that personality disorders are untreatable is changing as results from intervening treatments like DBT, are proving to be successful. Particularly for people with Borderline Personality Disorder.

The following list will hopefully help you understand how personality disorders are categorized in the DSM-IV, sometimes called a psychologist's bible.

Axis I: Clinical disorders and conditions requiring clinical attention

Axis I mental disorders of significant impairment include: Depression, schizophrenia, social phobia, learning disorders, anxiety disorders, bipolar, ADHD, eating disorders, cognitive disorders, substance-related disorders, dissociative disorders, autism, etc. Just about everything someone sees a psychologist for goes on Axis I---with the exception of personality disorders and mental retardation.

People with Axis I disorders are most generally ego-dystonic; in other words, they see their mental problem as being separate from themselves. Their condition is not consistent with self-perceptions. This short list illustrates how disorders are categorized in the DSM:

296.80 Bipolar disorder

303.90 Alcohol Dependence

309.81 Posttraumatic stress disorder

Axis II: Personality disorders and mental retardation

Axis II refers to Personality Disorders for the most part, manifesting significant impairment in how someone relates to the world. Only those with long-term rigid, inflexible, pervasive and exaggerated traits can be diagnosed with a personality disorder.

Another important distinction is that people with personality disorders do not perceive their problems to be related to themselves. In other words, they are ego-syntonic: They say, “There’s nothing wrong with me. Everyone else is the problem!”

People with Personality Disorders frequently present with Axis I disorders. Axis I disorders are more likely to cause a crisis requiring psychological intervention. Depression and substance abuse, for example, might be the only reason a narcissist would seek psychological help. So the psychologist treats the Axis I disorder(s) but generally does not treat the underlying personality disorder.

Also, people can be diagnosed with more than one personality disorder, sometimes crossing over into another ‘cluster’. These are the three groups, or ‘clusters’ of Axis II personality disorders: Cluster A, Cluster B, and Cluster C.

Cluster A: ‘Suspicious’. Odd, eccentric behavior.

301.00 Paranoid personality disorder

301.20 Schizoid personality disorder

301.22 Schizotypal personality disorder

Cluster B: “Emotional/Impulsive". Dramatic behavior.

301.50 Histrionic personality disorder

301.81 Narcissistic personality disorder

301.70 Antisocial personality disorder

301.83 Borderline personality disorder

Cluster C: ‘Anxious’. Fearful behavior.

301.40 Obsessive-Compulsive personality disorder

301.82 Avoidant personality disorder

301.6 Dependent personality disorder

Note: Dissociative Identity Disorder, DID, (formerly called 'multiple personality disorder') is not an Axis II disorder. DID is an Axis I diagnosis.

Note: Clinicians may refer to Mental retardation and Developmental Disabilities as MR/DD. 

Axis III: General Medical Conditions

Medical conditions may influence management of Axis I and II disorders, such as: acute medical conditions, physical disorders, brain injuries aggravating disease or symptoms, and HIV/Aids, for example.

Axis IV: psychosocial and environmental problems contributing to the disorder

Axis IV problems also impact Axis I and II disorders, such as: unemployment, divorce, relocation, death, retirement, illiteracy, economic problems, lack of health care/insurance, victim of crime, births, academic problems, job dissatisfaction, homelessness, poverty, unsafe neighborhood, etc.

Axis V: Global Assessment of Functioning Scale (GAF)

The GAF is used by mental health clinicians and doctors to rate an individual’s overall social, occupational and psychological functioning.

The GAF is factored on a scale of 1-100 based on the psychologist’s judgment as to how well a client is managing his or her life. This scale ranges from harming the self or others (1-10) to no symptoms at all (91-100).

Low functioning range, 1-10:
 Persistent danger of severely hurting self or others OR persistent inability to maintain minimum personal hygiene OR serious suicidal act with clear expectation of death.

High-functioning range, 91-100:
 Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many qualities. No symptoms.

The following is an example of a typical diagnostic assessment :

Axis I:
296.21 Major Depressive Disorder , Single Episode
303.90 Alcohol Dependence

Axis II:
301.6 Dependent Personality Disorder

Axis III:

Axis IV:
Recent Divorce, unemployment

Axis V:

 I hope this helps explain what psychologists mean by Axis II disorders and Cluster B personality disorders. Because it's difficult for the layperson to distinguish between NPD and BPD, for example, it's useful to look at all the personality disorders grouped in the Cluster B category.

I'd also like to recommend reading Joe Carver's article linked below. He writes, "...individuals who create the most damage to social and personal relationships, the abusers, manipulators, “players”, controllers, and losers are found in Cluster B."

 Hugs all,

P.S. I've also written about:
 Ego-dystonic versus Ego-syntonic behavior


  1. This a great and informative post. I'm always glad to see people touching on the other disorders since NPD seems to get so much coverage. Learning about all of them was helpful to me, because the sometimes seem to share traits and overlap at times. There's lots in here I never knew.

    Its also nice to hear somebody mentioning the perception of the disorders being untreatable is changing. There's a big stigma and apart from those who have it not wanting treatment, most doctors aren't interested in dealing with the difficulties either. I'm reading a good book on how to treat personality disorders, but like you mentioned, it also says many of the same things. Few come to treatment, and less stick to it. More often than not, it always focuses on solving those secondary short term issues.

  2. Several people have asked me to define Axis II, so it seemed useful to put a lot of information into one post.

    I've also been reading numerous articles about healing BPD, which is encouraging news to say the least.

    Some psychologists are interested in treating NPD, but I remain skeptical about 'cures'. For one thing, the crossover between DNP, NPD and Malignant Narcissism is too imprecise.

    What may appear to be a NPD may actually be Destructive Narcissistic Patterns (DNP) that are not as entrenched, not as rigid, nor as inflexible as malignant narcissism.

    I’ve heard people suggest that psychological diagnosis is a bit of an art form, after all!

    P. S. Thanks for reading that post. It's a struggle for me to write without telling a story, but I gave it my best shot! ;-)


  3. Half of this entry is all crushed and inflated/stacked together. There fore I couldn't read the whole thing.


    •••Their condition is not consistent with self- perceptions•••.

    296.80 Bipolar disorder

    303.90 Alcohol Dependence

    309.81 Posttraumatic stress

    I would disagree in terms of PTSD.
    Perhaps in a certain number of cases but really when it gets down to it people to be blind to all kinds of behaviors patterns (their own). That would be ordinary.

    As for myself ..I can tell you I always knew something wasn't right and I knew I suffered. I was able to see that I responded differently (overwhelm) to common events and circustances.

    I didn't like it one bit and hoped I would grow out of it.

    Got to one thought there was anything wrong with me. That is the funny part of this all. When I tell old friends I have PTSD most of them are like... WHAT?, There is nothing wrong with you. Well I kept it inside and just sweat a lot of bullets .

    anonymous eyes

  4. "I can tell you I always knew something wasn't right and I knew I suffered."

    Your comment suggests that you wanted to change your behavior to fit with your self-perceptions. That is the definition of ego-dystonic.

    Let me make an attempt to write another message defining the difference between ego-dystonic and ego-syntonic. Then perhaps we'll both be clearer about ego-syntonic narcissists who ARE NOT DISTURBED by behaviors that most of us would desperately want to change!

    The focus of this message was to help other people (and myself!) understand how mental illness is classified in the DSM. Many research articles refer to the Axis II, so it seemed important to know what Axis II meant.

    We need to learn as much as we can about mental illness, in others or ourselves! After all, personality disorders are not going to disappear. At least not in the short term. And many of us will suffer if we are ignorant about the differences between personality traits and personality disorders (particularly Cluster Bs)!


  5. "about the differences between personality traits and personality disorders (particularly Cluster Bs)!"

    I totally agree.

    I like this entry because it really tells how severe personality disorders are.

    While it would be easy to look at myself and say...I must be nuts because I suffered with Ego-Dystonic is far different than NPD.

    It all makes sense.

    I am thinking with ego-dystonic behaviors it would be real easy for a narcissist to put an individual such as myself in the funny farm.

    My fortune was knowing what I didn't want with myself which in the end served self in that i went to council ...something a narc wouldn't do.

    I can just see myself waving the flag and say..Sure I am ego dystonic and I am willing to work to change that..but that doesn't erase the X's narcissism.

    I aprecate this entry because it clears up any misunderstandings I might have had about the various possibilities of mental conditions.

    It assists in knowing and in responding to what is real.

    Thank You...Anonymous eyes

  6. This is good,CZ....however, having to live with and finally away from...far away from...(self-preservation) a Narcissist in the family of origin, is a withering and defeating circumstance for the vast majority of family members.

    The overwhelming issue is this: a person with such a personality disorder as pathological narcissism continues to spread confusion, vemon, despair. They don't see that anything they do is of 'hurt'...or IF they do, they don't have the ability to 'relate', connect to the wounds they so easily sting with their behavior and the end result on others. Actually, they don't have the mental wiring to care what they do: after all, they cast all blame for things on others, and the world in general.

    It is a living Hell for those caught up in the manipulations of a Narcissist of such extreme proportions: the entire family is affected for the entire duration of the Narcissist's life: even the death of this person is no respite, because the damage was done to others, especially the adult children, so early on, lives on. Patterning, defeatist thinking, etc. is so entrenched.

    There is so much a therapist can help with. Unfortunately, they generally don't get to the root of the main issue. Drug/alcohol abuse, etc...can be discerned as crutches to even a Narcissist, but how do you change the wiring and behavior of a person who has no empathy for people? I have found that this is the stumbling block in these cases: There is something so pathologically 'gone' in a Narcissist of this level that the idea of cure is not applicable. First, there has to be some "something' that would drive the Narcissist to therapy, yet any 'discomfort' of their lives is seen as made by others: there is so little self-awareness in these people that they can't be reached. They can't begin to break out of the constant isolation of the "me". They have no empathy for others. It's like a dead-zone in the soul for them.

    I have the greatest empathy for those who are in distress, BECAUSE of a sneaking reality that what THEY do has some bearing on their lives, and their discomfort. They are reaching out for answers and relief. There is hope here.

    However, my experience is different: the main person in my family who is this extreme is of no mind or character to even look at what she does: The pollution, the corruption spreads wide in the family, and all are touched in some significant and essential way.

    To this person: people are to be used and discarded. Over and over. It fortifies their power.

    You can't even begin to treat these disorders, clusters or whatever, until the person comes in for therapy. And then? This is actually very rare because they don't believe that 'they are the source of their own problems'.

    I've said nothing new here, but my experience over the course of many decades with not only this person, but the people around her, will remain the biggest sadness of my life.

    Life is like pealing a stinky onion, neh?

    Lady Nyo

  7. Dear LadyNyo,

    You are so right, the pain narcissists inflict on others is extreme and there is no end if their victim has any shred of self-respect by the time he or she realizes the relationship is destructive. I have found that the minute you stop "Taking their Shite", you are on the slippery slope to Devalue and Discard. Not repair. Not reconciliation.

    You think, as a normal person, that narcissists want to save the relationship, too.

    You think, as a normal person, that they'll take responsibility for their share of the problems.

    You think, as a normal person, that relational distress will be a MUTUAL wake-up call.

    Yet as you wrote, "any 'discomfort' of their lives is seen as made by others: there is so little self-awareness in these people that they can't be reached..."

    I suppose the degree of narcissism has everything to do with whether or not they can recover. There are many reports of Borderline PD being 'cured' but in all honesty, living with a recovered 'borderline' would be a huge commitment & challenge.

    Even when someone is no longer classified as 'borderline' or 'narcissistic', I am pretty certain they're difficult to live with. After all, I know how often I slip and the daily struggles i have with MYSELF and my 'issues' are not pathological.

    I also know from familial experiences, how important it is to give HOPE to people-with-issues or personality disorders. Hope that their efforts will be rewarded with improved relationships with others and with themselves.

    The problem with the narcissistic personality is that they have little regard or emotional investment in relationships. They are not highly invested in
    communal values that create, enhance, and maintain relationships. Even if the narcissist has a certain degree of empathy, he or she uses that empathy to 'manipulate' the people around them.

    I hope new therapeutic techniques will be able to 'cure' personality disorders of all sorts. But 'cure' does not mean they are easy-going, pleasant and other-focused human beings. If you're dating a narcissist-in-therapy, you might reconsider staying with them. If however, you have a narcissistic parent, spouse or child, then sign yourself up for therapy, too. Cuz you'll need it.


  8. There seems to be many symptoms in common between BPD and PTSD. I've been told by therapists that I have PTSD. But I've been reading about both. BPD fits in some aspects that seem to be the same as the way PTSD fits. You mention that people with PDs don't think they're the problem though, so does that automatically cancel me out for BPD?...because I do see and observe my behavior...have for years. And although I go through moments of "blaming my parents" at times of serious frustration over it, I take responsibility. Therapists think it's PTSD. But I'm not so sure. I've only just gotten back into therapy as I've had no health insurance until recently and out of pocket was cost prohibitive.

    1. Hi- Same Anon as above. I wanted to add that I'm a bit confused also about the difference between having the traits as opposed to the disorder itself. Doesn't having the traits make up the disorder?

      I like your blog by the way. Thanks.

    2. Hi anon,

      I must apologize for missing these comments two years ago! Undoubtedly, the holidays were keeping me busier than usual! (We usually reserve our BEST TRAGEDIES for Christmas so its not hard to imagine me missing your reply!) If you're still around, feel free to comment and we'll take it from there.


  9. Thank you so much for helping me understand abit more a freind recommended ur site.My partner has recently tried to commit suicide by jumping off a 120ft bridge an survived. This is the forth time hes tried to end his life (pills prev) hes in dop at the momment. Its great to b able just to talk thank u x

    1. Hello anonymous,

      I'm so sorry to hear about your partner and the suffering he/she experiences. I don't think most people realize the degree of misery narcissists endure, too.

      I hope your partner is doing better...and how about you? Are you handling this okay?



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