What are the characteristics and symptoms of Histrionic Personality Disorder and how is it diagnosed?

Histrionic personality disorder (HPD) is defined by the American Psychiatric Association as a personality disorder characterized by a pattern of excessive emotionality and attention-seeking, including an excessive need for approval and inappropriately seductive behavior, usually beginning in early adulthood. These individuals are lively, dramatic, vivacious, enthusiastic, and flirtatious.

They may be inappropriately sexually provocative, express strong emotions with an impressionistic style, and be easily influenced by others. Associated features may include egocentrism, self-indulgence, continuous longing for appreciation, and persistent manipulative behavior to achieve their own needs.

 

Characteristics

People with this disorder are usually able to function at a high level and can be successful socially and professionally. People with histrionic personality disorder usually have good social skills, but they tend to use these skills to manipulate other people and become the center of attention. Furthermore, histrionic personality disorder may affect a person’s social or romantic relationships or their ability to cope with losses or failures.

People with this disorder lack genuine empathy. They start relationships well but tend to falter when depth and durability are needed, alternating between extremes of idealization and devaluation. They may seek treatment for depression when romantic relationships end, although this is by no means a feature exclusive to this disorder.

They often fail to see their own personal situation realistically, instead tending to dramatize and exaggerate their difficulties. They may go through frequent job changes, as they become easily bored and have trouble dealing with frustration. Because they tend to crave novelty and excitement, they may place themselves in risky situations. All of these factors may lead to greater risk of developing depression.

Additional symptoms include:

• Exhibitionist behavior.
• Constant seeking of reassurance or approval.
• Excessive dramatics with exaggerated displays of emotions, such as hugging someone they have just met or crying uncontrollably during a sad movie (Svrakie & Cloninger, 2005).
• Excessive sensitivity to criticism or disapproval.
• Proud of own personality, unwillingness to change and any change is viewed as a threat.
• Inappropriately seductive appearance or behavior.
• Somatic symptoms, and using these symptoms as a means of garnering attention.
• A need to be the center of attention.
• Low tolerance for frustration or delayed gratification.
• Rapidly shifting emotional states that may appear superficial or exaggerated to others.
• Tendency to believe that relationships are more intimate than they actually are.
• Making rash decisions.

 

Causes

The cause of this disorder is unknown, but childhood events such as deaths in the immediate family, illnesses within the immediate family which present constant anxiety, divorce of parents and genetics may be involved. Histrionic Personality Disorder is more often diagnosed in women than men; men with some quite similar symptoms are often diagnosed with narcissistic personality disorder.

Little research has been conducted to determine the biological sources, if any, of this disorder. Psychoanalytic theories incriminate authoritarian or distant attitudes by one (mainly mother) or both of the parents of these patients, or love based on expectations from the child that can never be fully met.

 

Diagnosis

The person’s appearance, behavior, and history, along with a psychological evaluation, are usually sufficient to establish the diagnosis. There is no test to confirm this diagnosis. Because the criteria are subjective, some people may be wrongly diagnosed as having the disorder while others with the disorder may not be diagnosed. Treatment is often prompted by depression associated with dissolved romantic relationships. Medication does little to affect this personality disorder, but may be helpful with symptoms such as depression. Psychotherapy may also be of benefit.

 

DSM-IV-TR 301.50

The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines histrionic personality disorder (in Axis II Cluster B) as:

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

• is uncomfortable in situations in which he or she is not the center of attention
• interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
• displays rapidly shifting and shallow expression of emotions
• consistently uses physical appearance to draw attention to self
• has a style of speech that is excessively impressionistic and lacking in detail
• shows self-dramatization, theatricality, and exaggerated expression of emotion
• is suggestible, i.e., easily influenced by others or circumstances
• considers relationships to be more intimate than they actually are.

It is a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

 

ICD-10

The World Health Organization’s ICD-10 lists histrionic personality disorder as (F60.4) Histrionic personality disorder.

It is characterized by at least 3 of the following:

• self-dramatization, theatricality, exaggerated expression of emotions;
• suggestibility, easily influenced by others or by circumstances;
• shallow and labile affectivity;
• continual seeking for excitement and activities in which the patient is the center of attention;
• inappropriate seductiveness in appearance or behavior;
• over-concern with physical attractiveness.

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

 

Millon’s subtypes

Theodore Millon identified six subtypes of histrionic. Any individual histrionic may exhibit none or one of the following:

• Theatrical histrionic – especially dramatic, romantic and attention seeking.
• Infantile histrionic – including borderline features.
• Vivacious histrionic – synthesizes the seductiveness of the histrionic with the energy level typical of hypomania.
• Appeasing histrionic – including dependent and compulsive features.
• Tempestuous histrionic – including negativistic (passive-aggressive) features.
• Disingenuous histrionic – antisocial features.

 

Mnemonic

A mnemonic that can be used to remember the criteria for histrionic personality disorder is PRAISE ME:

P – provocative (or seductive) behavior
R – relationships, considered more intimate than they are
A – attention, must be at center of
I – influenced easily
S – speech (style) – wants to impress, lacks detail
E – emotional lability, shallowness

M – make-up – physical appearance used to draw attention to self
E – exaggerated emotions – theatrical

 

Differential diagnosis

• Clinical depression
• Anxiety disorders
• Panic disorder
• Somatoform disorders

A person suffering from HPD is highly reactive. If there is another major disorder present, such as delusional disorder, then emotional intensity will create anger, rage, abuse and distance in relationships.

It is important for the therapist and family members to monitor and record all situations that trigger the HPD so that the deep underlying overload of pain can be accessed and released for therapeutic change.

 

Treatment

Because of the lack of research support for work on personality disorders and long-term treatment with psychotherapy, the empirical findings on the treatment of these disorders remain based on the case report method and not on clinical trials. On the basis of case presentations, the treatment of choice is psychotherapy and/or cognitive-behavioral therapy, aimed at self-development through resolution of conflict and advancement of inhibited developmental lines. Group therapy can assist individuals with HPD to learn to decrease the display of excessively dramatic behaviors, but must be closely monitored because it may provide the person with an audience to play to (perform for), thus giving opportunity to perpetuate histrionic behavior.

• Family therapy
• Medications
• Alternative therapies
• Cognitive behavioral therapy

 

Epidemiology

Histrionic personality disorder shares a divergent history with conversion disorder and somatization disorder. Historically, they are linked to the ancient notion of hysteria, or “wandering womb.”(Note, however, that according to the Online Etymology Dictionary, the word “histrionic” derives not from the Greek hystera, but from the Latin histrionicus, “pertaining to an actor.”) Ancient Greeks thought that excessive emotionality in women was caused by a displaced uterus and sexual discontent.

Christian ascetics during the Middle Ages blamed women’s mental problems on witchcraft, sexual hunger, moral weakness, and demonic possession. By the 19th century, medical explanations proposed a weakness of women’s nervous system related to biological sex. Thus, “hysteria” reflected the stereotype for women as vulnerable, inferior, and emotionally unbalanced. The extent to which the definition of histrionic personality disorder currently reflects gender bias remains the subject of controversy.

“Hysteria” differentiated into conversion hysteria (later to become conversion disorder) and hysterical personality (later to become histrionic personality disorder) in the psychoanalytic literature as well as with the writings of Kraepelin, Schneider, and others. Sigmund Freud wrote primarily about conversion hysteria. Wilhelm Reich wrote about hysteria as a set of personality characteristics and differentiated conversion hysteria as a transient disorder from hysterical character. These early conceptualizations of both kinds of hysteria carried notions of women’s deficiency due to penis envy and feelings of castration. Paul Chodoff has written about the ways in which these diagnoses paralleled the misogynistic sentiment of the times.

The concept of hysterical personality was well developed by the mid-20th century and strongly resembled the current definition of histrionic personality disorder. The first DSM featured a symptom-based category, “hysteria” (conversion) and a personality-based category, “emotionally unstable personality.” DSM-II distinguished between hysterical neurosis (conversion reaction and dissociative reaction) and hysterical (histrionic) personality.

In DSM-III, the term hysterical personality changed to histrionic personality disorder to emphasize the histrionic (derived from the Latin word histrio, or actor) behavior pattern and to reduce the confusion caused by the historical links of hysteria to conversion symptoms. The landmark case of Ruth E. helped to fully define and emphasize the characteristics of the current DSM-IV diagnostic. DSM-III-R attempted to reduce the overlap between Histrionic Personality Disorder and borderline personality disorder by dropping three overlapping criteria and adding two criteria that emphasized histrionicity. DSM-IV dropped two more criteria that did not appear to contribute to the consistency of the diagnosis, according to research done by Bruce Pfohl.

 

Histrionic Personality Disorder: Summarized

Histrionic personality disorder is characterized by a long-standing pattern of attention seeking behavior and extreme emotionality. Someone with histrionic personality disorder wants to be the center of attention in any group of people, and feel uncomfortable when they are not. While often lively, interesting and sometimes dramatic, they have difficulty when people aren’t focused exclusively on them. People with this disorder may be perceived as being shallow, and may engage in sexually seductive or provocating behavior to draw attention to themselves.

Individuals with Histrionic Personality Disorder may have difficulty achieving emotional intimacy in romantic or sexual relationships. Without being aware of it, they often act out a role (e.g., “victim” or “princess”) in their relationships to others. They may seek to control their partner through emotional manipulation or seductiveness on one level, whereas displaying a marked dependency on them at another level.

Individuals with this disorder often have impaired relationships with same-sex friends because their sexually provocative interpersonal style may seem a threat to their friends’ relationships. These individuals may also alienate friends with demands for constant attention. They often become depressed and upset when they are not the center of attention.

People with histrionic personality disorder may crave novelty, stimulation, and excitement and have a tendency to become bored with their usual routine. These individuals are often intolerant of, or frustrated by, situations that involve delayed gratification, and their actions are often directed at obtaining immediate satisfaction. Although they often initiate a job or project with great enthusiasm, their interest may lag quickly.

Longer-term relationships may be neglected to make way for the excitement of new relationships.

 

Symptoms of Histrionic Personality Disorder

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

• Is uncomfortable in situations in which he or she is not the center of attention
• Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
• Displays rapidly shifting and shallow expression of emotions
• Consistently uses physical appearance to draw attention to themself
• Has a style of speech that is excessively impressionistic and lacking in detail
• Shows self-dramatization, theatricality, and exaggerated expression of emotion
• Is highly suggestible, i.e., easily influenced by others or circumstances
• Considers relationships to be more intimate than they actually are

As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it.

Histrionic personality disorder is more prevalent in females than males. It occurs about 2 to 3 percent in the general population.

Like most personality disorders, histrionic personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

 

How is Histrionic Personality Disorder Diagnosed?

Personality disorders such as histrionic personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose histrionic personality disorder.

Many people with histrionic personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.

A diagnosis for histrionic personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

 

Causes of Histrionic Personality Disorder

Researchers today don’t know what causes histrionic personality disorder. There are many theories, however, about the possible causes of histrionic personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

 

Histrionic Personality Disorder Treatment

Psychotherapy

Individuals who suffer from this disorder are usually difficult to treat for a multitude of reasons. As with most personality disorders, people present for treatment only when stress or some other situational factor within their lives has made their ability to function and cope effectively impossible. They are, however (unlike other people who suffer from personality disorders), much quicker to seek treatment and exaggerate their symptoms and difficulties in functioning. Because they also tend to be more emotionally needy, they are often reluctant to terminate therapy.

Psychotherapy, as with most personality disorders, is the treatment of choice. Group and family therapy approaches are generally not recommended, since the individual who suffers from this disorder often draws attention to themselves and exaggerates every action and reaction. People with disorder often come across as “fake” or shallow in their interpersonal relationships with others. Patients often are express all feelings with the same depth of emotion, unaware of the subtleties of their own emotional states and of the vast range available to them.

Therapy should generally be supportive and good rapport will usually be easily established with the patient early on. Clinicians may often find themselves placed in a “rescuer” role, in which the therapist will be asked to constantly reassure and rescue the client from daily problems. Every problem is usually expressed in a dramatic fashion. Many times the therapist will be perceived as sexually attractive to the patient. Boundary issues in relationships and a clear delineation of the therapeutic framework are relevant and important aspects of therapy.

Approaches which take advantage of matter-of-fact and realistic assessment of situations and problems can also be important. Solution-focused therapy is often appropriate with this client. Most therapy approaches should not be focused on the long-term, personality change of the individual, but rather short-term alleviation of difficulties within the person’s life. Few people could afford the time or cost required to “cure” someone of this disorder. This should be explicitly stated up-front at the onset of therapy to dismiss any thoughts the client may have of a “magical” cure for this disorder.

Suicidal behavior is often apparent in a person who suffers from histrionic personality disorder. Suicidality should be assessed on a regular basis and suicidal threats should not be ignored or dismissed. Suicide sometimes occurs when all that was intended was a gesture, so all such thoughts and plans should be taken with the same seriousness as with any other disorder. A suicide contract should be established to specify under what conditions the therapist may be contacted in case the client feels like hurting him or herself. Self-mutilation behavior may also be present in this disorder and should also be taken seriously as an issue of importance to discuss within therapy.

Therapists will find that taking a somewhat skeptical stance within therapy to be useful, due to the usual exaggeration of events and problems by the patient. By following a line of reasoning to its logical conclusion, the client can usually discover the unrealistic expectations and fears associated with many behaviors and thoughts. Since many people who have histrionic personality disorder will emphasize attractiveness (“style over substance”) in their lives and relationships, discussing alternatives and trying out new behaviors may be helpful. The therapist can also help by pointing out, in session, when the client is using shallow criteria in which to judge another. The patient should eventually look to be able to do this themselves throughout their lives.

Insight- and cognitive-oriented approaches are generally largely ineffective in treatment of this disorder and should be avoided. People with this disorder are often incapable of examining unconscious motivations and their own thoughts to a degree where it is helpful. While these approaches can be a part of a larger treatment plan, they should not be the focus. Helping the client to examine interactions from a more objective point of view and emphasizing alternative explanations for behavior is likely to be more effective. Examining and clarifying a client’s emotions are also important components of therapy.

Clinicians will often experience reactions to treating this disorder, because of the dramatic nature of the patient. Because of this possibility, therapists should be more attuned to their own feelings within the therapy setting and ensure that they are treating the patient fairly and with respect. As with Borderline Personality Disorder, individuals with histrionic personality disorder often find themselves discriminated against by mental health professionals because of the symptoms of their disorder. Clinicians and patients should be aware of this possible discrimination.

 

Medications

As with most personality disorders, medications are not indicated except for the treatment of specific, concurrent Axis I diagnoses. Care should be given when prescribing medications to someone who suffers from histrionic personality disorder, though, because of the potential for using the medication to contribute to self-destructive or otherwise harmful behaviors.

 

Self-Help

There are not any self-help support groups or communities that we are aware of that would be conducive to someone suffering from this disorder. Such approaches would likely not be very effective because a person with this disorder is likely to be very dramatic in their interactions with others, coming across as “artificial” or shallow.