Histrionic personality disorder

Histrionic personality disorder (HPD) is defined by the American Psychiatric

Association as a personality disorder characterized by a pattern of excessive attention-
seeking behaviors, usually beginning in early childhood, including
inappropriate seduction and an excessive desire for approval. People diagnosed with the
disorder are said to be lively, dramatic, vivacious, enthusiastic, and flirtatious. Women
are diagnosed with HPD roughly 4 times as often as men. It affects 2–3% of the general
population and 10–15% in inpatient and outpatient mental health institutions.
HPD lies in the dramatic cluster of personality disorders. People with HPD have a high
desire for attention, make loud and inappropriate appearances, exaggerate their
behaviors and emotions, and crave stimulation. They may exhibit sexually provocative
behavior, express strong emotions with an impressionistic style, and can be easily
influenced by others. Associated features include egocentrism, self-indulgence,
continuous longing for appreciation, and persistent manipulative behavior to achieve their
own needs.

Signs and symptoms

People with HPD are usually high-functioning, both socially and professionally. They
usually have good social skills, despite tending to use them to manipulate others into
making them the center of attention. HPD may also affect a person's social
and romantic relationships, as well as their ability to cope with losses or failures. They
may seek treatment for clinical depression when romantic (or other close personal)
relationships end.
Individuals with HPD often fail to see their own personal situation realistically, instead
dramatizing and exaggerating their difficulties. They may go through frequent job
changes, as they become easily bored and may prefer withdrawing
from frustration (instead of facing it). 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 clinical depression.
Additional characteristics may include:

 Exhibitionist behavior
 Constant seeking of reassurance or approval
 Excessive sensitivity to criticism or disapproval
 Pride of own personality and unwillingness to change, viewing any change as a
threat
 Inappropriately seductive appearance or behavior of a sexual nature
 Using factitious somatic symptoms (of physical illness) or psychological disorders
to garner attention
 Craving 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
 Blaming personal failures or disappointments on others
 Being easily influenced by others, especially those who treat them approvingly
 Being overly dramatic and emotional
 Influenced by the suggestions of others
Some people with histrionic traits or personality disorder change their seduction
technique into a more maternal or paternal style as they age.

Mnemonic
A mnemonic that can be used to remember the characteristics of histrionic personality
disorder is shortened as "PRAISE ME":

 Provocative (or seductive) behavior

 Relationships are considered more intimate than they actually are
 Attention-seeking
 Influenced easily by others or circumstances
 Speech (style) wants to impress; lacks detail
 Emotional liability; shallowness
 Make-up; physical appearance is used to draw attention to self
 Exaggerated emotions; theatrical

Causes
Little research has been done to find evidence of what causes histrionic personality
disorder and from where it stems. Although direct causes are inconclusive, there are a
few theories and studies conducted that suggests there are multiple possible causes.
There are neurochemical, genetic, psychoanalytical, and environmental causes
contributing to histrionic personality disorder. Traits such as extravagance, vanity, and
seductiveness of hysteria have similar qualities to women diagnosed with HPD. HPD
symptoms do not fully develop until the age of 15 with treatment only beginning at
approximately 40 years of age.

Neurochemical/physiological
Studies have shown that there is a strong correlation between the function of
neurotransmitters and the Cluster B personality disorders such as HPD. Individuals
diagnosed with HPD have highly responsive noradrenergic systems which is responsible
for the synthesis, storage, and release of the neurotransmitter, norepinephrine. High
levels of norepinephrine leads to anxiety-proneness, dependency, and high sociability.

Genetic
Twin studies have aided in breaking down the genetic vs. environment debate. A twin
study conducted by the Department of Psychology at Oslo University attempted to
establish a correlation between genetic and Cluster B personality disorders. With a test
sample of 221 twins, 92 monozygotic and 129 dizygotic, researchers interviewed the
subjects using the Structured Clinical Interview for DSM-III-R Personality Disorders
(SCID-II) and concluded that there was a correlation of 0.67 that histrionic personality
disorder is hereditary.
Psychoanalytic theory
Though criticized as being unsupported by scientific evidence, psychoanalytic theories
incriminate authoritarian or distant attitudes by one (mainly the mother) or both parents,
along with conditional love based on expectations the child can never fully meet. Using
psychoanalysis, Freud believed that lustfulness was a projection of the patient's lack of
ability to love unconditionally and develop cognitively to maturity, and that such patients
were overall emotionally shallow. He believed the reason for being unable to love could
have resulted from a traumatic experience, such as the death of a close relative during
childhood or divorce of one's parents, which gave the wrong impression of committed
relationships. Exposure to one or multiple traumatic occurrences of a close friend or
family member's leaving (via abandonment or mortality) would make the person unable
to form true and affectionate attachments towards other people.

HPD and antisocial personality disorder

Another theory suggests a possible relationship between histrionic personality disorder
and antisocial personality disorder. Research has found 2/3 of patients diagnosed with
histrionic personality disorder also meet criteria similar to those of the antisocial
personality disorder, which suggests both disorders based towards sex-type expressions
may have the same underlying cause. Women are hyper sexualized in the media
consistently, ingraining thoughts that the only way women are to get attention is by
exploiting themselves, and when seductiveness isn't enough, theatrics are the next step
in achieving attention. Men can just as well be flirtatious towards multiple women yet feel
no empathy or sense of compassion towards them. They may also become the center of
attention by exhibiting the "Don Juan" macho figure as a role-play.
Some family history studies have found that histrionic personality disorder, as well as
borderline and antisocial personality disorders, tend to run in families, but it is unclear if
this is due to genetic or environmental factors. Both examples suggest that predisposition
could be a factor as to why certain people are diagnosed with histrionic personality
disorder, however little is known about whether or not the disorder is influenced by any
biological compound or is genetically inheritable. Little research has been conducted to
determine the biological sources, if any, of this disorder.

Diagnosis
The person's appearance, behavior and history, along with a psychological evaluation,
are usually sufficient to establish a diagnosis. There is no test to confirm this diagnosis.
Because the criteria are subjective, some people may be wrongly diagnosed.

DSM 5
The current edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM 5,
defines histrionic personality disorder (in 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
The DSM 5 requires that a diagnosis for 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:
A personality disorder characterized by:

 shallow and labile affectivity,

 self-dramatization,
 theatricality,
 exaggerated expression of emotions,
 suggestibility,
 egocentricity,
 self-indulgence,
 lack of consideration for others,
 easily hurt feelings, and
 Continuous seeking for appreciation, excitement and attention.
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also
satisfies a set of general personality disorder criteria.

Comorbidity
Most histrionics also have other mental disorders. Comorbid conditions
include: antisocial, dependent, borderline, and narcissistic personality disorders, as well
as depression, anxiety disorders, panic disorder, somatoform disorders, anorexia
nervosa, substance use disorder and attachment disorders, including reactive attachment
disorder.

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

Subtype Description Personality Traits

Seeks to placate, mend, patch

up, smooth over troubles;
knack for settling differences,
Appeasing Including dependent moderating tempers by
histrionic and compulsive features yielding, compromising,
conceding; sacrifices self for
commendation; fruitlessly
placates the unpalatable.

Vivacious The seductiveness of the histrionic Vigorous, charming, bubbly,

histrionic mixed with the energy typical brisk, spirited, flippant,
of hypomania. Some narcissistic impulsive; seeks momentary
features can also be present cheerfulness and playful
adventures; animated,
 energetic, ebullient.

Impulsive, out of control;

moody complaints, sulking;
Tempestuous precipitous emotion, stormy,
Including negativistic features
histrionic impassioned, easily wrought-
up, periodically inflamed,
turbulent.

Underhanded, double-dealing,
scheming, contriving, plotting,
Disingenuous
Including antisocial features crafty, false-hearted;
histrionic
egocentric, insincere, deceitful,
calculating, guileful.

Affected, mannered, put-on;

postures are striking, eye-
Theatrical catching, graphic; markets self-
Variant of “pure” pattern
histrionic appearance; is synthesized,
stagy; simulates
desirable/dramatic poses.

Labile, high-strung, volatile

emotions; childlike hysteria
and nascent pouting;
Infantile demanding, overwrought;
Including borderline features
histrionic fastens and clutches to
another; is excessively
attached, hangs on, stays
fused to and clinging.

Treatment
Treatment is often prompted by depression associated with dissolved romantic
relationships. Medication does little to affect the personality disorder, but may be helpful
with symptoms such as depression. The only successful method studied and proven to
succeed is to fully break contact with their lovers in order to gain a sense of stability and
independence once again. Treatment for HPD itself involves psychotherapy,
including cognitive therapy.

Interviews and self-report methods

In general clinical practice with assessment of personality disorders, one form of
interview is the most popular; an unstructured interview. The actual preferred method is
a semi-structured interview but there is reluctance to use this type of interview because
they can seem impractical or superficial. The reason that a semi-structured interview is
preferred over an unstructured interview is that semi-structured interviews tend to be
more objective, systematic, replicable, and comprehensive. Unstructured interviews,
despite their popularity, tend to have problems with unreliability and are susceptible to
errors leading to false assumptions of the client.
One of the single most successful methods for assessing personality disorders by
researchers of normal personality functioning is the self-report inventory following up with
a semi-structured interview. There are some disadvantages with the self-report inventory
method that with histrionic personality disorder there is a distortion in character, self-
presentation, and self-image. This cannot be assessed simply by asking most clients if
they match the criteria for the disorder. Most projective testing depend less on the ability
or willingness of the person to provide an accurate description of the self, but there is
currently limited empirical evidence on projective testing to assess histrionic personality
disorder.

Functional analytic psychotherapy

Another way to treat histrionic personality disorder after identification is through functional
analytic psychotherapy. The job of a Functional Analytic Psychotherapist is to identify the
interpersonal problems with the patient as they happen in session or out of session. Initial
goals of functional analytic psychotherapy are set by the therapist and include behaviors
that fit the client's needs for improvement. Functional analytic psychotherapy differs from
the traditional psychotherapy due to the fact that the therapist directly addresses the
patterns of behavior as they occur in-session.
The in-session behaviors of the patient or client are considered to be examples of their
patterns of poor interpersonal communication and to adjust their neurotic defenses. To
do this, the therapist must act on the client's behavior as it happens in real time and
give feedback on how the client's behavior is affecting their relationship during
therapy. The therapist also helps the client with histrionic personality disorder by denoting
behaviors that happen outside of treatment; these behaviors are termed "Outside
Problems" and "Outside Improvements". This allows the therapist to assist in problems
and improvements outside of session and to verbally support the client and condition
optimal patterns of behavior". This then can reflect on how they are advancing in-session
and outside of session by generalizing their behaviors over time for changes or
improvement".

Coding client and therapist behaviors

This is called coding client and therapist behavior. In these sessions there is a certain set
of dialogue or script that can be forced by the therapist for the client to give insight on
their behaviors and reasoning". Here is an example from" the conversation is
hypothetical. T = therapist C = Client This coded dialogue can be transcribed as:

 ECRB – Evoking clinically relevant behavior

o T: Tell me how you feel coming in here today (CRB2) C: Well, to be
honest, I was nervous. Sometimes I feel worried about how things will go, but I
am really glad I am here.
 CRB1 – In-session problems
o C: Whatever, you always say that (Becomes quiet). I don’t know what I
am doing talking so much.
 CRB2 – In-session improvements
 TCRB1 – Clinically relevant response to client problems
o T: Now you seem to be withdrawing from me. That makes it hard for me
to give you what you might need from me right now. What do you think you want
from me as we are talking right now?”
 TCRB2 – Responses to client improvement
o T: That’s great. I am glad you’re here, too. I look forward to talking to you.
Functional ideographic assessment template
Another example of treatment besides coding is functional ideographic assessment
template. The functional ideographic assessment template, also known as FIAT, was
used as a way to generalize the clinical processes of functional analytic
psychotherapy. The template was made by a combined effort of therapists and can be
used to represent the behaviors that are a focus for this treatment. Using the FIAT
therapists can create a common language to get stable and accurate communication
results through functional analytic psychotherapy at the ease of the client; as well as the
therapist.

Epidemiology
The survey data from the National epidemiological survey from 2001–2002 suggests a
prevalence of HPD of 1.84 percent. Major character traits may be inherited, while other
traits may be due to a combination of genetics and environment, including childhood
experiences. This personality is seen more often in women than in men. Approximately
65% of HPD diagnoses are women while 35% are men. In Marcie Kaplan's A Women's
View of DSM-III, she argues that women are over diagnosed due to potential biases and
expresses that even healthy women are often automatically diagnosed with HPD.
Many symptoms representing HPD in the DSM are exaggerations of traditional feminine
behaviors. In a peer and self-review study, it showed that femininity was correlated with
histrionic, dependent and narcissistic personality disorders. Although two thirds of HPD
diagnoses are female, there have been a few exceptions. Whether or not the rate will be
significantly higher than the rate of women within a particular clinical setting depends
upon many factors that are mostly independent of the differential sex prevalence for
HPD. Those with HPD are more likely to look for multiple people for attention, which
leads to marital problems due to jealousy and lack of trust from the other party. This
makes them more likely to become divorced or separated once married. With few studies
done to find direct causations between HPD and culture, cultural and social aspects play
a role in inhibiting and exhibiting HPD behaviors.

History

Although it is said that the history of histrionic personality disorder stems from the
word hysteria, actually it comes from Etruscan histrio which means an actor. Hysteria can
be described as an exaggerated or uncontrollable emotion that people, especially in
groups, experience. Beliefs about hysteria have varied throughout time. It wasn’t
until Sigmund Freud who studied histrionic personality disorder in a psychological
manner. “The roots of histrionic personality can be traced to cases of hysterical neurosis
described by Freud.” He developed the psychoanalytic theory in the late 19th century and
the results from his development led to split concepts of hysteria. One concept labeled as
hysterical neurosis (also known as conversion disorder) and the other concept labeled as
hysterical character (currently known as histrionic personality disorder). These two
concepts must not be confused with each other, as they are two separate and different
ideas.
Histrionic personality disorder is also known as hysterical personality. Hysterical
personality has evolved in the past 400 years and it first appeared in the DSM II
(Diagnostic and Statistical Manual of Mental Disorders, 2nd edition) under the name
hysterical personality disorder. The name we know today as histrionic personality
disorder is due to the name change in DSM III, third edition. Renaming hysterical
personality to histrionic personality disorder is believed to be because of possible
negative connotations to the roots of hysteria, such as intense sexual expressions,
demon possessions, etc.
Histrionic personality disorder has gone through many changes. From hysteria, to
hysterical character, to hysterical personality disorder, to what it is listed as in the most
current DSM, DSM-5. "Hysteria is one of the oldest documented medical disorders.”
Hysteria dates back to both ancient Greek and Egyptian writings. Most of the writings
related hysteria and women together, similar to today where the epidemiology of
histrionic personality disorder is generally more prevalent in women and also frequently
diagnosed in women.

Ancient time
 Ancient Egypt – first description of the mental disorder, hysteria, dates back to
1900 BC in Ancient Egypt. Biological issues, such as the uterus movement in the
female body, were seen as the cause of hysteria. Traditional symptoms and
descriptions of hysteria can be found in the Ebers Papyrus, the oldest medical
document.
 Ancient Greece – Similar to ancient Egyptians, the ancient Greeks saw hysteria
being related to the uterus. Hippocrates (5th century BC) is the first to use the term
hysteria. Hippocrates believed hysteria was a disease that lies in the movement of
uterus (from the Greek hystera "uterus"). Hippocrates’s theory was that since a
woman’s body is cold and wet compared to a man’s body which is warm and dry, the
uterus is prone to illness, especially if deprived from sex. He saw sex as the
cleansing of the body so that being overemotional was due to sex deprivation.
 According to History Channel's Ancients Behaving
Badly, Cleopatra and Nero had histrionic personality disorder.
Middle Ages
 The Trotula – a group of three texts from the 12th century—discusses women’s
diseases and disorders as understood during this time period, including
hysteria. Trota of Salerno, a female medical practitioner from 12th-century Italy, is an
authoritative figure behind one of the texts of the Trotula. (Authoritative in that it is
her treatments and theories that are presented in the text). Some people believe
Trota's teachings resonated with those of Hippocrates.
Renaissance
 The uterus was still the explanation of hysteria, the concept of women being
inferior to men was still present, and hysteria was still the symbol for femininity.
Modern age

 Thomas Willis (17th century) introduces a new concept of hysteria. Thomas Willis

believed that the causes of hysteria was not linked to the uterus of the female, but to
the brain and nervous system.

 Hysteria was consequence of social conflicts during the Salem witch trials.

 Witchcraft and sorcery was later considered absurd during the Age of
Enlightenment in the late 17th century and 18th century. Hysteria starts to form in a
more scientific way, especially neurologically. New ideas formed during this time and
one of them was that if hysteria is connected to the brain, men could possess it too,
not just women.
 Franz Mesmer (18th century) treated patients suffering from hysteria with his
method called mesmerism, or animal magnetism.
 Jean-Martin Charcot (19th century) studied effects of hypnosis in hysteria.
Charcot states that hysteria is a neurological disorder and that it is actually very
common in men.
Contemporary age
 Sigmund Freud's work with Josef Breuer, Studies on Hysteria, contributes to
a psychoanalytic theory of hysteria.
 Freud believed that hysteria was caused by a lack of libidinal evolution.
Social implications
The prevalence of histrionic personality disorder in women is apparent and urges a re-
evaluation of cultural notions of normal emotional behavior. The diagnostic approach
classifies histrionic personality disorder behavior as “excessive”, considering it in
reference to a social understanding of normal emotionality.