Histrionic Personality Disorder
Melissa Arthur LCSW MA
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
Researchers have found that HPD appears primarily in men and women with above-average physical appearances. Some research has suggested that the connection between HPD and physical appearance holds for women rather than for men. Both women and men with HPD express a strong need to be the center of attention. Individuals with HPD exaggerate, throw temper tantrums, and cry if they are not the center of attention. Patients with HPD are naive, gullible, have a low frustration threshold, and strong dependency needs.
- A condition with onset at or before adolescence characterized by persistent patterns of dysfunctional behavior (excessive emotionality & attention seeking) deviating from one's culture and social environment that lead to functional impairment and distress to the individual and those who have regular interaction with the individual.
- Behaviors are perceived by the patient to be "normal" and "right" and they have little insight as to their responsibility for these behaviors.
- Condition is classified based on the predominant symptoms and their severity.
- Cluster B Personality Disorder (inclusive of antisocial, borderline, histrionic and narcissistic personality disorders) characterized by a pervasive pattern of excessive emotionality and attention seeking, present in a variety of contexts (5 or more symptom patterns to diagnose) (1C):
- Shows self-dramatization, theatricality, and exaggerated expressions of emotion
- Is suggestible, i.e., easily influenced by others or circumstances
- Uncomfortable when not center of attention
- Interaction with others is often characterized by inappropriate sexually seductive behavior
- Rapidly shifting and shallow expression of emotion
- Draws attention through physical appearance
- Has a style of speech that is excessively impressionistic and lacks detail
- Considers relationships more intimate than they are (1C)
- Starts in adolescence and early twenties and persists throughout one's life in the absence of treatment.(1C)
- 2-3% general population(1C)
- Tends to be identified more frequently in females(1C)
- Major character traits may be inherited
- Other character traits due to a combination of genetics and environment including adverse childhood experiences
Individuals who have experienced pervasive trauma during childhood have been shown to be at a greater risk for developing HPD as well as for developing other personality disorders.
HPD may be diagnosed more frequently in Hispanic and Latin-American cultures and less frequently in Asian cultures. Further research is needed on the effects of culture upon the symptoms of HPD.
Environmental and genetic factors including adverse childhood experiences including lack of parental attention.
There is a lack of research on the causes of HPD. Even though the causes for the disorder are not definitively known, it is thought that HPD may be caused by biological, developmental, cognitive, and social factors.
NEUROCHEMICAL/PHYSIOLOGICAL CAUSES. Studies show that patients with HPD have highly responsive noradrenergic systems, the mechanisms surrounding the release of a neurotransmitter called norepinephrine. Neurotransmitters are chemicals that communicate impulses from one nerve cell to another in the brain, and these impulses dictate behavior. The tendency towards an excessively emotional reaction to rejection, common among patients with HPD, may be attributed to a malfunction in a group of neurotransmitters called catecholamines. (Norepinephrine belongs to this group of neurotransmitters.)
DEVELOPMENTAL CAUSES. Psychoanalytic theory, developed by Freud, outlines a series of psychosexual stages of development through which each individual passes. These stages determine an individual's later psychological development as an adult. Early psychoanalysts proposed that the genital phase, Freud's fifth or last stage of psychosexual development, is a determinant of HPD. Later psychoanalysts considered the oral phase, Freud's first stage of psychosexual development, to be a more important determinant of HPD. Most psychoanalysts agree that a traumatic childhood contributes towards the development of HPD. Some theorists suggest that the more severe forms of HPD derive from disapproval in the early mother-child relationship.
Another component of Freud's theory is the defense mechanism. Defense mechanisms are sets of systematic, unconscious methods that people develop to cope with conflict and to reduce anxiety. According to Freud's theory, all people use defense mechanisms, but different people use different types of defense mechanisms. Individuals with HPD differ in the severity of the maladaptive defense mechanisms they use. Patients with more severe cases of HPD may utilize the defense mechanisms of repression, denial, and dissociation.
- Repression. Repression is the most basic defense mechanism. When patients' thoughts produce anxiety or are unacceptable to them, they use repression to bar the unacceptable thoughts or impulses from consciousness.
- Denial. Patients who use denial may say that a prior problem no longer exists, suggesting that their competence has increased; however, others may note that there is no change in the patients' behaviors.
- Dissociation. When patients with HPD use the defense mechanism of dissociation, they may display two or more personalities. These two or more personalities exist in one individual without integration. Patients with less severe cases of HPD tend to employ displacement and rationalization as defenses.
- Displacement occurs when a patient shifts an affect from one idea to another. For example, a man with HPD may feel angry at work because the boss did not consider him to be the center of attention. The patient may displace his anger onto his wife rather than become angry at his boss.
- Rationalization occurs when individuals explain their behaviors so that they appear to be acceptable to others.
BIOSOCIAL LEARNING CAUSES. A biosocial model in psychology asserts that social and biological factors contribute to the development of personality. Biosocial learning models of HPD suggest that individuals may acquire HPD from inconsistent interpersonal reinforcement offered by parents. Proponents of biosocial learning models indicate that individuals with HPD have learned to get what they want from others by drawing attention to themselves.
SOCIOCULTURAL CAUSES. Studies of specific cultures with high rates of HPD suggest social and cultural causes of HPD. For example, some researchers would expect to find this disorder more often among cultures that tend to value uninhibited displays of emotion.
PERSONAL VARIABLES. Researchers have found some connections between the age of individuals with HPD and the behavior displayed by these individuals. The symptoms of HPD are long-lasting; however, histrionic character traits that are exhibited may change with age. For example, research suggests that seductiveness may be employed more often by a young adult than by an older one. To impress others, older adults with HPD may shift their strategy from sexual seductiveness to a paternal or maternal seductiveness. Some histrionic symptoms such as attention-seeking, however, may become more apparent as an individual with HPD ages.
- Anxiety disorders
- Panic disorder
- Somatization disorders
- Body dysmorphic disorder (strong emphasized on physical appearance)
- Post traumatic stress disorder including dissociative disorders
- substance abuse
- Other psychiatric disorders in patient and family members.
DSM IV Criteria
Diagnostic Code: 301.50
The diagnosis of HPD is complicated because it may seem like many other disorders, and also because it commonly occurs simultaneously with other personality disorders. The 1994 version of the DSM introduced the criterion of suggestibility and the criterion of overestimation of intimacy in relationships to further refine the diagnostic criteria set of HPD, so that it could be more easily recognizable. Prior to assigning a diagnosis of HPD, clinicians need to evaluate whether the traits evident of HPD cause significant distress. (The DSMrequires that the symptoms cause significant distress in order to be considered a disorder.) The diagnosis of HPD is frequently made on the basis of an individual's history and results from unstructured and semi-structured interviews.
Signs and symptoms
- Distress, excessive emotionality (2C)
- Impairment of social and/or occupational functioning(2C)
- Not due to direct physiological effects of substance abuse, drug abuse, medication use or general medical conditions.
DSM-IV-TRlists eight symptoms that form the diagnostic criteria for HPD:
- Center of attention: Patients with HPD experience discomfort when they are not the center of attention.
- Sexually seductive: Patients with HPD displays inappropriate sexually seductive or provocative behaviors towards others.
- Shifting emotions: The expression of emotions of patients with HPD tends to be shallow and to shift rapidly.
- Physical appearance: Individuals with HPD consistently employ physical appearance to gain attention for themselves.
- Speech style: The speech style of patients with HPD lacks detail. Individuals with HPD tend to generalize, and when these individuals speak, they aim to please and impress.
- Dramatic behaviors: Patients with HPD display self-dramatization and exaggerate their emotions.
- Suggestibility: Other individuals or circumstances can easily influence patients with HPD.
- Overestimation of intimacy: Patients with HPD overestimate the level of intimacy in a relationship.
- Comprehensive interview and mental status examination
- Family session to assess persistent pattern of behavior
- Psychological testing, e.g., MMPI-II
- CT scan and MRI of the brain may be necessary in newly developed symptoms in the absence of a triggering event to rule out the rare instance of organic brain disease.
- Narcissistic Personality Disorder
- Somatization Disorder
- Borderline Personality Disorder
- Substance Abuse
- Can co-occur with Borderline, Narcissistic, Antisocial, and Dependent Personality disorders
Differential diagnosis is the process of distinguishing one mental disorder from other similar disorders. For example, at times, it is difficult to distinguish between HPD and borderline personality disorder. Suicide attempts, identity diffusion, and numerous chaotic relationships occur less frequently, however, with a diagnosis of HPD. Another example of overlap can occur between HPD and dependent personality disorder. Patients with HPD and dependent personality disorder share high dependency needs, but only dependent personality disorder is linked to high levels of self-attributed dependency needs. Whereas patients with HPD tend to be active and seductive, individuals with dependent personality disorder tend to be subservient in their demeanor.
In addition to the interviews mentioned previously, self-report inventories and projective tests can also be used to help the clinician diagnose HPD. The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and the Millon Clinical Mutiaxial Inventory-III (MCMI-III) are self-report inventories with a lot of empirical support. Results of intelligence examinations for individuals with HPD may indicate a lack of perseverance on arithmetic or on tasks that require concentration.
- In patients who have attempted overdose, transport all appropriate pill bottles to hospital
- Appropriate psychiatric security measures should be in place to prevent lethality.
- Emphasize importance of basic nutritional guidelines. No known special diet.
- Exercise as a means of reducing stress.
HPD, like other personality disorders, may require several years of therapy and may affect individuals throughout their lives. Some professionals believe that psychoanalytic therapy is a treatment of choice for HPD because it assists patients to become aware of their own feelings. Long-term psychodynamic therapy needs to target the underlying conflicts of individuals with HPD and to assist patients in decreasing their emotional reactivity. Therapists work with thematic dream material related to intimacy and recall. Individuals with HPD may have difficulty recalling because of their tendency to repress material.
Cognitive therapy is a treatment directed at reducing the dysfunctional thoughts of individuals with HPD. Such thoughts include themes about not being able to take care of oneself. Cognitive therapy for HPD focuses on a shift from global, suggestible thinking to a more methodical, systematic, and structured focus on problems. Cognitive-behavioral training in relaxation for an individual with HPD emphasizes challenging automatic thoughts about inferiority and not being able to handle one's life. Cognitive-behavioral therapy teaches individuals with HPD to identify automatic thoughts, to work on impulsive behavior, and to develop better problem-solving skills. Behavioral therapists employ assertiveness training to assist individuals with HPD to learn to cope using their own resources. Behavioral therapists use response cost to decrease the excessively dramatic behaviors of these individuals. Response cost is a behavioral technique that involves removing a stimulus from an individual's environment so that the response that directly precedes the removal is weakened. Behavioral therapy for HPD includes techniques such as modeling and behavioral rehearsal to teach patients about the effect of their theatrical behavior on others in a work setting.
Group therapy is suggested to assist individuals with HPD to work on interpersonal relationships. Psychodrama techniques or group role play can assist individuals with HPD to practice problems at work and to learn to decrease the display of excessively dramatic behaviors. Using role-playing, individuals with HPD can explore interpersonal relationships and outcomes to understand better the process associated with different scenarios. Group therapists need to monitor the group because individuals with HPD tend to take over and dominate others.
To teach assertion rather than avoidance of conflict, family therapists need to direct individuals with HPD to speak directly to other family members. Family therapy can support family members to meet their own needs without supporting the histrionic behavior of the individual with HPD who uses dramatic crises to keep the family closely connected. Family therapists employ behavioral contracts to support assertive behaviors rather than temper tantrums.
- No known drug to treat personality disorder, however, medications can reduce symptoms (3C) associated with the Axis I Disorders such as Mood disorders (Anti-depressants: SSRIs) and Anxiety disorders (Anxiolytics: benzodiazepines, buspirone, and the SSRIs) (3C)
Pharmacotherapy is not a treatment of choice for individuals with HPD unless HPD occurs with another disorder. For example, if HPD occurs with depression, antidepressants may be prescribed. Medication needs to be monitored for abuse.
Meditation has been used to assist extroverted patients with HPD to relax and to focus on their own inner feelings. Some therapists employ hypnosis to assist individuals with HPD to relax when they experience a fast heart rate or palpitations during an expression of excessively dramatic, emotional, and excitable behavior.
Many people with this disorder are able to function well socially and at work. Those with severe cases, however, might experience significant problems in their daily lives.
The personality characteristics of individuals with HPD are long-lasting. Individuals with HPD utilize medical services frequently, but they usually do not stay in psychotherapeutic treatment long enough to make changes. They tend to set vague goals and to move toward something more exciting. Treatment for HPD can take a minimum of one to three years and tends to take longer than treatment for disorders that are not personality disorders, such as anxiety disorders or mood disorders.
As individuals with HPD age, they display fewer symptoms. Some research suggests that the difference between older and younger individuals may be attributed to the fact that older individuals have less energy.
Research indicates that a relationship exists between poor treatment outcomes and premature termination from treatment for individuals with Cluster B personality disorders. Some researchers suggest that studies that link HPD to continuation in treatment need to consider the connection between overestimates of intimacy and premature termination from therapy.
Although prevention of the disorder might not be possible, treatment can allow a person who is prone to this disorder to learn more productive ways of dealing with situations.
Early diagnosis can assist patients and family members to recognize the pervasive pattern of reactive emotion among individuals with HPD. Educating people, particularly mental health professionals, about the enduring character traits of individuals with HPD may prevent some cases of mild histrionic behavior from developing into full-blown cases of maladaptive HPD. Further research in prevention needs to investigate the relationship between variables such as age, gender, culture, and ethnicity and HPD.
- Unstable relationships with family, friends and coworkers.
- May be characterized by separations and divorces
- Disruptive work patterns (e.g. absenteeism, frequent job changes and decreased productivity)
- Increased demand for outpatient medical visits due to psychological condition andattention seeking behavior
- If the patient is on a pharmacological regime, initial monitoring should be frequent (every 2 weeks) to evaluate the effectiveness, potential side effects of medication, and suicidal ideation.
- In the absence of pharmacological treatment, frequent regular visits (every 4-6 weeks) will help prevent attention-seeking phone calls/visits.
- 301.5 Histrionic personality disorder
Synonyms and related keywords:
character disorder, sociopathy, sociopath, psychopathy, hysteria, paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, antisocial personality disorder, borderline personality disorder, histrionic personality disorder, narcissistic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder, OCD, Minnesota Multiphasic Personality Inventory, MMPI, psychiatric disorder, mood disorder, substance abuse, suicide, alcoholism, delusional disorder, schizophrenia, depression, obsessive-compulsive disorder, anxiety disorder, somatization disorder, posttraumatic stress disorder, bulimia, Anorexia Nervosa, social phobia
- American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th ed). Washington DC: American Psychiatric Association.
- Kraus G, Reynolds DJ. The "A-B-C's of the cluster B's: Identifying, understanding and treating cluster B personality disorders. Clinical Psychology Review 2001;21(3):345-373.
- Ward RK. Assessment and management of personality disorders. American Family Physician 2004;70(8):1505-1512.
- Beck AT, Freeman A: Dependent personality disorder, in Cognitive Therapy of Personality Disorders. New York, Guilford, 1990, pp 283-308
- Blacker KH, Tupin JP: Hysteria and hysterical structures: developmental and social theories, in Hysterical Personality Style and the Histrionic Personality Disorders. Edited by Horowitz M. Northvale, NJ, Jason Aronson, 1991, pp 15-66
- Gabbard G: Psychodynamic Psychiatry in Clinical Practice, 3rd Edition. Washington, DC, American Psychiatric Press, 2000
- Horowitz MJ: Stress Response Syndromes. Northvale, NJ, Jason Aronson, 1986
- Horowitz MJ: States of Mind: Configurational Analysis of Personality. New York, Plenum, 1987
- Horowitz MJ: Introduction to Psychodynamics: A New Synthesis. New York, Basic Books, 1988
- Horowitz MJ (ed): Hysterical Personality Style and the Histrionic Personality Disorder, Revised Edition. Northvale, NJ, Jason Aronson, 1991a
- Horowitz MJ: Person Schemas and Maladaptive Interpersonal Patterns. Chicago, IL, University of Chicago Press, 1991b
- Horowitz MJ: Formulation as a Basis for Planning Psychotherapy. Washington, DC, American Psychiatric Press, 1997
- Horowitz MJ: Cognitive Psychodynamics: From Conflict to Character. New York, Wiley, 1998
- Horowitz MJ, Marmar C, Krupnick J, et al: Personality Styles and Brief Psychotherapy. New York, Basic Books, 1984
- Horowitz MJ, Marmar C, Weiss D, et al: Comprehensive analysis of change after brief dynamic psychotherapy. Am J Psychiatry 143:582-589, 1986
- Mueller WJ, Aniskiewicz AS: Psychotherapeutic Intervention in Hysterical Disorders. Northvale, NJ, Jason Aronson, 1986