Histrionic Personality Disorder

Excessive emotionality and attention seeking of a pervasive nature characterizes the Histrionic Personality (HP). In some classification schemes, this disorder was termed Hysterical Personality (DSM IV, 1994). Lively and dramatic, this individual puts on a show for other people in order to gain attention for his/herself. But the attention is a facade. Another way to characterize the histrionic performer is to see him or her as playing a big dramatic game in order to deny intimacy and split off from the real self. In fact, the histrionic person may identify the false self as the real self and seek confirmation for his/her false performing self. But, in fact, while in the midst of a great performance, the Histrionic Personality (HP) actually vacates the real self and disappears. He or she is not there, or present in the moment. Only the actor, the actress, the clown, or the troublemaker is there. Even though some people may appear to be amused, they may experience the HP as being a bit crazy. The ICD-10 (1994, p. 230) describes the histrionic personality disorder as characterized by shallow and labile affect, self-dramatization, exaggerated expression of emotions, suggestibility, egocentricity, self-indulgence, and lack of consideration for others. These individuals may engage in inappropriate seductiveness and overconcern with physical attractiveness. They are easily hurt and seek continuous excitement, attention and appreciation. Frances, et.al. (1995, p. 373) describes individuals with HPD as manipulative, vain, and demanding. However, in addition to the focus on physical appeal, the authors note that there may also be a genetic association between somatization disorder and the histrionic personality disorder. Benjamin (1993, pp. 165-166) believes that HPD falls into two subtypes: 1) those who are flirtatious and focused on physical attractiveness, and 2) those who are concerned with somatic symptoms. The DSM-IV™ Axis II HPD emphasizes the flirtatious version. However, individuals with HPD will vary in the degree to which they are sexually seductive or concerned about physical symptoms.

People with Histrionic Personality Disorder have established a pattern of excessive drama, and drawing attention to themselves. The behavior is established in early adulthood. The condition is indicated by a combination of the following behaviors;

Histrionic personality disorder is one of a group of conditions called dramatic personality disorders.

• Must be the center of attention.
• Displays inappropriate sexually provocative behavior.
• Expressions of emotions that are shallow and unbelievable.
• Come across as fakes and phonies.
• Great emphasis on physical appearance to attract attention.
• Theatrical, exaggerates, and uses speech that is vague and lacking in detail.
• Easily swayed by others.
• Considers friendships and relationships to be far more intimate than they are.

Signs and Symptoms of Histrionic Personality Disorder

In many cases, people with histrionic personality disorder have good social skills; however, they tend to use these skills to manipulate others so that they can be the center of attention.

A person with this disorder might also:

• Be uncomfortable unless he or she is the center of attention
• Dress provocatively and/or exhibit inappropriately seductive or flirtatious behavior
• Shift emotions rapidly
• Act very dramatically, as though performing before an audience, with exaggerated emotions and expressions, yet appears to lack sincerity
• Be overly concerned with physical appearance
• Constantly seek reassurance or approval
• Be gullible and easily influenced by others
• Be excessively sensitive to criticism or disapproval
• Have a low tolerance for frustration and be easily bored by routine, often beginning projects without finishing them or skipping from one event to another
• Not think before acting
• Make rash decisions
• Be self-centered and rarely show concern for others
• Have difficulty maintaining relationships, often seeming fake or shallow in their dealings with others
• Threaten or attempt suicide to get attention

Causes Histrionic Personality Disorder

The exact cause of histrionic personality disorder is not known, but many mental health professionals believe that both learned and inherited factors play a role in its development. For example, the tendency for histrionic personality disorder to run in families suggests that a genetic susceptibility for the disorder might be inherited. However, the child of a parent with this disorder might simply be repeating learned behavior. Other environmental factors that might be involved include a lack of criticism or punishment as a child, positive reinforcement that is given only when a child completes certain approved behaviors, and unpredictable attention given to a child by his or her parent(s), all leading to confusion about what types of behavior earn parental approval.

People with the condition do not generally appear for treatment unless the "wheels have fallen off", or the behavior is severely limiting their ability to operate in a self supporting way. Because they are so needy, they are reluctant to cut off the therapy since they have a captive audience.

Histrionic personality disorder is classified by psychologists with the group of personality disorders characterized by overly dramatic, emotional, impulsive or erratic reactions.

The 2000 edition of this manual (the fourth edition text revision, also called the DSM-IV-TR) classifies HPD as a personality disorder. More specifically, HPD is classified as a Cluster B (dramatic, emotional, or erratic) personality disorder. The personality disorders which comprise Cluster B include histrionic, antisocial, borderline, and narcissistic.

People with histrionic personality disorder seek stimulation and novelty and easily become bored with routine situations and relationships. Their low tolerance for inactivity leads to hedonistic or impulsive actions. They tend to be preoccupied with their appearance and attractiveness, and their demeanor is often charming and seductive, even if this behavior is inappropriate. These individuals pursue a fast-paced social and romantic lifestyle, although their relationships usually are shallow and fleeting. They also tend to be dependent on others.

How Is Histrionic Personality Disorder Diagnosed?

If symptoms are present, the doctor will begin an evaluation by performing a complete medical history and physical examination. Although there are no laboratory tests to specifically diagnose personality disorders, the doctor might use various diagnostic tests to rule out physical illness as the cause of the symptoms.

If the doctor finds no physical reason for the symptoms, he or she might refer the person to a psychiatrist or psychologist, health care professionals who are specially trained to diagnose and treat mental illnesses. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a person for a personality disorder.

Relationships

The 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. The partner, as well as the HPD, will be caught in the vice of emotional instability, upheaval, divorce and dissatisfaction. So marital therapy or relationship counseling will have to be part of the treatment plan. Communication will also be a big issue in the symptom picture because the false self and its needs for safety, security and validation will dominate the personality and make real contact a very difficult thing to achieve. Married HPD's may unconsciously , in a low key, engage in ongoing verbal stabs at spouses and children. It is as if they are annoyed with the needs of others. One HP constantly threw small verbal jabs at his oedipal stage son, without being aware that these little stabs could eventually turn the child off to the father's later attempts to be loving and affectionate. The wife would witness these little jabs but they we not severe enough to arouse her to tell her husband about these little hurts. But she would become slowly aware of his abusive behavior and couldn't be intimate with him because of his jabbing behavior towards their child. Granted, the child may have been mildly annoying to the father, but not enough to warrant hostile reactivity in a normal parent-child relationship.

Diagnostic Features

The essential feature of Histrionic Personality Disorder is pervasive and excessive emotionality and attention-seeking behavior. This pattern begins by early adulthood and is present in a variety of contexts.

Individuals with Histrionic Personality Disorder are uncomfortable or feel unappreciated when they are not the center of attention (Criterion 1). Often lively and dramatic, they tend to draw attention to themselves and may initially charm new acquaintances by their enthusiasm, apparent openness, or flirtatiousness. These qualities wear thin, however, as these individuals continually demand to be the center of attention. They commandeer the role of "the life of the party." If they are not the center of attention, they may do something dramatic (e.g., make up stories, create a scene) to draw the focus of attention to themselves. This need is often apparent in their behavior with a clinician (e.g., flattery, bringing gifts, providing dramatic descriptions of physical and psychological symptoms that are replaced by new symptoms each visit).

The appearance and behavior of individuals with this disorder are often inappropriately sexually provocative or seductive (Criterion 2). This behavior is directed not only toward persons in whom the individual has a sexual or romantic interest, but occurs in a wide variety of social, occupational, and professional relationships beyond what is appropriate for the social context. Emotional expression may be shallow and rapidly shifting (Criterion 3). Individuals with this disorder consistently use physical appearance to draw attention to themselves (Criterion 4). They are overly concerned with impressing others by their appearance and expend an excessive amount of time, energy, and money on clothes and grooming. They may "fish for compliments" regarding appearance and be easily and excessively upset by a critical comment about how they look or by a photograph that they regard as unflattering.

These individuals have a style of speech that is excessively impressionistic and lacking in detail (Criterion 5). Strong opinions are expressed with dramatic flair, but underlying reasons are usually vague and diffuse, without supporting facts and details. For example, an individual with Histrionic Personality Disorder may comment that a certain individual is a wonderful human being, yet be unable to provide any specific examples of good qualities to support this opinion. Individuals with this disorder are characterized by self-dramatization, theatricality, and an exaggerated expression of emotion (Criterion 6). They may embarrass friends and acquaintances by an excessive public display of emotions (e.g., embracing casual acquaintances with excessive ardor, sobbing uncontrollably on minor sentimental occasions, or having temper tantrums). However, their emotions often seem to be turned on and off too quickly to be deeply felt, which may lead others to accuse the individual of faking these feelings.

Individuals with Histrionic Personality Disorder have a high degree of suggestibility (Criterion 7). Their opinions and feelings are easily influenced by others and by current fads. They may be overly trusting, especially of strong authority figures whom they see as magically solving their problems. They have a tendency to play hunches and to adopt convictions quickly. Individuals with this disorder often consider relationships more intimate than they actually are, describing almost every acquaintance as "my dear, dear friend" or referring to physicians met only once or twice under professional circumstances by their first names (Criterion 8). Flights into romantic fantasy are common.

Associated Features and Disorders

• Depressed Mood
• Somatic or Sexual Dysfunction
• Anxious or Fearful or Dependent Personality
• Dramatic or Erratic or Antisocial Personality

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. They 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.

The actual risk of suicide is not known, but clinical experience suggests that individuals with this disorder are at increased risk for suicidal gestures and threats to get attention and coerce better caregiving. Histrionic Personality Disorder has been associated with higher rates of Somatization Disorder, Conversion Disorder, and Major Depressive Disorder. Borderline, Narcissistic, Antisocial, and Dependent Personality Disorders often co-occur.

How Is Histrionic Personality Disorder Treated?

In general, people with histrionic personality disorder do not believe they need therapy. They also tend to exaggerate their feelings and to dislike routine, which makes following a treatment plan difficult. However, they might seek help if depression -- possibly associated with a loss or a failed relationship -- or another problem caused by their actions causes them distress.

Psychotherapy (a type of counseling) is generally the treatment of choice for histrionic personality disorder. The goal of treatment is to help the individual uncover the motivations and fears associated with his or her thoughts and behavior, and to help the person learn to relate to others in a more positive way.

Medication might be used to treat the distressing symptoms that might occur with this disorder, such as depression and anxiety.

Prevention

Mental health intervention may allow people who are prone to this condition to learn more effective ways of understanding and dealing with their needs.

Specific Culture, Age, and Gender Features

Norms for interpersonal behavior, personal appearance, and emotional expressiveness vary widely across cultures, genders, and age groups. Before considering the various traits (e.g., emotionality, seductiveness, dramatic interpersonal style, novelty seeking, sociability, charm, impressionability, and a tendency to somatization) to be evidence of Histrionic Personality Disorder, it is important to evaluate whether they cause clinically significant impairment or distress. In clinical settings, this disorder has been diagnosed more frequently in females; however, the sex ratio is not significantly different than the sex ratio of females within the respective clinical setting. In contrast, some studies using structured assessments report similar prevalence rates among males and females. The behavioral expression of Histrionic Personality Disorder may be influenced by sex role stereotypes. For example, a man with this disorder may dress and behave in a manner often identified as "macho" and may seek to be the center of attention by bragging about athletic skills, whereas a woman, for example, may choose very feminine clothes and talk about how much she impressed her dance instructor.

Prevalence

Limited data from general population studies suggest a prevalence of Histrionic Personality Disorder of about 2%-3%. Rates of about 10%-15% have been reported in inpatient and outpatient mental health settings when structured assessment is used.

Differential Diagnosis

Other Personality Disorders may be confused with Histrionic Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Histrionic Personality Disorder, all can be diagnosed. Although Borderline Personality Disorder can also be characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, it is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and identity disturbance. Individuals with Antisocial Personality Disorder and Histrionic Personality Disorder share a tendency to be impulsive, superficial, excitement seeking, reckless, seductive, and manipulative, but persons with Histrionic Personality Disorder tend to be more exaggerated in their emotions and do not characteristically engage in antisocial behaviors. Individuals with Histrionic Personality Disorder are manipulative to gain nurturance, whereas those with Antisocial Personality Disorder are manipulative to gain profit, power, or some other material gratification. Although individuals with Narcissistic Personality Disorder also crave attention from others, they usually want praise for their "superiority," whereas the individual with Histrionic Personality Disorder is willing to be viewed as fragile or dependent if this is instrumental in getting attention. Individuals with Narcissistic Personality Disorder may exaggerate the intimacy of their relationships with other people, but they are more apt to emphasize the "VIP" status or wealth of their friends. In Dependent Personality Disorder, the person is excessively dependent on others for praise and guidance, but is without the flamboyant, exaggerated, emotional features of Histrionic Personality Disorder.

Histrionic Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effects of a general medical condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified).

Many individuals may display histrionic personality traits. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute Histrionic Personality Disorder.

Diagnostic criteria for 301.50 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:

(1) is uncomfortable in situations in which he or she is not the center of attention

(2) interaction with others is often characterized by inappropriate sexually seductive or provocative behavior

(3) displays rapidly shifting and shallow expression of emotions

(4) consistently uses physical appearance to draw attention to self

(5) has a style of speech that is excessively impressionistic and lacking in detail

(6) shows self-dramatization, theatricality, and exaggerated expression of emotion

(7) is suggestible, i.e., easily influenced by others or circumstances

(8) considers relationships to be more intimate than they actually are

The use of the term "histrionic" by professional in psychology is relatively recent and replaces the term "hysterical," which has been dropped due to its negative and sexist associations. Women are more likely than men to be diagnosed with histrionic personality disorder, although this may at least partly reflect gender and cultural biases that cause this pattern of behavior to be less easily recognized in men. Individuals with histrionic personality disorder can benefit from psychodynamic therapy or group therapy. The latter can help by enabling these individuals to learn how they relate to others and try out new ways of relating. The goals for individuals who undergo therapy should include gaining more control over emotional reactions and understanding how their overly dramatic behavior undermines their relationships or careers. Medication is ineffective in treating histrionic personality disorder, although it might be prescribed for accompanying symptoms, such as anxiety or depression.

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