Histrionic personality disorder

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Overview
Histrionic personality disorder (HPD) is a personality disorder characterized by a pattern of excessive emotionality and attention-seeking, including an excessive need for approval and inappropriate seductiveness, usually beginning in early adulthood.

The essential feature of the histrionic personality disorder is an excessive pattern of emotionality and attention-seeking behavior. These individuals are lively, dramatic, enthusiastic, and flirtatious. They may be inappropriately sexually provocative, express strong emotions with an impressionistic style, and be easily influenced by others.

The literature differentiates HPD according to gender. Women with HPD are described as self-centered, self-indulgent, and intensely dependent on others. They are emotionally labile and cling to others in the context of immature relationships. Females with HPD over-identify with others; they project their own unrealistic, fantasied intentions onto people with whom they are involved. They are emotionally shallow and have difficulty understanding others or themselves in any depth. Selection of marital or sexual partners is often highly inappropriate. Most all partners chosen will have symptoms of personality diseases far worse than their own. Women with HPD often tend to enter into abusive relationships with partners who increase in the abuse as time wears on. Pathology increases with the level of intimacy in relationships. Women with HPD may show inappropriate and intense anger. They may engage in self-mutilation and/or manipulative suicide threats as one aspect of general manipulative interpersonal behavior.

Males with HPD usually present problems of identity crisis, disturbed relationships, and lack of impulse control. They have antisocial tendencies and are inclined to exploit physical symptoms. These men are emotionally immature, dramatic, and shallow. Both men and women with HPD engage in disinhibited behavior.

People with this disorder are usually able to function at a high level and can be successful socially and at work. 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 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. Responsibility for failure or disappointment is usually blamed on others. 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.

Causes
The cause of this disorder is unknown but childhood events and genetics may both be involved. Histrionic Personality Disorder is more rarely diagnosed in men than in women; men with some quite similar symptoms are often diagnosed with antisocial personality disorder. However, some psychologists argue that it is more often diagnosed in women for the simple reason that attention-seeking and sexual forwardness are considered to be less socially acceptable for women than for men.

Little research has been conducted to determine the biologic sources of this disorder. Psychoanalytic theories incriminate seductive and authoritarian attitudes by fathers of these patients.

Risk Factors
Genetics
 * Major character traits may be inherited
 * Other character traits due to a phenotypical combination of genetics and environment, including childhood experiences

Symptoms
The symptoms include:


 * Constant seeking of reassurance or approval.
 * Excessive dramatics with exaggerated displays of emotions.
 * Excessive sensitivity to criticism or disapproval.
 * Inappropriately seductive appearance or behavior.
 * Excessive concern with physical appearance.
 * A need to be the center of attention (self-centeredness).
 * Low tolerance for frustration or delayed gratification.
 * Rapidly shifting emotional states that may appear shallow to others.
 * Opinions are easily influenced by other people, but difficult to back up with details.
 * Tendency to believe that relationships are more intimate than they actually are.
 * Making rash decisions.
 * Threatening or attempting suicide to get attention.

Diagnosis
The person's appearance, behavior, and history, and 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.

Diagnostic criteria (DSM-IV-TR = 304.50)
The Diagnostic and Statistical Manual of Mental Disorders, a widely used manual for diagnosing mental disorders, defines histrionic personality disorder 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:
 * 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.

Diagnostic criteria (ICD-10)
The International Statistical Classification of Diseases defines histrionic personality disorder as characterized by:
 * 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 centre of attention;
 * inappropriate seductiveness in appearance or behaviour;
 * over-concern with physical attractiveness.

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

History of the DSM-IV diagnosis
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 witchery, 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 a controversy (see writings by Paul Chodoff on this topic).

"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.

Associated features may include egocentricity, self-indulgence, continuous longing for appreciation, feelings that are easily hurt, and persistent manipulative behaviour to achieve own needs.

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 aimed at self-development through resolution of conflict and advancement of inhibited developmental lines. Group therapy is not recommended for those with HPD because it often perpetuates histrionic behavior because the person then has an audience to play off of.


 * Family therapy
 * Medications
 * Alternative therapies

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.

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.

Associated conditions

 * Clinical depression
 * Anxiety disorders
 * Panic disorder
 * Somatoform disorders
 * Anorexia


 * A previous version of this text is from the US National Library of Medicine.