Histrionic personality disorder
Histrionic personality disorder
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Definition
Histrionic personality disorder, often abbreviated as HPD, is a type of
personality disorder in which the affected individual displays an enduring
pattern of attention-seeking and excessively dramatic behaviors beginning
in early adulthood and present across a broad range of situations.
Individuals with HPD are highly emotional, charming, energetic,
manipulative, seductive, impulsive, erratic, and demanding.
Mental health professionals use the
Diagnostic and Statistical Manual of Mental Disorders
) to diagnose mental disorders. The 2000 edition of this manual (the
fourth edition text revision, also called the
) classifies HPD as a personality disorder. More specifically, HPD is
classified as a Cluster B (dramatic, emotional, or erratic) personality
disorder. The
which comprise Cluster B include histrionic, antisocial, borderline, and
narcissistic.
Description
HPD has a unique position among the personality disorders in that it is
the only personality disorder explicitly connected to a patient's physical
appearance. 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.
Cognitive style can be defined as a way in which an individual works with
and solves cognitive tasks such as reasoning, learning, thinking,
understanding, making decisions, and using memory. The cognitive style of
individuals with HPD is superficial and lacks detail. In their
inter-personal relationships, individuals with HPD use dramatization with
a goal of impressing others. The enduring pattern of their insincere and
stormy relationships leads to impairment in social and occupational areas.
Causes and symptoms
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
, 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,
, 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 comp 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
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
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- 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.
lists 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.
Demographics
General United States population
The prevalence of HPD in the general population is estimated to be
approximately 2%-3%.
High-risk populations
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.
Cross-cultural issues
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.
Gender issues
Clinicians tend to diagnose HPD more f however, when
structured assessments are used to diagnose HPD, clinicians report
approximately equal prevalence rates for males and females. In considering
the prevalence of HPD, it is important to recognize that gender role
stereotypes may influence the behavioral display of HPD and that women and
men may display HPD symptoms differently.
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
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.
requires 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.
Time of onset/symptom duration
Some psychoanalysts propose that the determinants of HPD date back as
early as early childhood. The pattern of craving attention and displaying
dramatic behavior for an individual with HPD begins by early adulthood.
Symptoms can last a lifetime, but may decrease or change their form with
Individual variations in HPD
Some classification systems distinguish between different types of
individuals with HPD: patients with appeasing HPD and patients with
disingenuous HPD. Individuals with appeasing HPD have personalities with
histrionic, dependent, and obsessive-compulsive components. Individuals
with disingenuous HPD possess personality traits that are classified as
histrionic and antisocial. Studies have shown that relationships exist
between somatic behaviors and women with HPD and between antisocial
behaviors and men with HPD.
Dual diagnoses
HPD has been associated with alcoholism and with higher rates of
. Personality disorders such as borderline, narcissistic, antisocial, and
dependent can occur with HPD.
Differential diagnosis
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
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
. 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.
Psychological measures
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.
Treatments
Psychodynamic therapy
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-behavioral therapy
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
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
and behavioral rehearsal to teach patients about the effect of their
theatrical behavior on others in a work setting.
Group therapy
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.
Family therapy
To teach assertion rather than avoidance of conflict, family therapists
need to direct individuals with HPD to speak directly to other family
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.
Medications
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.
Alternative therapies
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.
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.
Prevention
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
American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders.
4th edition, text revised. Washington, DC: American Psychiatric
Association, 2000.
Bockian, Neil, Ph.D., and Arthur E. Jongsma, Jr., Ph.D.
The Personality Disorders Treatment Planner.
New York: Wiley, 2001.
Bornstein, Robert F. "Dependent and Histrionic Personality Disorders." In
Oxford Textbook of Psychopathology,
edited by Theodore Millon, Ph.D., Paul H. Blaney, and Roger D. Davis.
Oxford: Oxford University Press, 1999.
Widiger, Thomas A., Ph.D., and Robert F. Bornstein, Ph.D. "Histrionic,
Narcissistic, and Dependent Personality Disorders." In
Comprehensive Handbook of Psychopathology,
edited by Patricia B. Sutker and Henry E. Adams. 3rd edition. New York:
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PERIODICALS
Bornstein, Robert F. "Implicit and Self-Attributed Dependency Needs in
Dependent and Histrionic Personality Disorders."
Journal of Personality Assessment
71, no. 1 (1998): 1-14.
Bornstein, Robert F. "Histrionic Personality Disorder, Physical
Attractiveness, and Social Adjustment."
Journal of Psychopathology and Behavioral Assessment
21, no. 1 (1999): 79-94.
Hilsenroth, Mark J., Daniel, J. Holdwick, Jr., Frank D. Castlebury, and
Mark A. Blais. "The Effects of DSM-IV Cluster B Personality Disorder
Symptoms on the Termination and Continuation of Psychotherapy."
Psychotherapy
35, no. 2 (Summer 1998): 163-176.
ORGANIZATIONS
American Psychiatric Association. 1400 K Street NW, Washington D.C. 20005.
American Psychological Association. 750 First Street, NE, Washington, D.C.
. (202) 336-5500.
Judy Koenigsberg, Ph.D.
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