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Histrionic personality disorder

Histrionic personality disorder

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 (the DSM ) to diagnose mental disorders. 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.

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

Causes

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.

Symptoms

DSM-IV-TR 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 frequently in females; 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.

Diagnosis

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 DSM 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 age.

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 somatization disorder , conversion disorder , and major depressive disorder . 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 . 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.

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 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

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 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.

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.

Prognosis

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 and HPD.

See also Minnesota Multiphasic Personality Inventory

Resources

BOOKS

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: Kluwer Academic/Plenum Publishers, 2001.

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. <http://www.psych.org>.

American Psychological Association. 750 First Street, NE, Washington, D.C. 20002-4242. (202) 336-5500. <http://www.apa.org>.

Judy Koenigsberg, Ph.D.

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Histrionic Personality Disorder

Histrionic personality disorder

A maladaptive or inflexible pattern of behavior characterized by emotional instability, excitability, over-reactivity, and self-dramatization.

Individuals with histrionic personality disorder tend to seek attention by exaggerating events, even if insignificant, and are immature, self-centered and often vain. They react emotionally to the slightest provocation. Histrionic personality disorder is classified by psychologists with the group of personality disorders characterized by overly dramatic, emotional, impulsive or erratic reactions. 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.

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 .

Further Reading

Morrison, James. DSM-IV Made Easy: The Clinician's Guide to Diagnosis. New York: The Guilford Press, 1995.

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