Histrionic personality disorder

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Histrionic personality disorder
Drama-icon.svg
Dramatic behavior is a key marker of histrionic personality disorder
Specialty Clinical Psychology, Psychiatry
Symptoms Persistent attention seeking, dramatic behavior, rapidly shifting and shallow emotions, sexually provocative behavior, undetailed style of speech, and a tendency to consider relationships more intimate than they actually are
Usual onsetSymptoms typically do not fully develop until late teens or early 20s
DurationLifelong
Causes Authoritarian parenting, highly responsive noradrenergic systems, genetics, childhood trauma
Diagnostic method Based on symptoms
Differential diagnosis Other personality disorders, substance abuse disorders, and personality change due to another medical condition
Treatment Functional analytic psychotherapy, functional ideographic assessment template, and coding client and therapist behaviors

Histrionic personality disorder (HPD) is a personality disorder characterized by a pattern of excessive attention-seeking behaviors, usually beginning in adolescence or early adulthood, including inappropriate seduction and an excessive desire for approval.

Contents

People with HPD have a high desire for attention, make loud and inappropriate appearances, exaggerate their behaviors and emotions, and crave stimulation. [1] They very often exhibit pervasive and persistent sexually provocative behavior, express strong emotions with an impressionistic style, and can be easily influenced by others. Associated features can include egocentrism, self-indulgence, continuous longing for appreciation, and persistent manipulative behavior to achieve their own wants.

Signs and symptoms

People diagnosed with HPD may be dramatic. [2] [3] [4] They often fail to see their own personal situation realistically, instead dramatizing and exaggerating their difficulties. Patients with this disorder can have rapidly shifting emotions and a decreased ability to recognize the emotions of others. [5] Their emotions may appear superficial or exaggerated to others. This disorder is associated with extraversion, [6] a lower tolerance for frustration or delayed gratification, [7] and openness to new experiences. People with HPD may have little self-doubt and often appear egocentric. [8]

Research has also shown those with histrionic personality have a greater desire for social approval and reassurance and will constantly seek it out, making those with HPD more vulnerable to social media addiction. [9] People with this disorder often display excessive sensitivity to criticism or disapproval. [10] They will work hard to get others to pay attention to them, [11] possibly as a method of testing the stability of relationships. [12] They may enjoy situations in which they can be the center of attention, and may feel uncomfortable when people are not paying attention to them. [6] People with this disorder may wear flamboyant clothing, try body modifications, [13] and fake medical conditions in an attempt to draw others' attention. [6] [14] They may be inappropriately sexually provocative, [15] [16] flirtatious, [6] [17] [18] or exploitative. [19] Sexually suggestive and exhibitionist behavior are also behaviors people with this condition sometimes exhibit, and are more likely to seek out casual sexual relationships. [20] When their desire for attention is not met, it can heighten the severity of their symptoms. [21]

Patients with HPD are usually high-functioning, both socially and professionally. They usually have good social skills, despite tending to use them to make themselves the center of attention. [6] HPD may also affect a person's social and romantic relationships, as well as their ability to cope with losses or failures. People with HPD tend to consider relationships closer than they usually are. [22] [23] [24] They may seek treatment for clinical depression when romantic (or other close personal) relationships end. [23] They may go through frequent job changes, as they become easily bored and may prefer withdrawing from frustration (instead of facing it). 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 clinical depression. [4] People with this condition can have an impressionistic and undetailed style of speech. [25]

Despite these traits, they can be prideful of their own personality, and may be unwilling to change, viewing any change as a threat. They may even blame their personal failures or disappointments on others. [26]

Causes

Little research has been done to find evidence of what causes histrionic personality disorder. Although direct causes are inconclusive, various theories and studies suggest multiple possible causes, of a neurochemical, genetic, psychoanalytic, or environmental nature. Traits such as extravagance, vanity, and seductiveness of hysteria have similar qualities to women diagnosed with HPD. [27] HPD symptoms typically do not fully develop until late teens or early 20s, [28] [29] while the onset of treatment only occurs, on average, at approximately 40 years of age. [30] [31]

Major character traits may be inherited, while other traits may be due to a combination of genetics and environment, including childhood experiences. [26]

Authoritarian parenting

There may be an association between having one or more parents with authoritarian or distant attitudes, and developing this disorder later in life. [32] [33]

Psychoanalytic theories incriminate authoritarian or distant attitudes by one (mainly the mother) or both parents, along with conditional love based on expectations the child can never fully meet. [1] Using psychoanalysis, Freud believed that lustfulness was a projection of the patient's lack of ability to love unconditionally and develop cognitively to maturity, and that such patients were overall emotionally shallow. [34] He believed the reason for being unable to love could have resulted from a traumatic experience, such as the death of a close relative during childhood or divorce of one's parents, which gave the wrong impression of committed relationships. Exposure to one or multiple traumatic occurrences of a close friend or family member's leaving (via abandonment or mortality) could make the person unable to form true and affectionate attachments towards other people. [35]

Neurochemical/physiological

Studies have shown that there is a strong correlation between the function of certain hormones, neurotransmitters, and the Cluster B personality disorders such as HPD. This seems to be especially evident with respect to the catecholamines. Individuals diagnosed with HPD have a highly responsive noradrenergic system, which is responsible for the synthesis, storage, and release of the neurotransmitter norepinephrine. High levels of norepinephrine lead to anxiety-proneness, dependency, novelty seeking, and high sociability. [30] [ medical citation needed ]

Genetic

Twin studies have aided in breaking down the genetic vs. environment debate. A twin study conducted by the Department of Psychology at the University of Oslo attempted to establish a correlation between genetics and Cluster B personality disorders. With a test sample of 221 twins, 92 monozygotic and 129 dizygotic, researchers interviewed the subjects using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and concluded that there was a correlation of 0.67 that histrionic personality disorder is hereditary. [36]

HPD and antisocial personality disorder

Another theory suggests a possible relationship between histrionic personality disorder and antisocial personality disorder. Research has found 2/3 of patients diagnosed with histrionic personality disorder also meet criteria similar to those of the antisocial personality disorder, [27] which suggests both disorders based towards sex-type expressions may have the same underlying cause.[ citation needed ]

Some family history studies have found that histrionic personality disorder, as well as antisocial and borderline personality disorders, tend to run in families, but it is unclear how much is due to genetic versus environmental factors. [37] Both examples suggest that predisposition could be a factor as to why certain people are diagnosed with histrionic personality disorder, however little is known about whether or not the disorder is influenced by any biological compound or is genetically inheritable. [37] Little research has been conducted to determine the biological sources, if any, of this disorder.

Diagnosis

The person's appearance, behavior and history, along with a psychological evaluation, are usually sufficient to establish a diagnosis. There is no test to confirm this diagnosis. Because the criteria are subjective, some people may be wrongly diagnosed. [38] [ medical citation needed ]

Assessment

In general clinical practice with assessment of personality disorders, one form of interview is the most popular: an unstructured interview. [39] The actual preferred method is a semi-structured interview but there is reluctance to use this type of interview because they can seem impractical or superficial. [39] The reason that a semi-structured interview is preferred over an unstructured interview is that semi-structured interviews tend to be more objective, systematic, replicable, and comprehensive. [39] Unstructured interviews, despite their popularity, tend to have problems with unreliability and are susceptible to errors leading to false assumptions of the patient. [39]

One of the single most successful methods for assessing personality disorders by researchers of normal personality functioning is the self-report inventory following up with a semi-structured interview. [39] A disadvantage to the self-report inventory method is that, with histrionic personality disorder, there is a distortion in character, self-presentation, and self-image. [39] This means that most clients cannot be assessed by simply asking them if they match the criteria for the disorder. [39] Most projective testing depends less on the ability or willingness of the person to provide an accurate description of the self, but there is currently limited empirical evidence on projective testing to assess histrionic personality disorder. [39]

Classification

Classification of personality disorders differs significantly between the two most prominent frameworks for classification of mental disorders, namely: the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, the most recent editions of which are the DSM-5-TR and ICD-11, respectively. While personality disorders, including HPD, are diagnosed as separate entities in the DSM-5; in the ICD-11 classification of personality disorders, they are assessed in terms of severity levels, with trait and pattern specifiers serving to characterize the particular style of pathology. [40] There is also a hybrid model, [41] called the Alternative DSM-5 model for personality disorders (AMPD), which defines personality disorder diagnoses through combinations of pathological traits and areas of overall impairment. [40]

In its categorical classification of personality disorders, located in section II, [42] the DSM-5 categorizes personality disorders into three clusters. Belonging to Cluster B, [43] HPD is characterized as a "pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts"; [44] it is operationalized through eight criteria, at least five of which must be met. [42] [44] While not listed as its own diagnostic entity in the AMPD, [45] what is conceptualized as histrionic personality disorder can instead be diagnosed as personality disorder – trait specified (PD-TS), [45] [42] which is a dimensional diagnosis that is constructed from the individual expression of personalty disorder, [46] as manifested in both a general impairment in personality functioning (criterion A) along with at least one pathological personality trait (criterion B). [47] It has been found that of these, the "traits most consistent with descriptions of HPD are attention seeking, separation insecurity, manipulativeness, emotional lability, intimacy avoidance (low), and restricted affectivity (low)." [42] PD-TS may not adequately cover HPD, as the AMPD does not cover "maladaptive interpersonal warmth". [42]

The World Health Organization's ICD-11 has replaced the categorical classification of personality disorders in the ICD-10, in which HPD was a distinct diagnostic category (F60.4), with a dimensional model containing a unified personality disorder (6D10) with severity specifiers, along with specifiers for prominent personality traits or patterns (6D11). [48] Severity is assessed based on the pervasiveness of impairment in several areas of functioning, as well as on the level of distress and harm caused by the disorder, [49] while trait and pattern specifiers are used for recording the manner in which the disturbance is manifested. [50] Histrionic personality disorder has been linked to moderate associations with the trait domains Dissociality (6D11.2), Disinhibition (6D11.3), and Negative Affectivity (6D11.0), reflecting tendencies toward emotional intensity, impulsivity, and a strong need for attention. [51] Some studies have also found inverse associations with Detachment (6D11.1), consistent with the highly expressive and socially engaged behavior typical of the disorder. [51]

Differential diagnosis

In order to find the most accurate diagnosis, a procedure of differential diagnosis is conducted. [52] There are several other conditions to consider, as they may appear similar to HPD. Other Cluster B personality disorders share features with HPD, particularly borderline (BPD) and narcissistic (NPD) personality disorders, with some characteristic features, however, facilitating telling them apart. [53] HPD also shares features with the mania and hypomania of bipolar disorder, such as excessive speech, grandiosity and hypersexuality, but HPD is different from these in its chronic nature, lack of decreased need for sleep, and it not responding well to medication. [53] Other conditions to consider are substance use disorders and personality change due to another medical condition, [44] as well as possibly illness anxiety disorder and somatic symptom disorder, as those who have these disorders "may use physical symptoms and complaints to signal distress". [53] Furthermore, the threshold for diagnosis is that the condition must be dysfunctional, distressing, maladaptive and temporally stable; histrionic traits may otherwise not be pathological. [44]

While HPD and BPD share features such as splitting, [53] manipulative behavior, emotional lability, [44] impulsivity, [53] and attention-seeking, characteristics of BPD such as feelings of emptiness and self-destructive behavior may serve to distinguish between them. [44] [53] In the case of NPD, the two disorders also involve a strong desire for attention; however, while people with HPD may employ vulnerability to solicit this attention, those with NPD desire admiration. [44] A "tendency to be impulsive, superficial, excitement seeking, reckless, seductive, and manipulative" is also characteristic of antisocial personality disorder (ASPD), but they differ in that people with ASPD engage in antisocial behavior, as well as manipulation in order to "gain profit, power, or some other material gratification". People with HPD, on the other hand, are driven to manipulate by a desire for nurturance, and they "tend to be more exaggerated in their emotions". [44] That tendency also serves to differentiate HPD from dependent personality disorder. [44]

Millon's subtypes

In 2000, Theodore Millon suggested six subtypes of histrionic personality disorder. Any individual histrionic may exhibit one or more of the following: [54]

SubtypeFeaturesTraits
Appeasing histrionicIncluding dependent and compulsive featuresSeeks to placate, mend, patch up, smooth over troubles; knack for settling differences, moderating tempers by yielding, compromising, conceding; sacrifices self for commendation; fruitlessly placates the unplacatable.
Vivacious histrionicIncluding hypomanic features, and possibly narcissistic featuresVigorous, charming, bubbly, brisk, spirited, flippant, impulsive; seeks momentary cheerfulness and playful adventures; animated, energetic, ebullient.
Tempestuous histrionicIncluding negativistic featuresImpulsive, out of control; moody complaints, sulking; precipitous emotion, stormy, impassioned, easily wrought-up, periodically inflamed, turbulent.
Disingenuous histrionicIncluding antisocial featuresUnderhanded, double-dealing, scheming, contriving, plotting, crafty, false-hearted; egocentric, insincere, deceitful, calculating, guileful.
Theatrical histrionicVariant of "pure" patternAffected, mannered, put-on; postures are striking, eyecatching, graphic; markets self-appearance; is synthesized, stagy; simulates desirable/dramatic poses.
Infantile histrionicIncluding borderline featuresLabile, high-strung, volatile emotions; childlike hysteria and nascent pouting; demanding, overwrought; fastens and clutches to another; is excessively attached, hangs on, stays fused to and clinging.

Treatment

Treatment is often prompted by depression associated with dissolved relationships. Medication does little to affect the personality disorder, but may be helpful with symptoms such as depression. [38] [ failed verification ] Treatment for HPD itself involves psychotherapy, including cognitive therapy. [1]

Functional analytic psychotherapy

Another way to treat histrionic personality disorder after identification is through functional analytic psychotherapy. [55] The job of a functional analytic psychotherapist is to identify the interpersonal problems with the patient as they happen in session or out of session. [55] Initial goals of functional analytic psychotherapy are set by the therapist and include behaviors that fit the client's needs for improvement. [55] Functional analytic psychotherapy differs from the traditional psychotherapy due to the fact that the therapist directly addresses the patterns of behavior as they occur in-session. [55]

The in-session behaviors of the patient or client are considered to be examples of their patterns of poor interpersonal communication and to adjust their neurotic defenses. [55] To do this, the therapist must act on the client's behavior as it happens in real time and give feedback on how the client's behavior is affecting their relationship during therapy. [55] The therapist also helps the client with histrionic personality disorder by denoting behaviors that happen outside of treatment; these behaviors are termed "Outside Problems" and "Outside Improvements". [55] This allows the therapist to assist in problems and improvements outside of session and to verbally support the client and condition optimal patterns of behavior". [55] This then can reflect on how they are advancing in-session and outside of session by generalizing their behaviors over time for changes or improvement". [55]

Coding client and therapist behaviors

In these sessions there is a certain set of dialogue, or a script, that can be forced by the therapist for the client to give insight on their behaviors and reasoning. [55] Here is an example; [55] the conversation is hypothetical. T = therapist C = Client. This coded dialogue can be transcribed as:

Functional ideographic assessment template

Another example of treatment besides coding is functional ideographic assessment template. [55] The functional ideographic assessment template, also known as FIAT, was used as a way to generalize the clinical processes of functional analytic psychotherapy. [55] The template was made by a combined effort of therapists and can be used to represent the behaviors that are a focus for this treatment. [55] Using the FIAT therapists can create a common language to get stable and accurate communication results through functional analytic psychotherapy at the ease of the client; as well as the therapist. [55]

Prognosis

Histrionic personality disorder is typically lifelong. [53]

Those with HPD are more likely to look for multiple people for attention, which leads to marital problems due to jealousy and lack of trust from the other party. This makes them more likely to become divorced or separated once married. [56] They also have an increased risk of suicide. [57] [58]

Epidemiology

Prevalence

Reported prevalence rates for HPD vary by source, with studies having reported rates within a range from 0–3.2% among the general population. [42] [44] [59] In clinical populations, this rises to 1–6%; furthermore, more recent studies, as of 2020, have estimated this prevalence to fall within the range of 10–15%. [42]

Comorbidity

There is a high rate of comorbidity between HPD and other personality disorders; this applies especially to other personality disorders belonging to Cluster B – these being: antisocial, borderline and narcissistic PD [53] – as well as dependent personality disorder. This stems from overlap in features and criteria between HPD and the aforementioned PDs, such as the attention-seeking also seen in narcissistic PD and the recklessness seen in antisocial PD. [42] While someone may be diagnosed with all the personality disorders for which they are eligible per their respective specified criteria, the disorders may also be distinguished from each other based on the characteristics which are not shared (see § Differential diagnosis). [44]

Other comorbid conditions include: depression, [60] anxiety disorders, panic disorder, somatoform disorders, anorexia nervosa, substance use disorder [61] [62] (such as alcohol use disorder or opioid use disorder [63] [64] ), body dysmorphia, [65] [66] and attachment disorders, including reactive attachment disorder. [67]

Sex ratio

More women than men receive a diagnosis of HPD, but this may not reflect actual prevalence, with several findings indicating a similar prevalence for women and men. [43] [44] While the rate of diagnosis is four times higher among women, this may stem from bias, resulting in overdiagnosis among women and underdiagnosis among men. [53] Furthermore, a higher rate among women may be related to other factors, such as a greater amount of women than men in the clinical setting, [25] with the sex ratio not differing significantly from this ratio. [44]

Gender roles may play a role, with a suggested reason for the sex ratio in diagnosis being "societal norms where sexual forwardness is less acceptable for women". [53] In Marcie Kaplan's A Women's View of DSM-III, she argues that women are overdiagnosed due to HPD reflecting stereotypical femininity and expresses that even healthy women are often automatically diagnosed with HPD. [19] [25] It has been found that histrionic features are more common among both masculine men and feminine women. [15] Another issue frequently mentioned with regard to the sex ratio is the "less representative symptom presentation in males". [43]

See also

References

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