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| Histrionic personality disorder | |
|---|---|
 | |
| Dramatic behavior is a key marker of histrionic personality disorder | |
| Specialty | Clinical Psychology,Psychiatry |
| Symptoms | Persistentattention seeking,dramatic behavior, rapidly shifting and shallow emotions,sexually provocative behavior, undetailedstyle of speech, and a tendency to consider relationships more intimate than they actually are |
| Usual onset | Symptoms typically do not fully develop until late teens or early 20s |
| Duration | Lifelong |
| 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 apersonality disorder characterized by a pattern of excessiveattention-seeking behaviors, usually beginning in adolescence or early adulthood, including inappropriateseduction and an excessive desire for approval. People diagnosed with the disorder are said to be lively, dramatic, vivacious, enthusiastic,extroverted, andflirtatious.
HPD is classified amongCluster B ("dramatic, emotional, or erratic") personality disorders in theDSM-5-TR.[1] People with HPD have a high desire for attention, make loud and inappropriate appearances,exaggerate their behaviors and emotions, and crave stimulation.[2] 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 includeegocentrism,self-indulgence, continuous longing for appreciation, and persistentmanipulative behavior to achieve their own wants.
| Personality disorders |
|---|
| DSM-5 classification |
Cluster A (odd or eccentric) Cluster B (dramatic, emotional, or erratic) Cluster C (anxious or fearful) Other personality disorders |
| ICD-11 classification |
Personality disorder Prominent traits or patterns |
| Others |
People diagnosed with HPD may bedramatic.[3][4][5] 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.[6] Their emotions may appear superficial or exaggerated to others. This disorder is associated withextraversion,[7] a lower tolerance for frustration ordelayed gratification,[8] andopenness to new experiences. People with HPD may have little self-doubt and often appear egocentric.[9]
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.[10] People with this disorder often display excessive sensitivity tocriticism or disapproval.[11] They will work hard to get others to pay attention to them,[12] possibly as a method of testing the stability of relationships.[13] 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.[7] People with this disorder may wear flamboyant clothing, trybody modifications,[14] andfake medical conditions in an attempt to draw others' attention.[7][15] They may be inappropriately sexually provocative,[16][17] flirtatious,[7][18][19] or exploitative.[20]Sexually suggestive andexhibitionist behavior are also behaviors people with this condition sometimes exhibit, and are more likely to seek out casual sexual relationships.[21] When their desire for attention is not met, it can heighten the severity of their symptoms.[22]
Patients with HPD are usually high-functioning, both socially and professionally. They usually have goodsocial skills, despite tending to use them to make themselves the center of attention.[7] HPD may also affect a person's social andromantic relationships, as well as their ability to cope with losses or failures. People with HPD tend to consider relationships closer than they usually are.[23][24][25] They may seek treatment forclinical depression when romantic (or other close personal) relationships end.[24]Substance disorders,[26] such asalcohol use disorder oropioid use disorder,[27][28] are all common in patients with histrionic personality disorder.[29][30] They are also at higher risks ofsuicide,[31][32]body dysmorphia (a preoccupation with perceived flaws in one's physical appearance),[33][34] anddivorce.[35] They may go through frequent job changes, as they become easily bored and may prefer withdrawing fromfrustration (instead of facing it). Because they tend to cravenovelty and excitement, they may place themselves in risky situations. All of these factors may lead to greater risk of developing clinical depression.[5] People with this condition can have an impressionistic and undetailed style of speech.[36]
Despite these traits, they can beprideful 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.[37]
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 ofhysteria have similar qualities to women diagnosed with HPD.[38] HPD symptoms typically do not fully develop until late teens or early 20s,[39][40] while the onset of treatment only occurs, on average, at approximately 40 years of age.[41][42]
Although 80% of diagnosed cases are in females,[citation needed] it may be equally prevalent or likely among men.[43] Little is known about how this disorder affects males,[citation needed] but it is thought that bias in the diagnosis of HPD may result in inadequate representation of males.[43]
There may be an association between having one or more parents with authoritarian or distant attitudes, and developing this disorder later in life.[44][45]
Psychoanalytic theories incriminateauthoritarian or distant attitudes by one (mainly the mother) or both parents, along with conditional love based on expectations the child can never fully meet.[2] 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.[46] 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.[47]
Studies have shown that there is a strong correlation between the function of certainhormones,neurotransmitters, and the Cluster B personality disorders such as HPD. This seems to be especially evident with respect to thecatecholamines. 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.[41][medical citation needed]
Twin studies have aided in breaking down thegenetic vs. environment debate. A twin study conducted by the Department of Psychology at theUniversity of Oslo attempted to establish a correlation between genetics and Cluster B personality disorders. With a test sample of 221 twins, 92monozygotic and 129dizygotic, researchers interviewed the subjects using theStructured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and concluded that there was acorrelation of 0.67 that histrionic personality disorder is hereditary.[29]
Another theory suggests a possible relationship between histrionic personality disorder andantisocial 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,[38] 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 andborderline personality disorders, tend to run in families, but it is unclear how much is due to genetic versus environmental factors.[48] 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.[48] Little research has been conducted to determine the biological sources, if any, of this disorder.
The person's appearance, behavior and history, along with apsychological 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.[49][medical citation needed]
In general clinical practice with assessment of personality disorders, one form of interview is the most popular: anunstructured interview.[50] The actual preferred method is asemi-structured interview but there is reluctance to use this type of interview because they can seem impractical or superficial.[50] 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.[50] Unstructured interviews, despite their popularity, tend to have problems with unreliability and are susceptible to errors leading to false assumptions of the patient.[50]
One of the single most successful methods for assessingpersonality disorders by researchers of normal personality functioning is theself-report inventory following up with a semi-structured interview.[50] A disadvantage to the self-report inventory method is that, with histrionic personality disorder, there is a distortion in character, self-presentation, andself-image.[50] This means that most clients cannot be assessed by simply asking them if they match the criteria for the disorder.[50] Mostprojective 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.[50]
Classification of personality disorders differs significantly between the two most prominent frameworks forclassification of mental disorders, namely: theDiagnostic and Statistical Manual of Mental Disorders and theInternational Classification of Diseases, the most recent editions of which are theDSM-5-TR andICD-11, respectively. While personality disorders, including HPD, are diagnosed as separate entities in the DSM-5; in theICD-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.[51] There is also a hybrid model,[52] called theAlternative DSM-5 model for personality disorders (AMPD), which defines personality disorder diagnoses through combinations of pathological traits and areas of overall impairment.[51]
In the Section II categorical classification of personality disorders in the DSM-5 HPD is defined by sets of characteristic symptoms and classified withinCluster B. While not listed as its own diagnostic entity in the AMPD,[53] what is conceptualized as histrionic personality disorder can instead be diagnosed aspersonality disorder – trait specified,[53] which is adimensional diagnosis that is constructed from the individual expression of personalty disorder,[54] as manifested in both a general impairment in personality functioning along with at least one pathologicalpersonality trait.[55]
TheWorld Health Organization's ICD-11 has replaced the categorical classification of personality disorders in theICD-10, in which HPD was a distinct diagnostic category (F60.4), with adimensional model containing a unifiedpersonality disorder (6D10) with severity specifiers, along with specifiers forprominent personality traits or patterns (6D11).[56] 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,[57] while trait and pattern specifiers are used for recording the manner in which the disturbance is manifested.[58] Histrionic personality disorder has been linked to moderate associations with the trait domainsDissociality (6D11.2),Disinhibition (6D11.3), andNegative Affectivity (6D11.0), reflecting tendencies toward emotional intensity, impulsivity, and a strong need for attention.[59] Some studies have also found inverse associations withDetachment (6D11.1), consistent with the highly expressive and socially engaged behavior typical of the disorder.[59]
Most histrionics also have other mental disorders. Comorbid conditions include:antisocial,dependent,borderline, andnarcissistic personality disorders,[60] as well asdepression,[61]anxiety disorders,panic disorder,somatoform disorders,anorexia nervosa,substance use disorder[62] andattachment disorders, includingreactive attachment disorder.[63]
In 2000,Theodore Millon suggested six subtypes of histrionic personality disorder. Any individual histrionic may exhibit one or more of the following:[64]
| Subtype | Features | Traits |
|---|---|---|
| Appeasing histrionic | Includingdependent andcompulsive features | Seeks 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 histrionic | Includinghypomanic features, and possiblynarcissistic features | Vigorous, charming, bubbly, brisk, spirited, flippant, impulsive; seeks momentary cheerfulness and playful adventures; animated, energetic, ebullient. |
| Tempestuous histrionic | Includingnegativistic features | Impulsive, out of control; moody complaints, sulking; precipitous emotion, stormy, impassioned, easily wrought-up, periodically inflamed, turbulent. |
| Disingenuous histrionic | Includingantisocial features | Underhanded, double-dealing, scheming, contriving, plotting, crafty, false-hearted; egocentric, insincere, deceitful, calculating, guileful. |
| Theatrical histrionic | Variant of "pure" pattern | Affected, mannered, put-on; postures are striking, eyecatching, graphic; markets self-appearance; is synthesized, stagy; simulates desirable/dramatic poses. |
| Infantile histrionic | Includingborderline features | Labile, 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 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.[49][failed verification] Treatment for HPD itself involvespsychotherapy, includingcognitive therapy.[2]
Another way to treat histrionic personality disorder after identification is throughfunctional analytic psychotherapy.[65] 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.[65] Initial goals of functional analytic psychotherapy are set by the therapist and include behaviors that fit the client's needs for improvement.[65] 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.[65]
The in-session behaviors of the patient or client are considered to be examples of their patterns of poorinterpersonal communication and to adjust their neurotic defenses.[65] To do this, the therapist must act on the client's behavior as it happens in real time and givefeedback on how the client's behavior is affecting their relationship during therapy.[65] 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".[65] 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".[65] 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".[65]
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.[65] Here is an example;[65] the conversation is hypothetical. T = therapist C = Client. This coded dialogue can be transcribed as:
Another example of treatment besides coding is functional ideographic assessment template.[65] The functional ideographic assessment template, also known as FIAT, was used as a way to generalize the clinical processes of functional analytic psychotherapy.[65] 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.[65] 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.[65]
The survey data from the National epidemiological survey from 2001 to 2002 suggests a prevalence of HPD of 1.84 percent.[66][medical citation needed] Major character traits may be inherited, while other traits may be due to a combination of genetics and environment, including childhood experiences.[37] This personality is seen more often in women than in men.[67] Approximately 65% of HPD diagnoses are women while 35% are men.[citation needed] In Marcie Kaplan'sA Women's View of DSM-III, she argues that women are overdiagnosed due to potential biases and expresses that even healthy women are often automatically diagnosed with HPD.[20] It has also been argued due to diagnostic bias that prevalence rates are equal among women and men.[68]
Many symptoms representing HPD in the DSM are exaggerations of traditional feminine behaviors. In a peer and self-review study, it showed that femininity was correlated with histrionic, dependent and narcissistic personality disorders.[16] Although it has typically been found that at least two thirds of HPD diagnoses are female, there have been a few exceptions.[69] Whether or not the rate will be significantly higher than the rate of women within a particular clinical setting depends upon many factors that are mostly independent of the differential sex prevalence for HPD.[36] 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.[70] With few studies done to find direct causations between HPD and culture, cultural and social aspects play a role in inhibiting and exhibiting HPD behaviors.
{{cite journal}}: CS1 maint: multiple names: authors list (link){{cite journal}}: CS1 maint: multiple names: authors list (link)In addition, the alternative model does not provide specific criteria for each of the ten PDs listed in Sect. II of the DSM-5, as it recommends considering dependent, schizoid, histrionic, and paranoid PDs as variants of 'Personality Disorder - Trait Specified.'
PD-TS is diagnosed when (1) moderate or higher impairment in at least two out of four elements of personality functioning (Criterion A) is accompanied by (2) at least one elevated pathological trait domain or facet (Criterion B) in the absence of (3) a pattern of traits consistent with a specific disorder (Criterion B) and/or a pattern of difficulties in personality functioning characteristic of a specific disorder (Criterion A).
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