Histrionic personality disorder

Template:Short description Template:Infobox medical condition Histrionic personality disorder (HPD) is defined by the American Psychiatric Association as 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. People diagnosed with the disorder are said to be lively, dramatic, vivacious, enthusiastic, extroverted and flirtatious.

HPD lies in the emotional cluster of personality disorders, also known as the Cluster B. People with HPD have a high desire for attention, make loud and inappropriate appearances, exaggerate their behaviors and emotions, and crave stimulation.<ref name="WebMD2">Template:Cite journal</ref> 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.Template:Personality disorders sidebar

Signs and symptoms

People diagnosed with HPD may be dramatic.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref name="ADAM2">Template:Cite encyclopedia</ref> 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.<ref>Template:Cite journal</ref> Their emotions may appear superficial or exaggerated to others. This disorder is associated with extraversion,<ref name="Cleveland2">Template:Cite web</ref> a lower tolerance for frustration or delayed gratification,<ref>Template:Cite book</ref> and openness to new experiences. People with HPD may have little self-doubt and often appear egocentric.<ref>Template:Cite journal</ref>

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.<ref>Template:Cite journal</ref> People with this disorder often display excessive sensitivity to criticism or disapproval.<ref>Template:Cite book</ref> They will work hard to get others to pay attention to them,<ref>Template:Cite web</ref> possibly as a method of testing the stability of relationships.<ref>Template:Cite journal</ref> 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.<ref name="Cleveland2" /> People with this disorder may wear flamboyant clothing, try body modifications,<ref>Template:Cite journal</ref> and fake medical conditions in an attempt to draw others' attention.<ref name="Cleveland2" /><ref>Template:Cite journal</ref> They may be inappropriately sexually provocative,<ref name=":1">Template:Cite journal</ref><ref>Template:Cite book</ref> flirtatious,<ref name="Cleveland2" /><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> or exploitative.<ref name=":2">Template:Cite journal</ref> Sexually suggestive and exhibitionist behavior are also behaviors people with this condition sometimes exhibit, and are more likely to seek out casual sexual relationships.<ref>Template:Cite journal</ref> Some people with histrionic traits or personality disorder change their seduction technique into a more parental style as they age.<ref name="AMN2">Template:Cite web</ref> When their desire for attention is not met, it can heighten the severity of their symptoms.<ref>Template:Cite journal</ref>

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.<ref name="Cleveland2" /> 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.<ref>Template:Cite journal</ref><ref name=":3">Template:Citation</ref><ref>Template:Cite web</ref> They may seek treatment for clinical depression when romantic (or other close personal) relationships end.<ref name=":3" /> Substance disorders,<ref>Template:Cite journal</ref> such as alcohol use disorder or opioid use disorder,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> are all common in patients with histrionic personality disorder.<ref name=":4">Template:Cite journal</ref><ref>Template:Cite journal</ref> They are also at higher risks of suicide,<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> body dysmorphia (a preoccupation with perceived flaws in one's physical appearance),<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> and divorce.<ref>Template:Cite journal</ref> 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.<ref name="ADAM2" /> People with this condition can have an impressionistic and undetailed style of speech.<ref name=":5">Template:Cite journal</ref>

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.<ref name="AMN2" />

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.<ref name="Barlow2">Barlow, H.D. & Durand, V.M. (2005). Personality Disorders. (pp. 443–444). Abnormal Psychology: An Integrative Approach (4th ed.). Belmont, CA: Thomas Wadsworth.</ref> HPD symptoms typically do not fully develop until late teens or early 20s,<ref>Template:Cite web</ref><ref>Template:Cite web</ref> while the onset of treatment only occurs, on average, at approximately 40 years of age.<ref name=":02">Template:Cite web</ref><ref name="Fancher2">Fancher, R.E. & Rutherford, A. (2012). Pioneers of psychology. New York, NY: W.W. Norton & Company.</ref>

Although 80% of diagnosed cases are in females, it may be equally prevalent among men. Little is known about how this disorder affects males, but it is thought to be more difficult to detect in men.

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.<ref>Template:Cite book</ref> <ref>Template:Cite bookTemplate:Page needed</ref>

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.<ref name="WebMD2" /> 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.<ref name="Pfohl2">Pfohl, B. (1995). Histrionic personality disorder. The DSM IV Personality Disorders, 173–192.</ref> 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.<ref name="Nickert2">Nickert, J. (n.d.) Histrionic Personality Disorder.</ref>

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.<ref name=":02" />Template: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.<ref name=":4" />

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,<ref name="Barlow2" /> which suggests both disorders based towards sex-type expressions may have the same underlying cause.

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.<ref name="Nolen-Hoeksema2">Nolen-Hoeksema, S. (2014). Personality Disorders. (pp. 266–267). Abnormal Psychology (6th ed.). New York, NY: McGraw-Hill.</ref> 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.<ref name="Nolen-Hoeksema2" /> 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.<ref name="psych-central2">Template:Cite web</ref>Template:Medical citation needed

DSM 5

The current edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM 5, defines histrionic personality disorder (in Cluster B) as:<ref name="dsmiv2">Template:Cite book</ref>

The DSM 5 requires that a diagnosis for any specific personality disorder also satisfies a set of general personality disorder criteria.

Alternative model

The Alternative DSM-5 Model for Personality Disorders (AMPD) does not list histrionic personality disorder as its own diagnostic entity.<ref>Template:Cite book</ref> However, it is stated in the AMPD that what is conceptualized as HPD can instead be diagnosed as Personality Disorder - Trait Specified, which is a dimensional diagnosis for personality disorders found in the alternative model.<ref>Template:Cite book</ref>

ICD-10

The World Health Organization's ICD-10 lists histrionic personality disorder (F60.4) as:<ref name="icd102">Template:Cite book (Template:ICD10)</ref>

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfy a set of general personality disorder criteria.

Comorbidity

Most histrionics also have other mental disorders. Comorbid conditions include: antisocial, dependent, borderline, and narcissistic personality disorders,<ref name="Hales2">Hales E and Yudofsky JA, eds, The American Psychiatric Press Textbook of Psychiatry, Washington, DC: American Psychiatric Publishing, Inc., 2003</ref> as well as depression,<ref>Template:Cite journal</ref> anxiety disorders, panic disorder, somatoform disorders, anorexia nervosa, substance use disorder<ref>Template:Cite web</ref> and attachment disorders, including reactive attachment disorder.<ref>Template:Cite journal</ref>

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:<ref name="Millon2">Template:Cite book</ref>

Subtype	Features	Personality Traits
Appeasing histrionic	Including dependent and compulsive 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	Including hypomanic features, and possibly narcissistic features	Vigorous, charming, bubbly, brisk, spirited, flippant, impulsive; seeks momentary cheerfulness and playful adventures; animated, energetic, ebullient.
Tempestuous histrionic	Including negativistic features	Impulsive, out of control; moody complaints, sulking; precipitous emotion, stormy, impassioned, easily wrought-up, periodically inflamed, turbulent.
Disingenuous histrionic	Including antisocial 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	Including borderline 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

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.<ref name="psych-central2" />Template:Failed verification Treatment for HPD itself involves psychotherapy, including cognitive therapy.<ref name="WebMD2" />

Interviews and self-report methods

In general clinical practice with assessment of personality disorders, one form of interview is the most popular: an unstructured interview.<ref name="Sutker2">Sutker, P.B. (2002). Histrionic, Narcissistic, and Dependent Personality Disorders. Comprehensive handbook of psychopathology (3rd ed., pp. 513–514). New York: Kluwer Academic.</ref> 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.<ref name="Sutker2" /> 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.<ref name="Sutker2" /> Unstructured interviews, despite their popularity, tend to have problems with unreliability and are susceptible to errors leading to false assumptions of the patient.<ref name="Sutker2" />

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.<ref name="Sutker2" /> 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.<ref name="Sutker2" /> This means that most clients cannot be assessed by simply asking them if they match the criteria for the disorder.<ref name="Sutker2" /> 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.<ref name="Sutker2" />

Functional analytic psychotherapy

Another way to treat histrionic personality disorder after identification is through functional analytic psychotherapy.<ref name="Callaghan2">Template:Cite journal</ref> 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.<ref name="Callaghan2" /> Initial goals of functional analytic psychotherapy are set by the therapist and include behaviors that fit the client's needs for improvement.<ref name="Callaghan2" /> 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.<ref name="Callaghan2" />

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.<ref name="Callaghan2" /> 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.<ref name="Callaghan2" /> 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".<ref name="Callaghan2" /> 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".<ref name="Callaghan2" /> 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".<ref name="Callaghan2" />

Coding client and therapist behaviors

In these sessions there is a certain set of dialogue or script that can be forced by the therapist for the client to give insight on their behaviors and reasoning".<ref name="Callaghan2" /> Here is an example;<ref name="Callaghan2" /> the conversation is hypothetical. T = therapist C = Client. This coded dialogue can be transcribed as:

• ECRB – Evoking clinically relevant behavior
  • T: Tell me how you feel coming in here today (CRB2) C: Well, to be honest, I was nervous. Sometimes I feel worried about how things will go, but I am really glad I am here.
• CRB1 – In-session problems
  • C: Whatever, you always say that. (becomes quiet). I don't know what I am doing talking so much.
• CRB2 – In-session improvements
• TCRB1 – Clinically relevant response to client problems
  • T: Now you seem to be withdrawing from me. That makes it hard for me to give you what you might need from me right now. What do you think you want from me as we are talking right now?".
• TCRB2 – Responses to client improvement
  • T: That's great. I am glad you're here, too. I look forward to talking to you.<ref name="Callaghan2" />

Functional ideographic assessment template

Another example of treatment besides coding is functional ideographic assessment template.<ref name="Callaghan2" /> The functional ideographic assessment template, also known as FIAT, was used as a way to generalize the clinical processes of functional analytic psychotherapy.<ref name="Callaghan2" /> 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.<ref name="Callaghan2" /> 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.<ref name="Callaghan2" />

Epidemiology

The survey data from the National epidemiological survey from 2001 to 2002 suggests a prevalence of HPD of 1.84 percent.<ref>Template:Cite journal</ref>Template: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.<ref name="AMN2" /> This personality is seen more often in women than in men.<ref>Template:Cite book</ref> Approximately 65% of HPD diagnoses are women while 35% are men. In Marcie Kaplan's A 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.<ref name=":2" /> It has also been argued due to diagnostic bias that prevalence rates are equal among women and men.<ref>Template:Cite journal</ref>

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.<ref name=":1" /> Although it has typically been found that at least two thirds of HPD diagnoses are female, there have been a few exceptions.<ref>Template:Cite journal</ref> 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.<ref name=":5" /> 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.<ref>Template:Cite journal</ref> 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.

See also

• Acting out