Histrionic personality disorder

Histrionic personality disorder (HPD) is defined by the American Psychiatric Association as a personality disorder characterized by a pattern of excessive emotions and attention-seeking, including inappropriately seductive behavior and an excessive need for approval, usually beginning in early adulthood. People affected by HPD are lively, dramatic, vivacious, enthusiastic, and flirtatious.

HPD affects four times as many women as men. It has a prevalence of 2–3% in the general population, and 10–15% in inpatient and outpatient mental health institutions.

HPD lies in the dramatic cluster of personality disorders. People with HPD have a high need for attention, make loud and inappropriate appearances, exaggerate their behaviors and emotions, and crave stimulation. They may exhibit sexually provocative behavior, express strong emotions with an impressionistic style, and can be easily influenced by others. Associated features include egocentrism, self-indulgence, continuous longing for appreciation, and persistent manipulative behavior to achieve their own needs.

Characteristics

People with HPD are usually high-functioning, both socially and professionally. They usually have good social skills, despite tending to use them to manipulate others into making them the center of attention. HPD may also affect a person's social and/or romantic relationships, as well as their ability to cope with losses or failures. They may seek treatment for clinical depression when romantic (or other close personal) relationships end.

Individuals with HPD often fail to see their own personal situation realistically, instead dramatizing and exaggerating their difficulties. 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. Additional characteristics may include:

• Exhibitionist behavior
• Constant seeking of reassurance or approval
• Excessive sensitivity to criticism or disapproval
• Pride of own personality and unwillingness to change, viewing any change as a threat
• Inappropriately seductive appearance or behavior of a sexual nature
• Using somatic symptoms (of physical illness) to garner attention
• A need to be the center of attention
• Low tolerance for frustration or delayed gratification
• Rapidly shifting emotional states that may appear superficial or exaggerated to others
• Tendency to believe that relationships are more intimate than they actually are
• Making rash decisions
• Blaming personal failures or disappointments on others
• Being easily influenced by others, especially those who treat them approvingly
• Being overly dramatic and emotional

Some histrionics change their seduction technique into a more maternal/paternal style as they age.

Mnemonic

A mnemonic that can be used to remember the characteristics of histrionic personality disorder is "PRAISE ME":

• Provocative (or seductive) behavior
• Relationships are considered more intimate than they actually are
• Attention-seeking
• Influenced easily
• Speech (style) wants to impress; lacks detail
• Emotional lability; shallowness
• Make-up; physical appearance is used to draw attention to self
• Exaggerated emotions; theatrical

Causes

The cause of histrionic personality disorder is unknown, but childhood events such as deaths or illnesses in the immediate family (which present constant anxiety), divorce of parents, and genetics may be involved. HPD is more often diagnosed in women than men; men with some similar symptoms are often diagnosed with narcissistic personality disorder.

Little research has been conducted to determine the biological sources, if any, of this disorder. Psychoanalytic theories incriminate authoritarian or distant attitudes by one (mainly the mother) or both of parents, along with conditional love based on expectations the child can never fully meet.

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.

DSM-IV-TR

The previous edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM IV-TR, defines histrionic personality disorder (in Cluster B) as:

A pervasive pattern of excessive emotionality and attention-seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

• is uncomfortable in situations in which he or she is not the center of attention
• interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
• displays rapidly shifting and shallow expression of emotions
• consistently uses physical appearance to draw attention to self
• has a style of speech that is excessively impressionistic and lacking in detail
• shows self-dramatization, theatricality, and exaggerated expression of emotion
• is suggestible, i.e., easily influenced by others or circumstances
• considers relationships to be more intimate than they actually are

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

ICD-10

The World Health Organization's ICD-10 lists histrionic personality disorder as:

A personality disorder is characterized by:

• shallow and labile affectivity,
• self-dramatization,
• theatricality,
• exaggerated expression of emotions,
• suggestibility,
• egocentricity,
• self-indulgence,
• lack of consideration for others,
• easily hurt feelings, and
• continuous seeking for appreciation, excitement and attention.

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies 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, as well as depression, bipolar disorder, anxiety disorders, panic disorder, somatoform disorders, anorexia nervosa, substance use disorder and attachment disorders, including reactive attachment disorder.^{[citation needed]}

Millon's subtypes

Theodore Millon identified six subtypes of histrionic personality disorder. Any individual histrionic may exhibit none or one of the following:

Subtype	Description	Personality Traits
Appeasing	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	The seductiveness of the histrionic mixed with the energy typical of hypomania. Some narcissistic features can also be present	Vigorous, charming, bubbly, brisk, spirited, flippant, impulsive; seeks momentary cheerfulness and playful adventures; animated, energetic, ebullient.
Tempestuous	Including negativistic features	Impulsive, out of control; moody complaints, sulking; precipitous emotion, stormy, impassioned, easily wrought-up, periodically inflamed, turbulent.
Disingenuous	Including antisocial features	Underhanded, double-dealing, scheming, contriving, plotting, crafty, false-hearted; egocentric, insincere, deceitful, calculating, guileful.
Theatrical	Variant of “pure” pattern	Affected, mannered, put-on; postures are striking, eyecatching, graphic; markets self-appearance; is synthesized, stagy; simulates desirable/dramatic poses.
Infantile	Including borderline features	Labile, high-strung, volatile emotions; childlike hysteria and nascent pouting; demanding, overwrought; fastens and clutches to another; is overly attached, hangs on, stays fused to and clinging.

Treatment

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

Epidemiology

Approximately 1–3% of the general population may be diagnosed with HPD. Major character traits may be inherited, while other traits may be due to a combination of genetics and environment, including childhood experiences. This personality is seen more often in women than in men. It has typically been found that at least two thirds of persons with HPD are female, however there have been a few exceptions. 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.