HISTRIONIC PERSONALITY DISORDER
Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. It occurs in 2% to 3% of the general population and in 10% to 15% of the clinical population. It is seen more often in women than in men. Clients usually seek treatment for depression, unexplained physical problems, and difficulties in relationships (APA, 2000).
The tendency of these clients to exaggerate the close-ness of relationships or to dramatize relatively minor occurrences can result in unreliable data. Speech is usu-ally colorful and theatrical, full of superlative adjectives. It becomes apparent, however, that although colorful and entertaining, descriptions are vague and lack detail. Overall appearance is normal, although clients may over-dress (e.g., wear an evening dress and high heels for a clinical interview). Clients are overly concerned with impressing others with their appearance and spend inor-dinate time, energy, and money to this end. Dress and flirtatious behavior are not limited to social situations or relationships but also occur in occupational and profes-sional settings. The nurse may feel these clients are charming or even seductive.
Clients are emotionally expressive, gregarious, and effu-sive. They often exaggerate emotions inappropriately. For example, a client says, “He is the most wonderful doctor! He is so fantastic! He has changed my life!” to describe a physi-cian she has seen once or twice. In such a case, the client cannot specify why she views the doctor so highly. Expressed emotions, although colorful, are insincere and shallow; this is readily apparent to others but not to clients. They experi-ence rapid shifts in moods and emotions and may be laugh-ing uproariously one moment and sobbing the next. Thus, their displays of emotion may seem phony or forced to observers. Clients are self-absorbed and focus most of their thinking on themselves, with little or no thought about the needs of others. They are highly suggestible and will agree with almost anyone to gain attention. They express strong opinions very firmly, but because they base them on little evidence or facts, the opinions often shift under the influ-ence of someone they are trying to impress.
Clients are uncomfortable when they are not the center of attention and go to great lengths to gain that status. They use their physical appearance and dress to gain atten-tion. At times, they may fish for compliments in unsubtle ways, fabricate unbelievable stories, or create public scenes to attract attention. They may even faint, become ill, or fall to the floor. They brighten considerably when given atten-tion after some of these behaviors; this leaves others feel-ing that they have been used. Any comment or statement that could be interpreted as uncomplimentary or unflat-tering may produce a strong response such as a temper tantrum or crying outburst.
Clients tend to exaggerate the intimacy of relation-ships. They refer to almost all acquaintances as “dear, dear friends.” They may embarrass family members or friends by flamboyant and inappropriate public behavior such as hugging and kissing someone who has just been introduced or sobbing uncontrollably over a minor inci-dent. Clients may ignore old friends if someone new and interesting has been introduced. People with whom these clients have relationships often describe being used, manipulated, or exploited shamelessly.
Clients may have a wide variety of vague physical com-plaints or relate exaggerated versions of physical illness. These episodes usually involve the attention clients received (or failed to receive) rather than any particular physiologic concern.
The nurse gives clients feedback about their social inter-actions with others, including manner of dress and non-verbal behavior. Feedback should focus on appropriate alternatives, not merely criticism. For example, the nurse might say,
“When you embrace and kiss other people on first meeting them, they may interpret your be-havior in a sexual manner. It would be more acceptable to stand at least 2 feet away fromthem and to shake hands.”
It also may help to discuss social situations to explore clients’ perceptions of others’ reactions and behavior. Teaching social skills and role-playing those skills in a safe, nonthreatening environment can help clients to gain confidence in their ability to interact socially. The nurse must be specific in describing and modeling social skills, including establishing eye contact, engaging in active listening, and respecting personal space. It also helps to outline topics of discussion appropriate for casual acquain-tances, closer friends or family, and the nurse only.
Clients may be quite sensitive to discussing self-esteem and may respond with exaggerated emotions. It is impor-tant to explore personal strengths and assets and to give specific feedback about positive characteristics. Encourag-ing clients to use assertive communication, such as “I” statements, may promote self-esteem and help them to get their needs met more appropriately. The nurse must con-vey genuine confidence in the client’s abilities.