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Chapter: Essentials of Psychiatry: Personality Disorders

Histrionic Personality Disorder

Histrionic personality disorder (HPD) is a pervasive pattern of excessive emotionality and attention-seeking.

Histrionic Personality Disorder




Histrionic personality disorder (HPD) is a pervasive pattern of excessive emotionality and attention-seeking (American Psychi-atric Association, 2000). Histrionic persons tend to be emotion-ally manipulative and intolerant of delayed gratification. HPD is indicated by the presence of five or more of the eight diagnostic criteria presented in DSM-IV criteria for HPD.


Etiology and Pathology


There is little research on the etiology of HPD. There is a sug-gestion that HPD may share a genetic disposition toward im-pulsivity or sensation-seeking with the antisocial personality. It has also been suggested that HPD is (in part) a severe, mal-adaptive variant of the personality dimensions of extraversion and neuroticism. Extraversion includes the facets of excitement seeking, gregariousness and positive emotionality, and neuroti-cism includes the facets of angry hostility, self-consciousness and vulnerability that are all characteristic of persons with HPD and there is considerable empirical support for the heritability of these personality dimensions.


Environmental and social–cultural factors, however, may also play a significant role in the development of HPD. There is some speculation that the fathers of females with HPD combine early sexual seductiveness with subsequent authoritarian puritani-cal attitudes, while the mother tends to be domineering, control-ling and intrusive. Such a history may indeed occur in some cases of HPD but there is unlikely to be a specific, common pattern to all cases. The tendency of a family to emphasize, value, or reinforce attention-seeking in a person with a genetic disposition toward emotionality may represent a more general pathway toward HPD.


Affective instability is an important feature of HPD, which may be associated with a hyperresponsiveness of the noradrener-gic system. This instability in the catecholamine functioning may contribute to a pronounced emotional reactivity to rejection and loss. However, the attention-seeking of HPD can be as important to the disorder as the emotionality. The purpose of the exagger-ated emotionality is often to evoke the attention and maintain the interest of others. Persons with HPD are intensely insecure regarding the extent to which others appreciate, desire, or want their company. They need to be the center of attention to reassure themselves that they are valued, desired, attractive, or wanted.


Assessment and Differential Diagnosis


HPD involves to some extent maladaptive variants of stereo-typically feminine traits. The DSM-IV-TR diagnostic criteria for HPD are sufficiently severe that a normal woman would not meet these criteria, but studies have indicated that clinicians will at times diagnose HPD in females who in fact have antisocial traits. Both of these disorders can involve impulsivity, sensation-seeking, low frustration tolerance and manipulativeness, and the presence of a female gender may at times contribute to a false presumption of HPD. It is therefore important to adhere closely to the DSM-IV-TR diagnostic criteria when confronted with his-trionic and antisocial symptoms in female patients.


Persons with HPD will often have borderline, dependent, or narcissistic personality traits. Prototypic cases of HPD can be distinguished from other personality disorders. For example, the prototypic narcissistic person ultimately desires admiration whereas the histrionic person desires whatever attention, inter-est, or concern can be obtained. As a result, the histrionic person will at times seek attention through melodramatic helplessness and emotional outbursts that could be experienced as denigrat-ing and humiliating to the narcissistic person. However, most cases will not be prototypic and the most accurate description of a patient’s constellation of maladaptive personality traits will be the provision of multiple diagnoses.


Epidemiology and Comorbidity


Approximately 1 to 3% of the general population may be diag-nosed with HPD. A controversial issue is its differential sex prev-alence. It is stated in DSM-IV-TR that the sex ratio for HPD is “not significantly different than the sex ratio of females within the respective clinical setting”. However, this should not be interpreted as indicat-ing that the prevalence is the same for males and females. It has typically been found that at least two-thirds of persons with HPD are female, although 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 independent of the differential sex prevalence for HPD.




Little is known about the premorbid behavior pattern of persons with HPD. During adolescence they are likely to be flamboy-ant, flirtatious and attention-seeking. As adults, persons with HPD readily form new relationships but have difficulty sus-taining them. They may fall in love quite quickly, but just as rapidly become attracted to another person. They are unlikely to be reliable or responsible. Relationships with persons of the same sexual orientation are often be strained due to their com-petitive sexual flirtatiousness. Employment history is likely to be erratic, and may be complicated by the tendency to become romantically or sexually involved with colleagues, by their af-fective instability and by their suggestibility. Persons with HPD may become devoted converts to faddish belief systems. They have a tendency to make impulsive decisions that will have a dramatic (or melodramatic) effect on their lives. The severity of the symptomatology may diminish somewhat as the person ages.





Persons with HPD readily develop rapport but it is often super-ficial and unreliable. Therapists may also fail to appreciate the extent of influence they can have on the highly suggestible HPD patient. Persons with HPD can readily become converts to what-ever the therapist may suggest or encourage. The transformation to the theoretical model or belief system of the psychiatrist is unlikely to be sustained.


A key task in treating the patient with HPD is countering their global and diffuse cognitive style by insisting on attend-ing to structure and detail within sessions and to the practical, immediate problems encountered in daily life. It is also important to explore within treatment the historical source for their needs for attention and involvement. Persons with HPD are prone to superficial and transient insights but they will benefit from a carefully reasoned and documented exploration of their current and past relationships.


Many clinicians recommend the use of group therapy for persons with HPD. It is quite easy for them to become involved within a group, which may then be very useful in helping them recognize and explore their attention-seeking, suggestibility and manipulation, as well as develop alternative ways to develop more meaningful and sustained relationships. However, it is also important to monitor closely their involvements within the group, as they are prone to dominate and control sessions and they may escalate their attention-seeking to the point of suicidal gestures. The intense affectivity of persons with HPD may also be responsive to antidepressant treatment, particularly those patients with substantial mood reactivity, hypersomnia and rejec-tion sensitivity.


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