HISTRIONIC PERSONALITY DISORDER
Presented by –
Deepsikha Dey
History of HPD
• The roots of histrionic behavior can be traced back to ancient times when
Greek and Roman physicians observed individuals who displayed excessive
theatricality and emotional expression. These individuals were described as
“hysterical” – A term derived from the Greek word ‘hysterical’, meaning uterus
– as these behaviors were believed to be exclusive to women and were caused
by disturbances in the uterus .
• In the late 19th century, during the era of psychoanalysis, Sigmund Freud
contributed to the understanding of histrionic behavior. He proposed the
concept of ‘hysteria’ as a psychological disorder primarily affecting women and
characterized by emotional excess and attention seeking behavior. Freud’s
theories, although controversial and often criticized, laid the groundwork for
the exploration of histrionic symptoms and behaviors.
• HPD was formally recognized as a distinct diagnostic category in the mid-20th
century. In 1980, the Diagnostic and statistical Manual of Mental Disorders, 3 rd
edition (DSM-III) included HPD as a diagnosable condition. The DSM-III
identified key criteria, including a pervasive pattern of excessive emotionality.
Diagnostic Criteria
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:
1. Is uncomfortable in situations in which he or she is not the center of
attention.
2. Interaction with others is often characterized by inappropriate sexually
seductive or provocative behavior.
3. Displays rapidly shifting and shallow expression of emotions.
4. Consistently uses physical appearance to draw attention to self.
5. Has a style of speech that is excessively impressionistic and lacking in detail.
6. Shows self-dramatization, theatricality and exaggerated expression of
emotion.
7. Is suggestive (i.e., easily influenced by others or circumstances).
8. Considers relationships to be more intimate than they actually are.
Some of the associated features include (Kaplan & Sadock’s Comprehensive
Textbook Of Psychiatry )
* Difficulties in achieving emotional intimacy in romantic or sexual
relationships.
* Craving for excitement and stimulation.
* Promiscuity or complete sexual naivete.
* Low tolerance for delayed gratification.
• Individuals with histrionic personality disorder have an interpersonal style
characterized by social dominance, which can span a spectrum of behaviors
that include a “warmer dominance“ that can be intrusive in nature (e.g., need
to be center of attention; exhibitionistic) to a “colder dominance” that can
include arrogant, controlling and aggressive behaviors.
• They may crave novelty, stimulation, and excitement and have a tendency to
become bored with their usual routine. These individuals are often intolerant
of, or frustrated by, situations that involve delayed gratification and their
actions are often directed at obtaining immediate satisfaction.
Complications
Complications include frequent suicidal gestures and threats go coerce better
caregiving. Interpersonal relations are unstable, shallow and generally ungratifying.
There are frequent marital problems secondary to the tendency to neglect long-term
relationships for the excitement of new relationships.
Prevalence Rate in India
Early studies on clinical samples from India reported a prevalence rate of 0.3-1.6% for
histrionic personality disorder (HPD). However, the prevalence rate of HPD in India
varies depending on the population studied (2010):
• University students : 19.1%
• Criminals: 7.3-33.3%
• Patients with substance use disorders: 20-55%
• Patients who attempted suicide: 47.8-62.2%
(source: www.ncbi.nlm.nih.gov.)
Etiology
Biological
Brain chemicals specifically-
• Norepinephrine: people with HPD have a highly responsive
noradrenargic system, which releases norepinephrine excessively.
• Catecholamines: A malfunction in catecholamines, a group of
neurotransmitters that includes norepinephrine, may be
responsible for the tendency of people with HPD to have an
excessive emotional reaction to rejection.
Anatomy of the brain reveals the fact that any specific injury,
impairment, reduced or smaller size of Amygdala, Hippocampus,
Orbitofrontal cortex , anterior cingulate gyrus and abnormalities in
superior frontal cortex can be seen in case of HPD patients
Psychological
• Parenting styles- children who experience parenting styles that lack
boundaries, are over-indulgent or inconsistent may be more likely to develop
histrionic personality disorder. In addition, parents who display dramatic,
erratic, volatile or inappropriate sexual behavior put their children at risk for
developing this condition. Problems in parent-child relationships lead to the
characteristic of low self-esteem in people with HPD.
• Learned behaviors- children may learn to seek attention by adopting
behaviors they see from their parents or caregivers.
• Attachment style- An anxious-preoccupied attachment style can develop
when a caregiver is inconsistent in meeting a child’s needs. This can lead to a
need for reassurance and attention from romantic partners.
Environmental
• Unpredictable attention- children who receive unpredictable attention from
their parents may develop patterns of behavior that persist into adulthood.
• Lack of boundaries- children who are exposed to dramatic or overly sexual
behavior by parents or caregivers or who experience a lack of appropriate
boundaries, may be predisposed to develop HPD.
Differential Diagnosis: Histrionic personality disorder is distinguished from
the following personality disorders:
• Antisocial (which includes antisocial behaviors and crime to gain profit, power
or some other material gratification; history of conduct disorder; no excessive
self-dramatization; and no exaggerated emotional expression).
• Borderline (which includes unstable self-concept, chaotic behaviors, self-
destructive gestures, chronic anxiety and identity disturbance)
• Narcissistic (which includes fear of having hidden imperfections and flaws revealed
and a sense of grandiosity and specialness).
Personality change due to another medical condition – Histrionic personality
disorder must be distinguished from personality change due to another medical
condition, in which the traits that emerge are a direct physiological consequence of
another medical condition.
Substance Use Disorders- The disorder must also be distinguished from symptoms
that may develop in association with persistent substance use.
Comorbidity
Histrionic personality disorder has been associated with higher rates of borderline,
narcissistic, paranoid, dependent and antisocial personality disorders; alcohol and
other substance use and misuse; as well as aggression and violence. Histrionic
personality disorder is also thought to be related to somatic symptom disorder,
functional neurological symptom disorder (conversion disorder) and major depressive
disorder.
Treatment
• Psychotherapy based on case report method aimed at self development
through resolution of conflict.
• Dynamic therapy remains the treatment of choice to externalize patient’s
inner emotions in treatment of histrionic PD.
• In this therapy interpretation of pathological relationships may evoke intense
feelings of anxiety, which have to be handled respectfully without humiliating
the patients.
• Self help groups and therapeutic community setting is more productive than
institutionalization in producing a change.
• Family therapy based on manifestations of the client can also be provided.
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