Histrionic Personality Disorderq

Sarah F Smith and Scott O Lilienfeld, Emory University, Atlanta, GA, United States
© 2017 Elsevier Inc. All rights reserved.

Description 1
History 2
Prevalence and Demographics 2
Co-occurrence and Comorbidity 3
Assessment 3
Etiology 4
Treatment 4
Further Reading 4
Relevant Websites 4

Glossary
Borderline personality disorder Personality disorder that overlaps substantially with histrionic personality disorder; it is
characterized by marked instability in mood, interpersonal relationships, impulse control, and identity.
Impressionistic speech Also known as hyperbolic speech. A term used to describe speech lacking in detail and emphasizing
emotion.
Histrionic From the Latin work histrionicus, meaning of or pertaining to actors, acting, or theatre.
Hysteria A historically common medical diagnosis in women marked by excessive emotionality and unexplained physical
symptoms. HPD traces its roots to this condition.
Hysterical personality disorder A precursor to histrionic personality disorder described briefly in the DSM-II in 1968. This
diagnosis emphasized seductiveness, impressionistic speech, dramatic and emotional displays, and clinging and demanding
relationships.
Thin slicing Rapid perceptions of small pieces of interpersonal behavior.

Description

Histrionic personality disorder (HPD) is a psychological condition that manifests itself by early adulthood. Like other personality
disorders, HPD is associated with enduring abnormalities in emotion, cognition, and interpersonal behavior. According to the most
recent version of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM), the DSM-5, published in 2013,
individuals with HPD are marked by excessive displays of emotionality and needs for attention. They are often flamboyant and
dramatic, frequently earning the reputation of the “life of the party.” Indeed, this theatrical behavior inspired the name
“histrionic,” after the Latin “histrionicus,” meaning pertaining to an actor.
Not surprisingly, people with HPD often experience discomfort when not the focus of interest. Their attention-seeking behavior,
which often expresses itself as enthusiasm and flirtatiousness, may initially charm a new friend or love interest. Nevertheless, this
behavior quickly becomes frustrating once it becomes evident that these dramatic behaviors serve largely as attention-grabbing
gestures. Individuals with HPD may also attempt to attract others through inappropriately seductive and sexual behavior. Because
they tend to use their physical appearance to draw attention to themselves, they often expend an excessive amount of resources on
fashion and grooming. In addition, they may “fish” for compliments and become distraught by an unflattering photograph or
minor criticism of their physical appearance.
Individuals with HPD are characterized by exaggerated expressions of emotion that typically strike others as overblown or insincere.
Their language often seems vague and generalized (sometimes termed “hyperbolic speech”), and is marked by black-and-white
opinions lacking in detail or supporting evidence (e.g., “That movie was just wonderful,” “He was a horrible, terrible boyfriend”).
Individuals with HPD are easily influenced by people and fleeting trends, and may be overly trusting of others. Additionally, people
with HPD tend to believe their interpersonal relationships to be more intimate than in actuality, and may refer to a casual acquaintance
as a cherished friend.
Some of the associated features of the disorder, which are not listed as formal diagnostic criteria in DSM-5, include persistent
difficulties with romantic and sexual relationships. The relationships and friendships of individuals with HPD often lack genuine
emotional intimacy, and their sexual seductiveness may coexist with a tendency to find sexual relationships consistently
unsatisfying. People with HPD may be manipulative, often coexisting with pronounced dependency on their romantic partners.
Their friendships are often unsuccessful, largely because friends are often alienated by their incessant demands for attention and

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sexually provocative behavior. Individuals with HPD usually expect immediate satisfaction and may become excessively frustrated
when forced to wait for desired rewards, such as a return call from a friend. They frequently seek excitement and novelty, although
their interest in new things wanes quickly. Finally, individuals with HPD may make manipulative suicidal gestures and threats to
gain attention, although they rarely commit suicide.

History

HPD traces its roots to the condition once known as hysteria, a state of excessive emotionality traditionally linked to females. The
origins of hysteria extend at least as far back as 1900 BC to the writings of ancient Egypt and Greece. At that time, hysteria was said to
be brought on by a misplaced uterus or “wandering womb”; indeed, the prefix “hyster” means womb in Latin. In Hellenic Greece,
people often thought of the uterus as akin to a wild animal, free to roam around a woman’s body. This wandering occurred when
the womb remained barren for an extended period of time. Thus, women with unsatisfactory sex lives, such as virgins and widows,
were considered especially prone to hysterical outbursts. In fact, in ancient Greece, sexual behavior was often prescribed as a remedy
for hysteria. In contrast, Bennett Simon, a professor of psychiatry at Harvard University, attributed this behavior not to sexual
dissatisfaction, but to a reaction to the oppressive male society of ancient Greece. Simon argued that women expressed an
unconscious resentment towards men in the form of uninhibited emotionality.
By the Middle Ages, theories regarding the causes of hysteria had shifted considerably. Hysteria was then viewed as the result of
wanton sexuality, which predisposed women to the disorder. Hysteria also became increasingly associated with witchcraft and
demonic possession. As early as the 17th century, doctors began to see what they called “disorders” in the personality traits of their
patients with hysteria. These traits included mental dullness, lethargy, egocentricity, and unexplained physical ailments, most of
which are not considered relevant when diagnosing HPD today. Other features, such as suggestibility and outbursts of emotion,
evolved into the idea of theatricality commonly associated with HPD today. Following the Middle Ages, hysteria was increasingly
recognized as a natural and physical disorder. Eventually, the idea of hysteria as a disease of the brain and mind emerged. Viennese
neurologist Sigmund Freud, whose work with hysterical patients in the late 19th and early 20th centuries laid the groundwork for
later theories on the unconscious, believed that women possessed innate characteristics, most importantly the absence of a penis,
which predisposed them to hysteria.
Following World War II, the American Psychiatric Association developed the DSM to standardize the vast array of diagnostic
systems used to diagnose mental disorders. Neither HPD nor hysterical personality was listed in the first edition, DSM-I, published
in 1952. Nevertheless, both conditions resemble the DSM-I entry for “emotionally unstable personality.” In 1968, “hysterical
personality” was described briefly in DSM-II, with an emphasis on seductiveness, impressionistic speech, histrionic and emotional
displays, and clinging and demanding relationships. Finally, HPD, now referred to by the somewhat less pejorative term histrionic
personality disorder, appeared in full-fledged form in DSM-III in 1980, with a substantial focus on dramatic and attention-seeking
behavior that persists in today’s diagnostic descriptions. Like all personality disorders, HPD has remained unchanged in its
diagnostic criteria from DSM-IV to DSM-5.

Prevalence and Demographics

Studies using standardized interviews suggest the prevalence of HPD to be about 2%–3% in the general population. Much higher
rates of HPD occur in clinical settings, with prevalence rates typically ranging between 10% and 15%. The differences in prevalence
across studies probably stem in part differences in the measures used to diagnose HPD.
DSM-5 warns readers that cultural factors may influence the manifestation of HPD. Nevertheless, the manual does not delineate
these factors or their specific effects on the manifestation of the disorder. In fact, scant research has examined cultural differences in
the prevalence or expression of HPD. Some researchers suspect that differing cultural norms affect the rate of HPD across various
populations. For example, HPD may be diagnosed less frequently in Asian than in North American cultures due to the discouragement
of overt sexuality in the former cultures. In contrast, in Hispanic cultures, where overt displays of sexuality are less stigmatized, HPD
may be more prevalent. Nevertheless, there is little systematic research on these conjectures.
Historically, HPD has been viewed as a predominantly female disorder, and DSM-5 notes that HPD may occur more often in
females than in males. Psychologist Paula Kaplan has speculated that HPD is a collection of exaggerated behaviors traditionally
perceived as feminine. Some authors, like George Washington University psychiatrist Paul Chodoff, have even argued that
merely behaving in a highly traditional “feminine” manner may lead to a diagnosis of HPD, although research evidence for this
claim is wanting. Notably, in nonclinical samples, HPD is about equally prevalent in males and females. This finding suggests
that the apparent sex difference in HPD may be due to a selection bias. Specifically, women with HPD may be more likely than
men with HPD to seek treatment, perhaps because they are more likely to suffer from co-occurring conditions, including depression.
Several researchers have examined the potential for sex-bias in the diagnosis of HPD. In 1989, University of Kentucky psychologists
Maureen Ford and Thomas Widiger examined psychologists’ ratings of a case vignette describing an individual with either HPD,
antisocial personality disorder (APD) – a condition marked by manipulativeness, dishonesty, and irresponsible behaviors – or an
equal number of features of both disorders. The sex of the individual was listed as male, female, or unspecified. For the APD vignette,
clinicians diagnosed the disorder more frequently in men than in women or in those of an unspecified gender. Clinicians tended to
diagnose females who exhibited APD features with HPD. When the vignette described an individual with HPD, clinicians diagnosed
it at high rates in women and low rates in men. In contrast, when clinicians rated individual diagnostic criteria in the DSM, sex
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differences disappeared, suggesting that sex bias for HPD exists at the level of the overall diagnosis, but not at the level of individual
diagnostic criteria.
Although HPD may be associated with traditional manifestations of femininity, David Klonsky, then at the University of Virginia,
and his colleagues also found associations between the disorder and masculinity in a 2002 study. Specifically, people who behaved in
a traditional fashion consistent with their biological sex, such as a stereotypically “masculine” male or a stereotypically “feminine”
female, displayed more histrionic features. Some authors have conjectured that traditionally “masculine” manifestations of HPD,
such as the “macho” male, may exist, but that but due to biased diagnostic criteria these people may be missed or underdiagnosed.

Co-occurrence and Comorbidity

HPD frequently co-occurs with other personality disorders, as well as a number of other major mental disorders. In particular,
substantial overlap exists between borderline personality disorder (BPD) and HPD. This overlap may be due in part to similarity
in the diagnostic criteria of these conditions, which include attention seeking and manipulativeness. However, individuals with
BPD tend to be more marked by self-destructiveness, feelings of emptiness, and anger-filled relationships than are individuals
with HPD. .DSM-IV attempted to reduce the overlap between these two conditions by removing the criteria of angry outbursts
and manipulative suicidal gestures from the diagnosis of HPD. In doing so, however, it may have deceased the validity of the
condition. Some researchers, such as psychologists Drew Westen and Christine Heim, then both at Emory University, have even
proposed the existence of a subtype of BPD with prominent histrionic features.
HPD also frequently co-occurs with APD, narcissistic personality disorder (NPD), and dependent personality disorder (DPD). Both
HPD and APD are characterized by manipulative behaviors, impulsiveness, and recklessness. However, HPD lacks the pervasive
involvement with antisocial and criminal behavior associated with APD. Individuals with HPD or NPD are both known to crave
attention; however, those with NPD are more likely to use this attention for validation rather than satisfaction of sexual or interpersonal
needs. Individuals with DPD and HPD are similar in their reliance on others for approval and guidance; however, individuals with DPD
typically lack the theatrical quality of those with HPD.
Moderate to high rates of co-occurrence between HPD and other mental disorders extend to somatic symptom disorder,
dissociative disorders (e.g., dissociative identity disorder, known formerly as multiple personality disorder), and mood disorders.
Still other conditions can be confused with HPD. In particular, bipolar disorder, known formerly as manic depression, may
superficially resemble HPD because of its high levels of impulsivity, self-centeredness, and extraversion, especially during manic
and hypomanic (mild manic) states.

Assessment

There are no published diagnostic instruments for the assessment of HPD per se. As a consequence, clinicians typically use “omnibus”
or broadband measures of personality disorders to diagnose HPD. These measures include the Structured Interview for DSM-IV Axis II
(SCID-II) and the Personality Diagnostic Questionnaire, DSM-IV version (PDQ-4), both of which contain subscales for HPD (note
that although both measures are based on DSM-IV, the HPD criteria are identical in DSM-5). In the SCID-II, a clinician rates one
item per HPD diagnostic criterion on a scale of one to three. A rating of one indicates the criterion is absent, while three indicates
the criterion reaches threshold or is true. In contrast, the PDQ-4 is a True-False self-report questionnaire. Other broadband measures
such as the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and Million Clinical Inventory, third edition (MCMI-III), may be
helpful in assessing HPD. For example, on the MMPI-2, individuals with HPD will often display a Hysteria-Psychopathic deviate
profile or a Psychopathic Deviate-Hypomania profile. Elevations on the Hysteria scale of the MMPI-2 reflect a Pollyannaish view of
the world along with a propensity toward physical complaints; elevations on the Psychopathic deviate scale reflect a propensity
toward antisocial behavior, including dishonesty and manipulativeness; and elevations on the Hypomania scale reflect
a propensity toward high levels of energy, poor impulse control, and grandiosity. Individuals with HPD sometimes also exhibit
high scores on the MMPI-2 Psychasthenia scale, reflecting self-doubt and worry.
Most diagnostic measures for HPD rely largely or entirely on self-report. Nevertheless, some authors have questioned the utility
of self-report in the assessment of HPD given that people with this condition tend to lack insight into the nature and extent of their
symptoms. As a consequence, the use of informants, such as co-workers or friends, may offer fresh opportunities for the assessment
of HPD and related personality disorders. In a pioneering study examining the effects of maladaptive personality traits on military
discharge, University of Virginia psychologist Thomas Oltmanns found that peer nominations of HPD were substantially superior
to self-reports of HPD in predicting early separation from active duty. This study suggests that informant reports can not only
provide meaningful information about the maladaptive traits associated with HPD, but help to circumvent some of the limitations
of self-reports in detecting this condition.
Another potentially fruitful avenue for the assessment of HPD stems from rapid perceptions of small pieces of interpersonal
behavior, or what psychologist Robert Rosenthal, now at the University of California at Riverside, termed “thin slicing.” In another
study by Oltmanns’ team, participants viewed the initial 30 sec of a videotaped interview of individuals diagnosed with personality
disorders, including HPD. Even from this brief clip of behavior, observers blind to participants’ diagnoses judged people with HPD
as more extraverted and likeable than other people. These findings suggest that relatively little interpersonal information may be
required to detect at least some of the hallmark interpersonal features of HPD.
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Etiology

The etiology (causation) of HPD remains poorly understood. Comparisons of monozygotic (identical) and dizygotic (fraternal)
twin pairs in research by University of Oslo psychologist Svenn Torgersen and his colleagues suggest that HPD is moderately
heritable, but that as yet unknown environmental factors also play a role in its development. Some authors have argued that early
parenting factors play a role in HPD; for example, some have contended that HPD stems from an anxious attachment style.
Nevertheless, it is not clear whether the deficits in interpersonal attachment observed in individuals with HPD are causes of the
disorder, or merely manifestations of it. Retrospective research on parenting practices among individuals with HPD has revealed
higher rates of reported controlling parenting styles than among healthy participants, although this difference may be colored in
part by biases in past reporting.
From a personality trait perspective, individuals with HPD differ from other individuals on the dimensions of the influential five
factor model of personality. In particular, studies show that HPD is associated with elevated scores on some facets of extraversion,
such as gregariousness and excitement-seeking, neuroticism, such as impulsivity, and openness to experience, such as fantasy, and
decreased scores on some facets of conscientiousness, such as self-discipline and deliberation. Nevertheless, the extent to which
these trait differences shed light on.

Treatment

Psychologists and psychiatrists have implemented a variety of interventions with HPD, none of which has been systematically
investigated in controlled studies. No studies have examined the potential utility of medications with HPD patients, so most of
the attention has been focused on psychotherapies.
Cognitive and cognitive-behavioral treatments are designed largely to alter the underlying assumptions of HPD patients.
University of Pennsylvania psychiatrist Aaron Beck and psychologist Arthur Freeman of the Philadelphia College of Osteopathic
Medicine have argued that HPD is associated with a set of core and often unspoken beliefs, such as “I need others to admire me
to be happy” or “Unless I am consistently entertaining, people close to me will abandon me.” Their treatment for HPD is centered
on challenging this and other core beliefs using cognitive restructuring and behavioral experiments (“homework”) intended to
disprove these beliefs. For example, Beck and Freeman might set up a behavioral experiment in which an HPD person remains quiet
at several parties and determines whether her friends actually abandon her.
Other commonly used therapies for HPD include (a) behavioral therapy, which attempts to extinguish maladaptive behaviors,
such as manipulativeness or excessive seductiveness, and to reinforce adaptive behaviors, such as efforts to achieve attention in
socially healthy ways (e.g., appropriate assertiveness); (b) interpersonal therapy, which attempts to improve the social skills of
individuals with HPD; and (c) psychodynamic therapies, which attempt to use the therapeutic relationship to resolve childhood
conflicts and parenting deficiencies (e.g., insufficient attention from one’s mother, father, or both) that ostensibly contribute to
HPD. Without controlled scientific data, however, it is difficult to recommend any of the aforementioned psychotherapies with
confidence. Research is needed to compare the efficacy of competing therapeutic approaches for HPD, and to ascertain whether
attempting to alter HPD individuals’ deep-seated personality traits is more fruitful than accepting these traits and instead attempting
to alter their problematic behavioral manifestations.

Further Reading

Alam, C.N., Merskey, C., 1992. The development of the histrionic personality. Hist. Psychiatry 3, 135–165.
Blagov, P.S., Fowler, K.A., Lilienfeld, S.O., 2007. Histrionic personality disorder. In: O’Donohue, W.T., Fowler, K.A., Lilienfeld, S.O. (Eds.), Personality Disorders: Toward the DSM-V.
Sage, Thousand Oaks, CA.
Bornstein, R.F., 1998. Implicit and self-attributed dependency needs in dependent and histrionic personality disorders. J. Personal. Assess. 71, 1–14.
Chodoff, P., 1982. Hysteria and women. Am. J. Psychiatry 139, 545–551.
Ford, M.R., Widiger, T.A., 1989. Sex bias in the diagnosis of histrionic and antisocial personality disorders. J. Consult. Clin. Psychol. 57, 301–305.
Hamburger, M.E., Lilienfeld, S.O., Hogben, M., 1996. Psychopathy, gender, and gender roles: implications for antisocial and histrionic personality disorders. J. Personal. Disord. 10,
41–55.
Pfohl, B., 1991. Histrionic personality disorder: a review of available data and recommendations for DSM-IV. J. Personal. Disord. 5, 150–166.
Shapiro, D., 1965. Neurotic Styles. Basic Books, New York.

Relevant Websites

http://my.clevelandclinic.org/disorders/Personality_Disorders/hic_Histrionic_Personality_Disorder.aspx – Cleveland clinic.

http://www.mentalhealth.com/dis/p20-pe06.html – International mental health.
http://www.nlm.nih.gov/medlineplus/ency/article/001531.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001531.htm – Medline plus.
http://www.webmd.com/mental-health/histrionic-personality-disorderhttp://www.webmd.com/mental-health/histrionic-personality-disorder – WebMD.

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Change History: September 2016. Scott O. Lilienfeld made some changes to the text.