What is histrionic personality disorder (HPD)?

Introduction

Of all psychiatric conditions, personality disorders are perhaps the most controversial. Nevertheless, virtually all researchers agree that they are disorders in which maladaptive and inflexible personality traits cause impairment. Although some personality disorders are distinguished by the suffering they produce in affected individuals, others are distinguished by the suffering they inflict on others. Histrionic personality disorder (HPD) falls into the latter category.

History

HPD traces its roots to hysteria, from Greek hysterikos (“wandering womb”), a concept with origins in ancient Egypt and Greece. Hysteria was thought to be a state of excessive emotionality and irrational behavior in women caused by a migration of the uterus to the brain. Derogatory views of hysterical women continued throughout the Middle Ages, but in the centuries that followed, writers proposed that hysteria was not limited to women and was a condition of the brain rather than the uterus. In the late 1800’s, French neurologist Jean Charcot used hypnosis to relieve conversion symptoms (deficits in sensory or motor function brought about by psychological factors) in hysterics. In doing so, Charcot approached hysteria as psychological rather than physiological in etiology. One doctor intrigued by the seeming efficacy of the new technique was the young Austrian neurologist Sigmund Freud. This early work with hysterical patients laid the groundwork for his theories of the unconscious.

Following World War II, a classification manual was developed by the American Psychiatric Association in an attempt to unify the array of diagnostic systems that were being used. This manual, the
Diagnostic and Statistical Manual of Mental Disorders
(DSM), has seen many versions and has remained standard in the mental health field. Hysterical personality was not included in the first DSM (1952, DSM-I) but is similar to the DSM-I description of “emotionally unstable personality.”

Description

In 1958, two American psychiatrists, Paul Chodoff and Henry Lyons, delineated the primary characteristics of hysterical personality. Among these core features were vanity, theatrical behavior, and coy flirtatiousness. DSM-II (1968) introduced the primary diagnosis of hysterical personality, with “histrionic personality” in parenthesis. The DSM-III (1980) marked an official shift in the nomenclature to “histrionic personality,” and “hysterical personality” was dropped completely.

The DSM-V (2013) describes the contemporary stance on the features of HPD, which have not changed significantly from the previous edition of the DSM. The essential feature is “pervasive and excessive emotionality and attention-seeking behavior.” Their vivacious and energetic manner initially may charm new acquaintances. However, such characteristics often grow tiresome as it becomes apparent that these individuals’ energy is directed primarily at gaining attention at any cost. They frequently use flamboyant displays of emotion, self-dramatization, and sexual suggestiveness to get attention. Their speech is often vague and tends toward global impressions without supporting details (for instance, they may declare enthusiastically that the film they just saw was wonderful but be unable to say why). Distorted interpersonal functioning is also characteristic of persons with HPD; they may accord relationships an unrealistic level of intimacy (such as introducing a casual acquaintance as “my dear friend”) and are also easily influenced by others.

Many associated features of HPD (those that are not formally included in the diagnostic criteria) reflect the poor relationships experienced by these individuals; true emotional intimacy, whether with romantic partners or platonic friends, is often absent. They tend not to trust their partners and often manipulate them. Friends may become alienated by these individuals’ constant demands for attention and sexually provocative behavior.

Prevalence and Demographic Correlates

Data from the general population indicate a prevalence rate of HPD of 2 to 3 percent. Higher rates, from 10 to 15 percent, are reported in clinical settings, with much of this variation probably attributable to differences in diagnostic measures used across studies. Although HPD has traditionally been viewed as a disorder of women, researchers in clinical settings have typically reported only a slight female predominance or, in some cases, approximately equal rates in men and women.

Although research examining cultural differences in HPD is scant, some researchers hypothesize that different social norms may produce disparate rates of this condition across cultures. For example, the impropriety of overt sexuality in Asian society could result in lower rates of HPD, whereas the spontaneous emotionality valued in Hispanic and Latin American society could lead to higher rates. Nevertheless, there are few systematic data addressing this possibility.

Relations to Other Disorders

Other personality disorders can be difficult to distinguish from HPD. Borderline personality disorder
is classified by the same attention-seeking and manipulative behavior as HPD but differentiated from HPD by self-destructiveness, angry interpersonal relations, and persistent feelings of emptiness. Antisocial personality disorder
and HPD both include reckless, seductive, and manipulative tendencies, but the former condition is distinguished by antisocial and often criminal acts. Persons with narcissistic personality disorder
similarly strive for attention but usually as a means of validating their superiority rather than satisfying interpersonal and sexual needs. Dependent personality disorder is characterized by the same reliance on others for approval and guidance but tends to lack the theatrical behaviors of HPD.

Further complicating the diagnosis of HPD are its high rates of co-occurrence with other conditions. Among the conditions that overlap the most frequently with HPD are somatization disorder (characterized by multiple bodily complaints for which there is no discernible medical cause), dissociative disorders (characterized by disruptions in identity, memory, or consciousness), and dysthymic disorder (a chronic form of relatively mild depression).

Causes and Treatment

Finally, little is known about either the causes or treatment of HPD. Although some authors, such as American psychiatrist C. Robert Cloninger, have argued that this condition is an alternative manifestation of antisocial personality disorder that is more common in women than in men, the evidence for this hypothesis is equivocal. Some psychodynamic theorists have conjectured that HPD stems from cold and unloving interactions with parents. Nevertheless, there is little research support for this hypothesis. Cognitive explanations of HPD typically focus on the underlying assumptions (such as, “Without other people, I am helpless”) characteristic of this condition. It is not clear, however, whether these explanations provide much more than descriptions of the thinking patterns of individuals with HPD.

A variety of treatments for HPD have been developed. These treatments include behavioral techniques, which focus on extinguishing inappropriate (such as dependent, attention-seeking) behaviors and rewarding appropriate (that is, independent) behaviors, and cognitive techniques, which focus on altering irrational assumptions (such as the belief that one is worthless unless constantly showered with attention). Nevertheless, because no controlled studies have examined the efficacy of these or other techniques, it is not known whether HPD is treatable.

Bibliography

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Chodoff, Paul, and Henry Lyons. “Hysteria, the Hysterical Personality, and 'Hysterical' Conversion.” American Journal of Psychiatry 114 (1958): 734-740. Print.

O’Donohue, William T., Katherine Alexa Fowler, and Scott O. Lilienfeld, eds. Personality Disorders: Toward the DSM-V. Los Angeles: Sage, 2007. Print.

Pfohl, Bruce. “Histrionic Personality Disorder.” The DSM-IV Personality Disorders. Ed. W. John Livesley. New York: Guilford, 1995. Print.

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Veith, Ilza. Hysteria: The History of a Disease. Northvale: Aronson, 1993. Print.

Widiger, Thomas A. The Oxford Handbook of Personality Disorders. Oxford: Oxford UP, 2012. Print.