Histrionic Personality Disorder

overview

Histrionic Personality Disorder (HPD) is a relatively rare condition, having a 1.8% lifetime prevalence rate.[1] HPD can be characterized by exaggerated displays of emotionality, excessive attention-seeking, self-dramatization, egocentricity, a lack of consideration for others and easily hurt feelings.[2]

Symptoms

The onset of Histrionic Personality Disorder is usually in the late teens or early 20s.[3] According to the Cleveland Clinic, potential symptoms of HPD include:[4]

Feeling underappreciated or depressed when they are not the center of attention.
Have rapidly shifting and shallow emotions.
Dramatic and extremely emotionally expressive, even to the point of embarrassing friends and family in public.
Have a "larger than life" presence.
Persistently charming and flirtatious.
Overly concerned with their physical appearance.
Use their physical appearance to draw attention to themselves by wearing bright-colored clothing or revealing clothing.
Act inappropriately sexual with most of the people they meet, even when they are not sexually attracted to them.
Speak dramatically and express strong opinions but with few facts or details to support their opinions.
Gullible and easily influenced by others, especially by the people they admire.
Think that their relationships with others are closer than they usually are.
Have difficulty maintaining relationships, often seeming fake or shallow in their interactions.
Need instant gratification and become bored or frustrated very easily.
Constantly seek reassurance or approval.

Causes

Studies have found a plethora of potential causes of Histrionic Personality Disorder. While more women and people assigned female at birth (AFAB) are diagnosed, researchers think that men and people assigned male at birth (AMAB) may be underdiagnosed.[5] Jane et al. (2007) add that there may be relatively little systemic gender bias in diagnostic criteria for personality disorders;[6,7] thus, underdiagnosis of men and people AMAB could be due to other factors.

A twin study by Oslo University found an association between genetics and HPD, thus indicating a hereditary factor.[8] Other studies have pointed to potential biological causes. A study found that people with Histrionic Personality Disorder have highly responsive norepinephrine systems, corresponding with anxiety-proneness, dependency and high sociability.[9] Chu et al. (2020) further that the inhibitory function of the brainstem, which mediates emotion and emotional regulation, is more dysfunctional under erotic conditions in histrionic patients.[10] Moreover, French (2022) found that parents whom role model histrionic behavior (e.g., dramatic, volatile, inappropriate sexual behavior) put children at higher risk for developing Histrionic Personality Disorder.[11] Yalch (2023) also found that in a large sample of college students, HPD has a higher association with a previous sexual assault when compared to the influence of temperament.[12]

Diagnosis

A licensed medical practitioner who suspects a patient may have Histrionic Personality Disorder often asks broad general questions that shed light on past history, relationships, previous work history, reality testing, and impulse control. Depending on the patient's awareness of their behavior, additional information may be collected from a patient's family and friends.[13]

French (2022) presents the following differential diagnosis to distinguish HPD from other types of personality disorders:[14]

Patients with Narcissistic Personality Disorder want attention, which results from admiration or veneration. Comparatively, people with Histrionic Personality Disorder are not particular about what type of attention they garner.

Both patients with Borderline Personality Disorder and patients with Histrionic Personality Disorder experience intense emotions. However, patients with Borderline Personality Disorder usually dislike themselves.

Both patients with Dependent Personality Disorder and patients with Histrionic Personality Disorder will prefer to be around others. However, patients with Dependent Personality Disorder tend to be more submissive, and their behavior is more inhibited as they are preoccupied with fears of rejection.

Complications

People with HPD can typically be high functioning, achieving success educationally, socially and professionally.[15] However, those with severe symptoms may struggle to reach their full potential.[16] Furthermore, there are some complications associated with Histrionic Personality Disorder:[17-19]

Somatic Symptom Disorder: A disorder in which individuals feel excessively distressed about a physical symptom they have. They may also have abnormal thoughts, feelings and behaviors in response to their symptoms.
Panic Attacks: A panic attack causes sudden, brief feelings of fear and strong physical reactions in response to ordinary, non-threatening situations.
Conversion Disorder: A medical problem involving the loss of function of a part of the nervous system. More specifically, the brain and body believe that a part of the nervous system is not functioning when there is no evidence of structural damage.
Extreme attention-seeking behavior in people with HPD may involve frequent suicidal threats and gestures.
Higher risk of developing depression and substance abuse disorder compared to the general population.
Histrionic symptoms during adolescence are related to a higher risk of developing binge-eating disorder and recurring purging behavior during mid-adult age.

Treatment

Psychotherapy (talk therapy) is the typical treatment for Histrionic Personality Disorder.[20] Babl et al. (2023) found that psychotherapy decreased HPD symptoms significantly in study participants aged 19-67. However, effectiveness depended on the patient trusting the therapist and reducing their actions to try and control their therapist.[21] The Cleveland Clinic presents the following as beneficial forms of psychotherapy for people with Histrionic Personality Disorder:[22]

Group Therapy: This is a type of psychotherapy in which a group of people meets to describe and discuss their problems together under the supervision of a therapist or psychologist.
Psychodynamic Psychotherapy: This type of therapy focuses on the psychological roots of emotional distress. The person undergoing therapy looks into problematic relationship patterns through self-reflection and self-examination.
Supportive Psychotherapy: This therapy aims to improve symptoms and maintain, restore, or improve self-esteem and coping skills. Supportive psychotherapy involves the examination of relationships and patterns of emotional response or behavior.
Cognitive Behavioral Therapy (CBT): A therapist or psychologist helps a person closely examine their thoughts and emotions. Through CBT, one can unlearn patterns of negative thoughts and behaviors and learn to adopt healthier thinking patterns and habits.

There is currently no medication to specifically treat personality disorders. However, there is medication for depression and anxiety that people with HPD can develop due to the disorder.[23]

If you think you or someone you know may have Histrionic Personality Disorder, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Maria Karla Bermudez

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Babl, A., Gómez Penedo, J. M., Berger, T., Schneider, N., Sachse, R., & Kramer, U. (2023). Change processes in psychotherapy for patients presenting with histrionic personality disorder. Clinical psychology & psychotherapy, 30(1), 64–72. https://doi.org/10.1002/cpp.2769

2 Chu Wang, Angst, J., Bach, M., Bär, K. J., Coolidge, F. L., Forkmann, T., Grant, B. F., Johnson, J. G., Kopeykina, I., Leible, T. L., Linden, M., Montorsi, F., Nicolò, G., Perretti, A., Plutchik, R., Schoenen, J., … Adolphs, R. (2020, January 29). Inhibitory brainstem reflexes under external emotional-stimuli in schizoid and histrionic personality disorders. Personality and Individual Differences. https://www.sciencedirect.com/science/article/pii/S0191886920300337

3 Histrionic personality disorder: Causes, symptoms & treatment. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/9743-histrionic-personality-disorder Updated April 29, 2022.

4 Ibid.

5 Ibid.

6 Ibid.

7 Jane, J. S., Oltmanns, T. F., South, S. C., & Turkheimer, E. (2007). Gender bias in diagnostic criteria for personality disorders: an item response theory analysis. Journal of abnormal psychology, 116(1), 166–175. https://doi.org/10.1037/0021-843X.116.1.166

8 R. Nalini, S. Panneerselvam. Histrionic Personality Disorder. Int. J. of Advances in Nur. Management. 2018; 6(4): 329-333. doi: 10.5958/2454-2652.2018.00075.6 https://ijanm.com/AbstractView.aspx?PID=2018-6-4-14

9 Ibid.

10 Chu et al. (2020)

11 French JH, Shrestha S. Histrionic Personality Disorder. [Updated 2022 Sep 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK542325/

12 Yalch, M. M., Mehta, A., Watters, K. N., Dawood, S., & Schroder, H. S. (2023). Relative Effects of Sexual Assault and Temperament Traits on Cognitive Characteristics of Histrionic Personality Disorder. Violence and victims, 38(2), 203–212. https://doi.org/10.1891/VV-2021-0149

13 Cleveland Clinic (2022)

14 French (2022)

15 Nalini et al. (2018)

16 Ibid.

17 Cleveland Clinic (2022)

18 French (2022)

19 Babl et al. (2023)

20 Cleveland Clinic (2022)

21 Babl et al. (2023)

22 Cleveland Clinic (2022)

23 Ibid.