Histrionic Personality Disorder
The cluster B grouped personality disorder, Histrionic Personality Disorder (HPD), was researched, critiqued and discussed pertaining to its historical context, diagnostic criteria, etiology, treatment methods and cultural considerations. A true idea of what it is to have such as disorder was presented in an attempt to better understand varying nuances of said diagnosis. Treatment methods, etiology theories and discussion issues were discussed from a variety of theoretical perspectives as pertaining to relevant research and perceptions of the diagnosis. Case studies and research studies were referenced and implemented into key arguments and discussions. Gender biases were discussed as well as possible cultural differences that could lead to misdiagnosis. Furthermore, an integrative idea in discussion was formulated pertaining to the diagnosis and high prevalence of this disorder in affluent culture.
Histrionic Personality Disorder (HPD) is one of the most common personality disorders diagnosed in the United States (Schotte, De Doncher, Maes, Cluydts & Cosyns, 1993). According to the research by Widiger & Frances (1988), Schotte and colleagues (1993) state that HPD “reflects a tendency to be self-dramatizing, attention seeking, overly gregarious, seductive and manipulative, exhibitionistic, shallow, frivolous, labile, vain and demanding.” This disorder, although not thoroughly researched, has been known to be present in more than 40 percent of inpatients. There is also a high tendency for those diagnosed with this disorder to be female (Morrison, 2001). Throughout this paper the historical context, diagnostic criteria, etiology and treatment of this disorder will be discussed. A look at the possible gender bias in its diagnosis and cultural considerations will be taken, as well as a focus on applicable theoretical orientations to various aspects of etiology and treatment of this widespread disorder.
Histrionic Personality Disorder is rooted in the term hysteria (Blais, Hilsenroth & Fowler, 1998). According to Blais and colleagues (1998), hysteria is one of the oldest documented medical conditions, and has been dated back to ancient Greek and Egyptian writings. The Greeks believed it was caused by a wandering or displaced uterus and sexual dissatisfaction that caused women to be overly emotional (Hothersall, 2004). During the Middle Ages, hysteria was thought to be a result of witchcraft, sexual longing, demon possession and a defective moral character. During the 19th century, hysteria was viewed as a weakened nervous system related to sex in women biologically. Throughout history this term has reflected a misogynistic stigma against women as being weak, unstable and inferior.
Hysteria was first studied in a psychological context by Sigmund Freud, and acted as a catalyst in the development of his psychoanalytic theory (Blais et al, 1998). Freud’s study of this condition focused on repressed sexuality, ad nauseam and cursory emotionality, feelings of castration and penis envy, and an immoderately developed fantasy life. The concept of hysteria has undergone many changes due to its implementation into the psychoanalytic theory. It actually split into two different conditions termed Conversion Hysteria/Disorder (Crimlisk & Ron,1999), and Hysterical Character (Blais et al, 1998). Hysterical Character currently presents in the DSM-IV as Histrionic Personality Disorder.
Histrionic Personality Disorder can be found in the cluster B group of personality disorders, according to the DSM-IV (Morrison, 2001). These personality disorders are alike in that they often present in an overly dramatic, erratic or emotional manner. The diagnostic criterion for HPD consists of ad nauseam emotionality and attention-seeking behavior. These begin by early adulthood and present in a plethora of situations that consist of at least five of the following: discontent in situations where the client is not at the center of attention, shallow and highly reactive emotional expression, sexually inappropriate behavior in relationships that may be provocative/seductive, vague/detail-lacking speech, using physical appearance to attract attention to self, ad nauseam emotional expression, highly impressionable by other’s opinions and circumstances, and a delusion that relationships are more intimate than they truly are. A therapist would diagnose this axis II disorder as Axis II: 301.50 HPD.
Clients affected by HPD allow this formerly mentioned attention-seeking behavior to leak into all spheres of their life (Morrison, 2001). They may fulfill their need for attention through speech and behavior that draws ones focus of attention toward themselves. They may speak, dress and behave in such a manner as to implement salient stimuli of others into their everyday lives. They are known to have a wide range of sexual functioning ranging from normal to promiscuous and even prudence. These people tend to be overly gregarious in that they make friends easily and must remain in the presence of others. In addition to being surrounded by others, they rely highly on social approval. These people may appear naïve as they are overly trusting of others and highly impressionable. The HPD affected client may also be very demanding and manipulative in interpersonal relationships, inconsistent in their behavior and easily bored or constantly seeking excitement and change. They may have a hair-trigger temper and an inability to implement analytic/logical thinking into their daily lives and functioning; often forgetting things attached to emotions.
Current prevalence rates for HPD range from three to 19 percent and affect 40 percent of inpatients in the United States (Schotte et al, 1993). Although this disorder is highly diagnosed in women, men are diagnosed with the disorder as well (Bornstein, 1998). There are high comorbidity rates in those who suffer from HPD with other diagnoses such as anxiety disorder, dyshtymia, dissociative disorders and somatization (Kellett, 2007). Clients who have been diagnosed with HPD usually enter into treatment due to symptoms of depression, rather than an awareness of any histrionic symptoms related to the personality disorder.
As formerly noted, there have been many cultural myths and false beliefs surrounding the actual causes of HPD’s precursor: hysteria. Currently, there is a substantial amount of debate over HPD’s true causes from a psychological standpoint. The psychoanalytic viewpoint might say that there is a link with the death of a first-degree relative during childhood or parental divorce while the biological viewpoint focuses on a link in genetics (Seligman, 1984). Others who implement more progressive (possibly eclectic) and/or cognitive approaches to psychology focus on dependency issues as a primary correlate (Bornstein, 1998).
Robert Bornstein conducted a study concerning dependency needs in those with HPD and Dependent Personality Disorder (Bornstein, 1998). He used a Rorschach scale as well as a self-report inventory to measure dependency needs in those with HPD. He found a statistically significant correlation between HPD and high levels of tacit dependency needs. He also found through this study that the dependency needs of the HPD individual may be masked due to denial, displacement and repression in a subconscious attempt to keep those needs out of one’s own awareness. This client may have a manipulative way of meeting those needs through drawing attention to him/herself, thus ensuring others are focusing on his/her needs, rather than consciously seeking intimacy with another. This client may also deny any overt dependency needs, thus owning an independent façade. He further noted that masking and repression may be used as a defense mechanism/coping strategy to deal with anxiety-laden emotions.
Treatment and Case Study
There are several psychological schools of thought, or theoretical orientations, which have been implemented into the treatment of HPD (Kellett, 2007). The theoretical orientations most widely used in the treatment of HPD are psychodynamic and psychoanalytic approaches, although, radical behavioral, cognitive, functional analytic, brief psychodynamic, interpersonal and cognitive-behavioral approaches have also been practiced. Some have even used hypnosis in the treatment of HPD. Despite such varying schools of thought towards the treatment of this disorder, there are a few key therapeutic emphases that are present amongst all varying treatments with the joint goal of suppressing or maintaining HPD symptom presentations. These are interpersonal processes, dissident states of mind, and excessively spread out or scattered identities.
Very little research has been conducted concerning the actual effectiveness of said treatments, leaving much emphasis on studying case histories (Kellett, 2007). Horowitz (1997, as cited by Kellett, 2007) developed a treatment plan for HPD which consisted of three phases. The first stage is stabilization, followed by the modification of one’s communication techniques and style, then finished with the modification of the client’s interpersonal patterns, schemas and reactions. As stated above, however, there isn’t sufficient data on the effectiveness of said treatment.
Stephen Kellett (2007) conducted a case study on the effectiveness of cognitive analytic therapy (CAT) in the treatment of HPD. He based his research off a single case consisting of 24 CAT sessions and a six-month follow-up period of four sessions. He constantly took data to establish a baseline for HPD symptoms and judged the treatment outcome on the degree to which the key variables were reduced throughout the course of treatment. He also measured positive changes that withstood the test of time after treatment. The variables measured daily were: a strong need to be noticed on a particular day, being focused on appearance on a particular day, being flirty on a particular day, feeling empty and feeling like a child. The responses were measured on a scale from zero to nine. In addition to reporting on the above specified variables, the client was given a self-report measure of psychological functioning. This was administered at the initial onset of treatment, at termination and again during the final follow-up session.
Kellett (2007) conducted CAT through a culmination of assessment, and implementation of sequential diagrammatic reformulations (SDR) of self-states attributed to symptoms of HPD. This method of treatment fused the psychoanalytic approach with cognitive restructuring. This particular client reported that she was repeatedly sexually abused by her brother as a child. She disclosed that she would try to nonverbally alert her parents of the abuse through acting out dramatically, thus drawing attention to herself. She reported that this behavior increased slowly, but “failed” over a long period of time. She also reported being bullied in grade school due to dyslexia as well as discord in the home with a gender bias from her parents that tended to permit her brother more freedom, but rule over her sister and herself in an incredibly strict manner. As an adult, the client reported issues of mistrust, dependency and short-term relationships resulting in early termination due to said mistrust and dependency issues.
Kellett (2007) conducted treatment in a structured and time-limited format as previously stated. The first three sessions consisted of assessment; gaining a baseline for problematic thoughts and behaviors that were focal points for change. On the fourth session the client was presented with four focal points for change which consisted of a need for attention (or to be noticed), pacing relationships, physical appearance preoccupation, and trust concerns. For four sessions, SDR was formulated and presented during the seventh session. The SDR focused on eight goals for the client consisting of: lowered criticism of self and others, interacting with others without the need for seductive clothing or make-up, lowered approval-seeking behavior, enjoying social company without the need to be the center of attention, healthy relationship pacing, healthy expression of pain-laden emotions, thinking through and planning behavior rather than acting in a reactive manner and being able to express feelings of anger as it relates to rejection and abuse. During the 24th session, the client and therapist prepared and read a termination letter which concluded the progress made and challenged the client on future obstacles that may lie ahead, as well as acknowledged issues that may arise as a result of termination.
The result of Kellett’s (2007) case study showed statistically significant improvements in three of the five focal points for change. The three focal points which clinically improved and withstood the test of time after termination were as follows: preoccupation with physical appearance, feelings of emptiness and feeling like a child inside. Kellett noted that problematic symptoms were exacerbated at the onset of termination, but over the long-term there was a reduction in problematic psychological functioning related to depression and personality integration.
There are several ethical concerns and debates surrounding the diagnosis of HPD. There tends to be a strong gender bias among the psychological community as it relates to diagnosis, in that women are much more frequently diagnosed with this disorder than men (Erickson, 2002). Kevin Erickson conducted a study on such biases and found that in comparison to sex-unspecified vignettes, there was a high correlation with sex-specified vignettes and a tendency for clinicians to diagnose females as HPD and males with Narcissistic Personality Disorder. Maureen Ford and Thomas Widiger (1989) conducted a similar study; randomly selecting 354 psychologists and presented them with one of nine possible case histories which presented symptoms of Histrionic and Antisocial Personality Disorders (APD). The case histories consisted of clients who were described as male, female or androgynous. The results showed a statistically significant gender bias in the diagnosis of personality disorders with a high tendency for female clients to be diagnosed with HPD and for male clients to be diagnosed APD.
Furthermore, Warner (1978, as cited by Ford & Widiger, 1989) conducted a research study in which 175 mental health professionals were presented with case histories consisting of mixed symptoms of both HPD and APD. Results showed female portrayed clients were diagnosed HPD 76% of the time, and APD 22% of the time. Male portrayed clients were diagnosed HPD 49% of the time and APD 41% of the time. Warner (1978, as cited by Ford & Widiger, 1989) stated a “tendency for therapists to perceive men as antisocial personalities and women as hysterical personalities even when the patients have identical features.”
In the Bornstien (1998) study concerning dependency needs in DPD and HPD, women scored significantly higher on the interpersonal dependence inventory than men, but scored equal to men on the Rorschach scale which also measured dependency needs. Self-report may also contribute to the higher diagnosis of HPD in women. There could be a strong cultural component in this as men are often socialized to mask such expressions of needs and/or emotions. Bornstien (1992, as cited by Bornstien, 1998) states that "boys are generally discouraged from expressing openly dependent feelings and needs, yet girls have historically been encouraged to exhibit feelings, because passive, feminine behavior has traditionally been regarded as consonant with the female (i.e., feminine) sex role. Parents, teachers, older siblings, and other role models… encourage children – either subtly or directly – to conform to traditional sex role expectations [with respect to the overt expression of underlying dependency needs]." (p.11)
In addition to there being a gender bias in the diagnosis of HPD, there are also cultural differences which may bias those towards a higher prevalence rate for diagnosis. For example, the LGBT (lesbian, gay, bi-sexual and transgendered) community may experience some of this bias. Gay men have been known to be misdiagnosed HPD when their behavior is simply an expression prevalent in their culture; a norm of behavior within their community (Hempstead, 2009).
Histrionic Personality Disorder appears to have several nuances in terms of historical context, etiology, treatment and ethical concerns. From an integrative theoretical point of view, HPD appears to be rooted in childhood events, the family system, as well as the environmental or cultural system. It appears to cause one to value attention and approval from others, and to be valued as sexy. There also appears to be interpersonal difficulties within the HPD client as well as a low emotional IQ. Many different methods of treatment appear to be used in treating this disorder, although there is a large scarcity in terms of data providing effectiveness of treatment.
With such a small amount of research pertaining to this disorder’s etiology and treatment, as well as the significantly high prevalence rate in America, one is left to wonder why more hasn’t been done by means of the psychological community in exploration of this subject. Perhaps it is so engrained in our culture as a common struggle amongst women that has affected humans since the beginnings of social culture. One ponders if there has been such little focus on it due to the ability of those affected to remain high-functioning. Maybe it isn’t sought out enough as cause for treatment, as many usually seek relief for its comorbid features, rather than HPD in and of itself.
Due to the nature of those seeking out treatment for comorbid features, rather than the personality disorder, paired with a high tendency for men to be diagnosed differently, one must wonder if this disorder is much more prevalent than statistics reflect. Perhaps there is a little histrionic tendency in all of us, or a possibility for any particular American to be diagnosed as such. Our culture places a high value on individuality and appearance. It is difficult to function in society and within the American culture without some degree of preoccupation with appearance and sexuality as our media and advertising has been saturated with it.
There is also a high tendency for those within the American culture to operate in an ego-centric manner, in concordance with our high value on individuality. Furthermore, the development of technological advances such as automobiles, telephones, computers and televisions paired with a strong emphasis on independence and autonomy within our culture truly leads us to be far less collectivistic. Being part of a more independent, individualistic culture with such technological advances truly isolates individuals far more than other cultures without such luxuries. When people are isolated from regular or constant human interaction on a regular basis, and encouraged to be unique and individual, perhaps they feel a need to draw attention to themselves in an attempt to validate these ideals rather than meshing into a group, thus overcompensating for the isolation they feel simply through being a part of our culture.
Histrionic Personality Disorder appears to be one of the least threatening diagnosis amongst personality disorders as those affected are high functioning and do not seek relief for the disorder itself. There is also very little research on HPD which makes treatment options limitless and based on a case by case perspective. The etiology and cultural ideas surrounding this disorder have changed and evolved over time, however, there are definitely some gender and cultural biases present concerning its diagnosis. With diagnoses and disorders having such a malleable and evolving nature, it is important for clinicians to remain open and ethically minded when diagnosing. Although there seems to be a deficit in research and diagnosis, the psychological community as a whole must be mindful to this; continuing to grow, evolve and change just as one would expect of a client.
Blais, M., Hilsenroth, M. & Fowler, C. (1998). Rorschach correlates of the DSM-IV histrionic personality disorder. Journal of Personality Assessment.70(2), 355-365.
Bornstein, R. (1998). Implicit and self-attributed dependency needs in dependent and histrionic personality disorders. Journal of Personality Assessment. 71(1), 1-14.
Crimlisk, H. & Ron, M. (1999) Conversion hysteria: history, diagnostic issues, and clinical practice. Cognitive Neuropsychiatry. 4(3), 165-180.
Erickson, K. (2002). Psychologist gender and sex bias in diagnosing histrionic and narcissistic personality disorders. Dissertaion Abstracts International: Section B: The Sciences and Engineering. 62(10-B), 4781.
Ford, M. & Widiger, T. (1989). Sex bias in the diagnosis of histrionic and antisocial personality disorders. Journal of Consulting and Clinical Psychology. 57(2), 301-305.
Hempstead, K. (2009, August). Personality Disorders. Lecture at National University, San Diego, CA.
Hothersall, D. (2004). History of Psychology. New York: McGraw-Hill.
Kellett, S. (2007). A time series evaluation of the treatment of histrionic personality disorder with cognitive analytic therapy. Psychology and Psychotherapy: Theory, Research and Practice. 80, 389-405.
Morrison, J. (2001). DSM-IV Made Easy: A Clinician’s Guide to Diagnosis. New York: Gulliford Press.
Schotte, C., Doncher, D., Maes, M., Cluydts, R. & Cosyns, P. (1993). MMPI assessment of the DSM-III-R histrionic personality disorder. Journal of Personality Assessment. 60(3), 500-510.
Seligman, M. (1984). Abnormal Psychology. New York: WW Norton & Company.