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Histrionic Personality Disorder
Introduction
Histrionic personality disorder (HPD) is a chronic, enduring psychiatric condition characterized by a consistent pattern of pervasive attention-seeking behaviors and exaggerated emotional displays. The condition is usually life-long and treatment-resistant, with onset typically in late adolescence or early adulthood. Individuals with HPD are often described as seductive, self-indulgent, flirtatious, dramatic, extroverted, and animated.[1] They may feel underappreciated or disregarded when they are not the center of attention.[2] Individuals with HPD can be vibrant, enchanting, overly seductive, or inappropriately sexual.[3] They may typically demonstrate rapidly shifting and shallow emotions that others may perceive as insincere.
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 "hystera," meaning uterus—as these behaviors were believed to be exclusive to women and were caused by disturbances in the uterus.[4] 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 excesses and attention-seeking behavior. Freud's theories, although controversial and often criticized, laid the groundwork for the exploration of histrionic symptoms and behaviors.[5]
HPD was formally recognized as a distinct diagnostic category in the mid-20th century. In 1980, the Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (DSM-III) included HPD as a diagnosable condition. The DSM-III identified key criteria, including a pervasive pattern of excessive emotionality, a need for attention, and exaggerated behaviors. Since its inclusion in the DSM-III, HPD criteria have undergone refinements in subsequent editions. The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV, 1994) and the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision (DSM-IV-TR, 2000) maintained the core diagnostic criteria, emphasizing attention-seeking behavior and self-dramatization, while also considering cultural context and gender differences. HPD is still recognized as a distinct diagnosis in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Text Revision (DSM-5-TR, 2022).
Clusters of Personality Disorders in DSM-5-TR
The DSM-5-TR divides personality disorders into clusters A, B, and C, each encompassing a distinct set of personality disorders with commonalities regarding symptoms, behaviors, and underlying psychological patterns.[6][7]
Cluster A: Cluster A encompasses personality disorders with odd or eccentric characteristics. These include paranoid, schizoid, and schizotypal personality disorders. Individuals within this cluster exhibit social withdrawal, mistrust, and difficulties forming close relationships.[8]
Cluster B: Cluster B encompasses personality disorders with dramatic, emotional, or erratic behaviors. This cluster includes HPD along with antisocial, borderline, and narcissistic personality disorders. Individuals within this cluster typically display impulsive actions, emotional instability, and challenges in maintaining stable relationships.[9]
Cluster C: Cluster C encompasses personality disorders with anxious and fearful characteristics. These include avoidant, dependent, and obsessive-compulsive personality disorders. Individuals within this cluster tend to experience significant anxiety, fear of abandonment, and an excessive need for control or perfectionism.[10] Despite the historical context of using the "cluster" system, limitations exist when approaching personality disorders.[11] While the diagnosis of HPD provides a framework for understanding and studying these behaviors, ongoing debates in psychology and psychiatry revolve around the nature and validity of personality disorders, including HPD. Our understanding of histrionic traits and behaviors continues to evolve.[12]
Etiology
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Etiology
Temperament Traits
Individuals with HPD exhibit specific temperament traits, as mentioned below.
- Harm avoidance: Individuals with HPD tend to exhibit low harm avoidance, showing a bias against inhibiting behaviors that could lead to punishment or non-reward.
- Novelty seeking: Individuals with HPD typically display high novelty-seeking behavior, characterized by a strong inclination to initiate novel activities that are likely to generate a reward signal.
- Reward dependence: Individuals with HPD exhibit high reward dependence, indicating a strong desire to engage in behaviors driven by social reward cues.
- Persistence: Individuals with HPD typically exhibit low persistence, which refers to the ability to maintain efforts and persist with behaviors despite obstacles, frustration, fatigue, or limited reinforcement.[13][14][15]
Research on the etiology of HPD is limited, with few high-quality studies available. Several factors are believed to contribute to the development of HPD, including genetic predisposition, childhood experiences, and environmental influences. However, an ongoing debate persists about the relative importance of these factors.[6] Child abuse and neglect, particularly child sexual abuse, are identified as significant risk factors for HPD.[16] Genetic studies propose a hereditary component in personality disorders, including HPD. Studies involving twins have suggested that genetic and environmental factors contribute to the etiology of HPD.[17] These findings suggest that genetic factors contribute to the vulnerability of HPD. However, the specific genes or genetic mechanisms involved in HPD have yet to be elucidated.
Medical conditions, specifically those with pathology that damage neurons, are often associated with personality disorders or changes. These conditions include, but are not limited to, head trauma, cerebrovascular diseases, cerebral tumors, epilepsy, Huntington's disease, multiple sclerosis, endocrine disorders, heavy metal poisoning, neurosyphilis, and AIDS.[18] Various psychological factors contribute to the development of personality traits and disorders, including unconscious processes, early childhood experiences, and the influence of internal conflicts.
Psychoanalyst Wilhelm Reich made significant contributions by exploring defense mechanisms and their connection to personality types. He introduced the concept of "character armor," which denotes defense mechanisms used to mitigate cognitive conflict stemming from internal impulses and interpersonal anxiety. For example, individuals with histrionic tendencies often tend to exhibit projection, splitting, displacement, and sexualization as defense mechanisms.[19][20]
Personality is defined as the set of established behavioral patterns through which individuals relate to and understand the world. A personality disorder arises when an individual develops an inflexible and uncompromising pattern of maladaptive thinking and behaving, leading to significant impairment of social or occupational functioning and causing interpersonal distress.[21] To meet diagnostic criteria, these patterns of thinking and behaving must markedly deviate from cultural norms. Such deviations typically manifest as disturbances in affectivity, cognition (inappropriate perception of self, others, or events), impulse control, or interpersonal functioning.[22]
Personality is a complex summation of biological, psychological, social, and developmental factors, thereby making each individual's personality unique, even among those diagnosed with a personality disorder. Personality encompasses the pattern of behaviors that individuals adapt to in response to constantly changing internal and external stimuli. This broader concept is often referred to as temperament, a heritable and innate psychobiological characteristic.[23][24] However, temperament is also influenced and shaped by epigenetic mechanisms, such as life experiences, including trauma and socioeconomic conditions, which serve as adaptive factors in personality development.[25][26]
Epidemiology
High-quality and multi-population studies to accurately quantify the prevalence of HPD are lacking, with many existing studies being outdated and thus limiting their applicability. Approximately 9% of the general population is affected by at least one personality disorder, with the prevalence of HPD estimated to range from 0.4% to 0.6% to as high as 1.8%.[27][28][29] Women are diagnosed with HPD at a rate approximately 4 times higher than men.
However, there may be a tendency to overdiagnose women with this disorder compared to men, possibly due to societal norms where sexual forwardness is less acceptable for women. Conversely, men may be underdiagnosed.[21] HPD is often ego-syntonic, meaning individuals typically perceive their behavior as normal and may struggle to recognize any problem.[22] This lack of insight can contribute to underdiagnosis until later in life when behavior patterns significantly interfere with relationships, work, or interpersonal well-being.[2]
History and Physical
The presentation of HPD varies widely. Therefore, obtaining a comprehensive medical and social history is essential for establishing an accurate diagnosis. Family members may often initiate referrals for evaluation, as individuals with HPD typically do not perceive their behaviors as problematic. They may demonstrate excessive sensitivity to criticism and engage in speech patterns aimed at charming or influencing the evaluating clinician.[30]
Patient history can vary widely, and individuals with HPD may emphasize topics designed to provoke a reaction, such as discussing sexual history or simulating medical conditions.[31] Research has explored the prevalence of sexual assault among those with HPD.[32][33] The mental status examination conducted during psychiatric evaluations is critical for assessment. However, the specific elements and findings of this examination can vary depending on the patient's history and the case context.
Assessments
Clinicians evaluate various aspects of behavior in individuals with HPD, including appearance, behavioral patterns, and speech characteristics.
Appearance: Clinicians should observe the patient's grooming and fashion choices closely. Individuals with HPD often dress provocatively or seek attention, which may include revealing clothing, suggestive or extensive tattoos, brightly colored hair, eccentric hairstyles, and multiple accessories.
Behavior: Individuals with HPD exhibit eccentric and disinhibited behaviors. They may display splitting behaviors depending on the course of the psychiatric interview. Additional behaviors can include dramatic storytelling, hypersexual gestures, and seeking attention through dramatic actions.
Speech: Individuals with HPD often speak loudly and dramatically. Their speech tends to be impressionistic and lacking in detail. They typically do not exhibit deficits in speech initiation or vocabulary.
Thought process: In individuals with HPD, the thought process is generally linear but may be limited in range and logic. They often exhibit high suggestibility and are easily influenced by the thoughts and opinions of those around them.
Cognition: Individuals with HPD typically exhibit normal cognition and orientation.
Impulse control: Individuals with HPD often struggle with poor impulse control, leading to the engagement of various pathological behaviors.
Judgment: Individuals with HPD may exhibit poor judgment.
Insight: As HPD is considered ego-syntonic, individuals with this disorder often lack insight into their condition and the impact of their behaviors on social and occupational functioning.
Evaluation
Diagnosing a personality disorder involves longitudinal observation of a patient's behavioral patterns across various contexts and circumstances to comprehensively understand their long-term functioning. Many features of personality disorders overlap with symptoms of acute psychiatric conditions, thereby posing challenges in differentiation from other comorbid psychiatric disorders. In some cases, extended observation may not be feasible or necessary, especially when an underlying personality disorder substantially contributes to hospitalizations or exacerbates another psychiatric condition (such as a major depressive episode). Establishing a firm diagnosis usually requires multiple sessions with the patient.[34][35]
To obtain a formal diagnosis of HPD, individuals must meet the diagnostic criteria specified in the DSM-5-TR. The diagnosis involves a comprehensive evaluation that incorporates multiple sources of information, such as personal history, collateral reports, and a mental status examination. This thorough assessment allows clinicians to effectively evaluate the individual's symptoms, functioning, and overall presentation.
A pervasive pattern of excessive emotional behavior and attention-seeking begins in early adulthood and persists across different contexts. Clinical features include at least 5 of the following behaviors:
- Uncomfortable when not the center of attention
- Interactions with others are overly sexual, inappropriate, or provocative
- Rapidly shifting and shallow emotions
- Consistently utilizes physical appearance to attract attention
- Speech that is impressionistic, vague, and lacks detail
- An exaggerated expression of emotion that is theatrical and self-dramatized
- Easily influenced by others or circumstances
- Perception of relationships as more intimate than they are [6]
Treatment / Management
Psychotherapy is the primary treatment for personality disorders, though evidence for its effectiveness in treating HPD is limited. The prevailing view is that HPD is a lifelong and treatment-resistant condition. Most studies report low efficacy in treating HPD, with low rates of symptom remission and a failure to achieve normative levels of functioning. Developing and maintaining therapeutic rapport is crucial in treating personality disorders. Individuals with HPD often do not recognize their illness and may resist the idea of treatment. As HPD is unlikely to remit without intervention, the focus of treatment may be on reducing interpersonal conflict and stabilizing psychosocial functioning.[36][37]
Psychotherapy techniques have been investigated as potential treatments for HPD, yielding generally mixed findings.[38] A study of 159 patients with HPD demonstrated improvement with clarification-oriented psychotherapy.[39] The therapeutic alliance is crucial in treating HPD, as it is with all personality disorders.[40] Psychotropic medications are generally ineffective for HPD, and agents approved by the US Food and Drug Administration (FDA) are not available for the treatment.[41] However, treating comorbid psychiatric conditions with psychotropic medications could likely improve symptoms.
Differential Diagnosis
HPD should be considered when a long-term pattern of rigid behaviors is observed over various internal and external stimuli. Many behaviors observed in HPD may overlap with symptoms of other psychiatric illnesses, and the condition may occur in isolation or in conjunction with another psychiatric condition. For instance, grandiosity, hypersexual behavior, and increased speech are common in manic or hypomanic episodes of bipolar disorder.[42] However, no decreased need for sleep exists in isolated HPD. Additionally, manic and hypomanic episodes are acute and relatively short-lived, typically responding well to medication. In contrast, HPD is chronic, rigid, and does not respond well to medications.[43]
Other differential diagnoses include cluster B personality disorders, specifically narcissistic personality disorder and borderline personality. Like HPD, patients with narcissistic personality disorder prefer to be the center of attention.[22] However, narcissistic personality disorder is characterized by fantasies of unlimited success, lack of empathy, and exploitative behavior. Overlap between borderline personality disorder and HPD includes impulsive behaviors and splitting. However, individuals with borderline personality disorder are more likely to exhibit suicidal behaviors, an intense fear of abandonment, and chronic feelings of emptiness.[6] Somatic symptom disorder and illness anxiety disorder may also be considered in the differential diagnosis for HPD, as patients with these conditions may use physical symptoms and complaints to signal distress.[44]
Pertinent Studies and Ongoing Trials
Understanding of HPD is limited, with high-quality population studies lacking. Most knowledge is based on small sample-size investigations, case reports, or case series, often from earlier eras of classification. A recent study examined associations between sexually coercive behavior in women, pornography use, and HPD.[45] Significant limitations exist in the current models describing all personality disorders, particularly the commonly used "cluster" system from the DSM. Despite attempts to classify behavioral patterns into syndromes, such as personality disorders, each personality poses challenges for diagnosis and research into specific personality disorders.[11]
Experts in personality disorders have suggested switching to a dimensional model of personality rather than a cluster model. Dimensional models generally describe temperament, utilize defense mechanisms, and identify pathological personality traits.[46] Although the DSM-5 did not incorporate these recommendations due to the radical change they would entail for clinical use, a paradigm shift is expected as further research aligns with evolving clinical guidelines. This potential shift is particularly evident as the DSM-5-TR has incorporated this research under emerging measures and models.
Notably, in this section of the DSM-5-TR, some personality disorders from the cluster model are removed, including HPD. Arguments for removing HPD as a standalone personality disorder include bias as a sex-based diagnosis (overdiagnosed in women), the inability of HPD to present a well-defined and unique set of psychiatric symptoms, and the declining influence of psychoanalytic thinking in the development of personality.[47]
Prognosis
Although limited studies report and predict the outcome of HPD, a consensus exists that the disorder usually lasts for life. HPD is unlikely to resolve without treatment. Interventions to optimize quality of life, reduce psychiatric comorbidity, and stabilize social factors are likely to improve the prognosis.[48]
Complications
Substance use disorders are common among personality disorders, but there is limited information on which specific personality disorders pose the highest risk for particular substance use disorders.[49] Personality disorders increase the likelihood of suicide and suicide attempts compared to those without personality disorders, so individuals with HPD should be frequently screened for suicidal ideation.[50]
Deterrence and Patient Education
Treatment of HPD is contingent upon developing and maintaining therapeutic rapport.[36] Patients are encouraged to express the symptoms they wish to address and to communicate openly with their treatment team. Rather than focusing solely on modifying the patient's behaviors, clinicians should strive to understand and address the specific concerns and challenges the patient faces. Patients are also encouraged to leverage their support networks, including current relationships, and to expand these networks as they gain comfort and confidence. Involving the patient's family can aid in monitoring for decompensation and providing education. The use of standardized assessments for quality of life may further enhance the patient's ability to function effectively in significant areas of life.[48]
Pearls and Other Issues
Psychodynamic psychotherapy has been found to offer a range of benefits in treating personality disorders, with some benefits persisting for years after completing treatment, as indicated by at least 5 meta-analyses.[51]
Enhancing Healthcare Team Outcomes
Diagnosing and treating HPD presents challenges that underscore the need for further psychiatric research. As diagnostic and treatment paradigms shift from a cluster system to a dimensional model of personality, the impact on clinical practice remains uncertain. This is particularly relevant as HPD is not considered a unique personality disorder in the dimensional model but rather a personality trait. When HPD is suspected, it is crucial for the healthcare team to conduct a comprehensive assessment that includes gathering collateral information. Considering the patient's perspective and establishing appropriate care goals are essential to avoid inappropriate medication use. Collaborating with social workers, therapists, and family members can help optimize social factors in the patient's life and promote stability.[52]
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