by David Porter, MA, LADC

Histrionic Personality Disorder

Histrionic Personality Disorder is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis assigned to individuals who are dramatic, excessively emotional given the context, and will seek to be the center of attention in a social situation. They are prone to explosive displays of anger over minor provocations, similar to a child's temper tantrum, sobbing and crying over mild sentimental situations, and may effusively greet casual acquaintances, or assume a sense of familiarity and intimacy which does not exist. Histrionic Personality Disorder is classified as a Cluster B Personality Disorder, with features similar to and overlapping with Borderline, Antisocial, and Narcissistic Personality Disorders (American Psychiatric Association, 2013).

Symptoms

According to the DSM-5, there are eight criterion for Histrionic Personality Disorder:

1. Discomfort if one is not the center of attention.
2. Inappropriate seductive, flirtatious, and provocative behavior.
3. Display of shallow and labile emotions.
4. Dressing in a manner to draw attention to themselves, e.g., low cut tops, short skirts.
5. Speech is overly impressionistic and shallow.
6. Dramatic, theatrical, and excessively emotional personal presentation.
7. Suggestible by others and the situation, prone to following fads.
8. Overestimates the level of intimacy in a relationship. (American Psychiatric Association, 2013).

Onset

The DSM-5 notes that the onset of Histrionic Personality Disorder is early adulthood (American Psychiatric Association, 2013). A degree of drama and emotional immaturity is age-typical behavior in adolescents, but as one matures, this typically diminishes and is replaced by a higher degree of emotional regulation.

Prevalence

According to the DSM-5, the prevalence of Histrionic Personality Disorder was found to be 1.84% in the early 2000's, and is diagnosed much more frequently in females than males (American Psychiatric Association, 2013).

Risk Factors

The DSM-5 does not specify risk factors for Histrionic Personality Disorder. It can be inferred that being female is a risk factor, as women have an incidence of Histrionic Personality Disorder four times greater than men (Out of The Fog, 2014 ; American Psychiatric Association, 2013). Heritability for Cluster B Personality Disorders, including Histrionic Personality Disorder has been established. In a study of n = 2800 twins in Norway, it was found that Cluster B Personality disorders were in the

“upper range” of heritability compared to other mental disorders (Torgersen, Reichborn-Kjennerud, Røysamb, Kubarych, & Kendler, 2012). It could be speculated that there are neurological factors at work in Histrionic Personality Disorder, such as an excess of limbic activity, and a deficit of prefrontal cortical activity. However, given neuroplasticity and neurological response to environmental input, it would be uncertain if this is a inherited feature, or the result of a kindling mechanism and entrenchment. Repeated episodes of emotional dyscontrol could precipitate further episodes. However, emotional dyscontrol is only one feature of Histrionic Personality disorder, so the causality may be more complex. Histrionic Personality Disorder may also be a learned behavior, passed from one generation to the next (Out of The Fog, 2014). A child who grows up with a mother who displays emotional dyscontrol and a dramatic presentation may emulate these behaviors, particularly if these behaviors facilitate attention, and create a disproportionate distribution of power in the family system.

Comorbidity

The DSM-5 indicates that Histrionic Personality Disorder is comorbid with Borderline Personality Disorder and substance abuse disorders (American Psychiatric Association, 2013). A study of n = 40,000 subjects in the US and UK revealed a comorbidity between Histrionic Personality Disorder and lifetime incidence of Alcohol Dependence at almost 50% (Trull, Jahng, & Sher, 2010). Tobacco Use Disorder is also found more frequently in individuals with Personality Disorders, including Histrionic Personality Disorder (Zvolensky, Jenkins, Johnson, & Goodwin, 2011). Alcohol, drug, and tobacco use disorders are all noted to have comorbidity with the personality disorders, as well as increased stress, less social support, suicidality, involvement with the criminal justice system, and interpersonal problems (Trull, Jahng, & Sher, 2010).

Treatment for Histrionic Personality Disorder

The DSM-5 does not specify treatment options for Histrionic Personality Disorder (American Psychiatric Association, 2013). Personality disorders are typically very treatment resistant, as personality can be defined as a relatively stable set of traits, values, attitudes, and beliefs about self, others and the world. A personality disorder is a maladaptive and dysfunctional version of the aforementioned description. The individual with a personality disorder will typically view others as the problem, and discount their own contribution. This makes them less likely to seek out psychotherapy, and they will hold a self- defeating view that the world must change for them, rather than seeing the value of conforming their behavior to societal expectations, at least to the degree necessary to function in life. It is noted that Histrionic Personality Disorder has responded well to FAP (Functional Analytic Therapy) which is a form of behavioral therapy based on reinforcement for behavior modification, according to two case studies. Further research with larger samples is needed to support this finding (Matusiewicz, Hopwood, Banducci, & Lejuez, 2010). Family therapy or couples counseling may be beneficial to assist family or partner to understand and cope with the IP's (Identified Patient's) behavior, and participate in modifying their behavior. In the case of couples counseling, the goal may be reconciliation, or as peaceful as possible termination of the relationship.

Impact on Functioning

Histrionic Personality Disorder can have a substantial impacts on social/interpersonal and occupational functioning. (American Psychiatric Association, 2013). Individuals with Histrionic Personality Disorder can be emotionally draining to deal with, (Out of The Fog, 2014) and may alienate themselves. They may initially have an energy level, passion, seductiveness, and spontaneity which will be attractive to some people, but others will grow weary of the drama and sever social contacts. (American Psychiatric Association, 2013. They will tend to be high maintenance employees, frequently complaining about the behaviors of others in the workplace. They tend to create problems where none exist, and rather than seeking solutions to problems, escalate and exaggerate the severity of the issue to create drama and draw more attention to themselves. This is an emotional/behavioral positive feedback loop which makes people with Histrionic Personality Disorder very difficult to cope with (Out of The Fog, 2014). Individuals with Histrionic Personality Disorder may make suicidal gestures to gain attention (American Psychiatric Association, 2013).

Differential Diagnosis

There are diagnostic rule-outs for the clinician to consider. In the DSM -5, disorders such as Borderline Personality Disorder, Narcissistic Personality Disorder, and substance abuse disorders are noted as diagnostic rule-outs. (American Psychiatric Association, 2013). Depression may be initially diagnosed due to self report of dissatisfaction with life, and exaggerated negativity (Out of The Fog, 2014) The hypomanic phase of Bipolar disorder could present with symptoms similar to Histrionic Personality Disorder, as someone in a hypomanic state will display exaggerated emotions, act dramatically, and may be hypersexual. A thorough evaluation will include differentiating between a hypomanic phase and enduring personality characteristics. PTSD (Post-traumatic Stress Disorder) should also be considered as a diagnostic rule out, as individuals with PTSD may be emotionally labile, crisis oriented, and prone to emotional dyscontrol if they feel threatened.

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References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.

Matusiewicz, A.K., Hopwood, C.J., Banducci, A.N., and Lejuez, C.W., (2010). The Effectiveness of Cognitive Behavioral Therapy for Personality Disorders. Psychiatry Clinics of North America. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3138327/

Out of The Fog (2014). Histrionic Personality Disorder. Out of the Fog. Retrieved March 22, 2014 from http://outofthefog.net/Disorders/HPD.html

Torgersen, S., Myers, J., Reichborn-Kjennerud, T., Røysamb, E., Kubarych, K.S., and Kendler, S.K.,(2012). The Heritability of Cluster B Personality Disorders Assessed both by Personal Interview and Questionnaire Journal of Personality Disorders. 26(6): 848–866. doi: 10.1521/pedi.2012.26.6.848. PMCID: PMC3606922. NIHMSID: NIHMS409228.

Trull,T.J., Jahng, S., and Sher, K.J. (2010).Revised NESARC personality disorder diagnoses: gender, prevalence, and comorbidity with substance dependence disorders. Journal of Personality Disorders. 24(4): 412–426. Retrieved March 19, 2014 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3771514/

Zvolensky, M.J., Jenkins, E.F., Johnson, K.A., Goodwin, R.D. (2011). Personality Disorders and Cigarette Smoking among Adults in the United States. Journal of Psychiatry Residents. 45(6): 835 841. doi:10.1016/j.jpsychires.2010.11.009. PMCID: PMC3095681. NIHMSID: NIHMS260258f North America ;33(3): 657–685. doi: 10.1016/j.psc.2010.04.007 PMCID: PMC3138327 NIHMSID: NI

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