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Histrionic Personality Disorder: Signs and Treatment


Histrionic personality disorder (HPD) is a third cluster B personality disorder, which is characterized by dramatic, impulsive, emotional personalities. HPD is sometimes also referred to as dramatic personality disorder. The core characteristics of this particular PD are unstable emotions and attention-seeking behaviors.

Prevalence

It is estimated that the prevalence of HPD in the general population is between 2 and 3%, which is similar to the prevalence for other PDs. In terms of gender differences, there seems to be a higher HPD diagnosis rate in women than in men. Research shows that women are four times more likely to be diagnosed with HPD when compared to men.

However, some clinicians and researchers note this difference might arise from gender stigma rather than the differences in prevalence of the disorder. This means that the behaviors that are characteristic of HPD are seen as less appropriate, less common, and even socially unacceptable for women. However, this is not the case for men. In addition, there are differences between symptomology reports between genders, with men being less likely to report behaviors, thoughts, and feelings symptomatic of HPD.

Causes

To date, the exact cause of HPD is not known. Research and clinical studies indicate there are three factors that play a role in developing this PD:

  1. Genetics: It has been observed that HPD runs in families, yet the evidence of gene involvement is scarce. As with many PDs, a family history of HPD or other PDs, psychiatric illness, and substance use disorder all increase a person’s risk of developing HPD.
  2. Parenting styles: In the case of HPD, it has been suggested that parenting style can be a contributing factor. The literature indicates that inconsistent parenting styles, especially when it comes to setting boundaries, predispose children to developing HPD. In addition to parenting styles, learnt parental behavior seems to influence the later development of this PD. Children whose parents, caretakers, or other role models behave erratically, dramatically, and exhibit inappropriate sexual tendencies are consideredat risk of developing HPD.
  3. Traumatic events: One of the proposed hypotheses suggests that HPD develops as a coping mechanism in response to trauma experienced during childhood. Hence, the extreme behaviors and beliefs that are characteristic of HPD are developed as a response that helps to cope with a traumatic event or environment.

The dynamic relationship between these causes is unclear as well as how much these factors separately or together contribute to a diagnosis of HPD. However, the combination of all three or some of these factors will increase a person’s risk of developing HPD.

Symptoms

As with the majority of PDs, a diagnosis of HPD is rarely established before 18 years of age, given the personality is under the development during adolescent years. A healthcare provider will make a diagnosis if an individual meets at least several of the following criteria:

Emotional

  1. Feeling uncomfortable, underappreciated, or depressed if the attention is not on you
  2. Experiencing only shallow emotions
  3. Expressing dramatic or exaggerated emotions
  4. Having major and rapidly shifting emotions
  5. Being suggestible (easily influenced by others), gullible, or easily influenced by others, especially the people they admire

Interpersonal

  1. Misperceiving relationships with others (e.g., thinking their relationships are closer than they are)
  2. Exhibiting difficulty maintaining stable relationships
  3. Expressing a need for instant gratification while becoming bored or easily frustrated if this does not occur
  4. Seeking constant reassurance or approval from others

Appearance, speech, and noticeable behaviors

  1. Using their appearance to draw attention to themselves (e.g., wearing bright colors, revealing clothes)
  2. Possessing impressionistic and vague speech
  3. Being overly concerned with their physical appearance
  4. Appearing fake or shallow in their interactions with others
  5. Having a “larger than life” presence
  6. Acting inappropriately in public to the point where it might cause embarrassment for others
  7. Acting sexually inappropriate during most of their encounters, even when they’re not sexually attracted to the individual they are attending to
  8. Being persistently charming and flirtatious
  9. Expressing strong opinions without or with only few facts and details to support such opinions
  10. Acting in a seductive or provocative manner regardless of the context

Treatment and help

Given the symptomatology of HPD, it can majorly affect various areas of an individual’s life and well-being if left untreated. A person’s relationships with others will especially be affected due to the inappropriate behaviors and inability to form close and meaningful bonds. Impulsivity and a distorted perception of reality caused by HPD might lead to difficulties at school or in the workplace. They might be unable to maintain a stable career.

The primary treatment for HPD is therapy. It is common for individuals not to realize or admit that their behaviors or ways of thinking are problematic, so they rarely seek out help by themselves. It is more likely they will seek out help for other comorbid conditions, such as anxiety or depression, but not HPD. If you have a loved one who exhibits the described behaviors, you may want to carefully suggest seeing a medical professional.

There are several therapies suggested for individuals with HPD:

  1. Supportive psychotherapy: This therapy has been successful in patients with HPD. It is centered around developing coping skills and increasing an individual's self-esteem. Successful treatment with supportive psychotherapy will lead to positive changes in maladaptive behaviors and better interpersonal skills. This type of therapy has been shown to be reassuring and non-threatening for patients.
  2. Psychodynamic psychotherapy: This therapy has been shown to yield positive results in individuals with HPD. It is primarily oriented towards understanding oneself and resolving underlying conflicts as well as emotional and self-esteem development.
  3. Group therapy or family therapy: This therapy is not often suggested for individuals with HPD due to their symptomatology. The pronounced need for attention and the tendency toward shallow emotions can be disruptive and upsetting for others involved in group sessions.

In addition to therapy, individuals with severe symptomatology might be prescribed medications such as antidepressants and antipsychotics. There are no medications that specifically treat HPD, but some medication can be used to manage severe symptoms.

Key takeaways:

Histrionic personality disorder is a personality disorder that causes attention-seeking behaviors.

HPD may be caused by genetics, an inconsistent parenting style, or a traumatic childhood.

Symptoms of HPD are emotional, interpersonal, and appearance-related.

Medication is not the first-line treatment but may be helpful in some severe cases.

The recommended treatments are supportive psychotherapy and psychodynamic psychotherapy, but group or family therapy may help some individuals.

References:

American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed. Arlington: American Psychiatric Association, 2013.

French, Jennifer H., and Sangam Shrestha. "Histrionic personality disorder." In StatPearls [Internet]. StatPearls Publishing, 2021.

Rienzi, B. M., & Scrams, D. J. (1991). Gender stereotypes for paranoid, antisocial, compulsive, dependent, and histrionic personality disorders. Psychological Reports, 69(3), 976-978.

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