Histrionic personality disorder
||This article needs attention from an expert in Psychology. (February 2012)|
|Histrionic personality disorder|
|Classification and external resources|
|Cluster A (odd)|
|Cluster B (dramatic)|
|Cluster C (anxious)|
Histrionic personality disorder (HPD) is defined by the American Psychiatric Association as a personality disorder characterized by a pattern of excessive emotions and attention-seeking, including inappropriately seductive behavior and an excessive need for approval, usually beginning in early adulthood. People affected by HPD are lively, dramatic, vivacious, enthusiastic, and flirtatious. HPD affects four times as many women as men. It has a prevalence of 2–3% in the general population, and 10–15% in inpatient and outpatient mental health institutions.
HPD lies in the dramatic cluster of personality disorders. People with HPD have a high need for attention, make loud and inappropriate appearances, exaggerate their behaviors and emotions, and crave stimulation. They may exhibit sexually provocative behavior, express strong emotions with an impressionistic style, and can be easily influenced by others. Associated features include egocentrism, self-indulgence, continuous longing for appreciation, and persistent manipulative behavior to achieve their own needs.
- 1 History
- 2 Characteristics
- 3 Causes
- 4 Diagnosis
- 5 Treatment
- 6 Epidemiology
- 7 See also
- 8 References
- 9 External links
The history of Histrionic Personality Disorder stems from the word hysteria. Hysteria can be described as an exaggerated or uncontrollable emotion that people, especially in groups, experience. The history and beliefs of hysteria has varied throughout time. Take for example, female hysteria. It wasn’t until Sigmund Freud who studied histrionic personality disorder in a psychological manner. “The roots of histrionic personality can be traced to cases of hysterical neurosis described by Freud.”  He developed the psychoanalytic theory in the late 19th century and the results from his development led to split concepts of hysteria. One concept labeled as hysterical neurosis (also known as conversion disorder)  and the other concept labeled as hysterical character (currently known as histrionic personality disorder). These two concepts must not be confused with each other, as they are two separate and different ideas.
Histrionic Personality Disorder is also known as and what you used to be hysterical personality. Hysterical personality has evolved in the past 400 years  and it first appeared in the DSM II (Diagnostic and Statistical Manual of Mental Disorders, 2nd edition) under the name hysterical personality disorder. The name we know today as histrionic personality disorder is due to the name change in DSM III, 3rd edition. Renaming hysterical personality to histrionic personality disorder is believed to be because of possible negative connotations to the roots of hysteria, such as intense sexual expressions, demon possessions, etc.
Histrionic Personality Disorder has gone through many changes. From hysteria, to hysterical character, to the development of hysterical personality, to what it is listed as in the most current DSM, DSM-V, the 5th edition. "Hysteria is one of the oldest documented medical disorders.”  Hysteria dates back to both ancient Greek and Egyptian writings. Most of the writings related hysteria and women together, similar to today where the epidemiology of histrionic personality disorder is generally more prevalent in women and also frequently diagnosed in women.
Historic Examples of HPD
- Ancient Egypt – first description of the mental disorder, hysteria, dates back to 1900 BC in Ancient Egypt. Biological causes of this mental disorder, such as the uterus movement in the female body was seen as the cause of hysteria. Traditional symptoms and descriptions of hysteria can be found in the Ebers Papyrus, the oldest medical document.
- Ancient Greece – Similar to ancient Egyptians, the ancient Greeks saw hysteria being related to the uterus of a female. Hippocrates (5th century BC) is the first to use the term hysteria. Hippocrates believed hysteria was a disease that lies in the movement of uterus (“hysteron”). Hippocrates’s theory was that since a woman’s body is cold and wet compared to a man’s body whose body is warm and dry, the uterus is prone to illness, especially is deprived from sex. He saw sex as the cleansing of the body so the causes of being overly emotional were due to sex deprivation.
- Works from Trotula de Ruggiero (11th century) display women’s diseases and disorders during this time period, disorders including hysteria. Her teachings resonated of Hippocrates and she is considered the first female doctor in Christian Europe.
- The uterus was still the explanation of hysteria, the concept of women being inferior to men was still present (despite the Renaissance era being a rebirth to the sciences and arts), and hysteria was still the symbol for femininity.
- Thomas Willis (17th century) introduces a new concept of hysteria. Thomas Willis believed that the causes of hysteria was not linked to the uterus of the female, but to the brain and nervous system.
- Hysteria was consequence of social conflicts during the Salem witch trials.
- Witchcraft and sorcery was later considered absurd during the Age of Enlightenment in the late 17th century and 18th century. Hysteria starts to form in a more scientific way, especially neurologically. New ideas formed during this time and one of them was that if hysteria is connected to the brain, men could possess it too, not just women.
- Franz Mesmer (18th century) treated patients suffering from hysteria in his method called mesmerism, or animal magnetism.
- Jean-Martin Charcot (19th century) studied effects of hypnosis in hysteria. Charcot states that hysteria is a neurological disorder and that it is actually very common in men.
- Sigmund Freud’s work, Studies on Hysteria, with Josef Breuer contributes to a psychoanalytic theory of hysteria. Freud believed that hysteria was caused by a lack of libidinal evolution.
People with HPD are usually high-functioning, both socially and professionally. They usually have good social skills, despite tending to use them to manipulate others into making them the center of attention. HPD may also affect a person's social and/or romantic relationships, as well as their ability to cope with losses or failures. They may seek treatment for clinical depression when romantic (or other close personal) relationships end.
Individuals with HPD often fail to see their own personal situation realistically, instead dramatizing and exaggerating their difficulties. They may go through frequent job changes, as they become easily bored and may prefer withdrawing from frustration (instead of facing it). Because they tend to crave novelty and excitement, they may place themselves in risky situations. All of these factors may lead to greater risk of developing clinical depression. Additional characteristics may include:
- Exhibitionist behavior
- Constant seeking of reassurance or approval
- Excessive sensitivity to criticism or disapproval
- Pride of own personality and unwillingness to change, viewing any change as a threat
- Inappropriately seductive appearance or behavior of a sexual nature
- Using somatic symptoms (of physical illness) to garner attention
- A need to be the center of attention
- Low tolerance for frustration or delayed gratification
- Rapidly shifting emotional states that may appear superficial or exaggerated to others
- Tendency to believe that relationships are more intimate than they actually are
- Making rash decisions
- Blaming personal failures or disappointments on others
- Being easily influenced by others, especially those who treat them approvingly
- Being overly dramatic and emotional
Some histrionics change their seduction technique into a more maternal/paternal style as they age.
- Provocative (or seductive) behavior
- Relationships are considered more intimate than they actually are
- Influenced easily
- Speech (style) wants to impress; lacks detail
- Emotional lability; shallowness
- Make-up; physical appearance is used to draw attention to self
- Exaggerated emotions; theatrical
There is little research done to find evidence as to what causes histrionic personality disorder and where it stems from, however there are a few theories that relate to the lineage of its diagnosis. Traits such as extravagance, vanity, and seductiveness of hysteria have similar qualities to women diagnosed with HPD.  An example of over-zealousness could be compared to the famous grande hystérie, a well-known demonstration of hypnotism by Jean-Martin Charcot by using his most well-known subject, Blanche Wittmann. Wittmann was known for her attractiveness and ability to make herself the center of attention from her hysteria and lavish performance. 
Psychoanalytic theories incriminate authoritarian or distant attitudes by one (mainly the mother) or both parents, along with conditional love based on expectations the child can never fully meet. Using psychoanalysis Freud believed the lustfulness was a projection of the patient's lack of ability to love unconditionally, maturely develop cognitively, and were overall emotionally shallow.  He believed the reason of not being able to love could have been from a traumatic death experience from a close relative during childhood or divorce between parents, which gave the wrong impression of committed relationships. Exposure to one traumatic or multiple occurrences of a close friend or family member leaving (abandonment or fate of mortality) would make the person unable to form true and affectionate attachments towards people. 
Another theory suggests that histrionic personality disorder and antisocial personality disorder could have a possible relationship to one another. Research has found two-thirds of patients diagnosed with histrionic personality disorder also meet similar criteria with antisocial personality disorder.  This suggests that both disorders based towards sex-type expressions may have the same underlying problem. Women are hyper-sexualized in the media consistently, engraining thoughts that the only way women are to gain attention is by exploiting themselves, and when seductiveness isn't enough, theatricals are the next step in achieving attention.  Men can just as well be flirtatious towards multiple women yet feel no empathy or sense of compassion towards them.  They may also be the center of attention from by exhibiting the "Don Juan" macho figure as a role-play.  Both examples suggest that predisposition could be a factor as to why certain people are diagnosed with histrionic personality disorder, however little is known whether or not the disorder is influenced by any biological compound or genetically inheritable.  Little research has been conducted to determine the biological sources, if any, of this disorder.
The person's appearance, behavior, and history, along with a psychological evaluation, are usually sufficient to establish a diagnosis. There is no test to confirm this diagnosis. Because the criteria are subjective, some people may be wrongly diagnosed.
The previous edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM IV-TR, defines histrionic personality disorder (in Cluster B) as:
A pervasive pattern of excessive emotionality and attention-seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
- is uncomfortable in situations in which he or she is not the center of attention
- interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
- displays rapidly shifting and shallow expression of emotions
- consistently uses physical appearance to draw attention to self
- has a style of speech that is excessively impressionistic and lacking in detail
- shows self-dramatization, theatricality, and exaggerated expression of emotion
- is suggestible, i.e., easily influenced by others or circumstances
- considers relationships to be more intimate than they actually are
The DSM-IV requires that a diagnosis for any specific personality disorder also satisfies a set of general personality disorder criteria.
A personality disorder characterized by:
- shallow and labile affectivity,
- exaggerated expression of emotions,
- lack of consideration for others,
- easily hurt feelings, and
- continuous seeking for appreciation, excitement and attention.
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
Most histrionics also have other mental disorders. Comorbid conditions include: antisocial, dependent, borderline, and narcissistic personality disorders, as well as depression, bipolar disorder, anxiety disorders, panic disorder, somatoform disorders, anorexia nervosa, substance use disorder and attachment disorders, including reactive attachment disorder.
|Appeasing||Including dependent and compulsive features||Seeks to placate, mend, patch up, smooth over troubles; knack for settling differences, moderating tempers by yielding, compromising, conceding; sacrifices self for commendation; fruitlessly placates the unplacatable.|
|Vivacious||The seductiveness of the histrionic mixed with the energy typical of hypomania. Some narcissistic features can also be present||Vigorous, charming, bubbly, brisk, spirited, flippant, impulsive; seeks momentary cheerfulness and playful adventures; animated, energetic, ebullient.|
|Tempestuous||Including negativistic features||Impulsive, out of control; moody complaints, sulking; precipitous emotion, stormy, impassioned, easily wrought-up, periodically inflamed, turbulent.|
|Disingenuous||Including antisocial features||Underhanded, double-dealing, scheming, contriving, plotting, crafty, false-hearted; egocentric, insincere, deceitful, calculating, guileful.|
|Theatrical||Variant of “pure” pattern||Affected, mannered, put-on; postures are striking, eyecatching, graphic; markets self-appearance; is synthesized, stagy; simulates desirable/dramatic poses.|
|Infantile||Including borderline features||Labile, high-strung, volatile emotions; childlike hysteria and nascent pouting; demanding, overwrought; fastens and clutches to another; is overly attached, hangs on, stays fused to and clinging.|
Treatment is often prompted by depression associated with dissolved romantic relationships. Medication does little to affect the personality disorder, but may be helpful with symptoms such as depression. Treatment for HPD itself involves psychotherapy, including cognitive therapy.
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Approximately 1–3% of the general population may be diagnosed with HPD. Major character traits may be inherited, while other traits may be due to a combination of genetics and environment, including childhood experiences. This personality is seen more often in women than in men. It has typically been found that at least two thirds of persons with HPD are female, however there have been a few exceptions. Whether or not the rate will be significantly higher than the rate of women within a particular clinical setting depends upon many factors that are mostly independent of the differential sex prevalence for HPD.
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