Histrionic+Personality+Disorder

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= = =__**1.0 Introduction **__=

Histrionic Personality Disorder (HPD) first appeared in the Diagnostic and Statistical Manual of Mental Disorders' second edition (DSM—II). At that time it was known as hysterical personality disorder.  In the third edition (DSM-III), hysteria was replaced by the term histrionic, mainly to differentiate the disorder’s associations from hysteria.  The criterion for the diagnosis of HPD in the DSM has changed in the past few years to isolate it from other personality disorders such as Dependent Personality Disorder (DPD) and Borderline Personality Disorder (BPD).  As of now, personality disorders have been grouped into clusters, where HPD has been categorized under cluster B; patients diagnosed with cluster B characteristics tend to have dramatic and unpredictable behaviours and react in an exaggerated emotional manner.

toc =__**2.0 Diagnosis **__=

Personality Disorders (PDs) are identified through behaviours that are not considered acceptable in the patient’s culture.  The onset of such disorders can be during early adulthood or even adolescence.  Studies have shown that those children who have been neglected emotionally by their parents/caregivers are more prone to developing Histrionic Personality Disorder.  Sufferers of PDs develop “traits,” which, although can stabilize through the lifespan of the patient, can cause many difficulties in the patient's life.  As a result, distress due to everyday challenges and impairment that causes conflicts in carrying-out everyday functions occurs.

DSM-IV-TR is a multi-axial system, which allows diagnosis of a patient and thus allowing the doctor to describe the patient’s disorder and the consequences that result. == **2.1 Diagnostic Criteria, as indicated by DSM-IV**, for Histrionic Personality Disorder includes the following characteristics in patients: ==
 * uses physical appearance to seek attention of others
 * is extremely sensitive and emotional
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">is very influential
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">expresses exaggerated emotions (dramatic behaviour) [[image:attention_seeker.jpg width="114" height="114" align="right"]]
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">is prone to emotion/mood changes
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">is uncomfortable when “spotlight” is not given
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">has imprecise and not too detailed speech
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">misunderstands the intimacy in relationship

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media type="youtube" key="Hsj8hpuZbl8?version=3" height="360" width="640" Subject is an actor, highlighting the syndromes of a person with HPD.

=__**<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">3.0 Challenges and Severity **__=

<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Personality Disorders are persistent, poorly-adaptive and can’t be undone. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> They continue throughout the lifetime of the patient and although stability in some behaviour may be achieved, the severity may change as one ages.

**<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">3.1 Everyday challenges: **
<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Patients with HPD have to deal with many challenging situations every day. Their inability to normally socialize with other people is their number one concern. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Because these individuals can be easily influenced, making reasonable decisions <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> can be difficult. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Due to their theatrical behaviour, overly emotional reactions and slurred speech they are unable to continue conversations effectively. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Moreover, victims of HPD are easily bored by repetitive events, thus maintaining a job or committing to a relationship may not be possible for them. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Furthermore, they seek adventurous events, wanting new experiences, and may therefore endanger their lives. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Their attention-seeking and inappropriate sexual behaviours make it difficult for the society to understand them and provide empathy for them. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Also, patients with HPD overestimate the intimacy of relationships (personal or professional) and thus them can be quite problematic. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Changes in mood and frustration can lead to displeasing behaviour. As a consequence, the patients may end up in depression (along with panic and anxiety) and seclusion, making it even more difficult for them to deal with failures and losses.

==<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">** 3.2 Age Related changes in Histrionic Personality Disorder:** ==


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">an increase in self-conceited behaviour
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">the patient behaves like a “brat”
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">cannot adjust well with age-related changes
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">frustration and irritability, both, heighten
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">changes in sexual attractiveness due to aging in physical appearance are perceived as disastrous

=__<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">4.0 Genetics/Environmental Factors that result in co-morbidity within Cluster B __=

<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Personality Disorders (PDs) have been grouped into clusters due to the overlapping criteria within the 10 DSM-IV PDs. Thus, studies have been conducted to find genetic or environmental factors that result in the co-morbidity that occurs within clusters. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">**,** <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Kenneth et al. (2008) conducted a study and concluded that genetic factors do not contribute to the cluster B typology, but rather environmental experiences result in the co-morbidity that occurs within cluster B. However, another study by Torgersen et al. (2008) states that both genetic and environmental factors influence clustering in PDs. Although, to what degree do these factors influence the overlapping that occurs in the criteria is still pretty difficult to conclude. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> It has been shown that Histrionic Personality Disorder shares genetics with Narcissistic Personality Disorder and also correlates highly with other personality disorders within cluster B in monozygotic twins. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Thus, there is some evidence accepting the validity of the cluster existence, even though the contribution of the genetic and environmental factors in developing PDs is still controversial.

=**__<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">5.0 Treatments __**=

<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Personality Disorders are one of the hardest “illnesses” to examine and treat efficiently. Every individual’s personality is unique; it reflects the way one perceives, understands, responds and interacts with self and the environment. Hence, when these “traits” begin to conflict with everyday functions, they transform into Personality Disorders. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> And because these traits are continuous throughout one’s lifetime, it is important to remember that PDs are mental illnesses, where treatments must modify problematic behaviours. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Moreover, medications do not tackle the pathology but rather the symptomatology and thus behaviour cannot be corrected. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Therefore, psychotherapeutic therapies may be more beneficial.

**<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">5.1 Dialectical Behaviour Therapy (DBT) and Cognitive Behavioural Therapy (CBT) **
<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">One of the biggest disadvantages for patients with HPD is that this disorder prevents long-lasting relationships. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Hence, psychotherapeutic therapies may not necessarily be favourable since sufferers tend to end their sessions ahead of time. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Because patients with Histrionic Personality Disorder have difficulty dealing with disappointments and losses, treatments must target minimizing the patient’s negativity towards self and others. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Two types of models have been introduced to tackle such treatment: Dialectical Behaviour Therapy (DBT) and Cognitive Behavioural Therapy (CBT). <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> DBT is a skill training therapy aiming to reduce impulsivity and improve stability, providing better coping skills. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> CBT, on the other hand, aims to change the patient’s beliefs and thoughts about certain situations and people. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">**,** <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> It targets the patient’s irrational perceptions, evolving them into reasonable structural beliefs. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">**,** <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Both, DBT and CBT are short-term treatments that last approximately 20 weeks and after treatment, follow-ups may be necessary.

**<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">5.2 Motivational Interviewing **
<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Another type of treatment that has been beneficial for HPD patients is known as Motivational Interviewing (MI). <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> In 1980’s Stephen Rollnick and William Miller created MI to target addictive behaviours. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> They described motivation as a condition where the patient accepts his/her behaviour as problematic <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">and is ready to initiate change. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> In this therapy, the physician attempts to mutually discuss behaviour changes with the patient – preventing any tackling manner. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Positive communication is critical, where the provider offers advices that are within the patient’s comfort zone, keeping the patient’s desires, reasoning and abilities within consideration. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> This allows the doctor to create a bond with the patient to further motivate him/her and help eliminate any factors that may cause resistance in the treatment. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Motivational treatment in such individuals is effective because these patients are avoidant of their problems – perhaps even in denial.

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 * Management Tools for MI:**


 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Step ** || **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Example ** ||
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">1. Before addressing the problem, seek permission from the patient || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">“In the last few visits you have disregarded my medical advice. Would you like to talk about that?” ||
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">2. Suggest the first step that may lead to change in behaviour || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">“Do you think there will be a problem in the future if you keep dismissing my advice?” ||
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">3. Check how willing the patient is about taking a step towards change and encourage him/her || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">“How do you feel about inflicting change? Rate yourself between 1 to 5, with 1 being ‘not at all’ and 5 being ‘extremely willing.’ ||
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">4. Assess how confident the patient is on his/her ability to make a change. || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">“What barriers, do you feel, may prevent you from taking this step? ||
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">5. Summarize the discussion, recommend follow-ups and highlight the suggestions the patient has agreed and disagreed to. || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">“I’ll see you again next week? We can then discuss how well you were able to cope with obstacles and, if necessary, come up with better solutions. ||

**<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Table 1: **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> highlights the steps one must take to effectively treat the patient by Motivational Interviewing (MI). Examples are provided. www.nimh.nim.gov ©

**<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">5.3 Electroconvulsive Therapy (ECT) **[[image:ect.jpg width="212" height="183" align="right"]]
<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Electroconvulsive Therapy, also known as electroshock, is a psychiatric treatment to treat depressions. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Patients are given anesthesia to induce seizures electrically. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> A recent case study was conducted on a man with depressive disorders along with the co-morbidity of Histrionic Personality Disorder. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> The patient was not able to maintain proper relationships and experienced several mood changes. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">**,** <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">He was not comfortable in social environments and avoided contact. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">**,** <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">As a result, he had isolated himself in seclusion, leading to depression, panic and anxiety attacks. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Because other treatments had not been beneficial for him, ECT was applied through bitemporal electrode placement. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">**,** <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">He was anesthesized with 15mg of Midazolim intravenously and treatment consisted of charges of 176.4 milliCoulomb (mC) given on alternative days (maximum 3/week) for a month for a total of 13 sessions. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> The results indicated that only after 3 sessions, his mood instability changed, as well as his ability to be empathetic towards others. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">And by the end of the treatment, his anxiety levels had reduced and depression and panic attacks had ceased, manifesting that histrionic symptoms had been reduced. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">**,** <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">He was more socially active and comfortable interacting with others in the next three months. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">**,** <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Furthermore, authors of this paper suggest that such treatment should avoid delay because victims of HPD may develop treatment resistance. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Other studies also suggest that ECT has a successful response in decreasing histrionic symptoms.

= = =**<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">6.0 Criticizing the validity of Histrionic Personality Disorder as a Personality Disorder **=

<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Recent research includes studies that are starting to criticize either the diagnostic criteria created for HPD or the validity of HPD as a PD. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">**,** <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">**,** <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">**,** <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Some are even suggesting that HPD should no longer remain a category in the DSM system because the validity lacks evidential support and the number of patients clinically examined is very low. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> Blagon and Westen (2008) argue that the diagnostic criteria created for HPD is not valid since patients with HPD also exhibit many characteristics common to Borderline Personality Disorder. The authors of another study suggest that the literature should be further revised to decide what disorders should remain or be eliminated in the near future. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">The fact that ‘gaps’ in the literature about certain disorders occur, where more preferred attention is given to certain disorders more than others, should not be dismissed. <span style="font-family: 'Times New Roman','serif'; font-size: 16px;"> A study by Bakkevig and Karterud (2010) claim that due to too much overlap between HPD and other disorders, this category should not be regarded as a separate PD. Although, certain features such as attention-seeking and inappropriate sexual behaviours should be retained and exhibited as a sub-category of narcissism instead.

=**<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">7.0 References: **=


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">1 **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Angstman, B., K. & Rasmussen, H., N. (2011). Personality Disorders: review and clinical application in daily practice. //American Family Physician, 84//(11), 1253-1260.


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">2 **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Bakkevig, F., J & Karterud, S. (2010). Is the diagnostic and statistical manual of mental disorders, fourth edition, histrionic personality disorder category a valid construct? //Comprehensive Psyhciarty, 51//(5), 462-470.

<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">**3**Blagov, P., S. & Westen, D. (2008). Questioning the coherence of histrionic personality disorder: borderline and hysterical personality subtypes in adults and adolescents. //The Journal of Nervous and Mental Disease, 196//(11), 785-797.


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">4 **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Bornstein R. F., (2011). Reconceptualizing personality pathology in DSM-5: limitations in evidence for eliminating Dependent Personality Disorder and other DSM-IV syndromes. //Journal of Personality Disorders, 25//(2), 235- 247.

**5**Kellett, S. (2007). A time series evaluation of the treatment of histrionic personality disorder with cognitive analytic therapy. //Psychology and Psycotherapy: Theory, Research and Practice,// 80(3), 389-405.


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">6 **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Kenneth, S.K., Steven, H., A., Czajkowski, N., Espen, R., Kristitian, T., Torgersen, S., ... Reichborn-Kjennerud, T. (2008). The structure of genetic and environmental risk factors for DSM-IV Personality Disorders: a multivariate twin study. //Archives of General Psychiatry, 65//(12), 1438-1466.


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">7 **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Lawton, M., Erin., Shields, J., A., & Oilmanns, F., T. (2011). Five-factor model personality disorder prototypes in a community sample: self – and informant – reports predicting interview-based DSM diagnoses. //Personality Disorders, 2//(4), 279-292.


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">8 **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Lobbestael, J., Arntz, A., & Bernstein, P.D. (2010). Disentangling the relationship between different types of childhood maltreatment and personality disorders. //Journal of Personality Disorders, 24//(3), 285-295.


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">9 **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Rapinesi, C., Serata, D., Del-Casale, A., Simonetti, A., Millioni, M., Mazzarini, L., ... Girardi, P. (2012). Successful and rapid response to electroconvulsive therapy of a suicidal patient with comorbid bipolar I disorder and histrionic personality disorder. //The Journal of Electroconvulsive Therapy,// //28//(1), 57-58.


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">10 **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Rapinesi, C., Serata, D., Del-Casale, A., Kotzalidis, G., D., Romano, S., Milioni, M., ... Girardi, P. (2012). Electroconvulsive therapy in a physically restrained man with comorbid major depression, severe agoraphobia with panic disorder and histrionic personality disorder. //The Journal of Electroconvulsive Therapy,// //28//(1), 72-73.


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">11 **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Searight, H., R. (2007). Efficient techniques for the primary care physician. //Primary Care, 34//(3), 551-570.


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">12 **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Suarez, M. & Mullins, S. (2008), Motivational interviewing and pediatric health behavior interventions. //Journal of Developmental & Behavioral Pediatrics. 29//(5), 417-418.


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">13 **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Torgersen, S., Czajkowski, N., Jacobson, K., Reichborn-Kjennerud, T., Roysamb, E., Neale, C., M., & Kendler, K., S. (2008). Dimesional representations of DSM-IV cluster B personality disorders in a population-based sample of Norwegian twins: a multivariate study. //Psychological Medicine, 36¸//1617 -1625.


 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">14 **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Vollm, B. (2009). Assessment and management of dangerous and severe personality disorders. Cu//rrent Opinion Psychiatry, 22//(5), 501-506.

<span style="display: block; height: 1px; left: -40px; overflow: hidden; position: absolute; top: 2336px; width: 1px;"> <span style="display: block; font-family: 'Times New Roman','serif'; font-size: 16px; height: 1px; left: -40px; overflow: hidden; position: absolute; top: 6170.5px; width: 1px;">**12toc**
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">15 **<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Zanni, R., G. (2007). The graying of personality disorders: persistent, but different. //The Consultant Pharmacist, 22//(12), 995-1003.

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