1.0 Introduction

Histrionic Personality Disorder (HPD) first appeared in the Diagnostic and Statistical Manual of Mental Disorders' second edition (DSM—II).3
At that time it was known as hysterical personality disorder. 3 In the third edition (DSM-III), hysteria was replaced by the term histrionic, mainly to differentiate the disorder’s associations from hysteria. 3 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).3 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.1

2.0 Diagnosis

Personality Disorders (PDs) are identified through behaviours that are not considered acceptable in the patient’s culture. 15 The onset of such disorders can be during early adulthood or even adolescence. 15 Studies have shown that those children who have been neglected emotionally by their parents/caregivers are more prone to developing Histrionic Personality Disorder.8 Sufferers of PDs develop “traits,” which, although can stabilize through the lifespan of the patient, can cause many difficulties in the patient's life. 15 As a result, distress due to everyday challenges and impairment that causes conflicts in carrying-out everyday functions occurs. 15

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.1

2.1 Diagnostic Criteria, as indicated by DSM-IV, for Histrionic Personality Disorder includes the following characteristics in patients: 1

  • uses physical appearance to seek attention of others
  • is extremely sensitive and emotional
  • is very influential
  • expresses exaggerated emotions (dramatic behaviour)attention_seeker.jpg
  • is prone to emotion/mood changes
  • is uncomfortable when “spotlight” is not given
  • has imprecise and not too detailed speech
  • misunderstands the intimacy in relationship ©

VIctims of Histrionic Personality Disorder may perceive their lives as a "Cinderella Story," expecting others to treat them as 'main lead.'©

Subject is an actor, highlighting the syndromes of a person with HPD.

3.0 Challenges and Severity

Personality Disorders are persistent, poorly-adaptive and can’t be undone. 15 They continue throughout the lifetime of the patient and although stability in some behaviour may be achieved, the severity may change as one ages. 15

3.1 Everyday challenges:

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. 1 Because these individuals can be easily influenced, making reasonable decisions
can be difficult. 1 Due to their theatrical behaviour, overly emotional reactions and slurred speech they are unable to continue conversations effectively. 1 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.1 Furthermore, they seek adventurous events, wanting new experiences, and may therefore endanger their lives. 15 Their attention-seeking and inappropriate sexual behaviours make it difficult for the society to understand them and provide empathy for them. 1 Also, patients with HPD overestimate the intimacy of relationships (personal or professional) and thus them can be quite problematic. 15 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. 15

favre_queen.jpg 3.2 Age Related changes in Histrionic Personality Disorder: 15

  • an increase in self-conceited behaviour
  • the patient behaves like a “brat”
  • cannot adjust well with age-related changes
  • frustration and irritability, both, heighten
  • changes in sexual attractiveness due to aging in physical appearance are perceived as disastrous

4.0 Genetics/Environmental Factors that result in co-morbidity within Cluster B

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.6,13 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.13 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.13 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.

5.0 Treatments

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.15 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. 15 Moreover, medications do not tackle the pathology but rather the symptomatology and thus behaviour cannot be corrected.15Therefore, psychotherapeutic therapies may be more beneficial.1

5.1 Dialectical Behaviour Therapy (DBT) and Cognitive Behavioural Therapy (CBT)

One of the biggest disadvantages for patients with HPD is that this disorder prevents long-lasting relationships.1 Hence, psychotherapeutic therapies may not necessarily be favourable since sufferers tend to end their sessions ahead of time.15 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. 15 Two types of models have been introduced to tackle such treatment: Dialectical Behaviour Therapy (DBT) and Cognitive Behavioural Therapy (CBT). 15 DBT is a skill training therapy aiming to reduce impulsivity and improve stability, providing better coping skills.15 CBT, on the other hand, aims to change the patient’s beliefs and thoughts about certain situations and people. 5,15 It targets the patient’s irrational perceptions, evolving them into reasonable structural beliefs.5, 15 Both, DBT and CBT are short-term treatments that last approximately 20 weeks and after treatment, follow-ups may be necessary. 15

5.2 Motivational Interviewing

Another type of treatment that has been beneficial for HPD patients is known as Motivational Interviewing (MI).11 In 1980’s Stephen Rollnick and William Miller created MI to target addictive behaviours.12 They described motivation as a condition where the patient accepts his/her behaviour as problematicready2change.gif
and is ready to initiate change.12 In this therapy, the physician attempts to mutually discuss behaviour changes with the patient – preventing any tackling manner. 12 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.12 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.14 Motivational treatment in such individuals is effective because these patients are avoidant of their problems – perhaps even in denial. 12 ©

Management Tools for MI:1

1. Before addressing the problem, seek permission from the patient
“In the last few visits you have disregarded my medical advice. Would you like to talk about that?”
2. Suggest the first step that may lead to change in behaviour
“Do you think there will be a problem in the future if you keep dismissing my advice?”
3. Check how willing the patient is about taking a step towards change and encourage him/her
“How do you feel about inflicting change? Rate yourself between 1 to 5, with 1 being ‘not at all’ and 5 being ‘extremely willing.’
4. Assess how confident the patient is on his/her ability to make a change.
“What barriers, do you feel, may prevent you from taking this step?
5. Summarize the discussion, recommend follow-ups and highlight the suggestions the patient has agreed and disagreed to.
“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.

Table 1: highlights the steps one must take to effectively treat the patient by Motivational Interviewing (MI). Examples are provided. ©

5.3 Electroconvulsive Therapy (ECT)ect.jpg

Electroconvulsive Therapy, also known as electroshock, is a psychiatric treatment to treat depressions. 9 Patients are given anesthesia to induce seizures electrically.9 A recent case study was conducted on a man with depressive disorders along with the co-morbidity of Histrionic Personality Disorder.9 The patient was not able to maintain proper relationships and experienced several mood changes. 9,10 He was not comfortable in social environments and avoided contact. 9,10 As a result, he had isolated himself in seclusion, leading to depression, panic and anxiety attacks. 9 Because other treatments had not been beneficial for him, ECT was applied through bitemporal electrode placement. 9,10 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.9 The results indicated that only after 3 sessions, his mood instability changed, as well as his ability to be empathetic towards others. 10 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. 9,10 He was more socially active and comfortable interacting with others in the next three months.9,10 Furthermore, authors of this paper suggest that such treatment should avoid delay because victims of HPD may develop treatment resistance. 9 Other studies also suggest that ECT has a successful response in decreasing histrionic symptoms. 10

6.0 Criticizing the validity of Histrionic Personality Disorder as a Personality Disorder

Recent research includes studies that are starting to criticize either the diagnostic criteria created for HPD or the validity of HPD as a PD. 2,3,4,7 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. 4 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.3The 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.3 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. 2

7.0 References:

1Angstman, B., K. & Rasmussen, H., N. (2011). Personality Disorders: review and clinical application in daily practice. American Family Physician, 84(11), 1253-1260.

2Bakkevig, 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.

3Blagov, 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.

4Bornstein 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.
5Kellett, 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.

6Kenneth, 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.

7Lawton, 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.

8Lobbestael, 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.

9Rapinesi, 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.

10Rapinesi, 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.

11Searight, H., R. (2007). Efficient techniques for the primary care physician. Primary Care, 34(3), 551-570.

12Suarez, M. & Mullins, S. (2008), Motivational interviewing and pediatric health behavior interventions. Journal of Developmental & Behavioral Pediatrics. 29(5), 417-418.

13Torgersen, 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.

14Vollm, B. (2009). Assessment and management of dangerous and severe personality disorders. Current Opinion Psychiatry, 22(5), 501-506.

15Zanni, R., G. (2007). The graying of personality disorders: persistent, but different. The Consultant Pharmacist, 22(12), 995-1003.