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8.164: Histrionic Personality Disorder

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    What is a person with Histrionic Personality Disorder like?

    The majority of cases of Histrionic Personality Disorder (HPD) are female. They may initially seem like average girls or young women, as their excessive focus on physicality can be seen in more reasonable quantities in most young ladies. At first this person may seem simply a little scattered, a little shallow, and a tad self-centered. However, a person with HPD exhibits far more than the normal amounts of all of these traits. Use of phrases that are ambiguous is frequent. “It was just like, you know, weird” would be a normative statement, or even “it was just like . . . you know?” This vague speech encompasses most of life, especially in regards to emotions and any cognitions. For example, one may see they have a distaste for something, and when inquiring as to why, simply get the response, “because it’s bad/yucky” or “I just don’t like it!” In this way, a person with HPD can often seem almost childlike in their speech patterns, as though they cannot introspect well enough to discern a more accurate description, or are too distracted or disinterested to even attempt to do so.

    However, this vagueness does not mean they are unsure. People with HPD tend to be very sure of everything they think and do, even if what they think and feel changes moment to moment. This confidence can be seen in many of their actions, though they are often more than happy to act meek if it will acquire them attention. This confidence in the truth of their opinions seems to lead to them expressing emotions as if they are incredibly severe. Though it is often debated whether the person with HPD experiences emotions more intensely, or simply reports them as more intense; we normally see expression of incredibly powerful emotions, but short lived, and very shallow. Though the term shallow may sound odd when referring to an emotion, when one converses with a person with HPD it usually becomes abundantly clear rather quickly. There is very little subtlety or shades of grey to the emotional spectrum of a person with HPD. If they are sad, they are distraught and the entire world is in peril; when they are happy, they are ecstatic, and euphoria barely expresses the joy they feel. In this way, such things as ‘bittersweet’ or simply doing pleasantly seems to be outside of the person with HPD’s realm of experience. Even emotions like envy, which are distinct to most people, seem to get subsumed into a broader emotion, such as anger. And where an average person may be irritable with someone, a person with HPD often skips straight to blind rage, and will start a fight or throw a tantrum in response.

    This extremity of expression is seen also in their conceptions, or at least their reports on their conceptions, of interpersonal relationships. A person is an enemy, or they are thick as thieves. A person with HPD may refer to you as their BFF (best friend forever) after only a couple of meetings. After four meetings, they may express that not only are they in love with you, you are in love with them! This confidence may seem to overlap with narcissistic personality disorder in many ways, and in this single aspect, the two do have similarities, but expression in other symptoms is much more specific in HPD.

    But, like the better known Narcissistic PD, people with HPD also crave the spotlight. They love, almost need to be the focal point of at least one person’s attention at any given time, but the more, the better. Where the two disorders differ, is that HPD sufferers almost exclusively use physical attractiveness and sexuality to gain this attention. Though sometimes they resort to emotionality, often in the form of temper tantrums, more often than not they take on the role of seductress. A young lady with HPD may think nothing of taking off her shirt in a room full of people if she felt that focus was shifting somewhere else. Once again, though many people enjoy being the center of attention, and many normal young women may use their bodies or sensuality to become the center of attention (see the average spring break videos), these behaviors are exaggerated, more frequent, and occur in less appropriate situations in a person with HPD.

    DSM-IV-TR criteria

    • 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:
    1. Uncomfortable in situations where he or she is not the center of attention.
    2. Interactions with others are often characterized by inappropriate sexually seductive or provocative behavior.
    3. Displays rapid shifting and shallow expressions of emotions.
    4. Consistently uses physical appearance to draw attention to self.
    5. Has a style of speech that is excessively impressionistic and lacking in detail
    6. shows self dramatization, theatricality, and exaggerated expression of emotion
    7. is suggestible, i.e., easily influenced by others or circumstances
    8. Consider relationships more intimate than they actually are.

    Associated features

    • Individuals have many emotional ups and downs. When not the center of attention in a social setting, individuals will find obvious ways to gain that attention back. They often, although unaware of it, act out a certain role, such as “victim” or “princess.” They often have trouble with their relationships with same-sex friends because of their sexually provocative style, and they may alienate friends because of their constant need for attention. They often easily become bored with routine and are frustrated by situations that involve delayed gratification. They use flirtatious or sexually provocative behavior to get what they want, usually attention from others. The cognitive style of individuals with HPD is superficial and lacks detail. In their inter-personal relationships, individuals with HPD use dramatization with a goal of impressing others. The enduring pattern of their insincere and stormy relationships leads to impairment in social and occupational areas (Encyclopedia of Mental Disorders).
    • Treatment for patients is difficult ultimately because most who suffer from HPD don’t seek treatment because symptoms don’t usually interfere with daily life.

    Child vs. adult presentation

    • HPD doesn’t show development until the teenage years, approximately 15 years of age. Treatment for sufferers is usually amongst the more mature age groups, generally in the early 40’s.

    Gender and cultural differences in presentation

    • Women are more likely to have HPD than men. Registered cases show that 65% are women and 35% are men that suffer from Histrionic Personality Disorder. Women tend to be over diagnosed with this disorder. This is largely due to our culture. If a man brags about his accomplishment it is seen as being macho, If a woman seeks the same kind of attention, she is diagnosed with Histrionic Personality Disorder.
    • According to the Encyclopedia of Mental Disordersm HPD appears primarily in men and women with above-average physical appearances. Some research has suggested that the connection between HPD and physical appearance holds for women rather than for men. Both women and men with HPD express a strong need to be the center of attention.
    • HPD may be diagnosed more frequently in Hispanic and Latin-American cultures and less frequently in Asian cultures. Further research is needed on the effects of culture upon the symptoms of HPD.

    Epidemiology

    • HPD affects an estimated 1-2% of the general population, whereas only 1% are involved in outpatient programs.
    • Prevalence rates are 10 to 15% in mental health settings (SAMHSA, 2009).
    • The lower prevalence rate is psychiatric settings may be understood in the context of the culturally adaptive qualities associated with the sex role stereotypes found in individuals with HPD.
    • No evidence of significant familial patterns. (Not necessarily a genetic link).
    • 10 to 15% of those in substance abuse treatment settings have HPD (SAMHSA, 2009).

    Dual diagnoses

    Etiology

    • The development of HPD illustrates a complicated interaction of biological predispositions and environmental responses. The temperament of extroversion and emotional expressiveness that underlie the character of an individual with HPD are recognized as having biological components. These factors interact with a lack of caregiver attention during formative years that led the child to develop strategies of attention grabbing presentation and shallow interaction that would elicit attention and connection

    Neurochemical/Physiological Causes:

    • Studies show that patients with HPD have highly responsive noradrenergic systems, the mechanisms surrounding the release of a neurotransmitter called norepinephrine. Neurotransmitters are chemicals that communicate impulses from one nerve cell to another in the brain , and these impulses dictate behavior. The tendency towards an excessively emotional reaction to rejection, common among patients with HPD, may be attributed to a malfunction in a group of neurotransmitters called catecholamines. (Norepinephrine belongs to this group of neurotransmitters.)

    Developmental Causes:

    • Psychoanalytic theory, developed by Freud, outlines a series of psychosexual stages of development through which each individual passes. These stages determine an individual’s later psychological development as an adult. Early psychoanalysts proposed that the genital phase, Freud’s fifth or last stage of psychosexual development, is a determinant of HPD. Later psychoanalysts considered the oral phase, Freud’s first stage of psychosexual development, to be a more important determinant of HPD. Most psychoanalysts agree that a traumatic childhood contributes towards the development of HPD. Some theorists suggest that the more severe forms of HPD derive from disapproval in the early mother-child relationship.

    Defense Mechanisms:

    • Another component of Freud’s theory, defense mechanisms are sets of systematic, unconscious methods that people develop to cope with conflict and to reduce anxiety. According to Freud’s theory, all people use defense mechanisms, but different people use different types of defense mechanisms. Individuals with HPD differ in the severity of the maladaptive defense mechanisms they use. Patients with more severe cases of HPD may utilize the defense mechanisms of repression, denial , and dissociation.

    Repression.

    • Repression is the most basic defense mechanism. When patients’ thoughts produce anxiety or are unacceptable to them, they use repression to bar the unacceptable thoughts or impulses from consciousness.

    Denial.

    • Patients who use denial may say that a prior problem no longer exists, suggesting that their competence has increased; however, others may note that there is no change in the patients’ behaviors.

    Dissociation.

    • When patients with HPD use the defense mechanism of dissociation, they may display two or more personalities. These two or more personalities exist in one individual without integration. Patients with less severe cases of HPD tend to employ displacement and rationalization as defenses.

    Displacement

    • occurs when a patient shifts an affect from one idea to another. For example, a man with HPD may feel angry at work because the boss did not consider him to be the center of attention. The patient may displace his anger onto his wife rather than become angry at his boss.

    Rationalization

    • occurs when individuals explain their behaviors so that they appear to be acceptable to others.

    Biosocial Learning Causes:

    • A biosocial model in psychology asserts that social and biological factors contribute to the development of personality. Biosocial learning models of HPD suggest that individuals may acquire HPD from inconsistent interpersonal reinforcement offered by parents. Proponents of biosocial learning models indicate that individuals with HPD have learned to get what they want from others by drawing attention to themselves.

    Sociocultural Causes:

    • Studies of specific cultures with high rates of HPD suggest social and cultural causes of HPD. For example, some researchers would expect to find this disorder more often among cultures that tend to value uninhibited displays of emotion.

    Personal Variables:

    • Researchers have found some connections between the age of individuals with HPD and the behavior displayed by these individuals. The symptoms of HPD are long-lasting; however, histrionic character traits that are exhibited may change with age. For example, research suggests that seductiveness may be employed more often by a young adult than by an older one. To impress others, older adults with HPD may shift their strategy from sexual seductiveness to a paternal or maternal seductiveness. Some histrionic symptoms such as attention-seeking, however, may become more apparent as an individual with HPD ages.

    Prevention

    • Early diagnosis can assist patients and family members to recognize the pervasive pattern of reactive emotion among individuals with HPD. Educating people, particularly mental health professionals, about the enduring character traits of individuals with HPD may prevent some cases of mild histrionic behavior from developing into full-blown cases of maladaptive HPD. Further research in prevention needs to investigate the relationship between variables such as age, gender, culture, and ethnicity and HPD.

    Empirically supported treatments

    • There are no known treatments for HPD, most patients use psychotherapy, but complications are commonly caused. Medication is not a wise decision due to the risk of the patient involving the medication in a self destructive way. There are no currently no self help groups for people with HPD. The exaggerated emotional activity of HPD patients tends them to develop relationships with their therapist, severely limiting a psychologist’s ability to help a HPD patient.

    Psychodynamic therapy:

    • HPD, like other personality disorders, may require several years of therapy and may affect individuals throughout their lives. Some professionals believe that psychoanalytic therapy is a treatment of choice for HPD because it assists patients to become aware of their own feelings. Long-term psychodynamic therapy needs to target the underlying conflicts of individuals with HPD and to assist patients in decreasing their emotional reactivity. Therapists work with thematic dream material related to intimacy and recall. Individuals with HPD may have difficulty recalling because of their tendency to repress material.

    Cognitive-behavioral therapy:

    • Cognitive therapy is a treatment directed at reducing the dysfunctional thoughts of individuals with HPD. Such thoughts include themes about not being able to take care of oneself. Cognitive therapy for HPD focuses on a shift from global, suggestible thinking to a more methodical, systematic, and structured focus on problems. Cognitive-behavioral training in relaxation for an individual with HPD emphasizes challenging automatic thoughts about inferiority and not being able to handle one’s life. Cognitive-behavioral therapy teaches individuals with HPD to identify automatic thoughts, to work on impulsive behavior, and to develop better problem-solving skills. Behavioral therapists employ assertiveness training to assist individuals with HPD to learn to cope using their own resources. Behavioral therapists use response cost to decrease the excessively dramatic behaviors of these individuals. Response cost is a behavioral technique that involves removing a stimulus from an individual’s environment so that the response that directly precedes the removal is weakened. Behavioral therapy for HPD includes techniques such as modeling and behavioral rehearsal to teach patients about the effect of their theatrical behavior on others in a work setting.

    Group therapy:

    • is suggested to assist individuals with HPD to work on interpersonal relationships. Psychodrama techniques or group role play can assist individuals with HPD to practice problems at work and to learn to decrease the display of excessively dramatic behaviors. Using role-playing, individuals with HPD can explore interpersonal relationships and outcomes to understand better the process associated with different scenarios. Group therapists need to monitor the group because individuals with HPD tend to take over and dominate others.

    Family therapy:

    • To teach assertion rather than avoidance of conflict, family therapists need to direct individuals with HPD to speak directly to other family members. Family therapy can support family members to meet their own needs without supporting the histrionic behavior of the individual with HPD who uses dramatic crises to keep the family closely connected. Family therapists employ behavioral contracts to support assertive behaviors rather than temper tantrums.

    Medications

    • Pharmacotherapy is not a treatment of choice for individuals with HPD unless HPD occurs with another disorder. For example, if HPD occurs with depression, antidepressants may be prescribed. Medication needs to be monitored for abuse.

    Portrayed in Popular Culture

    • Scarlett O’Hara from Gone with the Wind
    • Blance DuBois from A Streetcar Named Desire
    • The Penguin from Batman
    • He constantly compensates fro his short stance and horrible appearance with an active sense of panache
    • Constantly seeking attention to his small self
    • Bellatrix Lestrange from Harry Potter
    • The theatrical right-had woman of the Death Eaters craves the approval and appreciation of her master
    • Every movement of hers oozes sexuality

    DSM-V Changes

    (APA, 2010)

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