What is Histrionic Personality Disorder (HPD)?
Histrionic personality disorder, or HPD, is a long-term mental health condition. People with this disorder constantly seek attention and often show excessive emotions. They typically display this behavior continuously throughout their life, often becoming noticeable in their late teens or early twenties. People with HPD are often seen as alluring, self-centered, flirty, dramatic, outgoing, and lively. They may sometimes feel overlooked if they’re not the center of attention. They also tend to show quickly changing and shallow emotions, which others might see as insincere.
The term ‘histrionic’ dates back to ancient Greek and Roman times when doctors noticed certain people showing too much theatricality and emotion. They called these people ‘hysterical’, a term taken from the Greek word ‘hystera’, meaning uterus because they believed such behavior was exclusive to women caused by issues in the uterus. In the late 19th century, renowned psychoanalyst Sigmund Freud, despite his theories being controversial, contributed to understanding this behavior. He conceptualized ‘hysteria’ as a mental disorder, predominantly in women, distinguished by emotional excess and attention-seeking behaviors.
HPD officially became recognized as a separate diagnostic category about halfway through the 20th century. The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), published in 1980, included HPD as a diagnosable condition, focusing on behaviors such as excess emotions, needing attention, and exaggerated actions. This manual has been updated several times since then, refining the criteria for HPD while keeping the core principles. This disorder is still recognized in the most recent version of this manual, the fifth edition text revision (DSM-5-TR, 2022).
The DSM-5-TR splits personality disorders into three categories or ‘clusters’. Cluster A includes paranoid, schizoid, and schizotypal personality disorders, marked by unusual or strange characteristics, like social withdrawal and mistrust. Cluster B, where HPD falls, encompasses antisocial, borderline, and narcissistic personality disorders, noted for dramatic, emotional, or erratic behaviors, with the individuals usually showing impulsive actions, emotional instability, and trouble maintaining steady relationships. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders, characterized by anxious and fearful traits, with individuals often experiencing intense anxiety, fear of abandonment, and a strong need for control or perfection.
While these ‘clusters’ provide some structure in understanding personality disorders, including HPD, there are ongoing debates in the fields of psychology and psychiatry about the nature and validity of these disorders. Our comprehension of histrionic traits and behaviors is an ongoing journey.
What Causes Histrionic Personality Disorder (HPD)?
People diagnosed with Histrionic Personality Disorder (HPD) often display certain characteristic temperament traits. These can include a lack of concern for potentially harmful actions, a strong interest in new and exciting activities, and a high dependency on external rewards or social feedback. On the flip side, they may lack persistence, meaning they could struggle to keep working at something, especially when faced with obstacles or limited rewards.
Research into the causes of HPD is ongoing and somewhat limited. It’s believed a mix of factors contribute to its development, such as a person’s genetics, their childhood experiences, and their environmental influences. Child abuse and neglect, especially sexual abuse, are significant risk factors. Some studies also suggest a genetic component; however, the specific genes or mechanisms involved are not yet fully understood.
Medical conditions that affect the nervous system can often be associated with personality disorders. These can include head injuries, brain tumors, epilepsy, Huntington’s disease, multiple sclerosis, certain endocrine disorders, and others. Other contributing psychological factors include unconscious processes, early childhood experiences, and internal conflicts.
Personality is a complex mix of our biological, psychological, social, and developmental factors, making each person’s personality unique. A personality disorder develops when a person shows a rigid and unhealthy pattern of thinking and behaving that deviates from societal norms, leading to considerable social or occupational issues. Such deviations generally become evident as disturbances in a person’s emotions, self-perception, impulse control, or interpersonal functioning.
The notion of personality is intertwined with the concept of “temperament”, which is an inherent biological characteristic. However, temperament can also be influenced and shaped by life experiences, including trauma and social-economic conditions, which contribute to personality development.
Risk Factors and Frequency for Histrionic Personality Disorder (HPD)
There aren’t enough high-quality studies that show how common Histrionic Personality Disorder (HPD) is among different populations. A lot of the research is outdated which impacts its validity. Roughly 9% of people have at least one type of personality disorder, with HPD affecting between 0.4% to 1.8% of the population. Women are diagnosed with HPD about four times more than men.
However, this could be due to a trend of overdiagnosing women, perhaps because society tends to view overt sexual behavior as less acceptable for women. On the other hand, men might be underdiagnosed. People with HPD often see their behavior as normal (also known as being ego-syntonic) and have difficulty acknowledging any problems. This lack of awareness can lead to late diagnosis when their behavior starts to seriously affect their personal relationships, work, or overall emotional wellbeing.
Signs and Symptoms of Histrionic Personality Disorder (HPD)
Histrionic personality disorder (HPD) can show itself in a lot of different ways. This makes it important to take a close look at both the patient’s medical history and their social history. Usually, people with HPD don’t see their own behaviors as causing problems. They might take criticism poorly and try to charm or influence the doctor or therapist who is evaluating them.
Patients with HPD may also try to shock or surprise people by talking about provocative topics like their sexual history. They might even pretend to have physical illnesses. Research has been done looking at rates of sexual assault in people with HPD. A mental status examination is a vital part of the psychiatric evaluation of HPD patients, although what the clinician finds during this examination can change based on the patient’s personal history and their specific situation.
Clinicians will be looking for different things in patients with HPD:
- Appearance: People with HPD often try to stand out or get attention through their clothing, hairstyles, tattoos, or accessories. They might dress in a provocative or eccentric way.
- Behavior: The behavior of people with HPD can be exaggerated and outgoing to the point of being inappropriate or unstable. In a psychiatric interview, they may show different sides of their personality (splitting). They might also tell long, dramatic stories, make sexual gestures, or act out to get attention.
- Speech: Loud, dramatic speech is common in individuals with HPD. They can be vague and lack detail in their speech. But they usually do not have trouble getting started with speaking and have a good vocabulary.
- Thought process: Their thought process is usually straightforward, but can be narrow and lack logical consistency. They are easily swayed by others’ thoughts and opinions.
- Cognition: People with HPD generally have normal cognition and are oriented to their surroundings.
- Impulse control: Poor impulse control can be a problem for people with HPD, leading them to engage in harmful behaviors.
- Judgement: They often show poor judgement.
- Insight: Since HPD is viewed as ego-syntonic (meaning the symptoms are in harmony with the patient’s self-image and are not perceived as problematic), people with this disorder often don’t realize that they have a problem. They might not understand how their disruptive behaviors can affect their social and work lives.
Testing for Histrionic Personality Disorder (HPD)
Diagnosing a personality disorder involves watching and studying a patient’s behavior patterns in various situations over time. This helps doctors understand their long-term mental and emotional state. There can be challenges in this process because personality disorders share many traits with other mental health conditions. Sometimes, this thorough analysis is not necessary or possible, especially when a core personality disorder is the primary cause of hospitalizations or worsens another mental disorder like depression. Diagnosing typically takes multiple appointments with the patient.
To get an official diagnosis of Histrionic Personality Disorder (HPD), doctors refer to the specific guidelines outlined in a manual called the DSM-5-TR. This method requires a comprehensive evaluation that uses multiple pieces of information, like personal history, reports from other individuals, and a mental status examination. This completes a thorough assessment, which helps medical professionals effectively evaluate the person’s symptoms and overall behavior.
HPD is known for over-the-top emotional behavior and the need to be the center of attention. This behavior pattern starts in early adulthood and is noticeable in different situations. To be diagnosed with HPD, an individual must display at least five of the following behaviors:
- Feels awkward when not the center of attention
- Acts inappropriately, provocatively, or overtly sexual when interacting with others
- Shows quickly changing, superficial emotions
- Constantly uses their physical appearance to attract attention
- Speaks in an impressionistic, vague manner and lacks detail
- Displays theatrical, exaggerated emotional expressions
- Easily swayed by others or situations
- Perceives relationships as being closer than they truly are
Treatment Options for Histrionic Personality Disorder (HPD)
Psychotherapy, a type of therapy involving talking to a mental health professional, is usually the main treatment for personality disorders. However, research shows that it may not be very effective for Histrionic Personality Disorder (HPD), a condition often seen as lifelong and resistant to treatment. Studies frequently reveal low success rates with few people experiencing complete relief from symptoms or reaching normal daily functioning levels.
The relationship between the patient and therapist, known as the therapeutic alliance, plays a crucial role in the treatment of personality disorders like HPD. Establishing and maintaining this relationship can be challenging as individuals with HPD don’t typically acknowledge their illness and may not want to seek treatment. Due to its resistance to treatment, focus on managing HPD often involves reducing conflicts in relationships and achieving stability in daily life functions.
Different techniques in psychotherapy have been examined to help treat HPD, but the results have been inconsistent. There was, however, one study that showed improvements in patients with HPD when they were treated with clarification-oriented psychotherapy, a treatment focused on clarifying the individual’s emotional experiences.
Unfortunately, medications generally used for mental health disorders don’t seem to work well for HPD, and no drugs have been authorized by the US Food and Drug Administration (FDA) specifically for this disorder. But, treating other mental health disorders that some patients with HPD may also have, using these medications, could potentially help improve their symptoms.
What else can Histrionic Personality Disorder (HPD) be?
HPD, or Histrionic Personality Disorder, might be the cause if someone consistently acts in extreme ways, regardless of the situation. There are several other mental health conditions that share some symptoms with HPD, so it’s vital to look closely to get the correct diagnosis.
For instance, certain behaviors often seen in people experiencing a severe high or low mood swing of bipolar disorder also appear in HPD, such as exaggerated self-importance, being overly sexual, or talking too much. However, people with HPD don’t experience needing less sleep as those with bipolar disorder might, nor do their symptoms come and go rapidly as in bipolar disorder. What’s more, medications that usually help manage bipolar disorder don’t appear to work well for HPD.
There are a few other conditions that are similar to HPD, including narcissistic and borderline personality disorders. People with a narcissistic personality disorder, like those with HPD, enjoy being the focus of attention. However, narcissists also dream of endless success, don’t feel empathy, and often use people for their gain. While there’s some overlap between HPD and borderline personality disorder, including impulsive behaviors, those with borderline personality disorder are more likely to show harmful behaviors toward themselves, fear abandonment, and feel constantly empty.
When diagnosing HPD, healthcare professionals may also consider whether a person is acting out physical symptoms or nervousness about their health. These could be signs of somatic symptom disorder or illness anxiety disorder, conditions where individuals use certain physical symptoms to express emotional distress.
What to expect with Histrionic Personality Disorder (HPD)
While there are only a few studies on HPD (histrionic personality disorder), it’s generally agreed that the disorder tends to last for a lifetime. Without treatment, it’s unlikely that HPD will improve on its own. Ways to improve the outlook for those with HPD include interventions aimed at enhancing quality of life, reducing any accompanying mental health issues, and improving social stability.
Possible Complications When Diagnosed with Histrionic Personality Disorder (HPD)
People with personality disorders often struggle with substance use disorders, but we don’t have much information about which particular personality disorders are at highest risk for specific problems with substance use. Personality disorders increase the chances of suicide and suicide attempts. So, if someone has a histrionic personality disorder (HPD), a type of personality disorder, they should be checked often for thoughts of suicide.
Preventing Histrionic Personality Disorder (HPD)
Treating Histrionic Personality Disorder (HPD) largely depends on establishing and maintaining a strong relationship between the patient and their healthcare team. It is crucial for patients to feel comfortable expressing their symptoms and discussing openly with their therapists or doctors. The focus of the medical team should not only be on changing the patient’s behavior, but also understanding and addressing their specific issues and difficulties.
Patients are advised to tap into their personal support systems, such as friends and family, and are encouraged to expand this network as they become more comfortable and confident. Involving family members can help by providing additional monitoring and education about the patient’s condition. Regular quality of life check-ups could also enhance the patient’s overall functionality in key aspects of their lives.
