Histrionic Personality Disorder

A personality disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as having 2 essential features: moderate or greater impairment in personality functioning; and one or more pathological personallity traits. Histrionic personality disorder (HPD) was retained in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as a personality disorder although there was considerable discussion among members of the manual's Work Group about removing four of the 10 personality disorders listed in DSM-IV—among them HPD—and leaving only six. One likely reason for the proposal to drop HPD as a distinct personality disorder is that too few patients tentatively diagnosed with HPD were available during the field trials of DSM-5 to provide an adequate test of interrater reliability for this specific personality disorder. What is new in DSM-5 is that the personality disorders are no longer defined as constituting a separate axis or diagnostic area. The new edition of the diagnostic manual has moved from a multiaxial system to a single axis for diagnostic coding purposes. What the removal of the Axis II designation means is that the personality disorders are no longer artificially separated from other mental disorders.

Individuals with HPD tend to seek attention by exaggerating events, even if insignificant, and are immature, self-centered, and often vain. The English word histrionic is derived from the Latin word for actor, which reflects these individuals’ desire for attention from others and their penchant for self-dramatization. The colloquial term drama queen is a capsule description of this type of personality disorder. These individuals react emotionally to the slightest provocation.

In DSM-IV, HPD was classified in Group B, the group of personality disorders characterized by overly dramatic, emotional, impulsive, or erratic reactions. Other personality disorders in this group are the antisocial, borderline, and narcissistic personality disorders. People with HPD seek stimulation and novelty and easily become bored with routine situations and relationships. Their low tolerance for inactivity leads to hedonistic or impulsive actions, sometimes described as acting out. They tend to be preoccupied with their appearance and attractiveness, and their demeanor is often charming and seductive, even if this behavior is inappropriate. These individuals pursue a fast-paced social and romantic lifestyle, although their relationships usually are shallow and fleeting. They also tend to be emotionally dependent on others.

The use of the term histrionic by professionals in psychology is relatively recent and replaces the term hysterical, which was dropped due to its negative and sexist associations, derived as it is from the Greek word for uterus. Women in North America and the United Kingdom are three times more likely than men to be diagnosed with HPD, although this statistic may at least partly reflect gender and cultural biases that cause this pattern of behavior to be less easily recognized in men. It is thought that between 1% and 3% of the general population in North America meet the diagnostic criteria for HPD.

The causes of HPD are a matter of dispute, although most clinicians consider it to result from a combination of genetic and environmental factors. In some cases it appears to be a style of relating to others that individuals learned in their family of origin.

HPD is a personality disorder that can have a severe impact on family members, workplace colleagues, and others who must interact with the affected person on a frequent basis. People with HPD are unable to consider the long-term consequences of their behavior, and the turbulence they create for others can be humiliating for family members or employers as well as stressful to resolve. Friends or relatives of people with HPD may find themselves avoiding favorite activities or social events in order to protect themselves from the tantrums or embarrassing scenes created by the affected person.

Individuals with HPD may benefit from psychodynamic therapy or group therapy provided they are willing to undertake it; they often do not enter psychotherapy, however, because they typically do not think they need it. High-functioning individuals with HPD, particularly those with higher education or those in occupations that reward their flair for the dramatic (the performing arts, the fine arts, politics, professional sports, journalism) are often successful in getting what they want from others as well as obtaining professional acclaim. Low-functioning persons with HPD may seek professional help when their behavior causes a family or workplace crisis but are likely to leave treatment when the crisis appears to be over. The goals for individuals with HPD who are prepared to undergo therapy should include gaining more control over emotional reactions and understanding how their overly dramatic behavior undermines their relationships or careers. Medication is ineffective in treating HPD, although it might be prescribed for such accompanying symptoms as anxiety or depression.

See also Diagnostic and Statistical Manual ofMental Disorders (DSM-5); Narcissistic personality disorder; Personality disorders.