Histrionic personality disorder is typified by attention-seeking behaviors and over-emotionality.

 

The DSM-IV diagnostic criteria define histrionic personality disorder as a pervasive pattern of excessive emotionality and attention seeking that has begun by early adulthood and is present in a variety of contexts. At least five of the following features must be present:

The ICD-10 diagnostic criteria are virtually identical. However, they do not contain the feature of speech being overly impressionistic and lacking in detail, and only three of the character traits are required for diagnosis.

 

People with histrionic personality disorder have a need to be the center of attention and often dress and behave in ways to attract attention - they are often the `life and soul of the party'.

Their emotionality is often excessive and dramatic but lacks depth of feeling. They are frequently stylish and use language in a colorful manner, sprinkled with the latest faddish colloquialisms and slang.

They may spend an inordinate amount of time or money on clothes and grooming. They may look for compliments about their appearance and may be overly upset by a remark they regard as critical or a photograph that seems to show them in an unflattering light.

They may be dramatic, flirtatious or even openly seductive.

In the clinical setting, they are often flattering to the clinician and other staff, may arrive with gifts, and often provide dramatic and colorful physical and psychological symptoms that tend to be new with each visit. They may be inappropriately sexually provocative in their behavior in the clinical setting.

They are often naïvely suggestible and may be a victim of sexual predators or `con men'. There may be frequent, apparently intense but brief romantic or sexual relationships. Promiscuity is common, as are multiple marriages.

Compared with normal women, women with histrionic personality disorder tend to have:

Speech and thinking tend to driven by emotionality rather than by logic, and detail is often lacking. Strong opinions may be expressed with few underlying reasons being given for the opinion. Decisions are often made impulsively by `intuition' or `hunches'.

Their behavior may be embarrassing to others with what come to be regarded as excessive public displays of emotion (such as embracing even casual acquaintances, sobbing and crying on minor sentimental occasions, or displaying excessive temper on minor provocation).

 

The diagnosis of histrionic personality disorder is best made by a careful review of the patient's life history, supplemented if possible by the reports of others such as family members.

Enquiries into the characteristics of the patient's family system often reveal well-played roles and marks (e.g. `great seducer father', `very depressed mother') and can give the therapist a different interpretation of the case.

Formal psychological testing may be useful. There are no specific laboratory tests.

 

A number of conditions are frequently comorbid with histrionic personality disorder, including:

People with histrionic personality disorder are at risk of substance abuse, including habituation to prescribed medication. Medications with habituation potential (e.g. benzodiazepines and opiate analgesics) are relatively contraindicated in these patients.

Behavioral outcomes that are commonly seen in people with histrionic personality disorder include:

 

The differential diagnosis of histrionic personality disorder include:

 

Patients with mild forms of histrionic personality disorder benefit from therapy in terms of increased quality of interpersonal relationships and decreased somatization. Some improvement may occur as the patient gets older and increases in maturity.

Patients with severe forms of histrionic personality disorder and those with associated borderline or antisocial features are prone to continued marital or occupational instability, the effects of substance abuse, acting-out behaviors, and even imprisonment.

The aims of treatment are:

 

Regular life habits should be encouraged, including regular and healthy meals and good sleep hygiene. The histrionic patient often needs help to organize personal finances and work habits.

 

There is no specific pharmacological treatment for histrionic personality disorder. Treatment is non-pharmacological.

 

Individual psychodynamic psychotherapy remains the cornerstone of treatment. It can provide support at times of crisis (e.g. the break-up of a relationship). The therapist can model a well-modulated affective response, and through questions and interpretations can emphasize the need for problem solving and coping strategies rather than the use of emotional displays or somatization. The therapist must also carefully redirect the patient to resolve the areas of emotional conflict that are characteristically avoided or repressed. Long-term psychotherapy is often necessary. Therapists may benefit from special training in this area.

Other therapies that may be useful include:

It is worth noting that the histrionic patient is likely to attempt to subvert therapy and make it into a social event. Seductive behavior can not only circumvent the therapeutic process but, if the therapist succumbs, can lead to disaster for both patient and therapist.

 

People with histrionic personality disorder frequently present at times of severe emotional distress, often caused by disrupted interpersonal relationships. Supportive care, at times inpatient psychiatric treatment, is required for stabilization.

Long-term psychotherapy (months to years) to address is usually needed after acute episodes of emotionalism or somatization have been stabilized. Even after successful moderation of histrionic defenses, some brief psychotherapeutic interventions may be required at times of severe stress or loss.

Concepts of histrionic traits as compared with `hysterical' traits have been muddied by the confusing terminology used to describe these patients. Early psychoanalytic theories of fixation at an oedipal level of psychosexual development have largely been discarded.

Current explanations of etiology include the following:

 

The prevalence in the general population is 2-3%; in psychiatric patients (when structured assessment instruments are used), the prevalence rises to 10-15%.

The prevalence is higher in females than in males, although there may be a sex bias for females in favor of histrionic personality over antisocial personality.