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Histrionic Personality Disorder (HPD)

By

Mark Zimmerman

, MD, Rhode Island Hospital

Reviewed/Revised Sep 2023
View PATIENT EDUCATION

Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Diagnosis is by clinical criteria. Treatment is with psychodynamic psychotherapy.

Patients with histrionic personality disorder use their physical appearance, acting in inappropriately seductive or provocative ways, to gain the attention of others. They lack a sense of self-direction and are highly suggestible, often acting submissively to retain the attention of others.

Estimated prevalence is < 2% of the general population (1 General references Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Diagnosis is by clinical criteria. Treatment is with psychodynamic psychotherapy... read more ). The prevalence in females and males is similar. Prior reports of an increased prevalence among females was possibly influenced by ascertainment bias from hospital-based studies.

Comorbidities are common, particularly other personality disorders (antisocial Antisocial Personality Disorder (ASPD) Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. Diagnosis is by clinical criteria. Treatment may include cognitive-behavioral... read more , borderline Borderline Personality Disorder (BPD) Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations... read more , narcissistic Narcissistic Personality Disorder (NPD) Narcissistic personality disorder is characterized by a pervasive pattern of grandiosity, need for adulation, and lack of empathy. Diagnosis is by clinical criteria. Treatment is with psychodynamic... read more ) (2 General references Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Diagnosis is by clinical criteria. Treatment is with psychodynamic psychotherapy... read more ). Some patients also have somatic symptom disorder Somatic Symptom Disorder Somatic symptom disorder is characterized by multiple persistent physical complaints that are associated with excessive and maladaptive thoughts, feelings, and behaviors related to those symptoms... read more , which may be the reason they present for evaluation. Major depressive disorder Major depressive disorder (unipolar depressive disorder) Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more , persistent depressive disorder Persistent depressive disorder Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more , and conversion disorder Functional Neurological Symptom Disorder Functional neurological symptom disorder, previously known as conversion disorder, consists of neurologic symptoms or deficits that develop unconsciously and nonvolitionally and usually involve... read more may also coexist.

General references

  • 1. Morgan TA, Zimmerman M: Epidemiology of personality disorders. In Handbook of Personality Disorders: Theory, Research, and Treatment. 2nd ed, edited by WJ Livesley, R Larstone, New York, NY: The Guilford Press, 2018, pp. 173-196.

  • 2. Zimmerman M, Rothschild L, Chelminski I: The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry 162:1911-1918, 2005. doi: 10.1176/appi.ajp.162.10.1911

Symptoms and Signs of Histrionic Personality Disorder

Patients with histrionic personality disorder continually demand to be the center of attention and often become depressed when they are not. They are often lively, dramatic, enthusiastic, and flirtatious and sometimes charm new acquaintances.

These patients often dress and act in inappropriately seductive and provocative ways, not just with potential romantic interests, but in many contexts (eg, work, school). Because of their desire to impress others with their appearance, they are often preoccupied with how they look.

Expression of emotion may be shallow (turned off and on too quickly) and exaggerated. They speak dramatically, expressing strong opinions, but with few facts or details to support their opinions.

Patients with histrionic personality disorder are easily influenced by others and by current trends. They tend to be too trusting, especially of authority figures who, they think, may be able to solve all their problems. They often think relationships are closer than they are. They crave novelty and bore easily. Thus, they may change jobs and friends frequently. Delayed gratification is frustrating to them, so their actions are often motivated by obtaining immediate satisfaction.

Achieving emotional or sexual intimacy may be difficult. Patients may, often without being aware of it, play a role (eg, victim). They may try to control their partner using seductiveness or emotional manipulation while becoming very dependent on the partner.

Diagnosis of Histrionic Personality Disorder

  • Diagnostic and Statistical Manual of Mental Disorders, 5th Ed, Text Revision (DSM-5-TR) criteria

  • A persistent pattern of excessive emotionality and attention seeking

This pattern is shown by the presence of 5 of the following:

  • Discomfort when they are not the center of attention

  • Interaction with others that is inappropriately sexually seductive or provocative

  • Rapidly shifting and shallow expression of emotions

  • Consistent use of physical appearance to call attention to themselves

  • Speech that is extremely impressionistic and vague

  • Self-dramatization, theatricality, and exaggerated expression of emotion

  • Suggestibility (easily influenced by others or situations)

  • Interpretation of relationships as more intimate than they are

Also, symptoms must have begun by early adulthood.

Differential diagnosis

Histrionic personality disorders can be distinguished from other personality disorders based on characteristic features:

Diagnosis reference

  • 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022, pp. 757-760.

Treatment of Histrionic Personality Disorder

  • Psychodynamic psychotherapy

Little is known about the efficacy of cognitive-behavioral therapy and pharmacotherapy for histrionic personality disorder.

Psychodynamic psychotherapy, which focuses on underlying conflicts, may be tried. The therapist may start by encouraging patients to substitute speech for behavior, and thus, communicate with others in a less dramatic way. The therapist may also help patients realize how their histrionic behaviors are a maladaptive way to attract the attention of others and to manage their self-esteem.

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