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HISTRIONIC PERSONALITY DISORDER
 


Prediction: Lasts For Decades

      Occupational-Economic:
  • Works poorly with others (is easily bored, craves novelty, and must be the center of attention)
      Wisdom vs Irrationality: N/A
      Courage vs Negative Emotion: N/A
      Community vs Detachment: N/A
      Moderation vs Disinhibition:
  • Attention-seeking, desire for casual or illicit sex, harmful impulsiveness, emotional instability
  • "Drama queen", adopts role of "victim" or "princess", inappropriately seductive with others, self-absorbed
      Justice vs Antagonism:
  • Manipulative
      Medical: N/A


SYNOPSIS

Histrionic Personality Disorder F60.4 - ICD10 Description, World Health Organization

Histrionic personality disorder is characterized by shallow and labile affectivity, self-dramatization, theatricality, exaggerated expression of emotions, suggestibility, egocentricity, self-indulgence, lack of consideration for others, easily hurt feelings, and continuous seeking for appreciation, excitement and attention.
Histrionic Personality Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with histrionic personality disorder needs to show at least 5 of the following criteria:

  • Is uncomfortable in situations in which he or she is not the center of attention.

  • Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.

  • Displays rapidly shifting and shallow expression of emotions.

  • Consistently uses physical appearance to draw attention to self.

  • Has a style of speech that is excessively impressionistic and lacking in detail.

  • Shows self-dramatization, theatricality, and exaggerated expression of emotion.

  • Is suggestible, i.e., easily influenced by others or circumstances.

  • Considers relationships to be more intimate than they actually are.
Like all personality disorders, histrionic personality disorder is a deeply ingrained and enduring behaviour pattern, manifesting as an inflexible response to a broad range of personal and social situations. This behavior represents an extreme or significant deviation from the way in which the average individual in a given culture relates to others. This behaviour pattern tends to be stable. It causes subjective distress and problems in social performance.

Core Features

Individuals with histrionic personality disorder grow up having emotional instability and attention-seeking. The core features of this disorder are: (1) negative emotions (emotional lability), and (2) antagonism (attention-seeking, manipulativeness). This disorder is only diagnosed if: (1) it begins no later than early adulthood, (2) these behaviors occur at home, work, and in the community, and (3) these behaviors lead to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Lack Of Social Skills And Personality Disorders

There are certain social skills that are essential for healthy social functioning. Individuals with histrionic personality disorder lack the essential social skills of genuineness, chastity, and caution. They lack emotional stability (that is also lacking in individuals with borderline personality disorder) and cooperation/generosity (that is also lacking in narcissistic personality disorder).

    Social Skills That Are Lacking In Histrionic Personality Disorder

    SOCIAL SKILL LOW LEVEL HIGH LEVEL
    Genuineness Attention-Seeking Being genuine (not overly theatrical or attention-seeking)
    Chastity Desire for casual or illicit sex Avoidance of casual sex (“one night stands”) AND absence of intense desire for illicit sex
    Caution Harmful impulsiveness Thinking carefully before acting or speaking; being cautious
    Emotional Stability Emotional instability (emotions change rapidly and unpredictably) Having a predictable mood which does not quickly change
    Cooperation and Generosity Being manipulative or greedy Cooperating with others and doing a fair share of the work; unselfishly helping others

Antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, and borderline personality disorder are so closely related that they are referred to as the "antagonistic" cluster of personality disorders.

    Social Skills That Are Lacking In The "Antagonistic" Cluster Of Personality Disorders

    PERSONALITY DISORDER LACKING LACKING LACKING
    Antisocial Personality Respect (instead has disrespect) Responsibility (instead has irresponsibility) Honesty (instead has dishonesty)
    Narcissistic Personality Humility (instead has arrogance) Cooperation or Generosity (instead has being manipulative or greedy) Kindness (instead has callousness)
    Borderline Personality Emotional Stability (instead has emotional instability) Stable Self-Image (instead has unstable self-image) Social Stability (instead has social instability)
    Histrionic Personality Genuineness (instead has attention-seeking) Chastity (instead has desire for casual or illicit sex) Caution (instead has harmful impulsiveness)

Social Functioning

Individuals with histrionic personality disorder often act out a role (e.g., "victim" or "princess") in their interpersonal relationships. They are often very dependent on their partner, but seek to control their partner through emotional manipulation or seductiveness. Their attention-seeking eventually alienates their friends. Often old relationships are neglected to make way for the excitement of new relationships.

Negative Emotions

Their expression of emotion is overly dramatic and theatrical ("drama queen"). They may embarrass friends by their excessive public display of emotions.

    Negative Emotions
    • Expresses emotion in exaggerated and theatrical ways.
    • Emotions change rapidly and unpredictably.

Histrionic Traits

Individuals with histrionic personality disorder must be the center of attention and "the life of the party". They are overly concerned with impressing others by their appearance. They are highly suggestible, and easily influenced by others and by fads. They are hypersensitive to criticism. They are impulsive, excitement seeking, reckless, seductive and manipulative.

    Histrionic Traits
    • Is uncomfortable in situations in which he or she is not the center of attention.
    • Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
    • Displays rapidly shifting and shallow expression of emotions.
    • Consistently uses physical appearance to draw attention to self.
    • Has a style of speech that is excessively impressionistic and lacking in detail.
    • Shows self-dramatization, theatricality, and exaggerated expression of emotion.
    • Is suggestible, i.e., easily influenced by others or circumstances.
    • Considers relationships to be more intimate than they actually are.

Effective Therapies

The effectiveness of treatment for this disorder is unknown because there are no randomized controlled trials. The treatment of this disorder is very similar to that of borderline personality disorder. These attention-seeking, impulsive individuals need to have a long-term mentor to establish a stable, supportive relationship in which clear and consistent boundaries are established. This mentor must have the patience and strength to withstand the patient's many crises and limit-testing episodes. Communication should always be clear, honest, optimistic and directed towards teaching more mature coping skills. This mentor could be a primary care physician, or some other qualified therapist.

Ineffective Therapies

Medication is ineffective against the core symptoms of histrionic personality disorder.

Which Behavioral Dimensions Are Involved?

The ancient Greek civilization lasted for 1,300 years (8th century BC to 6th century AD). The ancient Greek philosophers taught that the 5 pillars of their civilization were: wisdom, courage, community, moderation, and justice. Psychiatry named the opposite of each of these 5 ancient themes as being a major dimension of psychopathology (i.e., irrationality, negative emotion, detachment, disinhibition, and antagonism). (Psychology named these same factors the "Big 5 dimensions of personality": "intellect", "neuroticism", "extraversion", "conscientiousness", and "agreeableness")

    Histrionic Personality Disorder: Disinhibition And Antagonism
            Wisdom vs Irrationality: N/A
            Courage vs Negative Emotion: N/A
            Community vs Detachment: N/A
            Moderation vs Disinhibition:
      • Attention-seeking, desire for casual or illicit sex, harmful impulsiveness, emotional instability
      • "Drama queen", adopts role of "victim" or "princess", inappropriately seductive with others, self-absorbed
            Justice vs Antagonism:
      • Manipulative

Prevalence

The frequency of histrionic personality disorder is equal in males and females, and this disorder is present in about 1.8% of the general population (and 10%-15% of psychiatric outpatients).

Course

Histrionic personality disorder has a chronic course.

Complications

The actual risk of suicide is not known, but individuals with histrionic personality disorder are at increased risk for attention-seeking suicidal gestures or threats.

Comorbidity

Some other disorders frequently occur with this disorder:

    Non-Personality Disorders

            Depressive Disorders:
      • Major depressive disorder
            Somatic Symptom and Related Disorders:
      • Somatic symptom disorder, conversion disorder

    Personality Disorders

            Negative Emotion Cluster:
      • Dependent personality disorders

            Antagonistic Cluster:
      • Antisocial, narcissistic, borderline personality disorders
        Note: Antisocial, narcissistic, borderline, and histrionic personality disorders are all closely related since they all share the same core feature of antagonism. This core feature is an exaggerated sense of self-importance, insensitivity towards the feelings and needs of others, and callous exploitation of others. These antagonistic behaviors put the individual at odds with other people. If an individual has one of these antagonistic personality disorders, they are very likely to have another.

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of this disorder.

Primate Evolution

There appears to be three different ways in which primates have evolved socially:
  • The chimpanzees have evolved to be socially antagonistic, competitive, callous, and manipulative. Thus chimpanzee social behavior most closely mirrors the antagonistic behavior of the antisocial-narcissistic-borderline-histrionic cluster of personality disorders.

  • In contrast, the bonobos have evolved to be socially anxious, peaceful, cooperative, and loving. Thus bonobo social behavior most closely mirrors the negative emotion (anxious) behavior of the avoidant-dependent cluster of personality disorders.

  • Another separate evolutionary path was followed by the orangutans. They evolved to become solitary hermits. Thus orangutan social behavior most closely mirrors the detached behavior of the paranoid-schizoid-schizotypal cluster of personality disorders.

Core Behaviors Of The Antagonistic Cluster Of Personality Disorders

Cleopatra Seducing Caesar and Mark Antony


In this cluster of personality disorders, the males tend to be like Caesar and have antisocial and/or narcissistic personality disorders, and the females tend to be like Cleopatra and have borderline and/or histrionic personality disorders. The core feature of this cluster of personality disorders is antagonism. These individuals seem to be unconcerned about how their actions harm or upset others.

    Antagonism: The Core Feature Of the Antagonistic Cluster of Personality Disorders

    • manipulativeness:
      In the past week, did you "con" or take advantage of someone?
    • callousness:
      In the past week, did you harm someone, but not care?
    • deceitfulness:
      In the past week, did you lie, steal, or cheat?
    • hostility:
      In the past week, were you actively hostile towards someone?
    • attention-seeking:
      In the past week, did you go out of your way to be the center of attention?
    • grandiosity:
      In the past week, did you treat others as if they were inferior to you?

Parental Behaviors Which Increase The Risk Of Developing A Personality Disorder

Research has shown that genetic, environmental, and prenatal factors all play important roles in the development of personality disorder. Recent research has also shown that low parental affection and harsh parenting increase the risk of a child later developing a personality disorder.

"Low affection" was defined as: low parental affection, low parental time spent with the child, poor parental communication with the child, poor home maintenance, low educational aspirations for the child, poor parental supervision, low paternal assistance to the child's mother, and poor paternal role fulfillment. "Harsh parenting" was defined as: harsh punishment, inconsistent maternal enforcement of rules, frequent loud arguments between the parents, difficulty controlling anger toward the child, possessiveness, use of guilt to control the child, and verbal abuse.

Setting Goals In Therapy

    Questions To Ask When Setting Goals

    In The Past Week:
    • WHO: was your problem?
    • EVENT: what did he/she do?
    • RESPONSE: how did you respond to that event?
    • OUTCOME: did your response help?
    • TRIGGER: what did you do that could have triggered this problem?
    • GOAL: what life skill(s) do you have to work on? (from checklist)

    Example Of Setting Goals In Interviewing A Person With Histrionic Personality Disorder

    In The Past Week:
    • WHO: was your problem?
      "My boyfriend."

    • EVENT: what did he/she do?
      "I was just talking to this guy at a party, and my boyfriend got all jealous."

    • RESPONSE: how did you respond to that event?
      "I stormed out of the party. I wish now that we hadn't made such a scene."

    • OUTCOME: did your response help?
      "No, I over-reacted. It wasn't worth upsetting everyone at the party."

    • TRIGGER: what did you do that could have triggered this problem?
      "My boyfriend knows that I like to flirt. I just got a little carried away that night."

    • GOAL: what life skill(s) do you have to work on? (from checklist)
      "I want to work on: (1) Genuineness ("being genuine - not overly theatrical or attention-seeking"), and (2) Chastity ("avoidance of casual sex [“one night stands”] AND absence of intense desire for illicit sex")."

Description


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