Histrionic Personality Disorder

What is histrionic personality disorder?

Histrionic personality disorder (HPD) is a personality disorder marked by exaggerated expression of emotions and attention-seeking behaviors. Those with HPD may appear lively, charming, and flirtatious. Their self-esteem relies predominantly on attention and approval from others.

Symptoms typically begin in early adulthood. ^[1] Individuals with HPD tend to quickly shift between dramatic and intense emotions, which may appear insincere. They may act and dress in inappropriate or seductive ways to get attention. They may also speak in a vague, theatrical manner that lacks substance. They are likely to be gullible and easily swayed by others. They often consider their relationships as more intimate than they are, referring to individuals they barely know as close friends.

Those with histrionic personality disorder do not often realize that their behavior is problematic and can make other people uncomfortable. They do not handle criticism or rejection well, but they do not understand that their actions drive others away.

Symptoms of histrionic personality disorder

People with HPD might:

• Act in inappropriate or sexual ways to get attention
• Dress in an overly provocative manner
• Be easily influenced by others, especially those they admire
• Be excessively concerned with their appearance
• Be overly sensitive to criticism
• Blame others for their failures
• Constantly seek reassurance from others
• Have a low tolerance for frustration
• Need immediate gratification
• Feel uncomfortable when they are not the center of attention
• Speak in a vague and grandiose manner, lacking in detail
• Interpret their relationships as more intimate or serious than they are
• Display unstable, shallow, and rapidly changing emotions ^[2][1]

Causes of histrionic personality disorder

The causes of HPD are not yet fully understood. However, psychologists believe that a combination of genetic and environmental risk factors can play a role. Genetic factors include a family history of HPD, other types of personality disorders, substance abuse, or other mental illnesses. ^[2]

Environmental factors include childhood trauma and emotional neglect. Parenting styles may also have an impact. Individuals may be at higher risk if their parents modeled inappropriate attention-seeking behaviors themselves. Parenting styles that lack boundaries, rules, or punishment may also predispose children to develop HPD. ^[2]

Complications of histrionic personality disorder

If HPD is left untreated, several complications can occur, including significant effects on the individual’s personal life and the development of other medical conditions.

Effects on personal life

The symptoms of HPD may cause individuals to:

• Experience difficulty in their interpersonal relationships, as they may use manipulation rather than developing real intimacy
• Have trouble maintaining jobs, due to their inability to accept criticism
• Take part in risky behaviors, both as a way to gain attention and because they are susceptible to peer pressure

Serious complications and other mental health conditions

People with HPD are more likely than the general population to develop:

• Depressive disorders
• Substance use disorders
• Panic attacks ^[2] 

While the actual prevalence of suicidal behavior is not known, those with HPD are at increased risk of using suicidal threats to get attention. ^[1]

Diagnosing histrionic personality disorder

Diagnosis of HPD begins with a psychological evaluation. A mental health professional will look at the history of the symptoms, as well as overall medical history. They will also consider the patient’s appearance, behavior, work history, and relationship history. 

Based on the above assessment, the professional will determine whether the patient meets the DSM-5’s criteria for HSP. They must first meet the diagnostic criteria for a personality disorder, marked by patterns of behavior, thoughts, and emotions that ^[1]:

• Is rigid and pervasive
• Remains steady over time
• Significantly differs from the norms of the individual’s culture
• Results in distress or debilitation, and
• Begins in adolescence or early adulthood

Then, they must meet at least five of the following criteria ^[1]:

• Behaves in a sexually provocative manner
• Is suggestible or easily swayed by others
• Perceives relationships to be more intimate than they actually are
• Consistently uses appearance to attract attention
• Displays exaggerated or theatrical displays of emotion
• Uses impressionistic, vague speech
• Shows erratic and shallow expression of emotion
• Expresses discomfort in situations where they are not the center of attention

Differential diagnoses that must be ruled out include borderline personality disorder (BPD), narcissistic personality disorder (NPD), and dependent personality disorder (DPD). Generally, the differences between HPD and these other psychiatric disorders are:

• Those with BPD have similarly unstable emotions, but unlike HPD, they also have feelings of emptiness and dislike themselves. ^[1]
• Those with NPD also seek attention, but they want to be admired. Those with HPD are not particular about the nature of the attention they seek.
• Those with DPD also seek approval, but they are much more inhibited and anxious.

Prevention of histrionic personality disorder

There is no specific way to prevent this disorder, as the causes are not well-understood. However, early recognition, diagnosis, and treatment are key to managing the symptoms of HPD and preventing complications.

Treatment for histrionic personality disorder

While those with HPD do not usually believe they need treatment, they may seek treatment for complications, such as depression. Therapy is generally the most effective treatment plan for someone with HPD.

Talk therapy

The primary treatment of choice for HPD is talk therapy. Supportive psychotherapy is generally recommended, as it is non-threatening and sympathetic to the patient. ^[2] This approach seeks to help the patient develop coping skills and increase self-esteem. It is important for the professional to set strict boundaries, as patients may act overly friendly or flirtatious with them.

Psychodynamic therapy

Psychodynamic therapy is also often used, and begins with revisiting underlying conflicts and developmental milestones that may have been missed. ^[2][3] The therapist then helps the patient learn new, healthier ways to express themselves and how to improve their self-esteem. 

Group therapy

Group therapy is not generally recommended. ^[2] Because those with HPD need to be the center of attention, they may feel uncomfortable in group settings and have trouble engaging in a meaningful way. Similarly, they may try to impress others in the group rather than express their true emotions.

Medication

While there is no specific medication used to treat HPD, medications for similar conditions can help. Anti-depressants, anti-psychotics, and mood stabilizers are often used to manage symptoms such as impulse control, mood swings, anxiety, and depression. ^[2]

Self-care for histrionic personality disorder

As a complement to therapy, practicing self-care can help improve overall well-being. People with HPD should exercise regularly, eat a healthy diet, practice healthy sleeping habits, and avoid drugs and alcohol. These practices can help to keep symptoms under control. Mindfulness techniques are also helpful as a way to manage stress and control impulsive behavior.

Helping someone with histrionic personality disorder

You can help someone with HPD by educating yourself on the condition. This will give you the tools you need to properly communicate with your loved one. It is important to remain calm and supportive, instead of critical of their behavior. Do not ignore them, as this can cause their behavior to escalate. Encourage them to seek treatment and help them find the appropriate resources.

Frequently asked questions about HPD

What is the outlook for people with HPD?

Although there is no cure, many people with HPD can live full lives. They can often still function well in social and professional settings. Those who receive treatment, through therapy and/or medication, tend to have better outcomes than those who do not. ^[2] Unfortunately, those with severe HPD may continue to have trouble at work and in interpersonal relationships. ^[2]

How common is HPD?

HPD is relatively rare. Research estimates it affects anywhere between 1-3% of the general population. ^[2][3] It is more common in women, who are four times as likely to be diagnosed as men. ^[2] However, it is suspected that women may be overdiagnosed and men underdiagnosed due to the nature of the symptoms. ^[2] Men may also be less likely to report their symptoms.

Histrionic personality disorder vs borderline personality disorder – What is the difference?

While both HPD and BPD can include attention-seeking, erratic, and manipulative behavior, there are some significant differentiators. People with BPD tend to have low opinions of themselves and fear abandonment. ^[3] On the other hand, those with HPD often do not see a problem with their behavior. Suicidal ideation and self-harm are also hallmark symptoms of BPD, but they are less common with HPD. ^[1]