How common is histrionic personality disorder?

Symptoms of HPD

People with histrionic personality disorder tend to be charming, lively, manipulative, seductive, enthusiastic, vibrant, and impulsive ^[1].  Their emotions are strong and volatile, and they constantly seek reassurance or approval. These people have an intense need to be the center of attention, are characterized by a “larger than life” personality, and are usually self-centered, in conversation and behavior ^[2]. They may be flirtatious, seductive, or sexually suggestive, even with people they are not attracted to. Their emotions are shallow and rapidly shifting, but also exaggerated in public. Furthermore, they exhibit dramatic behavior and express strong opinions but through vague speech and few facts ^[3]. People with HPD are also easily influenced and gullible, lack patience, are over-sensitive, and get frustrated easily ^[4]. 

The constant approval-seeking behavior, the emotional volatility, and the self-centered tendencies mean that HPD patients find it difficult to have satisfying or stable relationships with romantic partners, friends, or family. All these symptoms are common to other personality disorders and can have negative effects on people's life. However, people with histrionic personality disorder are still able to participate fully in their professional and social life.

So, how many people have HPD?

According to the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) of 2001 - 02 of the National Institute on Alcohol Abuse and Alcoholism / National Institutes of Health, ^[5] 14.9 percent of US citizens over 18 years old have a personality disorder. This same survey states that 1.8 percent, 3.8 million citizens, have HPD, showing it is one of the rarer types of personality disorder.

However, patients with these kinds of personality disorders tend to have chronic difficulty in interacting with the health care system. Therefore, it makes it difficult for physicians to assess patients’ mental health condition ^[6].

Histrionic personality disorder is ego-syntonic ^[7]. This means that people with this mental disorder think their behavior and way of thinking are normal and don’t consider it a problem. Therefore, patients with this personality disorder will not actively seek help, and if they do it is because they are suffering from anxiety or depression due to problems in their interpersonal relationships or work life, created by their HPD. This leads to difficulties in diagnosing histrionic personality disorder.

Histrionic personality disorder may also coexist with other personality disorders such as borderline personality disorder, narcissistic personality disorder, or antisocial personality disorder, which can suggest that they all share the same biologic vulnerability. HPD may also coexist with major or persistent depressive disorder, conversion disorder, or somatic symptom disorder ^[4].

HPD is diagnosed after the age of 18, as personality develops continuously through childhood and adolescence.

Is HPD more common in men or women?

Previous research showed that women are four times more likely to be diagnosed with HPD than men ^[8]. However, other research indicates this might only prove a greater prevalence in women in clinical settings, where the research was conducted. 

It states that men tend to be underdiagnosed as they are less likely to report their symptoms. Moreover, women may have been overly diagnosed with this disorder as in the past it was less socially acceptable for women to be sexually-forward or to express strong opinions and intense emotions in public. Therefore, histrionic personality disorder prevalence is equal for men and women ^[5],^[8].

What causes HPD?

The explicit causes for HPD are yet unknown ^[1], however, there are certain inherited or environmental factors that may lead to personality disorders and to HPD specifically:

• Genetic factors: some studies show that histrionic personality disorder tends to run in the family, therefore, there may be a genetic susceptibility ^[8]. A family history of personality disorders, anxiety disorders, or depressive disorders, is also a risk factor, as well as substance use disorder ^[7].
• Parenting styles: children who have inconsistent or unpredictable attention from their parents, a lack of boundaries, punishment or criticism as a child, or being rewarded for attention-seekingbehavior may lead to the child developing HDP during their teenage years ^[9]. Children learn their behavior from adults, so parents or caregivers with exaggerated, dramatic, volatile, erratic, and provocative behavior, or with overtly sexual behavior may also influence the development of HDP in their children.
• Childhood trauma: children who suffer from trauma develop coping or adaptation mechanisms to deal with their environment or certain situations, which can then lead to personality disorders as they grow up ^[1].