7. Histrionic personality disorder

Histrionic Personality Disorder Symptoms

By PSYCH CENTRAL STAFF

Histrionic personality disorder is characterized by a long-standing pattern of attention seeking behavior and extreme emotionality. Someone with histrionic personality disorder wants to be the center of attention in any group of people, and feel uncomfortable when they are not. While often lively, interesting and sometimes dramatic, they have difficulty when people aren’t focused exclusively on them. People with this disorder may be perceived as being shallow, and may engage in sexually seductive or provocative behavior to draw attention to themselves.
Individuals with Histrionic Personality Disorder may have difficulty achieving emotional intimacy in romantic or sexual relationships. Without being aware of it, they often act out a role (e.g., “victim” or “princess”) in their relationships to others. They may seek to control their partner through emotional manipulation or seductiveness on one level, whereas displaying a marked dependency on them at another level.
Individuals with this disorder often have impaired relationships with same-sex friends because their sexually provocative interpersonal style may seem a threat to their friends’ relationships. These individuals may also alienate friends with demands for constant attention. They often become depressed and upset when they are not the center of attention.
People with histrionic personality disorder may crave novelty, stimulation, and excitement and have a tendency to become bored with their usual routine. These individuals are often intolerant of, or frustrated by, situations that involve delayed gratification, and their actions are often directed at obtaining immediate satisfaction. Although they often initiate a job or project with great enthusiasm, their interest may lag quickly.
Longer-term relationships may be neglected to make way for the excitement of new relationships.
A personality disorder is an enduring pattern of inner experience and behavior that deviates from the norm of the individual’s culture. The pattern is seen in two or more of the following areas: cognition; affect; interpersonal functioning; or impulse control. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. It typically leads to significant distress or impairment in social, work or other areas of functioning. The pattern is stable and of long duration, and its onset can be traced back to early adulthood or adolescence.

Symptoms of Histrionic Personality Disorder

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

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

Because personality disorders describe long-standing and enduring patterns of behavior, they are most often diagnosed in adulthood. It is uncommon for them to be diagnosed in childhood or adolescence, because a child or teen is under constant development, personality changes and maturation. However, if it is diagnosed in a child or teen, the features must have been present for at least 1 year.
Histrionic personality disorder is more prevalent in females than males. It occurs in about 1.8 percent in the general population.
Like most personality disorders, histrionic personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

How is Histrionic Personality Disorder Diagnosed?

Personality disorders such as histrionic personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose histrionic personality disorder.
Many people with histrionic personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.
A diagnosis for histrionic personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

Causes of Histrionic Personality Disorder

Researchers today don’t know what causes histrionic personality disorder. There are many theories, however, about the possible causes of histrionic personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

What Are the Symptoms of Histrionic Personality Disorder?

In many cases, people with histrionic personality disorder have good social skills; however, they tend to use these skills to manipulate others so that they can be the center of attention.

A person with this disorder might also:

• Be uncomfortable unless he or she is the center of attention
• Dress provocatively and/or exhibit inappropriately seductive or flirtatious behavior
• Shift emotions rapidly
• Act very dramatically, as though performing before an audience, with exaggerated emotions and expressions, yet appears to lack sincerity
• Be overly concerned with physical appearance
• Constantly seek reassurance or approval
• Be gullible and easily influenced by others
• Be excessively sensitive to criticism or disapproval
• Have a low tolerance for frustration and be easily bored by routine, often beginning projects without finishing them or skipping from one event to another
• Not think before acting
• Make rash decisions
• Be self-centered and rarely show concern for others
• Have difficulty maintaining relationships, often seeming fake or shallow in their dealings with others
• Threaten or attempt suicide to get attention

What Causes Histrionic Personality Disorder?

The exact cause of histrionic personality disorder is not known, but many mental health professionals believe that both learned and inherited factors play a role in its development. For example, the tendency for histrionic personality disorder to run in families suggests that a genetic susceptibility for the disorder might be inherited. However, the child of a parent with this disorder might simply be repeating learned behavior. Other environmental factors that might be involved include a lack of criticism or punishment as a child, positive reinforcement that is given only when a child completes certain approved behaviors, and unpredictable attention given to a child by his or her parent(s), all leading to confusion about what types of behavior earn parental approval. Personality disorders also usually develop in relation to individual temperament and psychological styles and ways people learn to cope with stress while growing up.

How Is Histrionic Personality Disorder Diagnosed?

If signs of this personality disorder are present, the doctor will begin an evaluation by performing a complete medical and psychiatric history. If physical symptoms are present, a physical exam and laboratory tests (such as neuroimaging studies or blood tests) may also be recommended to assure that a physical illness is not causing any symptoms that may be present.

If the doctor finds no physical reason for the symptoms, he or she might refer the person to a psychiatrist or psychologist, health care professionals who are specially trained to diagnose and treat mental illnesses. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a person for a personality disorder.

How Is Histrionic Personality Disorder Treated?

In general, people with histrionic personality disorder do not believe they need therapy. They also tend to exaggerate their feelings and to dislike routine, which makes following a treatment plan difficult. However, they might seek help if depression -- possibly associated with a loss or a failed relationship -- or another problem caused by their actions causes them distress.

Psychotherapy (a type of counseling) is generally the treatment of choice for histrionic personality disorder. The goal of treatment is to help the individual uncover the motivations and fears associated with his or her thoughts and behavior, and to help the person learn to relate to others in a more positive way.

Medication might sometimes be used as supplemental treatment for distressing symptoms that might occur with this disorder, such as depression and anxiety.

What Complications Are Associated With Histrionic Personality Disorder?

Histrionic personality disorder can affect a person's social, professional, or romantic relationships and how they react to losses or failures. People with this disorder are also at higher risk than the general population to suffer from depression.

What Is the Outlook for People With Histrionic Personality Disorder?

Many people with this disorder are able to function well socially and at work. Those with severe cases, however, might experience significant problems in their daily lives

Can Histrionic Personality Disorder Be Prevented?

Although prevention of the histrionic personality disorder might not be possible, treatment can allow a person who is prone to this disorder to learn more productive ways of dealing with situations.

Histrionic personality disorder is a mental health condition in which people act in a very emotional and dramatic way that draws attention to themselves.

Causes

Cause of histrionic personality disorder is unknown. Genes and early childhood events may be responsible. It is diagnosed more often in women than in men. Doctors believe that more men may have the disorder than are diagnosed.

Histrionic personality disorder usually begins by late teens or early 20s.

Symptoms

People with this disorder are usually able to function at a high level and can be successful socially and at work.

Symptoms include:

• Acting or looking overly seductive
• Being easily influenced by other people
• Being overly concerned with their looks
• Being overly dramatic and emotional
• Being overly sensitive to criticism or disapproval
• Believing that relationships are more intimate than they actually are
• Blaming failure or disappointment on others
• Constantly seeking reassurance or approval
• Having a low tolerance for frustration or delayed gratification
• Needing to be the center of attention (self-centeredness)
• Quickly changing emotions, which may seem shallow to others

Exams and Tests

Histrionic personality disorder is diagnosed based on a psychological evaluation that assesses the history and severity of the symptoms.

The health care provider can diagnose histrionic personality disorder by looking at the person's:

• Behavior
• History
• Overall appearance
• Psychological evaluation

Treatment

People with this condition often seek treatment when they experience depression or anxiety from failed romantic relationships or other conflicts with people. Medicine may help the symptoms. Talk therapy is the best treatment for the condition itself.

Outlook (Prognosis)

Histrionic personality disorder can improve with talk therapy and sometimes medicines. Left untreated, it can cause problems in people's personal lives and prevent them doing their best at work.

Possible Complications

Histrionic personality disorder may affect a person's social or romantic relationships. The person may be unable to cope with losses or failures. The person may change jobs often because of boredom and not being able to deal with frustration. A person with this disorder craves new things and excitement, which leads to risky situations. All of these factors may lead to a higher chance of depression.

When to Contact a Medical Professional

See your health care provider or mental health professional if you or someone you know has symptoms of histrionic personality disorder.

References

Blais MA, Smallwood P, Groves JE, Rivas-Vazquez RA. Personality and personality disorders. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, PA: Elsevier Mosby; 2008:chap 39.

Histrionic Personality Disorder (HPD)

HPD Introduction

Histrionic Personality Disorder is characterized by an extreme interest in drawing the attentions of others, favorable or unfavorable, to oneself.

HPD is estimated to affect up to 1% of the population.

People who suffer from HPD are sometimes accused of being a "drama queen" or "drama major". They are the people who grab the microphone, hog the limelight, always change the subject to themselves, behave outrageously, have tantrums and generally refuse to be ignored.

HPD is a serious condition that isolates those who surround the people who have the disorder.

A mnemonic that has sometimes been used to describe the criteria for histrionic personality disorder is “PRAISE ME”:

P - provocative (or seductive) behavior
R - relationships, considered more intimate than they are
A - attention, must be at center of
I - influenced easily
S - speech (style) - wants to impress, lacks detail
E - emotional liability, shallowness

M - make-up - physical appearance used to draw attention to self
E - exaggerated emotions - theatrical

However, people who suffer from HPD are often just as interested in attracting negative attention, including shock, anger, outrage, shame, guilt and remorse.

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HPD Characteristics & Traits

The following list is a collection of some of the more commonly observed behaviors and traits of those who suffer from HPD. Click on the links on each one for more information about a particular trait or behavior and some ideas for coping with each.

Note that these traits are given as a guideline only and are not intended for diagnosis. People who suffer from HPD are all unique and so each person will display a different subset of traits. Also, note that everyone displays "borderline" behaviors from time to time. Therefore, if a person exhibits one or some of these traits, that does not necessarily qualify them for a diagnosis of HPD. See the DSM Criteria on this page for diagnostic criteria.

Acting Out - Acting Out behavior refers to a subset of personality disorder traits that are more outwardly-destructive than self-destructive.

"Always" and "Never" Statements - "Always" and "Never" Statements are declarations containing the words "always" or "never". They are commonly used but rarely true.

Anger - People who suffer from personality disorders often feel a sense of unresolved anger and a heightened or exaggerated perception that they have been wronged, invalidated, neglected or abused.

Baiting - A provocative act used to solicit an angry, aggressive or emotional response from another individual.

Belittling, Condescending and Patronizing - This kind of speech is a passive-aggressive approach to giving someone a verbal put-down while maintaining a facade of reasonableness or friendliness.

Blaming - The practice of identifying a person or people responsible for creating a problem, rather than identifying ways of dealing with the problem.

Bullying - Any systematic action of hurting a person from a position of relative physical, social, economic or emotional strength.

Bunny Boiling - Bunny Boiling is a reference to an iconic scene in the movie "Fatal Attraction" in which the main character Alex, who suffers from Borderline Personality Disorder, kills the family's pet rabbit and boils it on the stove. Bunny Boiling has become a popular reference to how people sometimes exhibit their rage by behaving destructively towards symbolic, important or treasured possessions or representations of those whom they wish to hurt, control or intimidate.

Catastrophizing - The habit of automatically assuming a "worst case scenario" and inappropriately characterizing minor or moderate problems or issues as catastrophic events.

Chaos Manufacture - Unnecessarily creating or maintaining an environment of risk, destruction, confusion or mess.

Cheating - Sharing a romantic or intimate relationship with somebody when you are already committed to a monogamous relationship with someone else.

Circular Conversations - Arguments which go on almost endlessly, repeating the same patterns with no resolution.

Compulsive Lying - Compulsive Lying is a term used to describe lying frequently out of habit, without much regard for the consequences to others and without having an obvious motive to lie. A compulsive liar is someone who habitually lies.

Denial - Believing or imagining that some painful or traumatic circumstance, event or memory does not exist or did not happen.

Depression - When you feel sadder than you think you should, for longer than you think you should - but still can't seem to break out of it - that's depression. People who suffer from personality disorders are often also diagnosed with depression resulting from mistreatment at the hands of others, low self-worth and the results of their own poor choices.

Domestic Theft - Consuming or taking control of a resource or asset belonging to (or shared with) a family member, partner or spouse without first obtaining their approval.

Emotional Blackmail - A system of threats and punishments used in an attempt to control someone’s behaviors.

Engulfment - An unhealthy and overwhelming level of attention and dependency on another person, which comes from imagining or believing one exists only within the context of that relationship.

Sense of Entitlement - An unrealistic, unmerited or inappropriate expectation of favorable living conditions and favorable treatment at the hands of others.

Escape To Fantasy - Taking an imaginary excursion to a happier, more hopeful place.

False Accusations - Patterns of unwarranted or exaggerated criticism directed towards someone else.

Favoritism - Favoritism is the practice of systematically giving positive, preferential treatment to one child, subordinate or associate among a family or group of peers.

Frivolous Litigation - The use of unmerited legal proceedings to hurt, harass or gain an economic advantage over an individual or organization.

Hoovers & Hoovering - A Hoover is a metaphor taken from the popular brand of vacuum cleaners, to describe how an abuse victim trying to assert their own rights by leaving or limiting contact in a dysfunctional relationship, gets “sucked back in” when the perpetrator temporarily exhibits improved or desirable behavior.

Hysteria - An inappropriate over-reaction to bad news or disappointments, which diverts attention away from the real problem and towards the person who is having the reaction.

Impulsiveness - The tendency to act or speak based on current feelings rather than logical reasoning.

Infantilization - Treating a child as if they are much younger than their actual age.

Magical Thinking - Looking for supernatural connections between external events and one’s own thoughts, words and actions.

Munchausen's and Munchausen by Proxy Syndrome- A disorder in which an individual repeatedly fakes or exaggerates medical symptoms in order to manipulate the attentions of medical professionals or caregivers.

Mood Swings - Unpredictable, rapid, dramatic emotional cycles which cannot be readily explained by changes in external circumstances.

Name-Calling - Use of profane, derogatory or dehumanizing terminology to describe another individual or group.

Panic Attacks - Short intense episodes of fear or anxiety, often accompanied by physical symptoms, such as hyperventilating, shaking, sweating and chills.

Projection - The act of attributing one's own feelings or traits to another person and imagining or believing that the other person has those same feelings or traits.

Push-Pull - A chronic pattern of sabotaging and re-establishing closeness in a relationship without appropriate cause or reason.

Raging, Violence and Impulsive Aggression - Explosive verbal, physical or emotional elevations of a dispute. Rages threaten the security or safety of another individual and violate their personal boundaries.

Sabotage - The spontaneous disruption of calm or status quo in order to serve a personal interest, provoke a conflict or draw attention.

Self-Aggrandizement - A pattern of pompous behavior, boasting, narcissism or competitiveness designed to create an appearance of superiority.

Self-Harm - Any form of deliberate, premeditated injury, such as cutting, poisoning or overdosing, inflicted on oneself.

Self-Victimization - Casting oneself in the role of a victim.

Targeted Humor, Mocking and Sarcasm - Targeted Humor is any sustained pattern of joking, sarcasm or mockery which is designed to reduce another individual's reputation in their own eyes or in the eyes of others.

Testing - Repeatedly forcing another individual to demonstrate or prove their love or commitment to a relationship.

Threats - Inappropriate, intentional warnings of destructive actions or consequences.

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Histrionic Personality Disorder (HPD) - The DSM Criteria

Histrionic Personality Disorder (HPD) is listed in the American Psychiatric Association’s Diagnostic & Statistical Manual (DSM) as a Cluster B (dramatic, emotional, or erratic) Personality Disorder:

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

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

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What it feels like to live with someone with HPD

Living with a person who suffers from HPD can be an exhausting, humiliating, frustrating and isolating experience. It may feel like living with a toddler or child.

When they create chaos, it is often you who are the one who has to clean it up, be the "reasonable" one, make excuses and pay the consequences.

People who act out with HPD traits typically do not seek solutions to the problems they manufacture, because solutions tend to reduce the amount of attention they are likely to receive. Those closest to them often become frustrated as their attempts to help out or improve the situation often go ignored and may even be sabotaged.

It's also common for people closest to an HPD suffer to temporarily "abandon" caring for the person in an attempt to "teach them a lesson" after their attempts to help have been ignored or rejected. However, this is likely to trigger an equally hysterical "why don't you care" reaction. This often leaves the non-personality-disordered individual feeling trapped, used, and manipulated.

Trying to make someone with HPD happy may feel like trying to fill a black hole or empty the ocean.  Your loved one’s personality disorder often prevents them from seeing the destructiveness of their own behaviors and keeps them from noticing or empathizing with your own needs .

When your loved one acts out in front of other people, you may feel embarrassed or humiliated to be associated with them. You may feel as though others assume that you are guilty by association. You may begin to avoid public groups, settings and situations for fear that it will not go well.

When your loved one acts out destructively, you may fear their next move. You may feel afraid for your own safety or feel angry that you are not being treated with respect.

Other symptoms of living with a person who suffers from HPD:

• Important problems or concerns take a back seat to trivial, fabricated or exaggerated problems of a loved one
• You find yourself making excuses or covering up abnormal public behavior.
• You find them rapidly cycling between extreme emotional highs and lows without pausing at normal.
• Other healthy relationships and activities you enjoy outside the relationship are seen as competitive and discouraged or forbidden.

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HPD Possible Causes

The instinctive desire to attract the attentions of others is an important survival skill in humans. It serves a useful purposeful in early childhood, gaining parental attention amidst a clamor of siblings, gaining social acceptance among childhood peers and in attracting members of the opposite sex during early adulthood. Most adults learn to self-regulate these attention-seeking instincts by considering their other long-term interests such as the advantages of stable relationships, earning the trust and respect of others, and the security of investments. People who suffer from HPD generally do not develop this level of emotional regulation or recognize when their short-term desire for attention is at odds with their own long-term interests.

The causes of histrionic personality disorder are not well understood and there is some debate over to what degree HPD is caused is by "nature or nurture". It is common for HPD to be passed down through family generations. Parents who have histrionic tendencies are often turbulent and inconsistent in their parenting approach. This has led to some debate over whether HPD traits are passed on genetically or by environment.

HPD is more commonly diagnosed in women than in men by a factor of about 4 to 1 (See Statistics).

HPD shares a number of similarities to NPD, which is more commonly diagnosed in men. This has led to some theories that Histrionic Personality Disorder is a feminine manifestation of Narcissistic Personality Disorder.

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HPD Treatment

See our Treatment Page.

People who suffer from HPD are often impulsive in nature, which tends to make them inconsistent when it comes to seeking and following up with therapy. They are prone to exaggerating their problems. They may seek out a therapist's help is dealing with a perceived crisis but will often drop away from the therapy program without following through on action items when their feelings change. This makes treatment of people with HPD especially difficult.

People with HPD are often diagnosed as having a depression when they exaggerate the negatives in their situation and may also be diagnosed as bipolar if the therapist observes them alternating between describing high or low emotional states.

It's common for people who suffer from Histrionic personality disorder to go through a repetitive series of failed relationships where a partner is initially idealizedfor their positive attributes, then devalued or "split black" after a disappointment occurs.

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Movies Portraying Histrionic Personality Disorder Traits

A Streetcar Named Desire - A Streetcar Named Desire is a is a 1947 play written by Tennessee Williams, later adapted for film, which tells the story of a woman who displays histrionic and borderline traits, who goes to live with her codependent sister and her narcissistic husband.

Gone With The Wind - Gone With The Wind is a 1939 romantic epic starring Vivien Leigh and Clark Gable, set in the American Civil War portraying the story of Scarlett O'Hara, a southern woman who manifests symptoms of Histrionic Personality Disorder (HPD).