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Day # 138: Histrionic Personality Disorder

Today we will continue our current theme of cluster B personality disorders as we discuss histrionic personality disorder.

Today's Content Level: Beginner and Intermediate

Introduction 1

  • Individuals with histrionic personality disorder (HPD) have a long-standing pattern of excessive emotionality and attention-seeking behavior.

  • Despite their extroverted and flamboyant personality they are often unable to maintain meaningful and long-lasting relationships.

  • Common traits/symptoms may include being -> dramatic, colorful, exaggerated, emotional, flamboyant, theatrical, extroverted, provocative, sexually inappropriate, and desperate for attention.

Diagnostic Criteria 2

  • The diagnosis of histrionic PD requires a pervasive pattern of attention seeking and excessive emotionality beginning by early adulthood and present in a variety of contexts.

  • ≥5 of the following must also be present: Mnemonic "PRAISE ME"

  • Provocative - Inappropriately seductive or provocative behavior

  • Relationships - Perceives relationships as more intimate than they actually are

  • Attention - Uncomfortable when not the center of attention

  • Influenced - Easily influenced by others or circumstances

  • Speech - Style of speech is excessively impressionistic and lacking in detail

  • Emotions - Rapidly shifting but shallow expression of emotion

  • "Make up" - Uses physical appearance to draw attention to self

  • Emotional - Theatrical and exaggerated expression of emotion

Epidemiology/Pathogenesis 3, 4, 5

  • Prevalence is estimated to be 1-3% of the general population.

  • More common in women (4:1 ratio), however some research suggests women may be overly diagnosed due to sexual-forwardness being less socially accepted for women and men may be less likely to report symptoms and thus be under-diagnosed.

  • As with all personality disorders, the dominant theory suggest histrionic PD develops from a combination of genetic vulnerability and environmental stressors.

  • Some studies suggest a genetic predisposition toward the disorder. Early childhood trauma is associated with all personality disorders, but has a less well-defined relationship with HPD. Another risk factor includes parenting styles and the following have been associated with HPD -> lack of boundaries; overindulgent or inconsistent; sexuality perceived as threatening; and modeling dramatic, erratic, volatile, or promiscuous behavior.

  • Prognosis: Symptoms and behaviors are usually chronic but often show fewer symptoms as they age. Due to attention and sensation seeking behaviors they may have a pattern of behaving promiscuously, abusing substances, and getting in trouble with the law. Patients who participate in therapy tend to have better outcomes as they gain insight into their condition and function more optimally socially and occupationally

Clinical Pearls 4, 5, 6

  • History: Histrionic PD begins by early adulthood. Individuals have a significant pattern of attention-seeking behavior and exaggerated expression of their thoughts and feelings. They tend to have a strong dependence on others and their need for reassurance is endless. Their pattern of seductive behaviors and acting on their sexual impulses may be a a way to reassure themselves that they are attracted and wanted. When they are not the center of attention or receiving praise they tend to use the dense mechanism of regression (revert to childlike behaviors) such as displaying temper tantrums, tears, and accusations. Histrionic PD tends to be ego-syntonic, meaning they consider their behavior to be normal, and this lack of insight may contribute to the under diagnosis of this disorder until later in life once patterns of behavior significantly interfere with relationships, work, or their sense of wellness.

  • Mental status exam: Individuals are generally cooperative during an interview and eager to provide a colorful and detailed history. They may exaggerate their thoughts and feelings and make everything sound very important. They tend to display a theatrical affect with frequent gesturing and language is often impressionistic (colorful but devoid of content). Seductive behavior is common in both sexes and they tend to be flirtatious or coy rather than sexually aggressive.

  • Optional personality questionnaires: Personality Assessment Inventory (PAI), Minnesota Multiphasic Personality Inventory (MMPI), Brief Histrionic Personality Scale (BHPS).

  • Differential diagnosis: Some studies have found an association between histrionic PD and somatization disorders and alcohol use disorder. Also consider other personality disorders in the differential diagnosis, particularly other cluster B disorders (borderline, narcissistic, antisocial). Individuals with borderline PD can also be characterized by attention seeking behavior and high emotionality, however patients with BPD tend to be less functional and have a pattern of self-destructiveness, anger, and chronic feelings of deep emptiness and identity disturbance. Individuals with narcissistic PD also crave attention, however they usually want praise for their power or superiority. Individuals with antisocial PD may also be seductive and thrill seeking, however this is in order to manipulate and gain power or profit over others.

Treatment 7, 8, 9, 10

  • General approach to personality disorders: In general, the first-line treatment of all personality disorders is psychotherapy, however, the data is not robust and depending on the personality disorder, patients rarely seek treatment themselves unless they have other comorbid behavioral health conditions. Patients with personality disorders may be highly symptomatic and are often prescribed multiple medications in a manner unsupported by evidence.

  • Psychotherapy: Supportive psychotherapy, psychodynamic therapy, cognitive behavioral therapy (CBT), and interpersonal therapy (IPT) have all been used with success. Psychodynamic, insight-oriented, approaches are sometimes recommended as the treatment of choice for HPD. The goals of therapy include -> understanding themselves and their behavior better, recognize attention-seeking behaviors as maladaptive, promote better communication by substituting excessively dramatic speech for a more adaptive action, and find healthier ways to develop self-esteem. Be mindful that patients may be inappropriately sexual and erotic transference is a common therapeutic pitfall. It is critical to set firm boundaries with patients and highlight the defenses present during sessions.

  • Pharmacotherapy: There are no FDA approved medications for histrionic PD. No clinical trials demonstrate efficacy of any medication for HPD specific symptoms. Expert guidelines recommend treatment of comorbid psychiatric conditions first rather than targeting HPD specific symptoms given lack of demonstrated efficacy (see treatment of depression; treatment of anxiety). Patients with profound affective dysregulation (mood swings, anger, aggression tearfulness) or difficulty with impulse control may be trialed on medication and clinical practice is largely based on expert opinion and case studies. Mood stabilizers (lamotrigine, lithium, valproate, carbamazepine, topiramate), antipsychotics, and antidepressants have been used with varying degrees of success. Expectations for treatment response should be attenuated and the potentially limited benefits must outweigh the risks associated with medication treatment.


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