The main characteristics of Histrionic Personality Disorder (HPD) are doing things to get attention and acting out in overly dramatic ways. This personality disorder begins as a teen or young adult. It is not diagnosed in children. It is long-lasting. Individuals with HPD, who do not seek treatment, repeat the same patterns of behavior for a lifetime.
The history of HPD goes all the way back to Egypt in 1,900 B.C. where the disorder had the name of “hysteria .” According to the article Women And Hysteria In The History Of Mental Health, from its first description in an ancient medical text called the Ebers Papyrus, all the way to the time of Freud, a “hysterical personality” was considered an exclusively female mental disorder. At one point, it was also necessary to distinguish having a “hysterical personality” from other forms of hysteria. For example, “hysterical blindness”; blindness which does not have an organic cause. New nomenclature defined physical symptoms without an organic cause as “conversion disorder”, which is completely different from HPD.
After the time of Freud, it became clear HPD affects both men and women. In recent times, “hysterical personality” disorder changed to “Histrionic Personality Disorder.” This is the current medical term used for the disorder as published in the fourth edition (year 2000) of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). The DSM is the reference book published by the American Psychiatric Association which gives the standard classifications for mental disorders. All mental health professionals in America use the DSM standards when evaluating patients to make a diagnosis.
The Handbook of Personality Disorders estimates about 2 to 3% of Americans have HPD. The United States Census estimates the current population of America at over 318 million. This means about 6 to 9 million people in America have HPD. Many of those with HPD go undiagnosed. Men receive the diagnosis less often than women; however this probably comes from cultural influences and the bias of mental health practitioners. Men show the symptoms of HPD differently than women. Asians, due to the cultural differences, show the symptoms of HPD less than Hispanics. Individuals with HPD are functional in some jobs better than others. Some professions, such as being an actor as an example, tolerate the symptoms of HPD more readily than others.
The DSM-IV-TR has eight official symptoms useful for making a diagnosis of HPD. They are:
1) Needing to always be the center of attention – Individuals with HPD feel harmed if the focus shifts away from them to another person. They will do anything necessary to make sure they stay on center stage, with all eyes on them. It does not matter if the attention is negative or positive. Even when other people dislike them intensely, this is better compared to being ignored. When attention is waning, often stunts of acting-out draw attention back to them. These stunts are sometimes outrageous, mean-spirited, such as picking on a weaker person, or inappropriate, like suddenly screaming out in a restaurant.
2) Acting in a sexually seductive way – Individuals with HPD often use sexuality in a manipulative way. Flirting inappropriately, wearing revealing clothing, and even being an exhibitionist, are all very common traits. Getting attention and getting what they want is the goal and sexy behavior helps them achieve this.
3) Sudden emotional changes – The emotions of individuals with HPD change like the weather and are just as unpredictable. One minute they are the life of the party, the next minute they fly into a rage. At times it may seem like they are two different people. For severe cases, it is possible to have HPD combined with multiple personality disorder.
4) Physical appearance is very important – One very common trait of individuals with HPD, especially women is obsession with physical appearance. Since they use sex as a manipulative weapon against others, having attractive physical appearance is a must. Even when they look perfectly fine to others, they are never satisfied everything is all right and find some way to complain or feel bad about how they look.
5) Manipulative speech – This is one of the more tricky manipulations. Individuals with HPD make every attempt to say what the other person wants to hear in order to manipulate them. At first glance, it is difficult to notice this, but there is a problem with the content and the context of the communication. It often turns outs not to be genuine. For example, when they pay someone else a compliment on how they look, they often do not state their true feelings. They only say nice things to get the other person to do what they want. The conversation stays on surface levels and rarely has much depth.
6) Overly dramatic – This is where the term “Drama Queen” fits perfectly. Even though “Drama Queen” sounds female it is just as applicable to men as it is to women. The characteristics are expressing emotions or reacting is ways which are over-the-top and ridiculous. If a tiny mouse runs across the room, they screech as if a herd of elephant-sized rats just invaded the space. The same goes for the stories they tell. Everything is embellished, bigger than what actually happened and most of the time they suffered some kind of personal injury (at least in their minds). Even when something terrific happens, they find some way to introduce a negative. For example, if they win the Lotto, they complain about having to go to the State Lottery office to collect the winnings. Nothing is ever good enough. Everything is just so tedious and tiresome and such a burden to them.
7) Highly suggestible – This one is surprising, considering the desire of individuals with HPD to manipulate others. Going along with rapid and dramatic emotional changes, is the ability to jump from one thing to another, which is similar to what people who have Attention Deficit Hyperactive Disorder (ADHD) do. For work efforts or projects they can start with great enthusiasm, but quickly get bored and have no follow-through. Then they jump to another project leaving the last one unfinished. They may start a dozen projects with no hope of ever finishing even half of them, only to abandon them all, just to start twelve new ones!
8) Inaccurate ideas about intimacy – Because they deal with surface, almost transitory relationships, they over-estimate the depth of the relationship. A person they met for five minutes once, suddenly becomes their best friend. This is especially the case if the person is famous. In their minds, everyone they meet is just a pawn in the chess game. Since they usually get their way, being the center of attention, they over-estimate how close other people really are to them.
Apparent “positive” attributes: Life of the party, gregarious, physically attractive, sexy, enthusiastic (at first), flatterer, dramatic, multi-tasking, flexible, and quick to make friends.
Apparent “negative” attributes: Acting out to get attention, shallow, obsession with looks, short attention span, impulsive, insincere, too much drama, starts many things finishes none, easily influenced, erratic, demanding, and lack of depth in relationships.
Combination of Causes
There has not been enough research done to really learn the exact cause of HPD. The current research supports a combination of factors which are responsible. The Encyclopedia of Mental Disorders reports, one strong candidate is having a severe childhood trauma and/or disapproval or being abandoned by the mother. They go on further to explain neurotransmitters play a role. Catecholamines in the brain, moderate emotional reactions. Individuals with HPD show imbalances in the release of the catecholamine called norepinephrine, which causes excessive emotional reactions to stimuli. Nevertheless some behavioral learning also plays a part when, for example, people learn the get their needs met, by causing everyone else to pay attention to them. Culture also plays a role. HPD is more widely found in cultures where emotional responses are less repressed in general such as Hispanics versus Asians.
Diagnosis of HPD is not easy because individuals with HPD are able to cope with the symptoms and even succeed in social situations or on the job (depending on the type of work). The DSM standards state for a condition to be classified as a disorder, it needs to cause the patient a great deal of distress. Psychology Today reports, individuals with HPD have unrealistic expectations, takes risks to create excitement, and then blame failures on others. This leads to a higher chance of depression. A diagnosis comes from assessing the history of the patient using structured and un-structured sessions, paying careful attention to the patient’s behavior showing signs of flirtatiousness or manipulative tendencies. Patients with 5 or more of the 8 recognized traits of HPD receive the diagnosis of HPD when the condition is causing distress to the patient.
There is no medicine specifically for HPD. However; if depression also plays a role, anti-depressant medicine is useful. The U.S. National Library of Medicine – National Institutes of Health says talk therapy treatment is best. This is also called cognitive behavioral therapy. The Encyclopedia of Mental Disorders describes cognitive behavioral therapy as a group of therapeutic efforts with the goals of reduction of thoughts which are dysfunctional, moderation of impulses, and lessening of dramatic behaviors. HPD therapy takes many years because, HPD affects individuals for their entire lives. Therapy does not necessarily get rid of the problem, but when therapy is successful it reduces the negative consequences.
The therapeutic techniques include relaxation, assertiveness training, response cost, and modeling. Relaxation combined with talk therapy helps identify automatic thoughts and impulsive behavioral patterns, so with practice modification is possible. Assertive training teaches coping skills based on one’s own abilities, not relying on the manipulation of others. Response cost therapy reduces overly dramatic reactions to stimuli. Learning to remove the stimulus causing the drama, lowers the response. Modeling shows patients how their behavior has a negative impact on others, especially on the job.
The Encyclopedia of Mental Disorders notes one of the challenges with HPD is patients do not continue with therapy long enough to see any positive benefits. The goals of HPD therapy require one to three years to achieve. Patient participation in the setting of the goals is essential. Nevertheless, with HPD, goals set by patients are often vague. Patients rapidly lose interest because of lack of excitement. The symptoms of HPD itself, are blocks to effective therapeutic results in treating the condition. As individuals with HPD get older the symptoms become less prominent. Sexual seduction shifts to maternal or paternal seduction and in general there is less energy to support other symptoms.
Dealing With a Person Who Has HPD
If a superior at work has HPD it may become almost intolerable being around them. The classic over-reactive, attention-seeking, manipulative “Drama Queen” is a severe challenge to work with. Scientific American in the article entitled, “Dangerous Liaisons: How to Deal with a Drama Queen” states such emotional volatility interrupts workflow and damages both working relationships and family happiness at home. The trouble is, those severely affected by this HPD condition cannot prevent themselves from causing a scene. They will even create a problem out of nothing, when one does not truly exist. Knowing these people have chemical imbalances in their brain, and may have suffered some serious childhood trauma, helps reduce counter-reactions. If forced to work with them, if possible ignore the tantrum until the storm passes.
Diagnosis of HPD in its earlier stages helps both the patient and their families to understand what is going on. Recognizing the long-lasting characteristics of HPD and starting therapy earlier helps prevent mild cases of HPD from turning into severe cases which later cause much patient distress.
HPD is a serious condition. Often, it leads to depression. Those who recognize these behaviors in themselves or significant others, should seek professional help for treatment of this condition.