A histrionic personality disorder is characterised by a pervasive pattern of excessive emotionality and attention seeking. Diagnosis is by clinical criteria. Treatment is with psychodynamic psychotherapy. Patients with histrionic personality disorder use their physical appearance, acting in inappropriately seductive or provocative ways, to gain the attention of others. They lack a sense of self-direction and are highly suggestible, often acting submissively to retain the attention of others. The estimated prevalence is < 2% of the general population. It is diagnosed more often in women, but this finding may reflect only a greater prevalence among women in clinical settings, where the data were obtained. In some studies, the prevalence in women and men was similar. Comorbidities are common, particularly other personality disorders (antisocial, borderline, narcissistic), suggesting that these disorders share a biologic vulnerability or casting doubt on whether histrionic personality disorder is a separate disorder. Some patients also have somatic symptom disorder, which may be the reason they present for evaluation. Major depressive disorder, dysthymia, and conversion disorder may also coexist.
Symptoms and Signs
Patients with histrionic personality disorder continually demand to be the centre of attention and often become depressed when they are not. They are often lively, dramatic, enthusiastic, and flirtatious and sometimes charm new acquaintances. These patients often dress and act in inappropriately seductive and provocative ways, not just with potential romantic interests, but in many contexts (eg., work, school). They want to impress others with their appearance and so are often preoccupied with how they look. Expression of emotion may be shallow (turned off and on too quickly) and exaggerated. They speak dramatically, expressing strong opinions, but with few facts or details to support their opinions. Patients with histrionic personality disorder are easily influenced by others and by current trends. They tend to be too trusting, especially of authority figures which, they think, may be able to solve all their problems. They often think relationships are closer than they are. They crave novelty and tend to bore easily. Thus, they may change jobs and friends frequently. Delayed gratification is very frustrating to them, so their actions are often motivated by obtaining immediate satisfaction. Achieving emotional or sexual intimacy may be difficult. Patients may, often without being aware of it, play a role (eg., victim). They may try to control their partner using seductiveness or emotional manipulations while becoming very dependent on the partner.
Clinical criteria (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]). For a diagnosis of histrionic personality disorder, patients must have a persistent pattern of excessive emotionality and attention seeking. This pattern is shown by the presence of ≥ 5 of the following:
- Discomfort when they are not the centre of attention
- Interaction with others that is inappropriately sexually seductive or provocative
- Rapidly shifting and shallow expression of emotions
- Consistent use of physical appearance to call attention to themselves
- Speech that is extremely impressionistic and vague
- Self-dramatisation, theatricality, and extravagant expression of emotion
- Suggestibility (easily influenced by others or situations)
- Interpretation of relationships as more intimate than they are
Also, symptoms must have begun by early adulthood.
Histrionic personality disorders can be distinguished from other personality disorders based on characteristic features:
- Narcissistic personality disorder: Patients with narcissistic personality disorder also seek attention, but they, unlike those with a histrionic personality disorder, want to feel admired or elevated by it; patients with histrionic personality disorder are not so picky about the kind of attention they get and do not mind being thought cute or silly.
- Borderline personality disorder: Patients with borderline personality disorder consider themselves bad and experience emotions intensely and deeply; those with a histrionic personality disorder do not see themselves as bad, even though their dependence on the reaction of others may stem from poor self-esteem.
- Dependent personality disorder: Patients with a dependent personality disorder, like those with a histrionic personality disorder, try to be near others but are more anxious, inhibited, and submissive (because they are worried about rejection); patients with histrionic personality disorder are less inhibited and more flamboyant.
The differential diagnosis for histrionic personality disorder also includes somatic symptom disorder and illness anxiety disorder.
General treatment of histrionic personality disorder is the same as that for all personality disorders. Little is known about the efficacy of cognitive-behavioural therapy and drug therapy for histrionic personality disorder. Psychodynamic psychotherapy, which focuses on underlying conflicts, may be tried. The therapist may start by encouraging patients to substitute speech for behaviour, and thus, patients can understand themselves and communicate with others in a less dramatic way. Then, the therapist can help patients realise how their histrionic behaviours are a maladaptive way to attract the attention of others and to manage their self-esteem.
Credit: MSD Manual, Last full review by Andrew Skodol, MD., May 2018.