Continuing Education Activity

Histrionic personality disorder (HPD) is a chronic and enduring condition marked by a consistent pattern of attention-seeking behaviors and an exaggerated display of emotions. Typically emerging in late adolescence or early adulthood, individuals with HPD are often characterized as narcissistic, self-indulgent, and flirtatious. Individuals with HPD may feel undervalued when not in the spotlight, leading to a persistent need for validation. Understanding HPD is limited, with most knowledge derived from small studies and older classification systems. Experts advocate for a shift from the cluster model to a dimensional model of personality, which may become standard as research evolves. The DSM-5-TR reflects this shift by removing HPD, citing diagnostic biases and a lack of distinct psychiatric symptoms.

This activity reviews the evaluation, treatment, and management of HPD as a life-long psychiatric disorder with current guidelines concerning gender bias for clinical knowledge. Participating clinicians are equipped with differentiating characteristics compared to other personality disorders, emphasizing the need for interprofessional collaboration when considering HPD as a diagnosis rather than a personality trait.

Objectives:

• Identify the DSM-5-TR diagnostic criteria for histrionic personality disorder in collaboration with psychiatry.
• Determine treatment options for histrionic personality disorder, including pharmacology and psychotherapy.
• Differentiate the presentation of histrionic personality disorder and standard mental status examination findings.
• Implement effective interprofessional team management to improve care coordination for patients with histrionic personality disorder.

Introduction

A pervasive pattern of attention-seeking behaviors and excessive emotional reactions characterize histrionic personality disorder (HPD). The condition is usually life-long, though onset is typically in late adolescence or early adulthood. Individuals with HPD are often described as seductive, self-indulgent, flirtatious, dramatic, extroverted, and animated.[1] Individuals with HPD may feel underappreciated or disregarded when they are not the center of attention.[2] They may be vibrant, enchanting, overly seductive, or inappropriately sexual.[3] Patients presenting with HPD typically demonstrate rapidly shifting and shallow emotions that others may perceive as insincere. 

The roots of histrionic behavior can be traced back to ancient times when Greek and Roman physicians observed individuals who displayed excessive theatricality and emotional expression. These individuals were described as "hysterical," a term derived from the Greek word "hystera," meaning uterus, as these behaviors were believed to be exclusive to women and were caused by disturbances in the uterus.[4] In the late 19th century, during the era of psychoanalysis, Sigmund Freud contributed to the understanding of histrionic behavior. He proposed the concept of "hysteria" as a psychological disorder primarily affecting women and characterized by emotional excesses and attention-seeking behavior. Freud's theories, although controversial and often criticized, laid the groundwork for the exploration of histrionic symptoms and behaviors.[5]

HPD was formally recognized as a distinct diagnostic category in the mid-20th century. In 1980, the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) included histrionic personality disorder as a diagnosable condition. The DSM-III identified key criteria, including a pervasive pattern of excessive emotionality, a need for attention, and exaggerated behaviors. Since inclusion in the DSM-III, HPD criteria have undergone refinements in subsequent editions. The DSM-IV (1994) and DSM-IV-TR (2000) maintained the core diagnostic criteria, emphasizing attention-seeking behavior and self-dramatization, but also emphasized the need to consider cultural context and gender differences. In the latest edition of the DSM, the DSM-5-TR (2022), HPD is still recognized as a distinct diagnosis.[6] The DSM-5-TR divides personality disorders into Cluster A, Cluster B, and Cluster C. Each cluster encompasses a distinct set of personality disorders with commonalities regarding symptoms, behaviors, and underlying psychological patterns.[7]

Cluster A 

Personality disorders with odd or eccentric characteristics. These include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. Individuals within this cluster exhibit social withdrawal, mistrust, and difficulties forming close relationships.[8]

Cluster B 

Personality disorders with dramatic, emotional, or erratic behaviors. This cluster includes antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder. Individuals within this cluster display impulsive actions, emotional instability, and challenges in maintaining stable relationships.[9]

Cluster C 

Personality disorders with anxious and fearful characteristics. These include avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. Individuals within this cluster tend to experience significant anxiety, fear of abandonment, and an excessive need for control or perfectionism.[10] Despite the historical context of using the "cluster" system, limitations exist when approaching personality disorders.[11] While the diagnosis of HPD provides a framework for understanding and studying these behaviors, the debate within the field of psychology and psychiatry regards the nature and validity of personality disorders, including HPD. Understanding histrionic traits and behaviors continues to evolve.[12]

Etiology

Temperament Traits

• Harm avoidance involves a bias towards inhibiting behavior that would result in punishment or non-reward. Individuals with HPD have low harm avoidance.
• Novelty seeking is an inherent desire to initiate novel activities likely to produce a reward signal. Individuals with HPD have high novelty-seeking activity. 
• Reward dependence describes the amount of desire to cater to behaviors in response to social reward cues. Individuals with HPD have high reward dependence. 
• Persistence refers to maintaining efforts and continuing with behaviors despite obstacles, frustration, fatigue, or limited reinforcement. Individuals with HPD typically have low persistence.[13][14][15]

Research on the etiology of HPD is limited, and high-quality studies are scarce. Several factors are believed to contribute to the development of HPD, including genetic predisposition, childhood experiences, and environmental influences.  However, the relative importance of these factors is still being debated.[6] Child abuse and neglect are noted as strong risk factors for HPD, with child sexual abuse being the strongest.[16] Genetic studies propose a hereditary component in personality disorders, including HPD. Studies involving twins have suggested that genetic and environmental factors contribute to the etiology of HPD.[17] These findings suggest that genetic factors contribute to the vulnerability of HPD. However, the specific genes or genetic mechanisms involved in HPD have yet to be elucidated. Medical conditions, specifically those with pathology that may damage neurons, are often associated with personality disorders or changes. This includes but is not limited to head trauma, cerebrovascular diseases, cerebral tumors, epilepsy, Huntington disease, multiple sclerosis, endocrine disorders, heavy metal poisoning, neurosyphilis, and acquired immune deficiency syndrome (AIDS).[18]

Various psychological factors contribute to the development of personality traits and disorders. These include unconscious processes, early childhood experiences, and the influence of internal conflicts. Psychoanalyst Wilhelm Reich contributed significantly to understanding defense mechanisms and their relationship to personality types. He introduced the concept of "character armor," which refers to defense mechanisms that develop within individuals to alleviate cognitive conflict arising from internal impulses and interpersonal anxiety. For instance, individuals with histrionic tendencies tend to exhibit projection, splitting, displacement, and sexualization as defense mechanisms.[19][20]

Personality is the set of established behavior patterns when one relates to and understands the world. A personality disorder arises when one develops an inflexible and uncompromising pattern of maladaptive thinking and behaving, significantly impairing social or occupational functioning and causing interpersonal distress.[21] Patterns of thinking and behaving must deviate substantially from cultural norms to meet the diagnostic criteria. Divergence from cultural expectations would manifest as disturbances with affectivity, cognition (perceives self, others, or events inappropriately), impulse control, or interpersonal functioning.[22] 

Personality is a complex summation of biological, psychological, social, and developmental factors; therefore, each personality is unique amongst those labeled with a personality disorder. Personality is a pattern of behaviors that an individual adapts to constantly changing internal and external stimuli. This is broadly described as temperament, a heritable and innate psychobiological characteristic.[23][24] However, temperament is further shaped through epigenetic mechanisms, namely through life experiences such as trauma and socioeconomic conditions; these are adaptive etiological factors in personality development.[25][26] 

Epidemiology

High-quality and multi-population studies that attempt to quantify the prevalence of HPD are lacking, and most of the attempted studies are outdated (from a different era of DSM), limiting their applicability. Approximately 9% of the general population has at least 1 personality disorder, and the prevalence of histrionic personality disorder is estimated to be 0.4 to 0.6% to as high as 1.8%.[27][28][29][28] Women are 4 times more likely to be diagnosed with histrionic personality disorder than men.

However, women may be overly diagnosed with this disorder compared with men due to sexual forwardness being less socially acceptable for women; likewise, men may be underdiagnosed.[21] Histrionic personality disorder tends to be ego-syntonic, meaning people with this disorder typically consider their behavior normal and struggle to identify a problem.[22] This lack of insight may contribute to the underdiagnosis until later in life when behavior patterns significantly interfere with relationships, work, or interpersonal wellness.[2]

History and Physical

The presentation of HPD is variable. Therefore, obtaining a thorough medical and social history of the illness is essential in formulating the diagnosis. A family member may refer individuals with HPD for evaluation, as the individual with HPD is unlikely to see their behaviors as problematic. They may be excessively sensitive to criticism and speak in a way that attempts to lure the evaluating clinician.[30]

History can vary widely, and they are likely to talk about activities that provoke a reaction, such as sexual history or faking a medical condition.[31] Sexual assault has been studied in those with HPD.[32] In recent years, individuals with HPD have had similar behaviors and postings on social media websites.[33] The mental status examination, conducted during psychiatric evaluations, is crucial in assessing individuals with HPD. However, specific elements and findings of the examination can vary depending on each case of HPD.  

Assessment

Appearance: The patient's general grooming and fashion choices should be noted. Individuals with HPD are likely to dress provocatively or with attention-seeking features. This can include revealing clothing, suggestive or extensive tattoos, brightly colored hair, and eccentric hairstyles, and they may wear multiple accessories. 

Behavior: Individuals with HPD have eccentric and disinhibited behaviors. They may have splitting behaviors depending on how the psychiatric interview is proceeding. Other behaviors can include dramatic storytelling, hypersexual gestures, and acting out to become the center of attention. 

Speech: Individuals with HPD are likely to speak loudly and dramatically. Their speech is generally impressionistic and lacking in detail. Deficits with speech initiation or vocabulary are not expected.

Thought process: In individuals with HPD, the thought process is expected to be linear but limited in range and logic. These individuals tend to be easily suggestible and easily persuaded by their thought processes to others around them. 

Cognition: General cognition and orientation are not expected to be impaired in individuals with HPD. 

Impulse control: Individuals with HPD have poor impulse control, which results in the engagement of many of their pathological behaviors. 

Judgment: Judgment in individuals with HPD can be poor.

Insight: HPD is ego-syntonic, so individuals with HPD typically have poor insight into their condition and how their behaviors impact their social and occupational functioning. 

Evaluation

Diagnosis of a personality disorder is based on a longitudinal observation of a patient's behaviors across various circumstances to provide a broad understanding of long-term functioning. Many personality disorder features can overlap with symptoms of acute psychiatric conditions. Personality disorders can be challenging to differentiate from other comorbid psychiatric disorders. Instances may exist when a longitudinal observation is not always feasible or required, mainly when an underlying personality disorder significantly contributes to hospitalizations or relapse of another psychiatric condition (ie, major depressive episode). Several visits with a patient are usually required to establish a firm diagnosis of HPD.[34][35] 

To obtain a formal diagnosis of HPD, individuals must meet the diagnostic criteria specified in the DSM-5-TR. The diagnosis involves a thorough evaluation that considers multiple sources of information, including personal history, collateral information, and a mental status examination. This comprehensive assessment enables clinicians to assess the individual's symptoms, functioning, and overall presentation.

A pervasive pattern of excessive emotional behavior and attention-seeking begins in early adulthood and is present in various contexts. Clinical features include at least 5 of the following:

1. Uncomfortable when not the center of attention
2. Interactions with others are overly sexual, inappropriate, or provocative
3. Rapidly shifting and shallow emotions
4. Consistently utilizes physical appearance to draw attention
5. Impressionistic and vague speech that lacks detail
6. An exaggerated expression of emotion that is theatrical and self-dramatized
7. Easily influenced by others or circumstances
8. Considers relationships to be more intimate than they are [6]

Treatment / Management

Psychotherapy is the primary treatment of personality disorders, though limited evidence exists for the effectiveness of treating HPD. The general acceptance is that the condition is life-long and treatment-resistant. Most studies have reported no efficacy in treating HPD, low rates of remission of symptoms, and failure to reach normative levels of functioning. Developing and maintaining therapeutic rapport is an essential component of treating personality disorders. Individuals with HPD generally do not recognize their illness and they may be resistant to the idea of treatment. As HPD is unlikely to remit without treatment, the focus of treatment may be aimed at reducing interpersonal conflict and stabilizing psychosocial functioning.[36][37]

Psychotherapy techniques are investigated as potential treatments for HPD, with generally mixed findings.[38] One study of 159 patients with HPD demonstrated improvement when undergoing clarification-oriented psychotherapy.[39] The importance of the therapeutic alliance is as important in HPD as in treating all personality disorders.[40] Psychotropic medications are generally ineffective in treating HPD, and no FDA-approved agents are available to treat the condition.[41] However, treating comorbid psychiatric conditions with psychotropic medications would likely improve symptoms. 

Differential Diagnosis

Histrionic personality disorder should be considered when a long-term pattern of rigid behaviors is observed over various internal and external stimuli. Many behaviors observed in HPD may overlap with symptoms of other psychiatric illnesses, and the condition may occur in isolation or in conjunction with another psychiatric condition. Grandiosity, hypersexual behavior, and increased amounts of speech are common symptoms of a manic or hypomanic episode on the bipolar spectrum.[42] However, no decreased need for sleep exists in isolated HPD. Additionally, manic and hypomanic episodes are acute episodes that are relatively short-lived and respond to medication. At the same time, HPD is chronic and rigid and does not respond well to medication treatments.[43]

Other differential diagnoses include cluster B personality disorders, specifically narcissistic personality disorder and borderline personality. Like HPD, patients with narcissistic personality disorder prefer to be the center of attention.[22] Narcissistic personality disorder has symptoms that focus on fantasies of unlimited success, lack of empathy, and exploitative behavior. Overlap between borderline personality disorder and HPD includes impulsive behaviors and splitting; however, individuals with borderline personality disorder are more likely to have suicidal behaviors with an intense fear of abandonment and chronic feelings of emptiness.[6] Somatic symptom disorder and illness anxiety disorder may also be considered in the differential diagnosis for HPD, as patients may use physical symptoms and complaints to signal distress.[44]

Pertinent Studies and Ongoing Trials

A generally limited understanding of HPD is available, with high-quality population studies lacking. Most knowledge is based on small sample-size investigations, case reports, or case series. These studies are generally from earlier eras of classification. A recent study looked at associations between sexually coercive behavior in women, pornography use, and HPD.[45] 

Significant limitations to the existing models describe all personality disorders—the "cluster" system is commonly utilized due to the implementation of the DSM. Despite attempts to classify behavioral patterns into syndromes, such as personality disorders, each personality poses challenges for diagnosis and research into specific personality disorders.[11]

Experts in personality disorders have suggested switching to a dimensional model of personality rather than a cluster model. The dimensional models generally describe temperament, utilize defense mechanisms, and identify pathological personality traits.[46] Although the DSM-5 did not incorporate these recommendations due to the radical change for clinical use, the paradigm will likely shift as further research solidifies in congruence with evolving clinical guidelines. This potential shift is particularly evident as the DSM-5-TR incorporated this research into publication under emerging measures and models.

Notably, in this section of the DSM-5-TR, some of the cluster model personality disorders are removed, and this includes the removal of HPD. Arguments for the removal of HPD as a standalone personality disorder include bias as a sex-based diagnosis (overdiagnosed in women), the inability of HPD to have a well-defined and unique set of psychiatric symptoms, and loss of influence from psychoanalytic thinking in the development of personality.[47]

Prognosis

Limited studies report and predict the outcome of HPD, although a consensus exists that the disorder usually lasts for life. Ultimately, HPD is unlikely to resolve on its own or with treatment. Still, interventions to optimize quality of life, including reducing psychiatric comorbidity and stabilizing social factors, are likely to improve the prognosis of HPD.[48]

Complications

Substance use disorders are common among personality disorders but with limited implications into which personality disorders pose the most risk for a particular substance use disorder.[49] Personality disorders lead to an increased likelihood of suicide and suicide attempts compared to those without personality disorders, and individuals with HPD should be screened for suicidal ideation regularly.[50]

Deterrence and Patient Education

The treatment of HPD is contingent upon developing and maintaining therapeutic rapport.[36] Patients are encouraged to express the symptoms they wish to address and communicate to a treatment team. Rather than focusing on changing the patient's behaviors, clinicians should aim to understand and address the specific concerns and challenges that the patient is facing. Further, patients are encouraged to utilize support networks through their current relationships and expand their circle as they develop comfort and confidence. Involving the patient's family is another way of monitoring for decompensation and providing education. Utilizing standardized assessments for quality of life may reveal ways to optimize the ability to function in significant areas of life for an individual with HPD.[48]

Enhancing Healthcare Team Outcomes

The diagnosis and treatment of HPD is a complicated topic but ultimately is an area of psychiatric research that requires further study. As diagnostic and treatment models shift away from a cluster system and towards a dimensional model of personality, the implications on clinical practice are unknown. This is particularly relevant as HPD is not considered a unique personality disorder in the dimensional model but rather a personality trait. 

Still, when a treatment team suspects HPD, a comprehensive history with collateral information is recommended before diagnosing HPD. Including the patient's perspective and determining the appropriate care goals is essential to prevent inappropriate medication use. Collaboration with social workers, therapists, and family to optimize the social factors in a patient's life can provide stability to individuals with HPD.[51]

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Disclosure: Tyler Torrico declares no relevant financial relationships with ineligible companies.

Disclosure: Jennifer French declares no relevant financial relationships with ineligible companies.

Disclosure: Sunny Aslam declares no relevant financial relationships with ineligible companies.

Disclosure: Sangam Shrestha declares no relevant financial relationships with ineligible companies.