The Histrionic Patient - A Case Study

Vivid description of what it's like living with Histrionic Personality Disorder. Read therapy notes from woman diagnosed with Histrionic Personality Disorder.

Notes of first therapy session with Marsha, female, 56, diagnosed with Histrionic Personality Disorder

Marsha visibly resents the fact that I have had to pay attention to another patient (an emergency) "at her expense" as she puts it. She pouts and bats suspiciously long eyelashes at me: "Has any of your female patients fallen in love with you?" - she suddenly changes tack. I explain to her what is transference and countertransference in therapy. She laughs throatily and shakes loose an acid blond mane: "You may call it what you want, doctor, but the simple truth is that you are irresistibly cute."

I steer away from these treacherous waters by asking her about her marriage. She sighs and her face contort, on the verge of tears: "I hate what's been happening to Doug and me. He has had such a stretch of bad luck - my heart goes out to him. I really love him you know. I miss what we used to be. But his rage attacks and jealousy are driving me away. I feel that I am suffocating."

Is he a possessive paranoid? She shifts uneasily in her seat: "I like to flirt. A little flirting never hurt nobody is what I say." Does Doug share her insouciance? He accuses her of being too provocative and seductive. Well, is she? "A woman can never be too much of either" - she protests mockingly.

Has she ever cheated on her husband? Never. So, why his jealous tantrums? Because she has been pretty direct with men she fancied, told them what she would do with them and to them if circumstances were different. Was this a wise thing to do in public? Maybe not the wisest, but it sure was fun, she laughs.

How did men react to her advances? "Usually, with an enormous erection." - she chuckles - "How did you react, doctor?" I was embarrassed, I admit, even annoyed. She doesn't believe me, she says. No red-blooded male has ever been put off by the lure of an attractive female and "from where I sit, you sure look as red-blooded as they come."

Doug has been her fourth serious relationship this year. How can such a short-lived liaison be meaningful? "Depth and intimacy can be created overnight" - she assures me, they are not a function of the length of acquaintance. But surely they depend on the amount of time spent together? "Is this your wife?' - she points at a silver-framed picture on my desk - "I bet you are hitting it off in the sack!" Actually, I tell her, that's my daughter. She shrugs off her faux-pas and sprawls across my duvet, long legs exposed to the hip and crossed at the ankles.

She sighs theatrically and shields her eyes with her hand: "I wish it was all over." Does she mean her relationship with Doug? "No, silly", she was referring to her tumultuous life and its vagaries. Does she really mean it? Of course not. She rolls to one side, leaning on her elbow, face supported by an open palm: "I just wish people were more lighthearted, you know? I wish they knew how to enjoy life to the maximum, give and take with joy. Isn't this what psychotherapy is all about? Aren't these the skills you, as a psychiatrist, are trying to instil in your patients?"

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

next:  The Schizoid Patient ~ back t o: Case Studies: Table of Contents

APA Reference Vaknin, S. (2009, October 1). The Histrionic Patient - A Case Study, HealthyPlace. Retrieved on 2024, June 6 from https://www.healthyplace.com/personality-disorders/malignant-self-love/histrionic-patient-a-case-study

Medically reviewed by Harry Croft, MD

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Histrionic Personality Disorder

Clinical presentation.

The clinical presentation of the Histrionic Personality Disorder can be characterized by the following behavioral and interpersonal style, thinking style, and feeling style.

The behavioral style is characterized as charming, dramatic, and expressive, while also being demanding, self-indulgent, and inconsiderate.

Persistent attention-seeking, mood lability, capriciousness, and superficiality further characterize their behavior.

  • Interpersonally, these individuals tend to be exhibitionistic and flirtatious in their manner, with attention-seeking and manipulativeness being prominent.
  • The thinking or cognitive style of this personality can be characterized as impulsive and thematic, rather than being analytical, precise, and field-independent.

In short, their tendency is to be non-analytic, vague, and field-dependent.

Histrionic personalities are easily suggestible and rely heavily on hunches and intuition. They avoid awareness of their own hidden dependency and other self-knowledge, and tend to be “other-directed” with respect to the need for approval from others. Therefore, they can easily dissociate their “real” or inner self from their “public” or outer self.

Their emotional or affective stle is characterized by exaggerated emotional displays and excitability, including irrational outbursts and temper tantrums Opens in new window .

Although they are constantly seeking reassurance that they are loved, they respond with only superficial warmth and charm and are generally emotionally shallow. Finally, they are exceedingly rejection-sensitive.

DSM-5 Characterization

Individuals with this personality disorder are characterized by an unremitting pattern of attention-seeking and emotionality.

  • They tend to be uncomfortable in situations where they cannot be the center of attention.
  • Their emotional reactions tend to be shallow and rapidly shifting. Typically, they draw attention to themselves with the way they dress.
  • Their manner of speech tends to be impressionistic with few details.

These individuals are easily influenced by others or circumstances. They are likely to perceive relationships as more intimate than they really are. They often engage in provocative and inappropriate seductive sexual behavior. Furthermore, they are dramatic and overly exaggerate their emotional expressions (American Psychiatric Association, 2013).

Biopsychosocial – Adlerian Conceptualization

The following biopsychosocial formulation may be helpful in understanding how the Histrionic Personality Disorder develops. Biologically and temperamentally, the Histrionic Personality Disorder appears to be quite different from the Dependent Personality Disorder Opens in new window .

Unlike the dependent personality, histrionic personality is characterized by a high energy level and emotional and autonomic reactivity.

Millon and Everly (1985) noted that histrionic adults tended to display a high degree of emotional lability and responsiveness in their infancy and early childhood. Their temperament that can be characterized as hyper-responsive and externally oriented for gratification.

Psychologically, Histrionic Personality Disorder has the following characteristic view of self, world-view, and life goal.

In addition to biological and psychological factors, social factors such as parenting style and injunction, and family and environmental factors, influence the development of the histrionic personality .

The parental injunction for the histrionic personality involves reciprocity: “I’ll give you attention, if you do X.” A parenting style that involves minimal or inconsistent discipline helps insure and reinforce the histrionic pattern.

The histrionic child is likely to grow with at least one manipulative or histrionic parent who reinforces the child’s histrionic and attention-seeking behavior.

Finally, the following sequence of self and system perpetuants are likely to be seen in the Histrionic Personality Disorder :

  • denial of one’s real or inner self;
  • a preoccupation with externals;
  • the need for excitement and attention-seeking which leads to a superficial charm and interpersonal presence;
  • and the need for external approval. This, in turn, further reinforces the dissociation and denial of the real or inner self from public self, and the cycle continues.

Treatment Considerations

The differential diagnosis of the Histrionic Personality Disorder includes the Narcissistic Personality Disorder Opens in new window and the Dependence Personality Disorder Opens in new window . It also includes the Histrionic-Borderline Disorder, which is a decompensated version of the Histrionic Personality Disorder Opens in new window , and, according to Millon (2011), the Histrionic-Antisocial Personality Disorder.

Associated diagnoses include: Persistent Depressive Disorder Opens in new window , Social Anxiety Disorder Opens in new window , and Obsessive-Compulsive Disorder Opens in new window . In addition, Major Depressive Opens in new window and Bipolar Disorders Opens in new window are common in the decompensated Histrionic Personity Disorder .

The treatment of the Histrionic Personality Disorder may present a considerable challenge to the clinician. For the purpose of this discussion, we will limit ourselves to some general considerations about treatment goals, limits, and medications.

General treatment goals include helping the individual integrate gentleness with strength, moderating emotional expression, and encouraging warmth, genuineness, and empathy. Because the histrionic personality can present as dramatic, impulsive, seductive, and manipulative with potential for suicidal gestures, the clinician needs to discuss the matter of limits early in the course of therapy regarding professional boundaries and personal responsibilities.

Some histrionic personalities, particularly those who bear some resemblance to Hysteroid Dysphoria Opens in new window , respond to certain antidepressant agents, particularly Parnate and Nardil (Liebowitz & Klein, 1979). Otherwise, unless a concurrent acute psychotic or Major Depressive Episode is present, psychotherapy is the principal mode of treatment.

  •  Borderline Personality Disorder Opens in new window
  •  Narcissistic Personality Disorder Opens in new window
  •  Dependent Personality Disorder Opens in new window
  • American Psychiatric Association. Diagnositc and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Association, 2013.
  • Widiger, T. A. & Bornstein, R. F. (2001). Histrionic, dependent, and narcissistic personality disorders. In H. E. Adams & P. B. Sutker (Eds)., Comprehensive handbook of psychopathology (pp. 509 – 534). New York: Kluwer Academic.
  • Dobbert, Duane L. Understanding Personality Disorders: An Introduction. Lanham, MD: Rowman & Littlefield, 2011.
  • Sperry, Len. Handbook of Diagnosis and Treatment of the DSM-5 Personality Disorders, 3rd ed. New York, NY: Routledge, 2016.

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Name : Michael Scott Source : The Office (American television show, 2005-2011)

Background Information

Michael Scott is a forty-six year old Caucasian male from Scranton, Pennsylvania. Scott is the regional manager at Dunder Mifflin Inc., a local paper and printer distribution company, where he has worked for the last fifteen years. There are no known medical conditions held by Scott, though his family history is unknown. He claims to be of English, Irish, German, Scottish, and Native American descent, though this is unconfirmed, and perhaps an exaggeration. The patient’s outward appearance is well put together, as he presents as a business professional, and there are no obvious health concerns. Despite his seemingly composed demeanor, Scott displays exaggerated emotions and reactions. In addition to this, romantic relationships have proven turbulent for Scott throughout his life, as he goes from one relationship to the next with the other person usually being the one to end it. He has few close friends or relatives, and tends to perceive new friendships as closer than they actually are. Scott believes his subordinates to be his family, and often times gets involved in their personal lives without their consent. His parents divorced when he was young (age unknown), and he displays clear resentment towards his stepfather and sister, whom he once didn’t talk to for fifteen years. Scott has a very close relationship with his mother now, though this was not case when he was a child. Though Scott seems to be lacking in managerial style, responsibility, and delegation, he demonstrates above average sales abilities due to his personable qualities. Scott does not have a history of drug or alcohol abuse, though he will drink in social situations and when pressured to do so by coworkers.

Description of the Problem

The patient demonstrates many personality traits that could be indicative of a variety of disorders. Scott seeks attention every opportunity he gets, and this often interferes with his ability to function in his job as manager. In addition to attention-seeking, Scott often interrupts his subordinates from working to discuss his personal life. This behavior not only affects his ability to work, but it interferes with the overall productivity of the office. It is Scott’s belief that he should not be seen as just a boss, but more of a close friend and even family member, to the dismay of his subordinates. This expectation of a close bond leads Scott to display rapidly shifting emotions, from exuberant and hopeful, to depressed and hopeless. There seems to be a lack of consistency in his behavior, rather a dramatic shift from extremely happy to irreversibly sad. In Scott’s depressed state, he feels as if the entire office should be focused on his problem and that others’ problems pale in comparison, such as his birthday being of more importance than a coworkers cancer scare. When he is happy, however, work at the office ceases to a halt, as his well-being is put before the needs of the company. In addition to his attention-seeking and rapidly shifting emotions, the patient is easily suggestible and is often the victim of pyramid schemes and persuasive coworkers. Scott also shows a pattern of theatric behavior, including different characters, voices, and personalities, in which he uses as distractions on a constant basis.

The diagnosis that seems to fit most appropriately for Scott is Histrionic Personality Disorder (301.50) .

To qualify for a diagnosis of Histrionic Personality Disorder, a person must display the following general criteria of a Personality Disorder:

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:

1. Cognition (I.e., ways of perceiving and interpreting self, other people, and events) 2. Affectivity (I.e., the range, intensity, and appropriateness of emotional response) 3. Interpersonal functioning 4. Impulse Control Mr. Scott displays dysfunctions in many, if not all, of the above categories. His thoughts are consumed by his thinking that he is a comedian, consistently referring to his improv classes and impersonations. The affectivity displayed by the patient is continuously out of proportion to the situation, such as halting the workday for an office meeting over a minor problem, oftentimes a non-work related problem. His interpersonal and relationship functioning is severely limited, demonstrated by his lack insight into the true feelings (I.e. distain) of the people in his life. His impulse control is lacking, if not nonexistent. B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. The displayed symptoms cause, and have caused, significant distress in the areas of work relationships, friendships, and romantic relationships. The observed behavior also has negative consequences in many aspects of his life, including resentment and distain from coworkers, as well as from his superiors and romantic partners. C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. The inflexible nature of his symptoms clearly affects his ability to function in his day-to-day tasks. His ability to function is severely impacted by his need for attention, as he demonstrates a lack of motivation and productiveness in his occupation and social life. This enduring pattern has also led to resentment from his subordinates, who believe he is incompetent due to his emotional outbursts. D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. Scott’s symptoms have been present for at least six years, though they seem to have been present during his entire employment at Dunder Mifflin, and are pervasive in both his work and personal life. The symptoms can be traced back to his early adulthood, as demonstrated by his lack of friendships and romantic relationships in the past. The symptoms may also be a result of early childhood experiences, as he lacked a father-figure and his mother seemingly neglected him.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. Although the patient demonstrates some characteristics consistent with Narcissistic Personality Disorder, he is too suggestible to fit this criteria. As those with Narcissistic PD are interpersonally exploitative, Scott demonstrates a need for immediate attention as opposed to a need for future success. Neither mood, psychotic, nor anxiety disorders better account for his symptoms.

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma). The presenting symptoms are not the result of drugs, alcohol or head trauma.

To fit the Diagnostic Criteria for 301.50 Histrionic Type, at least five (or more) of the following criteria must be met:

1. Uncomfortable in situations in which they are not the center of attention In many instances, such as making a coworkers wedding all about him, caring more about his superficial wound than an employee with a concussion, holding impromptu meetings to discuss his personal life, or dozens of other examples, Scott demands the attention be on him and only him. Typically in a situation in which he is not the center of attention, Scott is visibly uncomfortable and can barely sit still. 2. Interaction with others are often characterized by inappropriate sexually seductive or provocative behavior Although Scott does not demonstrate sexually seductive behavior, he exhibits provocative behavior on a regular basis by use of inappropriate jokes or sexual advances on coworkers. 3. Displays rapid shifting and shallow expressions of emotions Scott goes from angry, to upset, to jealous, to happy, to ecstatic very rapidly, and displays a pattern of shallow emotions. For instance, after hitting a coworker with his car, the patient displayed little remorse or genuine emotion. 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 After a superficial wound, the patient exaggerated the symptoms for the entire day, demanding the focus of that workday be on his recovery. Scott also demonstrates theatricality through use of characters, voices, and impromptu presentations. 7. Is suggestible, I.e., easily influenced by others or circumstances Scott is highly suggestible, and has been observed to lose substantial amounts of money in pyramid schemes due to his trusting nature and easily influenced personality. The patient is so suggestible that he has participated in highly risky behaviors, such as placing his face in drying cement, from pressure from those around him. 8. Considers relationships more intimate than they actually are In many aspects of his life, the patient demonstrates a destructive attachment style, oftentimes believing those around him are closer to him than they actually are. Scott believes the office staff to be his family, and considers a temporary employee to be his best friend after only one day of knowing him. As with his friendships, Scott’s personal relationships suffer from the same overzealous attitude. While once dating a woman, Scott placed his own photo over the photo of her ex-husband, while also proposing to her after three dates.

Accuracy of portrayal

To those watching The Office, the portrayal of Michael Scott as a person with Histrionic Personality Disorder is quite good, though those with the disorder are more often females than males. Those with Histrionic Personality Disorder are known to use their body as a seductive tool, and Scott’s portrayal lacks this important quality of the disorder. However, due to the differing presentation of Histrionic Personality Disorder between men and women, this trait may be unnecessary for the diagnosis. The sudden change of emotion is quite accurately portrayed, as well as the attention-seeking behavior patterns. As symptom expression is accurately portrayed, so too is the onset of symptoms. Histrionic PD is expressed most often in a person’s early adult years, and those with the disorder typically come from a family history of neglect or lack of attention from the primary caregiver during pivotal developmental years. For this reason, the attention-seeking and self-centered behavior tends to manifest later in life as a result of the early experience. This symptom is accurately portrayed in the show as well. Overall, the portrayal of Michael Scott as a person with Histrionic Personality Disorder is accurate in many ways.

The best course of treatment for Scott would be therapy. Cognitive-behavioral therapy would be beneficial in a similar way by helping him to cope with his emotional outbursts. CBT would provide Scott tools for controlling his behavior in a more systematic and structured way to be able to function more productively in the workplace. In addition to systematic planning, it is recommended that Scott be given assertiveness training to help with his propensity for taking advice from others. Behavioral rehearsals may aid in his workplace manner and help him to establish appropriate workplace behaviors. Although family counseling is not an option, it is recommended that Scott participate in relationship counseling to help establish a long-lasting, stable relationship.

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Name : Regina George

Source : Mean Girls (movie, 2004)

Regina George is a sixteen year old Caucasian female. She is a junior in high school at North Shore High School. Regina comes from a very wealthy family and does not have a job besides attending school. She is presumed to be in good health since the film did not mention any health conditions. Regina George is considered the ring leader of the meanest girl clique at North Shore High. She is the queen bee of the popular girls group that pride themselves on making each other look as hot as possible while they put others down in the process.

As previously mentioned Regina comes from a very affluent family. They live in a beautiful mansion considered to be the biggest and most lavish house out of any of the ‘mean girl clique’. Regina’s relationship with her parents is very twisted and abnormal. One example of this backward relationship is displayed when Regina brings her friends over and her mom insists on inserting herself into Regina and her friend’s conversations. Not only does her mom think of her as her best friend but her parents allowed her take the master bedroom simply because she desired it. Regina does not have a strong relationship with either parent but drifts more toward her mother.

Regina George has a preoccupation with her looks. She is constantly talking about how she is either too fat or that she is not pretty enough and also seeks confirmation about her body and looks through others. She does not have a regular drinking problem or drug abuse issue since she is so preoccupied with her appearance and that would definitely tarnish her ideal reputation. Her obsession with her appearance would have to be one of her biggest weaknesses. With regard to her weight, she is constantly seeking new and unsearched ways of losing weight.

This patient displays many of the traits associated with a number of personality disorders, but most strongly shows symptoms of Histrionic Personality Disorder. Regina George is an attention junkie. She seeks out attention from people in every aspect of her daily life. This hunger for attention has created tension between Regina and her group of friends. Her need for attention impairs her abilities to function inside the classroom, hindering her performance in school. Regina often wears seductive clothing that most girls and women would not walk out the front door in, let alone wear to school. Another way Regina actively seeks attention is by talking about people behind their backs. In a three way phone call, she deliberately tries to sabotage one of her close friend’s relationships with another close friend of hers. This attack displays her need to be needed. She felt threatened by their relationship so the only means of coping with the problem to her was by pinning two of her friends against each other. When Regina has a problem, the only way she knows to resolve it is by making someone else feel inferior. Along with these distorted coping skills, Regina displays extreme variances in her emotions. When she is happy she is through the moon happy and when she is mad she is definitely going to let someone know about it. When Regina has a problem going on in her life, she thinks that every single one of her friends must stop what they are doing and solve the problem with or for her. One example of this is shown when Regina is eating lunch, wants something else to eat, and then she says that she is really trying to lose five pounds. She is flabbergasted when the rest of the clique does not immediately pipe in to say that she is already flawless.

The diagnosis that seems to fit most appropriately for Regina George is Histrionic Personality Disorder (301.50). To qualify for a diagnosis of Histrionic Personality Disorder, a person must display the following general criteria of a Personality Disorder:

  • Cognition (I.e., ways of perceiving and interpreting self, other people, and events)
  • Affectivity (I.e., the range, intensity, and appropriateness of emotional response)
  • Interpersonal functioning
  • Impulse Control

Regina George has shown impairments through all of these conditions. She has shown that all that consumes her thoughts is the obsession she has with her appearance and the appearance of others. Her displayed affectivity is most often over exaggerated to the situation. Most notable was her reaction to her “friend” not inviting her to her house party: she single handedly brought the entire student body to a crippling halt by sharing a “burn book” with them. This book contained pictures and captions (written by Regina herself) about different people in their school. The pictures were not the most flattering and the captions were mean spirited and hurtful to say the least.

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

Her symptoms have caused her significant turmoil in her relationships at home, school, and in her daily life. Her behavior has caused many issues in all aspects of her life, such as with friends turning against her, her family not being very supportive and the entire student body rallying against her.

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Regina’s apparent inflexible nature has caused tremendous impairment among her social life as well as her occupational or school life. Regina’s preoccupation with her outward appearance has left her little if any time to focus on things that really matter to people such as her character and demeanor towards others.

D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

The behaviors that Regina displays in the movie Mean Girls has been going on her entire life, per her mother’s report. She has been the same appearance obsessed girl since she was born. This pattern of attention seeking, mean behavior escalated in middle school when she made up a rumor about a girl being a lesbian in the eighth grade.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

This patient does display some of the characteristics of a person with narcissistic personality disorder and perhaps even some dependent PD characteristics, but the disorder that Regina displays through the entire movie is HPD.

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

The symptoms are not as a result of drugs, alcohol, or any general medical condition.

  • Uncomfortable in situations in which they are not the center of attention

Regina George is not only uncomfortable in situations in which she is not the center of attention but she most notably does not allow herself to be in a situation where she is not the center of attention. When a new girl starts going to North Shore, and the girl is as pretty as or prettier than her, Regina makes a consorted effort to make that girl her new best friend forever.

  • Interaction with others are often characterized by inappropriate sexually seductive or provocative behavior

Regina definitely displays this behavior in every aspect of her life. She cannot even sing in the Christmas talent show without being in a midriff tube top shirt with a matching much too short skirt.

  • Displays rapid shifting and shallow expressions of emotions

Regina has an extremely wide range of shallow emotions. For example when she is confronted with an old friend (the one she spread the lesbian rumor about) she shrugs it off as if it never happened. Her ability to show no remorse and be so nonchalant about something that destroyed a young impressionable human being show her shallow expression of emotion.

  • Consistently uses physical appearance to draw attention to self

She uses her body, her beauty, and her weight to keep people focused on herself. When someone tries to shift the conversation she always finds a way to get the attention back on herself.

  • Has a style of speech that is excessively impressionistic and lacking in detail

Regina has an immature speaking style. When talking in the cafeteria she uses many words that are not even words such as ‘skeeze’ to describe other students.

  • Shows self-dramatization, theatricality, and exaggerated expression of emotion

In regard to her constant obsession with her weight, Regina has all of her friends focus on the things that she should be doing on her own to lose the weight. When Regina goes to a dress shop to be fitted for her prom dress and finds that she cannot fit the one she wants she has a tyrannical outburst.

  • Is suggestible, I.e., easily influenced by others or circumstances

Regina is highly suggestible especially since she does not focus on the facts. She is a person who will take a person for their word. When one of her friends tries to help her with a “weight-loss” bar she takes it without question. She is shocked to later find out that the bars she has been eating for the past few months has been the sole contributor to her slow but steady weight gain.

  • Considers relationships more intimate than they actually are

Accuracy of Portrayal

To the average person watching the movie Mean Girls , Regina George would seem like the typical high school bitch. She is popular, pretty, and, most of all, rich. To most laypeople they would not think to make the connection that she has histrionic personality disorder even though she does a phenomenal job portraying an individual with this disorder. Regina displays the symptom most commonly associated with having histrionic personality disorder, those being sexually seductive behaviors. Regina is sexually seductive in appropriate times such as high school girls and Halloween but most notably she is seductive at times when it is completely inappropriate. Her extreme variances and range of shallow emotions are another key symptom of histrionic personality disorder. The fact that Regina is unhappy and uncomfortable with not being the center of attention is another symptom of histrionic personality disorder. The portrayal of Regina George in the movie Mean Girls is an accurate portrayal a person living with histrionic personality disorder.

The best treatment for histrionic personality disorder is through therapy. The most effective therapy treatment would be Cognitive Behavioral Therapy. Cognitive Behavioral Therapy would help Regina to be able to control her emotionality better as well as give her some tools to cope with life in a more adaptive way. Regina would benefit from CBT in that it would help her in her interpersonal relationships to be better able to make and maintain friendships.

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Histrionic Personality Disorder

Reviewed by Psychology Today Staff

Histrionic personality disorder is characterized by constant attention -seeking, emotional overreaction, and seductive behavior. People with this condition tend to overdramatize situations, which may impair relationships and lead to depression . Yet they are highly suggestible, easily susceptible to the influence of others.

Personality reflects deeply ingrained patterns of behavior and the manner in which individuals perceive, relate to, and think about themselves and their world. Personality traits are conspicuous features of personality and are not necessarily pathological, although certain styles of personality may cause interpersonal problems.

Personality disorders denote rigid, inflexible, and maladaptive patterns of thinking and behaving, leading to impairment in functioning and or significant internal distress. Most personality disorders have their onset in adolescence or early adulthood, are stable over time, and lead to significant inner turmoil or impairment.

Individuals with histrionic personality disorder exhibit excessive emotionality—a tendency to regard things in an emotional manner—and are attention -seekers. People with this disorder are uncomfortable or feel unappreciated when they are not the center of attention. Typical behaviors may include the constant seeking of approval or attention, self-dramatization, and theatricality. People with histrionic personality disorder may act in a self-centered way or sexually seductive in inappropriate situations, including social, occupational, and professional relationships, beyond what is appropriate for the social context. They may be lively and dramatic, and may initially charm new acquaintances with their enthusiasm, apparent openness , or flirtatiousness. They may also, however, embarrass friends and acquaintances with excessive public displays of emotion , such as embracing casual acquaintances with passion, sobbing uncontrollably over minor setbacks, or having temper tantrums.

People with histrionic personality disorder commandeer the role of "life of the party." Here are additional characteristics of this disorder:

  • Their interests and conversation will be self-focused.
  • They use their physical appearance to draw attention to themselves.
  • They tend to believe that relationships are more intimate than they actually are.
  • Their emotional expression may be shallow and rapidly shifting.
  • Their style of speech is excessively impressionistic and lacking in detail.
  • They may do well with jobs that value and require imagination and creativity , but will probably have difficulty with tasks that demand logical or analytical thinking.

Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions estimate that the prevalence of histrionic personality disorder is 1.84 percent.

According to the DSM-5 , for a diagnosis of histrionic personality disorder to be given, five or more of the following symptoms must be present:

  • Self-centeredness, feeling uncomfortable when not the center of attention
  • Constantly seeking reassurance or approval
  • Inappropriately seductive appearance or behavior
  • Rapidly shifting emotional states that appear shallow to others
  • Overly concerned with physical appearance, and using physical appearance to draw attention to self
  • Opinions are easily influenced by other people, but difficult to back up with details
  • Excessive dramatics with exaggerated displays of emotion
  • Tendency to believe that relationships are more intimate than they actually are
  • Is highly suggestible (easily influenced by others)

In addition, the symptoms must cause significant impairment or distress in an individual.

Individuals with histrionic personalities may seem unempathetic, but they really suffer from little self-awareness and low emotional intelligence . They may appear manipulative in situations when they are not the center of attention.

People with a cluster B personality disorder may have a higher risk for suicidal thoughts. People with histrionic personalities and mood disorders like depression may have an even higher risk.

The cause of histrionic personality disorder is unknown, but childhood events and genetics may both be involved. HPD occurs more frequently in women than in men, although some experts contend that it is simply more often diagnosed in women, because attention-seeking and sexual forwardness are less socially acceptable for women than for men.

People with this disorder are usually able to function at a high level and can do well in social and occupational environments. They may seek treatment for depression when their romantic relationships end. They often fail to see their own situation realistically, instead tending to overdramatize and exaggerate. Instead of taking responsibility for failure or disappointment, those with the disorder typically cast blame on others. Because they tend to crave novelty and excitement, they may place themselves in risky situations. Their behavior may lead to a greater risk of developing depression.

Narcissistic personality and histrionic personality can sometimes overlap. These two disorders are within the Cluster B group of personality disorders. People in this group suffer thinking and behavior patterns that are unpredictable or erratic; they are also engulfed in high drama that is centered on the self.

The recommended form of treatment for histrionic personality disorder is psychotherapy . That said, therapy for people with this diagnosis is often challenging, because they may exaggerate their symptoms or ability to function. They may also be emotionally needy and challenge the behavioral boundaries set up by the therapist. Therapy should generally be supportive and solution-focused.

Because depression can be associated with failed romantic relationships, patients with histrionic personality disorder often seek treatment when they are experiencing symptoms of depression.

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The Link Between Histrionic Personality Disorder and Relationships

Woman in bed suffering from Histrionic Personality Disorder seeking professional help

Histrionic personality disorder can have a significant impact on relationships . Individuals with this disorder often exhibit attention-seeking behavior, excessive emotionality, and a need for constant validation. This guide provides an overview of the unique dynamics and challenges that individuals with histrionic personality disorder face in their interactions with others. Understanding these dynamics can help foster healthier and more supportive relationships.

What is Histrionic Personality Disorder?

Histrionic Personality Disorder (HPD) is a mental health condition characterized by a pattern of excessive attention-seeking behavior, emotional instability, and a need for constant validation. Individuals with HPD often have a strong desire to be the center of attention and may engage in dramatic or provocative behavior to achieve this. They may also have difficulty forming and maintaining stable relationships, as their need for validation and attention can put a strain on their interactions with others. It is important to seek professional help if you or someone you know is experiencing symptoms of HPD, as treatment and therapy can help manage and improve the condition.

Individuals with a histrionic personality disorder may exhibit a range of symptoms and behaviors. They may have an exaggerated sense of self-importance and constantly seek reassurance and praise from others. They may also have a tendency to be overly dramatic and emotional, often displaying intense and rapidly shifting emotions. People with HPD may have difficulty regulating their emotions and may engage in attention-seeking behaviors, such as dressing provocatively or speaking in a theatrical manner. They may also tend to be easily influenced by others and struggle with forming and maintaining healthy relationships. Treatment for histrionic personality disorder typically involves therapy, such as cognitive-behavioral therapy, to help individuals learn healthier ways of coping with their emotions and seeking validation.

Common Signs and Symptoms of Histrionic Personality Disorder.

Histrionic Personality Disorder (HPD) is characterized by a range of signs and symptoms that can impact an individual’s relationships. Some common signs of HPD include excessive attention-seeking behavior, a need for constant validation and approval, exaggerated emotions and expressions, a tendency to be easily influenced by others, and a preoccupation with physical appearance. Individuals with HPD may also engage in dramatic or provocative behavior to gain attention and may have difficulty maintaining stable relationships due to their intense need for validation. It is important to seek professional help if you or someone you know is exhibiting these symptoms, as a proper diagnosis and treatment plan can significantly improve quality of life.

The Impact of Histrionic Personality Disorder on Relationships.

Histrionic Personality Disorder (HPD) can have a significant impact on relationships. Individuals with HPD often struggle with maintaining stable and healthy connections with others due to their excessive attention-seeking behavior and constant need for validation. Their exaggerated emotions and expressions can be overwhelming for their partners, friends, and family members. Additionally, their tendency to be easily influenced by others can lead to difficulties in setting boundaries and making independent decisions. The preoccupation with physical appearance may also create challenges in relationships, as the individual may prioritize their own image over the needs and feelings of their loved ones. It is important for individuals with HPD and their loved ones to seek professional help and support in order to navigate these challenges and develop healthier relationship dynamics.

Challenges Faced by Individuals with Histrionic Personality Disorder in Relationships.

Individuals with Histrionic Personality Disorder (HPD) face unique challenges in their relationships. Their excessive attention-seeking behavior and constant need for validation can strain their connections with others. Their exaggerated emotions and expressions can be overwhelming for their partners, friends, and family members. Additionally, their tendency to be easily influenced by others can lead to difficulties in setting boundaries and making independent decisions . The preoccupation with physical appearance may also create challenges in relationships, as the individual may prioritize their own image over the needs and feelings of their loved ones. It is important for individuals with HPD and their loved ones to seek professional help and support in order to navigate these challenges and develop healthier relationship dynamics.

Woman in bed suffering from histrionic personality disorder seeking professional help

Neuroscience and Brain-Based Counseling for Histrionic Personality Disorder

Neuroscience and brain-based counseling have shown incredibly promising results in helping individuals with Histrionic Personality Disorder (HPD). The field of neuroscience has revealed that certain areas of the brain, such as the amygdala and the limbic system , play a significant role in emotional regulation and response inhibition, both of which are often impaired in individuals with HPD. Brain-based counseling techniques , such as the ones I use to treat my own patients with HPD, dramatically help these individuals gain better control over their emotional responses and impulsive behaviors. This approach can significantly improve the management of HPD symptoms and enhance the quality of relationships. It’s important to note that each individual’s experience with HPD is unique, and that is why each treatment program I create is tailored to their specific needs and circumstances.

Strategies for Managing and Improving Relationships with Histrionic Personality Disorder.

Managing and improving relationships with someone with Histrionic Personality Disorder (HPD) can be challenging. Still, it is possible to create healthier dynamics with the right strategies.

  • Educate yourself: Learn about HPD and its impact on relationships. Understanding the disorder can help you empathize and respond effectively.
  • Set boundaries: Establish clear boundaries and communicate them assertively. This can help prevent the individual with HPD from overstepping boundaries or manipulating situations.
  • Encourage therapy: Encourage the individual with HPD to seek therapy. Therapy can help them develop healthier coping mechanisms and improve their self-awareness.
  • Practice active listening: Show genuine interest and actively listen to their concerns and emotions. This can help them feel validated and understood.
  • Encourage self-reflection: Encourage the individual with HPD to reflect on their behavior and its impact on others. This can promote personal growth and self-awareness.
  • Foster open communication: Create a safe space for open and honest communication. Encourage the individual with HPD to express their needs and concerns while also expressing their own.
  • Seek support: Reach out to support groups or therapy for yourself. Dealing with HPD in a relationship can be challenging, and having support can help you navigate the difficulties.
  • Practice self-care: Take care of your own mental and emotional well-being. Set aside time for activities that bring you joy and help you recharge.
  • Encourage healthy coping mechanisms: Help individuals with HPD develop healthier coping mechanisms, such as engaging in hobbies, practicing mindfulness, or seeking professional help when needed.
  • Celebrate progress: Acknowledge and celebrate any positive changes or progress made by the individual with HPD. This can reinforce their motivation to continue working on their relationships.

Remember, managing relationships with someone with HPD requires patience, understanding, and support. Seeking professional help and guidance is crucial for sufferers and beneficial for both parties.

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Dr. Sydney Ceruto

A Pioneer in Neuroscience-Based Coaching

As the founder of MindLAB Neuroscience, Dr. Sydney Ceruto has been a leading force in integrating neuroscience into coaching and counseling for over two decades. With three master's degrees in psychology and two PhDs in behavioral and cognitive neuroscience, she is widely considered a top expert in her field.

Harnessing the power of neuroscience-based coaching , Dr. Ceruto's innovative approach focuses on neuroscience, neuroplasticity, and neural pathway rewiring to foster lasting positive change in mental health.

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case study of someone with histrionic personality disorder

Histrionic Personality Disorder (HPD)

  • Symptoms and Signs |
  • Diagnosis |
  • Treatment |

Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Diagnosis is by clinical criteria. Treatment is with psychodynamic psychotherapy.

(See also Overview of Personality Disorders. )

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.

Estimated prevalence is < 2% of the general population ( 1 ). The prevalence in females and males is similar. Prior reports of an increased prevalence among females was possibly influenced by ascertainment bias from hospital-based studies.

Comorbidities are common, particularly other personality disorders ( antisocial , borderline , narcissistic ) ( 2 ). Some patients also have somatic symptom disorder , which may be the reason they present for evaluation. Major depressive disorder , persistent depressive disorder , and conversion disorder may also coexist.

General references

1. Morgan TA, Zimmerman M: Epidemiology of personality disorders. In Handbook of Personality Disorders: Theory, Research, and Treatment . 2nd ed, edited by WJ Livesley, R Larstone, New York, NY: The Guilford Press, 2018, pp. 173-196.

2. Zimmerman M, Rothschild L, Chelminski I :  The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry 162:1911-1918, 2005. doi: 10.1176/appi.ajp.162.10.1911

Symptoms and Signs of Histrionic Personality Disorder

Patients with histrionic personality disorder continually demand to be the center 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). Because of their desire to impress others with their appearance, they 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 who, they think, may be able to solve all their problems. They often think relationships are closer than they are. They crave novelty and bore easily. Thus, they may change jobs and friends frequently. Delayed gratification is 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 manipulation while becoming very dependent on the partner.

Diagnosis of Histrionic Personality Disorder

Diagnostic and Statistical Manual of Mental Disorders , 5th Ed, Text Revision (DSM-5-TR) criteria

For a diagnosis of histrionic personality disorder ( 1 ), 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 center 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-dramatization, theatricality, and exaggerated 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.

Differential diagnosis

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 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 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 dependent personality disorder, like those with 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.

Differential diagnosis for histrionic personality disorder also includes somatic symptom disorder and illness anxiety disorder .

Diagnosis reference

1. American Psychiatric Association:  Diagnostic and Statistical Manual of Mental Disorders , 5th ed, Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022, pp. 757-760.

Treatment of Histrionic Personality Disorder

Psychodynamic psychotherapy

General principles for treatment of histrionic personality disorder are the same as those for all personality disorders.

Little is known about the efficacy of cognitive-behavioral therapy and pharmacotherapy 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 behavior, and thus, communicate with others in a less dramatic way. The therapist may also help patients realize how their histrionic behaviors are a maladaptive way to attract the attention of others and to manage their self-esteem.

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case study of someone with histrionic personality disorder

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5 Ways to Cope When a Loved One Has Histrionic Personality Disorder

December 13, 2021

Histrionic Personality Disorder

Are you involved with someone who has to be the center of attention at all times? Someone who engages in overly dramatic, highly emotional, volatile, excitable, or erratic behavior? If so, your romantic partner, family member, or friend may have histrionic personality disorder. Although these people can seem like the life of the party, their behavior can be exhausting for anyone who loves them. How can you cope when a loved one has this mental health condition?

WHAT IS HISTRIONIC PERSONALITY DISORDER?

Histrionic personality disorder is characterized by extreme attention-seeking behavior and exaggerated emotions. The word histrionic is defined as “dramatic or theatrical.” One of 10 types of personality disorders recognized by mental health experts, histrionic personality disorder falls within the “Cluster B” category of personality disorders. Cluster B disorders also includes narcissistic personality disorder , borderline personality disorder , and antisocial personality disorder.

People with histrionic personality disorder have a constant need to seek approval from others. They employ charm, seduction, manipulation, and flirtatiousness to draw attention to themselves. These larger-than-life types tend to get upset or feel depressed when they are overlooked or aren’t in the spotlight.

An estimated 2-3% of the population has histrionic personality disorder, and women are 4 times as likely to have the condition than men. However, experts suggest women may be over-diagnosed with the disorder while men may be under-diagnosed.

SYMPTOMS OF HISTRIONIC PERSONALITY DISORDER

There is a wide array of symptoms associated with histrionic personality disorder, including:

  • Attention-seeking
  • Approval-seeking
  • Exaggerated emotions that can shift rapidly
  • Overly dramatic
  • Manipulative
  • Dressing provocatively or wearing colorful clothing
  • Inappropriately flirtatious
  • Excessively concerned about physical appearance
  • Upset or depressed if not the center of attention
  • Impulsivity
  • Being gullible or easily influenced by others
  • Sensitive to criticism
  • Seeming shallow or insincere

These symptoms can interfere with daily life and cause trouble in relationships, at work, or in school. These symptoms can range from mild to severe and can lead to other mental health problems, such as depression , anxiety , or substance abuse . In some instances, people may even threaten or attempt suicide to gain attention.

WHAT CAUSES HISTRIONIC PERSONALITY DISORDER?

It isn’t clear what causes histrionic personality disorder, but mental health experts suggest that several factors—both inherited and environmental—contribute to the condition. Among the factors believed to increase risk are having a genetic vulnerability, experiencing childhood trauma , over-indulgent or inconsistent parenting, or having a parent who acts in an overly dramatic fashion.

HISTRIONIC PERSONALITY DISORDER AND THE BRAIN

Early research on Cluster B personality disorders (histrionic, narcissistic, borderline, and antisocial) revealed significant neurocognitive impairment in these individuals in multi-step behavior planning. Newer research, including a 2021 functional brain imaging study in the Journal of Neuroimaging, shows that each personality disorder is associated with unique patterns of activity in certain brain structures and neural networks. Abnormal activity within the limbic and paralimbic systems, sometimes referred to as the emotional centers of the brain, was noted in several personality disorders. Despite these findings, the authors of this study point to a need for more neuroimaging studies to explore the specific brain changes associated with conditions such as histrionic personality disorder.

DEALING WITH SOMEONE WHO HAS HISTRIONIC PERSONALITY DISORDER

Individuals with this condition are ego-syntonic, which means they believe their behavior is normal, so they have a hard time admitting they have a problem. Because of this, it can be challenging to get these people to seek psychiatric treatment, which often centers on psychotherapy . This leaves loved ones struggling to cope with their overly dramatic and emotional behavior. For this reason, it is often the spouse or other family members who go to psychotherapy to learn how to handle everyday life.

Some of the strategies that can help you cope with a loved one’s histrionic personality disorder include:

Get educated.

Learning as much as you can about histrionic personality disorder can help you understand why your partner or family member acts the way they do. This can help you avoid taking their dramatic antics personally.

Suggest couples therapy.

Although a person with histrionic personality disorder may not be aware that they have a problem, they may be willing to go to marital therapy if they think it is intended to help you. Once in the safe space of a therapist’s office, you may be able to explore your loved one’s troubling behaviors.

Make time to shine.

When your loved one constantly steals the spotlight, it can leave you feeling underappreciated. Be sure to schedule time with friends or other family members— without the person who has histrionic personality disorder —so you can step out of the background.

Set boundaries for children.

If you have kids, set boundaries to limit their exposure to the drama created by the parent with histrionic personality disorder.

Recognize if it’s time to move on.

When a loved one’s attention-seeking behaviors leave you so physically exhausted and emotionally depleted that it is disrupting your ability to parent your children, feel your best, or perform at work or school, it may be time to end the relationship.

Histrionic personality disorder and the anxiety, stress, and depression it can cause others can’t wait. At Amen Clinics, we’re here for you. We offer in-clinic brain scanning and appointments, as well as mental telehealth, clinical evaluations, and therapy for adults, teens, children, and couples. Find out more by speaking to a specialist today at 888-288-9834 or visit our contact page  here .

18 Comments »

Whilst this might be true, this is not so easily done for a parent or sister of the person. Where does responsibility come in?

Comment by D.J. — December 15, 2021 @ 5:52 AM

So, this is going to sound histrionic. But, it is the truth. My children’s father was definitely a narcissistic, histrionic personality!!! We were together for 25 years. I tried ALL of the above suggestions. He never thought he had a problem. His angry tirades would last from 30 minutes to 2-3 hours, and were definitely linked to his childish resentment of having to work or take care of his responsibilities. I was a terrible people pleaser who took his blame shifting to heart. We were a total mess!! I am 71 now and so there wasn’t any help for such situations back in the 70’s where we lived. I sought counsel from a pastor, who after 2 meetings with us, sadly looked at me and said, “I can’t help you.” But, I have to give credit where credit is due. I was, and am, a praying woman. Although I seriously considered suicide, and yes, murder, several times, God heard my desperate cries and gave me and my children the grace to hang onto. I finally realized I didn’t have to keep punishing myself for my mistake of marrying him. Jesus had paid enough!! For me!! It still took me years to stop trying to “fix him, our marriage”. I left him, with much fear, finally when I feared someone was going to die. Either he would use one of his hunting guns on me, or we’d be the murder/ suicide family, or he or my teenage son would kill the other. Please, if you are relating to any of this, GET HELP!! The greatest shame and regrets I have are staying too long and subjecting my kids to this abuse. They are scarred for life. And now they are acting out a lot of what they were programmed with from their childhood onto their own kids. But, until you can get that help or make that break, know this, God is Real, and He wants to be your very best friend in the middle of your mess. He can give you the grace and strength to endure the now, and He can make a way out when you need it. He won’t always answer the way we want, because it involves someone else’s will and wounding. But, He loves you and them. Today, I am remarried to a wonderful man, though not perfect. And I know the love of God, His blessings, and His forgiveness like never before. My Ex and I are friendly and he still hasn’t changed. Someone once told me, “hurting people hurt people.” And my Ex used to say, when I would ask him why he was so angry, when he was on one of his rants, “I’m not angry, I’m hurt.” But, he couldn’t tell me or anyone else what had hurt him. So sad. And for so many, so true. Don’t try to go it alone, or try to hide the reality you live with. We are all broken to some degree. But, be the one who gets help, who gets your healing, who sets an example to your kids of what is acceptable or unacceptable behavior. That gives them hope that they can have a better future. And that seeking emotional, relational help is not something to be ashamed of. And most of all, don’t put it off. Don’t let pride or fear stop you from growing, learning, and getting the help that is now out there for you and your family. Keep the faith.

Comment by EvaS. — December 16, 2021 @ 4:22 AM

How do you cope when it’s an 18 yr old granddaughter and the parents don’t see it and running around catering to her for fear of her suicidal threats and accusations against others who she envies and is jealous.

Comment by Kathy — December 20, 2021 @ 5:50 AM

Sometimes a very tough situation can lead to success in not only the target but also it’s broader surroundings!

Comment by Grant Schettler — December 20, 2021 @ 6:03 AM

Good suggestions, however you don’t give a lot of suggestion if it is one of your children that has this DX

Comment by Leigh Guy — December 20, 2021 @ 7:50 AM

My adopted daughter was diagnosed with this… she is a lot for anyone to handle. The extreme drama even now at almost 19 is frustrating at times as her siblings and other family members don’t understand her continued attention seeking behaviors. But, she is sweet when she wants to be and I love her deeply. She is avoiding therapy at this time and Moved out of state, telling others I kicked her out (not true). This mama will always worry about her, but at least I understand why she does what she does.

Comment by Carrie Blase — December 20, 2021 @ 9:26 AM

I have 3 daughters & my oldest daughter who is 56 has HPD & finally after putting up with her nonsense for years I have cut the apron strings! Life is too short to suffer the hurt she has caused with her toxic ways.

Comment by Linda Rowan — April 2, 2022 @ 3:29 PM

My mother seems to display all the symptoms of HPD but I can not cut ties with her. She is the only family member I have. How do I deal with always feeling like a prop in her play? It’s relentless.

Comment by Lou Blair — June 4, 2022 @ 8:57 AM

How to cope and help a 70 year old man with HPD to get counseling or realization of his disorder. There is a young victim involved and has been manipulated into his charm to think he gives attention where her husband is lacking. Praying for the victim and the husband to see a so called friends agenda.

Comment by G. Thompson — June 21, 2022 @ 9:09 PM

The hard truth is how painful this condition is to marriage. Leaving loved ones feeling treated less than, but seeing the charming public nicess to strangers. It hurts. Feels like your hiding in public. You are always the bad guy when boundaries are set. From my experience, I would rather go back to the man who would physically abuse or try to kill me than deal with the immense emotional pain and stress of walking on egg shells constantly. And counseling? Here’s phrase that was stated ‘I’ll only go if they agree with me’…. waste of time, energy, love it seems😞

Comment by Devin — June 24, 2022 @ 11:31 AM

My sister has recently passed and on looking up I believe she lived with hysterical personality disorder, she was born deaf and wonder if this could be related to her personality disorder. She was never treated for this as mental health was not easily available at that time

Comment by Rose Boobyer — July 6, 2022 @ 8:51 AM

My brother has this disorder and I can no longer cope with him. The latest drama was his wife sent me a photo of him looking as if he partially hanged himself with paracord looped around his neck holding his head up with his eyes closed in response to me being angry with him for not paying money back to me that I loaned him over a month ago to fix his car. She said "Look at what you made him do! I found him like this!"

So if you found your unconscious spouse who might have hanged himself your reaction is to take a picture? Wouldn’t you cut them down and do CPR instead?

I am no longer able to tolerate the stress he causes me. I had a mild stroke last year and I don't want another one, so I'm utilizing No Contact with him.

Comment by Sissy — November 17, 2022 @ 12:28 AM

I have a friend who has many symptoms of HPD. I googled 'why does my friend exhaust me' and this came up. We have been friends for years but as I get older her behaviour causes me more angst. When we are together she has to have all our attention. She can be outrageous and doent seem to realise that others are exiting fast also to not get trapped. After doing a relaxation class she actually undoes all the results. I sometimes have to rush off so she doesn't rob me of the benefits. When we talk on the phone by brain cannot keep up as she jumps from one subject to another and sometimes subjects do not correlate. I feel very anxious and feel my blood pressure is rising. When I question "where is this going" she gets defensive and makes me feel as if it is my brain that is not coping. What steps can I take to keep this friend but learn to manage her without feeling such anxiety? When we have been out she will even say inappropriate things to strangers just to get their attention and cause embarrassment both to them and myself. Can someone please advise me as I ended up in tears after an hour long call today with me having to end the call saying I was so tired. She seems to like hearing her own voice and talks about so much and I can't keep up. I suffer from anxiety and don't like hurting people so this makes it hard for me. Thanks for some answer. Gail Savage

Comment by Gail Savage — February 16, 2023 @ 11:07 PM

Interesting article, thanks for this helpful advice!

Comment by Whitney Sawyer — May 19, 2023 @ 7:17 PM

I have lived with a young woman with histrionic personality disorder for a year before I even knew of the condition. I can tell you that they were very charming and I had at one moment in time actually believed that this woman was the love of my life. I know now that dealing with cluster B personality disorders is a sure fire way to end one's mental stability. She was inherently manipulative, deceitful, and a liar. This woman had a crush on me since her earlier teen years and targeted me to be in a relationship with me when she was of age. She used me to be the center of attention at all times and cared for like a child. I was like the parent in this relationship. Histrionic is no thing to mess with, should anyone read this, and should you have any self esteem or care for your future, RUN FOR THE HILLS. This person cannot be fixed. It stems from hereditary functions as well as childhood trauma, sort of like a generational curse that cannot be cured. More specifically, she matched more closely the definition of "infantile histrionic". Basically a more pitiful version of narcissism. They use many tools of the narcissist such as stonewalling, scapegoating, flying monkeys, gaslighting, etc. But she also cheated on me, and played the victim card for attention. She tried to keep me on the back burner like all the other exes that she either slandered as abusers or who had dumped her. They are incapable of true love as they can only move into the infatuation stage of love(but even that may have been a scheming test), and it's all down hill from there. They are always chasing love, but only because it makes them feel loved to have a host to feed off of, to escape any responsibility and the harshness of reality. I could go on but if this doesn't dissuade you, nothing will.

Comment by Bubba Johnson — June 5, 2023 @ 10:30 PM

I recently had to call for time out with an old friend whose behaviour was becoming increasingly erratic, demanding and draining. It certainly fits the criteria of HPD, especially the flirting and overestimating the closeness of relationships with ego-syntonic lack of awareness. She complains constantly of loneliness yet has vast network of friends and acquaintances, and chases romantic partners who show only mild interest. Even if she has met such men once or twice, she's already planning their future together and reacts with rage if he doesn't think the same way. I hadn't realised how exhausted I had become by all of this until I said I needed a break. I have so much more peace of mind now, and energy for my own family. It is not being a bad friend to draw a line and expect the other party to take responsibility for themself. If they won't go into therapy or put it into practice, as Bubba says above, you end up being parentified and it's a bad situation.

Comment by EB — July 21, 2023 @ 8:01 AM

My daughter seems to be a text book example of HDP. I’ve always walked on egg shells when dealing with her. She is the mother to my 4 precious grandchildren. I love them and help with them almost daily. We are or were very close. The children never want to leave my house and go home. It breaks my heart. Well 6 weeks ago I made the mistake of gently criticizing some of her parenting in a text. So, now She’s completely cut me off from her and them. She’s blocked me on all social media, blocked my phone number and anything else she can think to do to hurt me. I went to her house a few days ago and begged at her door to see the children. She called the police and put a tresspass on me. Now I feel crazy for even attempting to reason with her, but I’m terrified she’s taken them from me for good this time. She’s done it before but never this long and never to this extent. It’s broken our family completely apart. No one wants anything to do with her now. I don’t know if there is anything to be done or if there is anyway she will let me see my grandchildren again She won’t let them have any contact not letters not calls nothing. The oldest turns 8 next month and is so attached to me. I’m so very worried about all of them. I pray everyday and night for wisdom and strength to deal with this.

Comment by Kat A — September 4, 2023 @ 8:39 PM

Have realized in recent years, through therapy and personal growth, that I likely grew up with a mom and sister with undiagnosed HPD. I came upon the description of HPD a while back and was able to start making sense of the effect it had and still has on me and my other siblings.

It's hard, because we were raised with approval, or the withholding thereof, as our mom's means of parental control. And it is still thrown at us today in defense or our reactions to our sister.

Sad to have come from such a deeply dysfunctional family.

Comment by Jacqueline Gargiulo — December 10, 2023 @ 10:01 AM

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Case Studies of Fictional Characters

  • Histrionic Personality Disorder

What is a person with Histrionic Personality Disorder like?

The majority of cases of Histrionic Personality Disorder (HPD) are female. They may initially seem like average girls or young women, as their excessive focus on physicality can be seen in more reasonable quantities in most young ladies. At first this person may seem simply a little scattered, a little shallow, and a tad self-centered. However, a person with HPD exhibits far more than the normal amounts of all of these traits. Use of phrases that are ambiguous is frequent. “It was just like, you know, weird” would be a normative statement, or even “it was just like . . . you know?” This vague speech encompasses most of life, especially in regards to emotions and any cognitions. For example, one may see they have a distaste for something, and when inquiring as to why, simply get the response, “because it’s bad/yucky” or “I just don’t like it!” In this way, a person with HPD can often seem almost childlike in their speech patterns, as though they cannot introspect well enough to discern a more accurate description, or are too distracted or disinterested to even attempt to do so.

However, this vagueness does not mean they are unsure. People with HPD tend to be very sure of everything they think and do, even if what they think and feel changes moment to moment. This confidence can be seen in many of their actions, though they are often more than happy to act meek if it will acquire them attention. This confidence in the truth of their opinions seems to lead to them expressing emotions as if they are incredibly severe. Though it is often debated whether the person with HPD experiences  emotions more intensely, or simply reports them as more intense; we normally see expression of incredibly powerful emotions, but short lived, and very shallow. Though the term shallow may sound odd when referring to an emotion, when one converses with a person with HPD it usually becomes abundantly clear rather quickly. There is very little subtlety or shades of grey to the emotional spectrum of a person with HPD. If they are sad, they are distraught and the entire world is in peril; when they are happy, they are ecstatic, and euphoria barely expresses the joy they feel. In this way, such things as ‘bittersweet’ or simply doing pleasantly seems to be outside of the person with HPD’s realm of experience. Even emotions like envy, which are distinct to most people, seem to get subsumed into a broader emotion, such as anger. And where an average person may be irritable with someone, a person with HPD often skips straight to blind rage, and will start a fight or throw a tantrum in response.

This extremity of expression is seen also in their conceptions, or at least their reports on their conceptions, of interpersonal relationships. A person is an enemy, or they are thick as thieves. A person with HPD may refer to you as their BFF (best friend forever) after only a couple of meetings. After four meetings, they may express that not only are they in love with you, you are in love with them! This confidence may seem to overlap with narcissistic personality disorder in many ways, and in this single aspect, the two do have similarities, but expression in other symptoms is much more specific in HPD.

But, like the better known Narcissistic PD, people with HPD also crave the spotlight. They love, almost need to be the focal point of at least one person’s attention at any given time, but the more, the better. Where the two disorders differ, is that HPD sufferers almost exclusively use physical attractiveness and sexuality to gain this attention. Though sometimes they resort to emotionality, often in the form of temper tantrums, more often than not they take on the role of seductress. A young lady with HPD may think nothing of taking off her shirt in a room full of people if she felt that focus was shifting somewhere else. Once again, though many people enjoy being the center of attention, and many normal young women may use their bodies or sensuality to become the center of attention (see the average spring break videos), these behaviors are exaggerated, more frequent, and occur in less appropriate situations in a person with HPD.

DSM-IV-TR criteria

  • 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:
  • Uncomfortable in situations where he or she is not the center of attention.
  • Interactions with others are often characterized by inappropriate sexually seductive or provocative behavior.
  • Displays rapid shifting and shallow expressions of emotions.
  • Consistently uses physical appearance to draw attention to self.
  • Has a style of speech that is excessively impressionistic and lacking in detail
  • shows self dramatization, theatricality, and exaggerated expression of emotion
  • is suggestible, i.e., easily influenced by others or circumstances
  • Consider relationships more intimate than they actually are.

Associated features

  • Individuals have many emotional ups and downs. When not the center of attention in a social setting, individuals will find obvious ways to gain that attention back. They often, although unaware of it, act out a certain role, such as “victim” or “princess.” They often have trouble with their relationships with same-sex friends because of their sexually provocative style, and they may alienate friends because of their constant need for attention. They often easily become bored with routine and are frustrated by situations that involve delayed gratification. They use flirtatious or sexually provocative behavior to get what they want, usually attention from others. The cognitive style of individuals with HPD is superficial and lacks detail. In their inter-personal relationships, individuals with HPD use dramatization with a goal of impressing others. The enduring pattern of their insincere and stormy relationships leads to impairment in social and occupational areas (Encyclopedia of Mental Disorders).
  • Treatment for patients is difficult ultimately because most who suffer from HPD don’t seek treatment because symptoms don’t usually interfere with daily life.

Child vs. adult presentation

  • HPD doesn’t show development until the teenage years, approximately 15 years of age. Treatment for sufferers is usually amongst the more mature age groups, generally in the early 40’s.

Gender and cultural differences in presentation

  • Women are more likely to have HPD than men. Registered cases show that 65% are women and 35% are men that suffer from Histrionic Personality Disorder. Women tend to be over diagnosed with this disorder. This is largely due to our culture. If a man brags about his accomplishment it is seen as being macho, If a woman seeks the same kind of attention, she is diagnosed with Histrionic Personality Disorder.
  • According to the Encyclopedia of Mental Disordersm HPD appears primarily in men and women with above-average physical appearances. Some research has suggested that the connection between HPD and physical appearance holds for women rather than for men. Both women and men with HPD express a strong need to be the center of attention.
  • HPD may be diagnosed more frequently in Hispanic and Latin-American cultures and less frequently in Asian cultures. Further research is needed on the effects of culture upon the symptoms of HPD.

Epidemiology

  • HPD affects an estimated 1-2% of the general population, whereas only 1% are involved in outpatient programs.
  • Prevalence rates are 10 to 15% in mental health settings (SAMHSA, 2009).
  • The lower prevalence rate is psychiatric settings may be understood in the context of the culturally adaptive qualities associated with the sex role stereotypes found in individuals with HPD.
  • No evidence of significant familial patterns. (Not necessarily a genetic link).
  • 10 to 15% of those in substance abuse treatment settings have HPD (SAMHSA, 2009).

Dual diagnoses

  • HPD has been associated with alcoholism and with higher rates of somatization disorder , conversion disorder , and major depressive disorder . Personality disorders such as borderline, narcissistic, antisocial, and dependent can occur with HPD.
  • The development of HPD illustrates a complicated interaction of biological predispositions and environmental responses. The temperament of extroversion and emotional expressiveness that underlie the character of an individual with HPD are recognized as having biological components. These factors interact with a lack of caregiver attention during formative years that led the child to develop strategies of attention grabbing presentation and shallow interaction that would elicit attention and connection

Neurochemical/Physiological Causes:

  • Studies show that patients with HPD have highly responsive noradrenergic systems, the mechanisms surrounding the release of a neurotransmitter called norepinephrine. Neurotransmitters  are chemicals that communicate impulses from one nerve cell to another in the brain , and these impulses dictate behavior. The tendency towards an excessively emotional reaction to rejection, common among patients with HPD, may be attributed to a malfunction in a group of neurotransmitters called catecholamines. (Norepinephrine belongs to this group of neurotransmitters.)

Developmental Causes :

  • Psychoanalytic theory, developed by Freud, outlines a series of psychosexual stages of development through which each individual passes. These stages determine an individual’s later psychological development as an adult. Early psychoanalysts proposed that the genital phase, Freud’s fifth or last stage of psychosexual development, is a determinant of HPD. Later psychoanalysts considered the oral phase, Freud’s first stage of psychosexual development, to be a more important determinant of HPD. Most psychoanalysts agree that a traumatic childhood contributes towards the development of HPD. Some theorists suggest that the more severe forms of HPD derive from disapproval in the early mother-child relationship.

Defense Mechanisms :

  • Another component of Freud’s theory, defense mechanisms are sets of systematic, unconscious methods that people develop to cope with conflict and to reduce anxiety. According to Freud’s theory, all people use defense mechanisms, but different people use different types of defense mechanisms. Individuals with HPD differ in the severity of the maladaptive defense mechanisms they use. Patients with more severe cases of HPD may utilize the defense mechanisms of repression, denial , and dissociation.

Repression.

  • Repression is the most basic defense mechanism. When patients’ thoughts produce anxiety or are unacceptable to them, they use repression to bar the unacceptable thoughts or impulses from consciousness.
  • Patients who use denial may say that a prior problem no longer exists, suggesting that their competence has increased; however, others may note that there is no change in the patients’ behaviors.

Dissociation.

  • When patients with HPD use the defense mechanism of dissociation, they may display two or more personalities. These two or more personalities exist in one individual without integration. Patients with less severe cases of HPD tend to employ displacement and rationalization as defenses.

Displacement

  • occurs when a patient shifts an affect from one idea to another. For example, a man with HPD may feel angry at work because the boss did not consider him to be the center of attention. The patient may displace his anger onto his wife rather than become angry at his boss.

Rationalization

  • occurs when individuals explain their behaviors so that they appear to be acceptable to others.

Biosocial Learning Causes :

  • A biosocial model in psychology asserts that social and biological factors contribute to the development of personality. Biosocial learning models of HPD suggest that individuals may acquire HPD from inconsistent interpersonal reinforcement offered by parents. Proponents of biosocial learning models indicate that individuals with HPD have learned to get what they want from others by drawing attention to themselves.

Sociocultural Causes :

  • Studies of specific cultures with high rates of HPD suggest social and cultural causes of HPD. For example, some researchers would expect to find this disorder more often among cultures that tend to value uninhibited displays of emotion.

Personal Variables :

  • Researchers have found some connections between the age of individuals with HPD and the behavior displayed by these individuals. The symptoms of HPD are long-lasting; however, histrionic character traits that are exhibited may change with age. For example, research suggests that seductiveness may be employed more often by a young adult than by an older one. To impress others, older adults with HPD may shift their strategy from sexual seductiveness to a paternal or maternal seductiveness. Some histrionic symptoms such as attention-seeking, however, may become more apparent as an individual with HPD ages.
  • Early diagnosis can assist patients and family members to recognize the pervasive pattern of reactive emotion among individuals with HPD. Educating people, particularly mental health professionals, about the enduring character traits of individuals with HPD may prevent some cases of mild histrionic behavior from developing into full-blown cases of maladaptive HPD. Further research in prevention needs to investigate the relationship between variables such as age, gender, culture, and ethnicity and HPD.

Empirically supported treatments

  • There are no known treatments for HPD, most patients use psychotherapy, but complications are commonly caused. Medication is not a wise decision due to the risk of the patient involving the medication in a self destructive way. There are no currently no self help groups for people with HPD. The exaggerated emotional activity of HPD patients tends them to develop relationships with their therapist, severely limiting a psychologist’s ability to help a HPD patient.

Psychodynamic therapy :

  • HPD, like other personality disorders, may require several years of therapy and may affect individuals throughout their lives. Some professionals believe that psychoanalytic therapy is a treatment of choice for HPD because it assists patients to become aware of their own feelings. Long-term psychodynamic therapy needs to target the underlying conflicts of individuals with HPD and to assist patients in decreasing their emotional reactivity. Therapists work with thematic dream material related to intimacy and recall. Individuals with HPD may have difficulty recalling because of their tendency to repress material.

Cognitive-behavioral therapy :

  • Cognitive therapy is a treatment directed at reducing the dysfunctional thoughts of individuals with HPD. Such thoughts include themes about not being able to take care of oneself. Cognitive therapy for HPD focuses on a shift from global, suggestible thinking to a more methodical, systematic, and structured focus on problems. Cognitive-behavioral training in relaxation for an individual with HPD emphasizes challenging automatic thoughts about inferiority and not being able to handle one’s life. Cognitive-behavioral therapy teaches individuals with HPD to identify automatic thoughts, to work on impulsive behavior, and to develop better problem-solving skills. Behavioral therapists employ assertiveness training to assist individuals with HPD to learn to cope using their own resources. Behavioral therapists use response cost to decrease the excessively dramatic behaviors of these individuals. Response cost is a behavioral technique that involves removing a stimulus from an individual’s environment so that the response that directly precedes the removal is weakened. Behavioral therapy for HPD includes techniques such as modeling and behavioral rehearsal to teach patients about the effect of their theatrical behavior on others in a work setting.

Group therapy :

  • is suggested to assist individuals with HPD to work on interpersonal relationships. Psychodrama techniques or group role play can assist individuals with HPD to practice problems at work and to learn to decrease the display of excessively dramatic behaviors. Using role-playing, individuals with HPD can explore interpersonal relationships and outcomes to understand better the process associated with different scenarios. Group therapists need to monitor the group because individuals with HPD tend to take over and dominate others.

Family therapy :

  • To teach assertion rather than avoidance of conflict, family therapists need to direct individuals with HPD to speak directly to other family members. Family therapy can support family members to meet their own needs without supporting the histrionic behavior of the individual with HPD who uses dramatic crises to keep the family closely connected. Family therapists employ behavioral contracts to support assertive behaviors rather than temper tantrums.

Medications

  • Pharmacotherapy is not a treatment of choice for individuals with HPD unless HPD occurs with another disorder. For example, if HPD occurs with depression, antidepressants may be prescribed. Medication needs to be monitored for abuse.

Portrayed in Popular Culture

  • Scarlett O’Hara from Gone with the Wind
  • Blance DuBois from A Streetcar Named Desire
  • The Penguin from Batman
  • He constantly compensates fro his short stance and horrible appearance with an active sense of panache
  • Constantly seeking attention to his small self
  • Bellatrix Lestrange from Harry Potter
  • The theatrical right-had woman of the Death Eaters craves the approval and appreciation of her master
  • Every movement of hers oozes sexuality

DSM-V Changes

  • Histrionic Personality Disorder will be represented and diagnosed by a combination of core impairment in personality functioning and specific pathological personality traits, rather than as a specific type.
  • Prominent Personality Traits
  • Histrionism, Emotional lability

(APA, 2010)

  • Abnormal Psychology: An e-text!. Authored by : Dr. Caleb Lack. Located at : http://abnormalpsych.wikispaces.com/ . License : CC BY-NC-SA: Attribution-NonCommercial-ShareAlike

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Historical roots of histrionic personality disorder

Filipa novais.

1 Neurosciences and Mental Health Department, Santa Maria Hospital, Lisbon, Portugal

Andreia Araújo

2 Child and Adolescent Psychiatry Department, Hospital Dona Estefânia, Lisbon, Portugal

Paula Godinho

Histrionic Personality Disorder is one of the most ambiguous diagnostic categories in psychiatry. Hysteria is a classical term that includes a wide variety of psychopathological states. Ancient Egyptians and Greeks blamed a displaced womb, for many women’s afflictions. Several researchers from the 18th and 19th centuries studied this theme, namely, Charcot who defined hysteria as a “neurosis” with an organic basis and Sigmund Freud who redefined “neurosis” as a re-experience of past psychological trauma. Histrionic personality disorder (HPD) made its first official appearance in the Diagnostic and Statistical Manual of Mental Disorders II (DSM-II) and since the DSM-III, HPD is the only disorder that kept the term derived from the old concept of hysteria. The subject of hysteria has reflected positions about health, religion and relationships between the sexes in the last 4000 years, and the discussion is likely to continue.

Introduction

Histrionic personality disorder (HPD) is the only modern category in diagnostic classifications that conserved a derivative of the old concept Hysteria ( Sulz, 2010 ). Several psychiatric disorders derived from the original term hysteria such as the conversion disorder, the somatization disorder, somatoform disorders, phobic anxiety, the term mass hysteria, and finally the HPD. Although different authors extensively studied this theme across time, the authors will focus on HPD.

The word hysteria derived from the Greek term “hystera,” meaning the womb or uterus. It has been used since ancient times and appears in texts of the Egyptians, Greeks, and Romans. Since then, the meanings of hysteria have mirrored the preoccupations of the societies at each time.

In the old Rome, the word “Histrione” was already used to define the actors that represented coarse farces representing those who are false and theatrical ( Zimmerman, 1999 ).

From Egyptians to Hippocrates

The oldest record is an Egyptian medical papyrus dating from around 1990 BC, the Kahun Papyrus , which is the first known medical gynecological text. Plato (429 ± 347 BC) described this phenomenon as “The animal within them is desirous of procreating children, and when remaining unfruitful…gets discontented and angry, and wandering in every direction through the body…drives them to extremity, causing all varieties of disease…” ( Illis, 2002 ). Many women’s afflictions, including choking, mutism, and paralysis were attributed to a condition called the “wandering womb” or “the wicked womb.” It was Hippocrates (460 ± 377 BC) who first introduced the term “Hysteria” and described it as the consequence of a dry womb rising toward the throat searching for humidity, thereby impeding breathing. The neurotoxic effects of the “frustrated uterus” would affect widows and virgins ( Bogousslavsky, 2011 ). Galen (AD 129 ± 216 BC) instead blamed the blocked menstrual flow and sexual abstinence. One of his most striking views was that men could also suffer hysterical symptoms caused by retained sperm. His ideas contributed to initiate a debate, which had run for centuries, over whether men could or not have hysteria. Galen’s views persisted among the medical practitioners of Christian post-Roman Britain ( Edwards, 2009 ).

From Middle Ages to the 18th Century

During Middle Ages, as the attitude toward sickness changed from naturalistic to demonotheologic, with Augustine of Hippo (354–430 AC) and other theologians, hysteria came to be seen as a manifestation of demonic possession. Convulsions and the so-called “suffocations of the matrix” were considered as an expression of sexual pleasure and, therefore, sin. Devil could enter women’s body to possess them and the hysterical become the witch, persecuted by the Catholic Church and many of those were killed by the inquisition ( Roudinesco and Plon, 2000 ).

With the renewed interest on empiricism and science during Renaissance, old Greek concepts of hysteria were recuperated. Similar therapies to those prescribed in ancient Greek civilizations, such as genital stimulation by horse riding, dancing and, in particular, marriage and sexual intercourse were still prescribed for such condition ( Edwards, 2009 ).

Several researchers including Charles Lepois, Thomas Willis, Thomas Sydenham, and Pierre Pomme had great interest in the study of hysteria ( Teive et al., 2014 ).

Some of these authors defied the original theories that connected hysteria to the uterus and some defended that the disease was originated in the brain. One of the first was Thomas Willis (1621 ± 1675) who argued that hysterical disorders, the so-called “convulsive distempers,” were caused by an excess of animal spirits carried by the nerves to different parts of the body, introducing a new etiology for the disease. He believed in a nervous origin instead of vapors opening the door to the desexualisation of the disease ( Risse, 1988 ).

The famous clinician Thomas Sydenham, (1624–1689) was one of the most important contributors to the study of hysteria at his time. He published a treatise on hysteria called Epistolary Dissertation on the Hysterical Affections and stated that hysteria was the most common of all diseases afflicting both men and women and the more richer and civilized a patient was, the more likely he or she was to be afflicted. One of his most remarkable conclusions was that hysteria could take multiple forms in order to imitate several other diseases, frequently triggered by intense emotions such as anger, grief, terror or passions ( Gilman et al., 1993 ).

William Cullen, (1769), a noted Scottish physician, published Synopsis Nosologiae Methodicae , a classification of diseases where hysteria figured on the group called neuroses . These diseases were considered to result from nervous system malfunction involving changes in sensibility and motion. Hysteria was included in the class of illnesses characterized by irregular muscular contractions, the so-called spasmodic diseases, but Cullen still admitted that in its origin were gynecological problems ( Risse, 1988 ).

Philippe Pinel, (1745–1826) considered that diagnostic difficulties were associated with the numerous disorders and symptoms attached to it, so he defended the study of hysteria in its uncluttered or “pure state.” He included hysteria in his “ Nosographie Philosophique ” (1813) placing it in the group called “Neuroses” ( Whitaker et al., 2007 ).

During this period, hysteria was a serious subject in medical schools and textbooks. Some authors considered it to reflect psychological frustrations directly linked to the restricted role of women in society ( Risse, 1988 ). Griesinger, (1817–1868) kept the view that hysteria was related to genital disorders and sexual frustration but also involving “morbid action of… the brain” ( Gilman et al., 1993 ).

In 1859 Pierre Briquet, (1796–1881) published his “ Traité Clinique et Therapeutique de L’Hysterie ” presenting data from 430 hysterical patients collected in 10 years. He rejected the idea of the uterine origin of the disease and considered it as a “neurosis of the brain” in someone of the “hysterical type.” Briquet had a remarkable contribution for development of the HPD; he considered this type of personality traits as the ground for the development of the histrionic disorders ( Mai and Merskey, 1981 ). He introduced sociological and material concepts in the comprehension of hysteria, such as living and working conditions. The industrialization, with the development of the trains and the subsequent numerous traumatic accidents, brought up the discussion about the hysteria in men. Between 1880 e 1900, hysteria was epidemic: writers, doctors and historians agreed to refer to the industrial social crises, like strike, as a sign of the feminine convulsive nature and frequently applied the terms hysteria and “uterine furies” to designate them ( Roudinesco and Plon, 2000 ).

At the end of the 19-century, Salpêtrière Hospital acquired a remarkable importance on the study of hysteria and hypnotism due to the famous French neurologist, Jean-Martin Charcot (1825 ± 1893), who created the study of Diseases of the Nervous System there, in 1862. He had many remarkable collaborators such as Albert Pitres, Paul Richer, Georges Gilles de la Tourette, Paul Sollier, Joseph Babinski, Sigmund Freud, and Pierre Janet creating the famous Salpêtrière’ s School of Neurology. His interest on hysteria probably started after 1870, when Charcot’s took charge of the Delasiauve service, a place where mainly epileptics and hysterics were admitted ( Bogousslavsky et al., 2009 ). Using a photographic camera, after long and detailed observations and methodical comparisons of hysteria with other conditions, he considered two main forms of hysteria—with and without convulsions. The hysteroepilepsy or “ grandes crises d’hystérie ” were described as having four stages: 1. Epileptoid; 2. Contortions and acrobatic postures (Clownism); 3. Emotional gestures (“ attitudes passionnelles ”); and 4. Final delirium ( Teive et al., 2014 ). Charcot considered hysteria as a “neurosis” with an organic basis and described permanent clinical features in patients who were also prone to paroxysmal fits, the “stigmata”: sensory dysfunction, hyperexcitability and visual field narrowing ( Bogousslavsky et al., 2009 ).

According to him, the presumed neurological impairment was dynamic in nature and produced by unconscious mental processes ( Macmillan, 1997 ). Hysterical symptoms occurred in genetically predisposed individuals and were manifested within familiar circumstances. Therefore, he stated that a fundamental condition of the treatment should be the isolation from family members and called this “the moral or mental side of treatment” ( Illis, 2002 ).

One of Charcot’s most remarkable students was Babinski, (1857–1932) who defined hysteria as a psychic state that would give the patient the ability of “auto-suggestion,” so that the patient would be able “to be persuaded” and therefore was prone to “healing” by suggestion ( Philippon and Poirier, 2009 ). Consequently he recommended the term “pithiatism” (from the Greek: created by suggestion and curable by persuasion). Despite the influences of his master, he presented his own theory about hysteria, as well as several approaches and specific criteria in order to differentiate organic from hysterical symptomatology ( Mai, 2004 ; Allilaire, 2007 ; Clarac et al., 2008 ).

Later, Charcot introduced hypnosis as a therapeutic technique and also as an experimental tool to the study of hysterical phenomena and its underlying neurophysiology and psychogenic trauma-related mechanisms of the hysterical neuroses ( Levin, 1978 ).

The principles of hypnosis have been previously established by Franz Anton Mesmer, (1734–1815) who created the so-called “Animal magnetism,” a pervasive property of nature that could be used as an effective therapy for a wide variety of conditions and its therapeutically application—the “mesmerization” ( Lanska and Lanska, 2007 ).

Charcot and his group have been criticized by the School of Nancy and his main investigator Hippolyte Bernheim, (1840–1919), a French physician and neurologist. While Charcot believed that hypnosis was based on physiologically well-determined phenomenon only applied, as a therapeutic and diagnostic technique, to hysterical patients, Bernheim proposed that it was based on changes in psychological functioning; different features of hypnosis would therefore reflect different degrees of suggestibility. He also argued that suggestibility was a normal human trait and not an abnormal phenomenon as Charcot defended ( Macmillan, 1997 ).

Both Bernheim and Charcot had important influences on Sigmund Freud’s, (1856–1939) latter theories. Freud, who later developed the psychoanalytic theory leading to the redefinition of hysteria and the creation of different syndromes that came from the original concept, went to the famous Salpêtrière in October 1885 in order to study with Charcot. He started translating some of Charcot’s lectures and defending his views. 2 years after, he translated Bernheim’s work and visited Nancy in the summer of 1889 ( Macmillan, 1997 ).

Another important author that had influenced the work of Freud was Pierre Janet, (1859–1947), also a Charcot follower. Many of Freud’s basic concepts were developed or elaborated by Janet, such as psychological automatism, consciousness, subconsciousness, narrowed field of consciousness, dissociation, suggestibility, fixed idea, and emotion ( Hart and Horst, 1989 ). Janet considered that hysteria results from the idea the patient has about pathology, translating it into a physical disability. He studied five hysteria’s symptoms: anesthesia, amnesia, abulia, motor control diseases, and modification of character ( Tasca et al., 2012 ).

In 1895, Freud and Breuer, (1842–1925) published the “Studies on Hysteria,” including the famous case study of Anna O and the formulation of three types of hysteria: defense, retention and hypnoid hysteria ( Breuer and Freud, 1955 ). Freud defied the traditional idea that defended that hysteria was caused by the lack of conception and motherhood, proposing that hysteria was a disorder caused by a lack of libidinal evolution (setting the stage for the Oedipal conflict), so the consequence, and not the cause, would be the lack of conception as a result of the incapacity of the hysterical to live a mature relationship. Hysterical symptoms would therefore be the expression of the impossibility of fulfillment of the patient’s sexual drive. Freud also added, to this paradigm, the concepts of “primary benefit” and “secondary advantage” associated with the use of these symptoms to satisfy patient’s needs ( Tasca et al., 2012 ). This new paradigm concerning the emotional origin of hysterical symptoms was often applied to shell shock and other “war neurosis” during the World War I and II ( Crocq and Crocq, 2000 ). In fact, with the war and after that, during the 1940s and the 1950s, the interests in this matter grew rapidly.

Freud explored traumatic experiences occurring in the family in order to provide an explanation for hysteria. Unacceptable feelings connected to seduction were repressed and converted into somatic symptoms. Latter he found that many of these reports were false, so he concentrate on intrapsychic factors. Patients repressed not actual happenings but their own sexual fantasies ( Slipp, 2014 ).

Histrionic Personality Disorder

Although the roots of modern histrionic personality can be traced back to Freud’s description of “hysterical neuroses” ( Sperry, 2003 ), personality was already a matter of attention before.

In the mid-19th century, Ernst von Feuchtersleben, (1765–1834) who wrote the Textbook of Medical Psychology (1845) made the first psychosocial description of what would become the histrionic personality. He described hysterical women as being sexually heightened, selfish and “overprivileged with satiety and boredom” ( Millon, 2011 ).

Ernst Kretschmer, (1888–1964), a German psychiatrist known for the establishment of a typology based on the human constitution, suggested that hysterics show “a preference for what is loud and lively, a theatrical pathos, an inclination for brilliant roles…(and) a naïve, sulky egotism” ( Bornstein et al., 2015 ). Another Kretschmer’s important contribution was the demand for objective criteria in order to distinguish hysteria from simulation ( Lerner, 2003 ).

The first providing a detailed psychoanalytic description of the hysterical personality style was Wilhelm Reich, (1897–1957), an Austrian psychoanalyst. He wrote “coquetry in gait, look or speech betrays, especially in women, the hysterical character type…We find fickleness of reactions…and…a strong suggestibility, which never appears alone but is coupled with a strong tendency to reactions of disappointment…”

A decade after his work, Otto Fenichel, (1897–1946), a psychoanalyst of the so-called “second generation,” added another characteristic to this description: the pseudo-hypersexuality, noting that these individuals “are inclined to sexualize all nonsexual relations…” ( Bornstein et al., 2015 ).

Easser and Lesser, (1965) seek to integrate two different earlier approaches: the ego psychology school and Freud’s libido theory. They proposed a classification of hysterics consisting on two extremes—the hysterical personality and the “hysteroid” (borderline) personality. Zetzel, (1968) also divided patients into “good” hysterics, who function well, and “bad” hysterics, who have weak egos and poor object relations. This latter group of patients has a profile and level of functioning similar to the one seen in borderline patients ( Slipp, 2014 ).

Several theorists studied the particular traits of this type of personality including histrionic’s impressionist cognitive style and inattention to detail. In his book, “Hysterical Personality Style and the Histrionic Personality Disorder,” Horowitz (1991) , focused on the connection between perception and behavior in histrionic personality; he argued that it was based on an underlying information processing bias. A disturbed mental representation of the self would constitute the link to the various features of this type of character. On the other hand, according to the biosocial-learning model, proposed by Theodore Millon and other authors, this personality type may arise from unconscious patterns of reinforcement provided by parents and others ( Blaney et al., 2015 ). The cognitivists Beck et al. (2004) suggested that histrionic person believe that potential caregivers are not trustful and should be manipulated instead. According to these authors, their core believes include “I am inadequate and unable to handle the life on my own” and “It is necessary to be loved by everyone, all the time.”

Since the first attempts to the establishment of diagnostic criteria in hysteria, there has been considerable controversy, considering the etiology, the definition and even the existence of such condition.

Discussion and Conclusion

The terms hysteria, hysterical personality, and HPD mark the development of unceasing attempts to identify a distinct pattern of psychopathology ( Bakkevig and Karterud, 2010 ).

The first edition of the American Diagnostic and Statistical Manual (DSM-I), published in American Psychiatric Association (1952) , had no category for hysterical personality although some of its features were included in the “emotionally unstable personality.” The DSM-II ( American Psychiatric Association, 1968 ) was strongly impacted by psychoanalysis: some personality disorders had to be differentiated from other neuroses with the same name (e.g., hysterical, obsessive-compulsive, and neurasthenic personalities and neuroses). Following the medical model created by Emil Kraepelin, in DSM-III ( American Psychiatric Association, 1980 ), and the subsequent DSM-III-R ( American Psychiatric Association, 1987 ) and DSM-IV ( American Psychiatric Association, 1994 ), personality disorders were described as discrete types and grouped into three clusters. The term hysterical from DSM-II was replaced with “histrionic” in DSM-III following the proposition of Paul Chodoff who considered pejorative the description of the “hysterical female” as labile, egocentric, seductive, frigid and childish, as described in his article “The diagnoses of hysteria: An overview” ( Chodoff, 1974 ). From DSM-III to DSM-IV-TR, ( American Psychiatric Association, 2000 ) diagnostic criteria of HPD had several changes mainly due to the argument of “unspecificity.” An important change occurred from DSM-III-R to DSM-IV:5 criteria were considered the threshold for obtaining the diagnosis, as compared to 4 criteria in DSM-III–R. This lead to a decline in the number of patients diagnosed with HPD ( Blais and Baity, 2006 ).

The merits of compounding typological and dimensional models of personality were questioned during the preparation of DSM-5, reopening a century-old debate ( Crocq, 2013 ). Data, although sparse, actually suggest that the rate of presentation of “hysteria” in neurological practice has remained stable over time ( Stone et al., 2008 ).

Bakkevig and Karterud (2010) , in a study carried out with a sample of patients attending psychiatric day hospital, concluded that the prevalence of HPD was very low (0.4%) and comorbidity was high, especially with borderline, narcissistic, and dependent personality disorders. They suggested that the HPD category should be deleted from the DSM system, excepting that clinical phenomena of exhibitionism and attention-seeking, which are the dominant personality features of HPD, should be preserved in an exhibitionistic subtype of narcissism. Nevertheless, HPD remains present in DSM-5 ( American Psychiatric Association, 2013 ).

Edwards (2009) advocates that those who argue that hysteria has disappeared from clinical practice, “miss the point” and “that it has merely changed to reflect the preoccupations of our society…”

Concerns with stigma and lack of specificity of the term hysteria, and its derivative histrionic, led to its residual presence in modern classifications but the theme and its modern diagnosis that emerged from the original concept kept their topicality and importance in clinical practice.

For about 4000 years the construct of hysteria and its derivatives has reflected attitudes about health, religion and relationships between the sexes and the interest raised by this condition is likely to continue ( Illis, 2002 ).

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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