The Disorder That is Histrionic Personality Disorder (HPD)

Histrionic Personality Disorder (HPD)

* The Knowhow of Histrionic Personality Disorder (HPD) :::
Histrionic personality disorder (HPD) is defined by the American Psychiatric Association as a personality disorder characterized by a pattern of excessive emotionality and attention-seeking, including an excessive need for approval and inappropriate seductiveness, usually beginning in early adulthood.

Researchers Widiger & Frances (1988), Schotte and colleagues (1993) state that HPD “reflects a tendency to be self-dramatizing, attention seeking, overly gregarious, seductive and manipulative, exhibitionistic, shallow, frivolous, labile, vain and demanding.”

Histrionic personality disorder is one of a group of conditions called dramatic personality disorders. The word histrionic means “dramatic or theatrical.”
People with this disorder lack genuine empathy. They start relationships well but tend to falter when depth and durability are needed, alternating between extremes of idealization and devaluation.

They may seek treatment for depression when romantic relationships end, although this is by no means a feature exclusive to this disorder.They often fail to see their own personal situation realistically, instead tending to dramatize and exaggerate their difficulties.
This disorder is more common in women than in men and usually is evident by early adulthood.


* Historical Context :::
HPD is rooted in the term hysteria as mentiond by Blais, Hilsenroth & Fowler, 1998. According to Blais and colleagues (1998), hysteria is one of the oldest documented medical conditions, and has been dated back to ancient Greek and Egyptian writings.
The Greeks believed it was caused by a wandering or displaced uterus and sexual dissatisfaction that caused women to be overly emotional, 2004.
During the Middle Ages, hysteria was thought to be a result of witchcraft, sexual longing, demon possession and a defective moral character.
During the 19th century, hysteria was viewed as a weakened nervous system related to sex in women biologically. Throughout history this term has reflected a misogynistic stigma against women as being weak, unstable and inferior.

Hysteria was first studied in a psychological context by Sigmund Freud, and acted as a catalyst in the development of his psychoanalytic theory, 1998.
Freud’s study of this condition focused on repressed sexuality, ad nauseam and cursory emotionality, feelings of castration and penis envy, and an immoderately developed fantasy life. The concept of hysteria has undergone many changes due to its implementation into the psychoanalytic theory.
It actually split into two different conditions termed Conversion Hysteria/Disorder, and Hysterical Character. Hysterical Character currently presents in the DSM-IV as Histrionic Personality Disorder.

* Symptoms :::
- Dress provocatively and/or exhibit inappropriately seductive or flirtatious behavior.
- Be gullible and easily influenced by others.
- Constant seeking of reassurance or approval.
- Excessive dramatics with exaggerated displays of emotions, such as hugging someone they have just met or crying uncontrollably during a sad movie.
- Excessive sensitivity to criticism or disapproval.
- Somatic symptoms, and using these symptoms as a means of garnering attention.
- Be self-centered and rarely show concern for others.
- Have difficulty maintaining relationships, often seeming fake or shallow in their dealings with others.
- A need to be the center of attention.
- Low tolerance for frustration or delayed gratification.
- Rapidly shifting emotional states that may appear superficial or exaggerated to others.
- Tendency to believe that relationships are more intimate than they actually are.
- Making rash decisions.
- Be easily bored by routine, often beginning projects without finishing them or skipping from one event to another.
- Not think before acting.
- Threaten or attempt suicide to get attention.
- Blaming failure or disappointment on others.
Also,
The Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV)-TR lists similiar symptoms that form the diagnostic criteria for HPD:
- Center of attention: Patients with HPD experience discomfort when they are not the center of attention.
- Sexually seductive: Patients with HPD displays inappropriate sexually seductive or provocative behaviors towards others.
- Shifting emotions: The expression of emotions of patients with HPD tends to be shallow and to shift rapidly.
- Physical appearance: Individuals with HPD consistently employ physical appearance to gain attention for themselves.
- Speech style: The speech style of patients with HPD lacks detail. Individuals with HPD tend to generalize, and when these   individuals speak, they aim to please and impress.
- Dramatic behaviors: Patients with HPD display self-dramatization and exaggerate their emotions.
- Suggestibility: Other individuals or circumstances can easily influence patients with HPD.
- Overestimation of intimacy: Patients with HPD overestimate the level of intimacy in a relationship.


*  Causes :::
The following may give us an idea on the causes of HPD :
+ Neurochemical 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. 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.

+ Bio-Social Learning causes :
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.

+ Socio-Cultural 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 :
The 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.

+ Defense mechanisms, Repression, Denial, Dissociation and Rationalization are other forms of causes leading to HPD.


* Types of HPD :::
Theodore Millon identified six subtypes of histrionic :
- Theatrical histrionic - especially dramatic, romantic and attention seeking.
- Infantile histrionic - including borderline features.
- Vivacious histrionic - synthesizes the seductiveness of the histrionic with the energy level typical of hypomania.
- Appeasing histrionic - including dependent and compulsive features.
- Tempestuous histrionic - including negativistic (passive-aggressive) features.
- Disingenuous histrionic - antisocial features.

* Case studies :::
Currently, there is a substantial amount of debate over HPD’s true causes from a psychological standpoint. The psychoanalytic viewpoint might say that there is a link with the death of a first-degree relative during childhood or parental divorce while the biological viewpoint focuses on a link in genetics (Seligman, 1984). Others who implement more progressive (possibly eclectic) and/or cognitive approaches to psychology focus on dependency issues as a primary correlate (Bornstein, 1998).

Few Case studies are as follows :
(1) The Kellet Research :
Very little research has been conducted concerning the actual effectiveness of said treatments, leaving much emphasis on studying case histories (Kellett, 2007). Horowitz (1997, as cited by Kellett, 2007) developed a treatment plan for HPD which consisted of three phases.
The first stage is stabilization, followed by the modification of one’s communication techniques and style, then finished with the modification of the client’s interpersonal patterns, schemas and reactions.

Stephen Kellett (2007) conducted a case study on the effectiveness of cognitive analytic therapy (CAT) in the treatment of HPD. He based his research off a single case consisting of 24 CAT sessions and a six-month follow-up period of four sessions.
The variables measured daily were: a strong need to be noticed on a particular day, being focused on appearance on a particular day, being flirty on a particular day, feeling empty and feeling like a child.

The responses were measured on a scale from zero to nine. In addition to reporting on the above specified variables, the client was given a self-report measure of psychological functioning. This was administered at the initial onset of treatment, at termination and again during the final follow-up session.
(SDR) was formulated and presented during the upcoming sessions. The SDR focused on goals for the clients.

The result of Kellett’s (2007) case study showed statistically significant improvements in three of the five focal points for change. The three focal points which clinically improved and withstood the test of time after termination were as follows: preoccupation with physical appearance, feelings of emptiness and feeling like a child inside. This data helped widely in later researches.

(2) Kevin Erickson :
He conducted a study on such biases and found that in comparison to sex-unspecified vignettes, there was a high correlation with sex-specified vignettes and a tendency for clinicians to diagnose females as HPD and males with Narcissistic Personality Disorder.

(3) Maureen Ford and Thomas Widiger (1989) :
They conducted a similar study; randomly selecting 354 psychologists and presented them with one of nine possible case histories which presented symptoms of Histrionic and Antisocial Personality Disorders (APD).
The case histories consisted of clients who were described as male, female or androgynous. The results showed a statistically significant gender bias in the diagnosis of personality disorders with a high tendency for female clients to be diagnosed with HPD and for male clients to be diagnosed APD.

(4) The Warner Research :
Warner conducted a research study in which 175 mental health professionals were presented with case histories consisting of mixed symptoms of both HPD and APD.
Results showed female portrayed clients were diagnosed HPD 76% of the time, and APD 22% of the time. Male portrayed clients were diagnosed HPD 49% of the time and APD 41% of the time.
Warner stated a “tendency for therapists to perceive men as antisocial personalities and women as hysterical personalities even when the patients have identical features.”

(5) Robert Bornstein :
He conducted a study concerning dependency needs in those with HPD and Dependent Personality Disorder (1998). He used a Rorschach scale as well as a self-report inventory to measure dependency needs in those with HPD.
He found a statistically significant correlation between HPD and high levels of tacit dependency needs. He also found through this study that the dependency needs of the HPD individual may be masked due to denial, displacement and repression in a subconscious attempt to keep those needs out of one’s own awareness.
The client may have a manipulative way of meeting those needs through drawing attention to him/herself, thus ensuring others are focusing on his/her needs, rather than consciously seeking intimacy with another.
The client may also deny any overt dependency needs, thus owning an independent façade. He further noted that masking and repression may be used as a defense mechanism/coping strategy to deal with anxiety-laden emotions.

(6) The Hempstead Research, 2009 :
The LGBT (lesbian, gay, bi-sexual and transgendered) community may experience some of this bias. Gay men have been known to be misdiagnosed HPD when their behavior is simply an expression prevalent in their culture; a norm of behavior within their community.

* Treatment :::
+ Psychodynamic therapy
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
Group therapy is suggested to assist individuals with HPD to work on interpersonal relationships.
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.

* Demographics :::
- General United States population :
The prevalence of HPD in the general population is estimated to be approximately 2% - 3%.

- High-risk populations :
Individuals who have experienced pervasive trauma during childhood have been shown to be at a greater risk for developing HPD as well as for developing other personality disorders.

- Cross-cultural issues :
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.

- Gender issues :
Clinicians tend to diagnose HPD more frequently in females; however, when structured assessments are used to diagnose HPD, clinicians report approximately equal prevalence rates for males and females.
In considering the prevalence of HPD, it is important to recognize that gender role stereotypes may influence the behavioral display of HPD and that women and men may display HPD symptoms differently.

* Conclusion :::
Histrionic Personality Disorder appears to be one of the least threatening diagnosis amongst personality disorders as those affected are high functioning and do not seek relief for the disorder itself.
There is also very little research on HPD which makes treatment options limitless and based on a case by case perspective.
The etiology and cultural ideas surrounding this disorder have changed and evolved over time, however, there are definitely some gender and cultural biases present concerning its diagnosis.
With diagnoses and disorders having such a malleable and evolving nature, it is important for clinicians to remain open and ethically minded when diagnosing.