Histrionic Personality Disorder (HPD) is characterized by chronic patterns of inappropriate seductiveness, attention seeking behavior, shallow and rapidly changing emotions, theatricality, impressionistic and vague speech, and being easily influenced. Individuals with HPD can appear lively and charming and at the same time their flamboyance can embarrass other people around them. Treating HPD typically involves psychotherapy; however, it has low to moderate treatability.
What Is Histrionic Personality Disorder?
Histrionic Personality Disorder is recognized as a maladaptive personality disorder with which an individual seeks to assert power, influence, or control by seeking attention, using emotional drama, seductive behaviors, and provocative actions. Individuals with HPD are often victims of trauma in childhood and their exaggerated emotional displays and vague, superficial expressions are defensive measures.5
Histrionic Personality Disorder remains a controversial diagnosis due to negative historical bias, feminist theory, lack of empirical research, and arguments in the psychiatric community about the overlap of its diagnostic features. Histrionic Personality Disorder is difficult to separate from other disorders and is closely aligned with somatization disorder, dependent personality disorder, narcissistic personality disorder, and antisocial personality disorder. These personality disorders all share emotional instability, drama, and impulsiveness. Somatization includes unexplained physical ailments.
Signs of Histrionic Personality Disorder
Though it might be useful to identify warning signs of personality disorders in childhood to provide early interventions, it can also be a trap. Children and teens are developing their personalities as their brains and bodies mature, and they interact with their environments. The stigma or misdiagnosis of children and teens can have long-term negative impacts. Therefore, personality disorders are generally not diagnosed until after age 18.
Adults diagnosed with histrionic personality disorder can be flamboyantly dramatic with expressive affect without much substance or depth. Their behaviors and emotions are superficial and change quickly. They can be described in positive ways as lively, exciting, and “the life of the party.”3 Histrionic Personality Disorder also brings a self-centeredness and thoughtless disregard of others. They can be impatient and easily bored. People around them may feel embarrassed by their exaggerated behaviors and emotional displays.4
Individuals with Histrionic Personality Disorder pay a good deal of attention to their overall appearance. They are high utilizers of cosmetic enhancements.6 Both men and women can be flirtatious and seductive in ways that are manipulative. They like to be noticed and liked; being the center of attention is important to them. This trait makes it easy for them to become addicted to social media due to seeking social approval.9
Individuals with Histrionic Personality Disorder can also manifest manipulative traits in quiet ways using guileless charm and seduction that leads to short-term rewards. Discreet drama is simmering underneath an overt appearance of naivete and helplessness. The superficiality of individuals with Histrionic Personality Disorder make them gullible and easy targets of manipulation themselves.
The symptomatology of this diagnosis may seem superficial, but like all personality disorders there are cognitive deficits that impair problem solving and judgment. Chronic emotional disruptions limit capacity for concentration and logical thinking. Further, outward emotional displays often mask serious internal misery and act as a defense against internal conflict.
Symptoms of Histrionic Personality Disorder
Per DSM-5 criteria, a diagnosis of a histrionic personality disorder requires a pervasive and ubiquitous pattern of consistent attention-seeking behaviors and emotional dysregulation as outlined by specific manifestations.
Diagnosis of Histrionic Personality Disorder requires meeting five (or more) of the following criteria:
- Uncomfortable when not the center of attention
- Seductive or provocative behavior
- Shifting and shallow emotions
- Uses appearance to draw attention
- Impressionistic and vague speech
- Dramatic or exaggerated emotions
- Suggestible (easily influenced by others)
- Considers relationships more intimate than they are
Histrionic Personality Disorder diagnosed individuals use repression and dissociation as a significant defense mechanism against traumatic injuries.7
Research has suggested that personality disorder characteristics change over a lifetime as is expected for normal personality in general. Ruiz and his colleagues found that the changes are slow and moderate.8 Their 2020 research counters older notions that personality disorders can change rapidly over a ten-year period.8
Since 1952, Histrionic Personality Disorder has been included in the Diagnostic and Statistical Manual of Mental Disorders (DSM); however, the language has changed over time to reflect early negative bias. The first two editions of the DSM used the terms “emotionally unstable persons,” “hysterical neuroses,” and “hysterical personality” which harkened back to a disorder of women, which it is not.5 Histrionic Personality Disorder appears equally in men and women and does not relate to the womb.7
Causes of Histrionic Personality Disorder
The causes of Histrionic Personality Disorder are unresolved.3,5,7 Like many other personality disorders, there has been very little empirical research on this disorder. It is surmised most personality disorders arise from a combination of genetics, environment and parenting. French in his article, Histrionic Personality Disorder, states that children with parents who are volatile, erratic, dramatic and sexually inappropriate put their children at risk for Histrionic Personality Disorder.
Additionally, if parents do not set boundaries, are overly indulgent and model Histrionic Personality Disorder behaviors, their children may learn to manage the world the same way.3 French also points out that research has shown that individuals with Histrionic Personality Disorder are often victims of childhood trauma.
Treatment of Histrionic Personality Disorder
There are no identified evidence-based practices to treat Histrionic Personality Disorder. Limited research indicates that individuals with Histrionic Personality Disorder require supportive, individual psychotherapy that offers encouragement in a non-threatening environment. Due to their need for personal attention, it is not a good idea to engage them in group or family therapy.3
Various psychotherapies can be effective in improving self-esteem, reducing and managing emotional distress with coping mechanisms, and teaching skills that may have been lacking or unlearned in childhood. It is imperative that the clinician set firm boundaries due to Histrionic Personality Disorder’s manipulative behaviors.
Helpful therapy options for Histrionic Personality Disorder include:
- Long-Term Individual Psychotherapy (talk therapy): The emphasis is on sympathetic and attentive listening with the goals of improving self-esteem, teaching coping mechanisms and reducing emotional dysregulation.
- Psychodynamic Therapy: This therapy focuses on gaining insight and learning change skills, and includes delving into underlying conflicts. Clients work to understand and resolve traumatic conflicts and decrease emotional instability.
- Cognitive Behavioral Therapy: CBT emphasizes learning the relationship between thoughts, emotions, physical sensations, and behaviors to change unhelpful patterns of behavior.
- Biofeedback Therapy for Emotion Regulation: Stressful body changes are electronically monitored and observed by the client. The monitor provides feedback so the client can see how new behaviors decrease physical, psychological and emotional distress.
There are no specific FDA-approved medications for personality disorders. However, since other symptoms are frequently present, they can be treated with medications. The three categories of medications are anti-depressants, mood stabilizers and antipsychotics. Research indicates the following medications may be effective in treating histrionic personality disorder:3
- Antidepressants: desipramine, fluoxetine, amitriptyline, and fluvoxamine
- Mood stabilizers: lamotrigine, carbamazepine, topiramate, valproate, and lithium
- Antipsychotics: risperidone, aripiprazole, olanzapine, and haloperidol
Individuals must be assessed by a psychiatric medical provider if medication is sought as an intervention.
How to Get Help for Histrionic Personality Disorder
Finding a qualified therapist to treat Histrionic Personality Disorder can be somewhat difficult. There are many therapists who take short courses in personality disorder treatment, but that does not ensure they are qualified clinicians. It is important to seek professionals with specialized training and experience working with personality disorders. Inept treatment is worse than no treatment at all.
Do not be afraid to ask therapists about their education, training, certifications, experience and treatment philosophy. It is important to have the right fit so that treatment goals can be accomplished within a safe environment as quickly as possible. You can find a therapist through a referral from your primary care physician, or use an online directory. There are some intensive residential programs, but the cost may be prohibitive.
There are several online groups created for individuals with personality disorders. The groups can be informative, supportive and encouraging. They remind clients that they are not alone. Try Personality Disorders Awareness Network Resources and Mental Health America Groups for lists of online personality disorder groups.
Histrionic Personality Disorder Statistics
Most research indicates about 2-3% of the population suffers with Histrionic Personality Disorder, while approximately 9%-15% of the population are diagnosed with personality disorders in general.3,5,7 While women are four times more likely to be diagnosed with Histrionic Personality Disorder, it can be attributed to over diagnosis. It remains underdiagnosed in men. Men’s sexualized behavior may be more socially acceptable, and men are more reluctant to report symptoms.3,5
4 Ways to Manage Histrionic Personality Disorder
Histrionic Personality Disorder is felt by individuals as ego syntonic.5 This means that they believe their behavior is normal; it matches up with how they view the nature of their personality. This can create difficulties with family, friends, and intimate relationships as Histrionic Personality Disorder causes individuals to blame others because they are “fine”. They unconsciously continue destructive patterns without realizing they are the performers of ineffective behaviors instead of the victims.
Here are four suggestions for people working to manage Histrionic Personality Disorder:
1. Get an Accurate Diagnosis
Just having clear, specific information will help make sense of life’s challenges. It takes the mystery out of the question “what’s wrong with my life?” Therapists offer reassurance that change is possible, and a fulfilling life is within reach.
2. See a Therapist
Find a trusted therapist and begin looking at the ways that life goes awry. Having someone who truly understands and recognizes the key problems with Histrionic Personality Disorder will provide an opportunity for personal growth. Gaining insight and learning new skills can be positively life changing.
3. Consider Medication
Managing Histrionic Personality Disorder may include seeking psychiatric medical assistance for symptoms of depression, anxiety, PTSD, or unidentified, chronic physical ailments. Effectively treating one aspect of the illness can leave room for more effort to address other negative impacts of Histrionic Personality Disorder. Also, making changes in small steps is more likely to result in continued commitment to change.
4. Practice Mindfulness
Learn and practice any mindfulness tradition, such as Yoga, Qi Gong, Tai Chi, or meditation. This can go a long way to reducing emotional instability. Mindfulness practices positively impact mind, body and emotions providing overall stress relief. It doesn’t cost anything except some time for learning a new skill, and determination.
5 Tips for Supporting a Loved One With Histrionic Personality Disorder
To maintain relationships with individuals with Histrionic Personality Disorder, here are five recommendations:
1. Practice Radical Acceptance
A concept found in Dialectical Behavioral Therapy that asks one to accept the situation without judgment. It does not mean liking it, or condoning it, it means realizing and accepting that it is the present reality.
2. Educate Yourself
Become educated about this disorder and find the empathy to mentalize how Histrionic Personality Disorder feels and how it disrupts the person’s world. Imagine how exhausting and shallow it is to perform the drama of constant emotional dysregulation, and manipulation.
3. Set & Maintain Boundaries
Set firm, specific, appropriate boundaries. Make it clear what the boundaries are and hold to them without giving in to the whining, flattery, provocation, or dramatic flair. Remember: “Don’t buy the candy for your kid at the grocery store check-out. It may help in the moment, but you are now trapped in this cycle forever!”
4. Pay Attention to & Stop Manipulative Behaviors
This is particularly important when the manipulation is sexualized. Giving in positively reinforces the effectiveness of this inappropriate behavior and it becomes generalized to everyone.
5. Practice Self-Care
Find ways to care for your own mental, physical and emotional health. Maintain personal time, see a therapist, go to church, join a group, play a sport, or take a walk, whatever makes you feel grounded, peaceful and energized is appropriate.
HPD vs. Other Attention Seeking Personality Disorders
It’s important to tell the difference between Histrionic Personality Disorder and other personality disorders, particularly Borderline Personality Disorder, Antisocial Personality Disorder, and Narcissistic Personality Disorder.
Histrionic Personality Disorder vs. Borderline Personality Disorder
There are many key differences between Histrionic Personality Disorder and Borderline Personality Disorder, including distinctions in the following areas:
- Manipulation: Histrionic Personality Disorder behavior includes a higher level of overt sexual manipulation, flirtatiousness, and charm to maintain control over others and achieve rewards. BPD behavior feels manipulative due to emotional drama, crisis and chaos as compared to Histrionic Personality Disorder refined nuances to control others.7
- Thought Patterns: Histrionic Personality Disorder does not include dichotomous thinking, switching back and forth between opposite extremes like BPD tends to do. To individuals with Histrionic Personality Disorder their behavior is normal. For individuals with BPD their behavior makes them “weird, unusual, an outsider, as if something is wrong with them.”
- Attachment: BPD uses suicidal threats to maintain relationship proximity. Histrionic Personality Disorder imagines relationships are more intimate than they are but does care when the relationship is no longer useful.
- Self-Harm: Histrionic Personality Disorder is not known for self-harming to regulate emotions. It is more likely for them to seek admirers who they can manipulate for their own ends.
- Attention Seeking: You can count on both disorders to seek attention, but in different ways. Histrionic Personality Disorder works hard to keep up appearances, to be liked, and have social connections. BPD will want to be known for intellect or competence more than appearance and they will fight abandonment.
- Suicidal Thoughts & Behaviors: BPD diagnosis includes a greater likelihood of suicidal thoughts and completed suicides then Histrionic Personality Disorder.7
Similarities between Histrionic Personality Disorder and Borderline Personality Disorder include:
- Emotional instability: Both are disorders of emotional instability with rapid emotional changes.
- Dramatic Emotional Expression: Both disorders have characteristics of exaggerated and dramatic emotional expression; however, it appears differently. Histrionic Personality Disorder may exude more positive emotions and a need to be liked and BPH more negative emotions, including anger and rage.
- Impulsivity: Histrionic Personality Disorder and BBD individuals exhibit impulsive behaviors and poor problem solving.
Histrionic Personality Disorder vs. Antisocial Personality Disorder
Histrionic Personality Disorder can be compared to antisocial personality disorder, narcissistic personality disorder and dependent personality disorder. Antisocial personality disorder has the same type of manipulative behaviors, including charm, seduction and superficiality.
Histrionic Personality Disorder vs. Narcissistic Personality Disorder
The overlapping characteristics with narcissistic personality disorder are self-centeredness, provocation and using manipulations for control or influence. Due to poor problem-solving skills, naivete, and helplessness, individuals with Histrionic Personality Disorder appear similar to those with dependent personality disorder who need others to guide and validate their behavior.
A well-trained clinician using appropriate tests and assessments will be able to parse out the overlapping symptoms and provide an accurate diagnosis.
