Cluster B personality disorders include those related to impulsive, dramatic, emotional, or erratic behavior. These include antisocial personality disorder (ASPD), borderline personality disorder (BPD), histrionic personality disorder (HPD), and narcissistic personality disorder (NPD). We will review histrionic personality disorder on this page.

Histrionic Personality Disorder

Histrionic personality disorder (HPD) is a personality disorder characterized by a pattern of excessive attention-seeking behaviors, usually beginning in early childhood, including inappropriate seduction and an excessive need for approval. People diagnosed with the disorder are said to be lively, dramatic, vivacious, enthusiastic, and flirtatious.

People with a histrionic personality disorder (HPD) may feel underappreciated or disregarded when they are not the center of attention. People with this disorder are typically “the life of the party” and have a “larger than life” presence. People with histrionic personality disorder (HPD) have a high need for attention, make loud and inappropriate appearances, exaggerate their behaviors and emotions, and crave stimulation. They may exhibit sexually provocative behavior, express strong emotions with an impressionistic style, and can be easily influenced by others.

Diagnostic Criteria

The DSM-5 defines histrionic personality disorder as 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 characteristics:

• is uncomfortable in situations in which they are not the center of attention
  

  Figure 1. Individuals with histrionic personality disorder crave stimulation and need to be the center of attention.

• interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
• displays rapidly shifting and shallow expression 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
• considers relationships to be more intimate than they actually are

Differential Diagnosis

The differential diagnosis (unique attributes that differentiate a disorder from others with similar features) for histrionic personality disorder includes narcissistic personality disorder, borderline personality disorder, dependent personality disorder, somatic symptom disorder, and illness anxiety disorder.

• Like histrionic personality disorder, patients with narcissistic personality disorder prefer to be the center of attention. However, patients with narcissistic personality disorder want attention, which results from admiration or veneration, whereas people with histrionic personality disorder are not particular about what type of attention they garner.
• Patients with histrionic personality disorder are similar to those with borderline personality because both demographics of patients experience intense emotions; however, patients with borderline personality disorder usually dislike themselves.
• Dependent personality disorder should be considered in the differential diagnosis for histrionic personality disorder as with both personality disorders; the patient will prefer to be around others. However, patients with dependent personality disorder tend to be more submissive, and their behavior is more inhibited as they are preoccupied with fears of rejection.
• Somatic symptom disorder and illness anxiety disorder are also included in the differential for histrionic personality disorder as patients with a histrionic personality disorder may use physical symptoms and complaints to gain attention from others.

Comorbidity

Most people with histrionic personality disorder also have other mental disorders. Comorbid conditions include antisocial, dependent, borderline, and narcissistic personality disorders as well as depression, anxiety disorders, panic disorder, somatoform disorders, anorexia nervosa, substance use disorder, and attachment disorders.

Epidemiology

The prevalence of histrionic personality disorder in the general population runs about 2%-3%. It is possible for people to have more than one personality disorder. Women are four times more likely to be diagnosed with histrionic personality disorder than men. However, research suggests that women may be overly diagnosed with this disorder when compared to men due to sexual-forwardness being less socially acceptable for women. Furthermore, men may be less likely to report their symptoms and thereby be under-diagnosed. Histrionic personality disorder tends to be ego-syntonic, meaning people with this disorder typically consider their behavior to be normal and struggle to identify a problem.

Etiology

Histrionic personality disorder probably develops as a combination of both learned and inherited factors. One hypothesis is that histrionic personality disorder may develop as a result of trauma experienced during childhood. Children may endure their trauma by coping with their environment in ways that may ultimately lead to a personality disorder. Personality disorders in childhood may originate as an adaptation to cope with a traumatic situation or traumatic environment.

Parenting styles may also influence the likelihood of developing a histrionic personality disorder. Parenting that lacks boundaries is over-indulgent, or inconsistent may predispose children to develop a histrionic personality disorder. Because histrionic personality disorder tends to run in families, there is some consideration that there is genetic susceptibility for this disorder that may be inherited. As with all psychiatric disorders, having a family history of personality disorders, psychiatric illness, or substance use disorders is a risk factor for histrionic personality disorder.

Treatment

Supportive psychotherapy is a recommended modality of treatment for patients with histrionic personality disorder, as this approach is found to be encouraging, reassuring, and non-threatening. Supportive psychotherapy aims to reduce emotional distress, improve self-esteem, and to enhance the patient’s coping skills, all through attentive and sympathetic listening.

Psychodynamic psychotherapy (also called insight-oriented therapy) has also proven to be a successful approach in treating patients with histrionic personality disorder. The goal of this therapy is to alter an aspect of a patient’s dysfunctional personality by integrating crucial developmental milestones a patient may have missed during previous stages of emotional maturation. Psychodynamic psychotherapy aims to resolve underlying, unconscious conflicts in an effort for patients to understand themselves and their behaviors better. The patients are encouraged to substitute excessively dramatic speech for a more adaptive action or behavior, to promote better communication with others. Through psychodynamic psychotherapy, patients learn to recognize that hyper-sexual, attention-seeking behaviors are maladaptive, and discover new, healthier ways to develop self-esteem.

While the gold standard for treating personality disorders is psychotherapy, patients with histrionic personality disorder may be profoundly symptomatic. Patients may experience affective dysregulation, where they frequently endure mood swings, anger, tearfulness, anxiety, and depression. While there are no FDA-approved medications for the treatment of histrionic personality disorder, affective dysregulation may be treated with antidepressants, mood stabilizers, and antipsychotics. Antidepressants that have proven to be effective include desipramine, fluoxetine, amitriptyline, and fluvoxamine. The mood stabilizers with proven therapeutic benefits include lamotrigine, carbamazepine, topiramate, valproate, and lithium. Research has demonstrated that antipsychotics such as risperidone, aripiprazole, olanzapine, and haloperidol have been useful in treating affective dysregulation. Patients with histrionic personality disorder may struggle with impulse control and regulation of their behaviors. Clinical trials have demonstrated that mood stabilizers specifically can target these symptoms.