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This post is part 6 of a series on a group of mental disorders known as Personality Disorders: so far, we’ve covered all of the Cluster A disorders, while today’s topic is the last part of Cluster B (see previous posts for details).
Today’s topic is Histrionic Personality Disorder. The word “histrionic” comes from the Latin word histrio, meaning “actor”; it also has the secondary meaning of “excessively dramatic or emotional; affected”. As Cluster B is known as the “dramatic” or “erratic” disorders, the title is fitting.
The DSM IV defines histrionic personality disorder as a long-term 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-
- is uncomfortable in situations in which he or she is not 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
In some ways, the symptoms of HPD are similar to those of BPD, especially in terms of rapidly changing emotions and viewing relationships as stronger or closer than they are. A major difference between the two is that HPD usually only affects the person’s reactions to others, rather than their view of themselves. While a person with BPD can bounce between seeing themselves as valuable or as worthless, depending on their interactions with others and their current mood, a person with HPD will not generally have the self-loathing aspect. Usually, they see nothing wrong with their actions or reactions, and will interpret any argument or disappointment as the other person’s fault.
Also, a person with BPD will alternate between wanting to pull other people closer or wanting to push others away to protect them. A person with HPD, on the other hand, does not have this belief, and will almost always try to pull others towards them.
So, if a histrionic person does not consider themselves to have any problems, then how can they be identified in a medical setting? One way of discovering that someone may have HPD is their reaction to a relationship ending. As they consider the relationship to be stronger than it actually is, a break-up will be a severe shock to them, especially if they believed that they were being a perfect partner… they may therefore report feeling intense depression to a doctor at the end of a relationship, and feeling victimised by the break-up. It is only when this pattern is found and the person is asked about it, that the histrionic traits can be picked up on.
Arguably, Histrionic PD could be seen as a “flipped” version of BPD. Where I have talked before about the idea of a person with BPD having little emotional object permanence for others, so needing others to be around constantly to remember their feelings towards them, HPD may reflect little object permanence for the self. So a person with HPD may feel like they only exist when they exist to others. i.e. they must be in someone’s attention in order to feel like they are being “real”.
As for a fictional example; many, many people have suggested the same character: Scarlett O’Hara from Gone With The Wind. She is an expert manipulator, able to make lots of men (even those engaged or married) fall for her while being unsure or unaware of her feelings for them. She wants to be the centre of attention in any situation, even doing so by interrupting a conversation on war to call it trivial. Although her main motivation is for a good cause (protecting her homestead, and herself from having to go through any more traumatic experiences), she is unable to realise when she has gone too far in achieving a goal.
While often appearing very competent (highly social, effective, intelligent and able to function well), she also can switch into a very self-centered, almost infantile mode… a trait common in real-life people with HPD. Although it is important to note that even though she fits the criteria incredibly well, her character was written years before the idea of HPD came about. (Of course, very few characters are ever developed or written with a specific disorder in mind.)
Psychological Criticisms of HPD
A criticism of the HPD criteria is that they are not gender-fair… in fact, they sound like an exaggerated version of what are regarded as negative female traits. Seeing as the majority of psychiatric professionals are male, it raises accusations of gender bias against female patients, especially as it includes criteria that cannot easily be applied to male patients, such as seduction and theatricality.
An example of this gender bias is in its diagnostic rates: over 75% of people diagnosed with NPD are male, while about 75% of people diagnosed with HPD are female.HPD has very similar criteria to both the Borderline and Narcissistic Personality Disorder criteria: the only major differences are that HPD does not feature suicidal behaviour (a strong Borderline trait) or envious/jealous behaviour (a Narcissistic trait). In fact, HPD and NPD are so similar that they could be seen as male and female sides of the same disorder, rather than two separate diagnoses.
Similarly to Schizoid PD, people with HPD will not usually be personally distressed by their thoughts or behaviours. Also, they are generally less likely to get into legal or medical trouble than people with many of the other PDs (again, Schizoid excepted; these two share some interesting parallels and differences). For example, many people with ASPD have criminal convictions, many with BPD will have attempted suicide, and many people with PDs may struggle to keep jobs. However, someone with HPD will usually appear to be very competent, perhaps more successful than the average person. This suggests that HPD may function as a milder version of NPD/ BPD.
Finally, HPD is the Cluster B disorder with the least existing research; possibly because people with HPD tend to keep a lower profile in regards to legal and medical services, or because people with HPD are unlikely to volunteer themselves for treatment or research into it. This lack of research means the potential causes, triggers, or treatments for HPD are even less clear than with other PDs.