Histrionic personality disorder vs narcissistic personality disorder

Pearls & Considerations

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This disorder is difficult to treat.

Like most personality disorders, patients present for treatment primarily when stress or other situational factors within their lives have made their ability to function and cope effectively impossible.

Suicidality and risk of self-injury should be assessed on a regular basis, and suicidal threats and self-mutilation should not be ignored or dismissed. Patients may present with a higher risk for, or history of, suicidal gestures.

Patients may report high rates of impulsive behavior motivated by sensation- or novelty-seeking.

An alternative model in DSM-5, section III, reconceptualizes histrionic personality disorder as “Personality Disorder, Trait Specified,” which rates (1) impairment in personality functioning (identity, self-direction, empathy, and/or intimacy) and (2) pathologic trait domains such as attention seeking, grandiosity, and manipulativeness.

Abstract

Histrionic personality disorder (HPD) is a personality disorder marked by excessive displays of emotionality and need for attention. HPD owes its historical origins to the early descriptions of ‘hysteria,’ although it gradually evolved into a more circumscribed diagnosis characterized by theatrical displays and interpersonal dysfunction. HPD overlaps markedly with a number of other conditions, including somatization disorder, antisocial personality disorder, and borderline personality disorder, although it is separable from them. A variety of psychotherapeutic approaches have been developed for HPD, although research on the treatment of HPD is still in its infancy.

Histrionic Personality Disorder

The most notable features ofhistrionic personality disorder (HPD) are excessive emotionality and an almost insatiable need for attention. These individuals are overly concerned with their physical appearance, they have poor frustration tolerance (with emotional outbursts), and their speech is impressionistic and vague. They view physical attractiveness as the core of their existence, and as such, are often provocative in dress, flamboyant in mannerisms, and inappropriately seductive in behavior. While they appear superficially charming, others tend to view them as vain and lacking in genuineness. Histrionic and narcissistic personality disorders are closely associated.

The differential diagnosis for HPD includes other cluster B personality disorders and somatization disorder. BPD differs from HPD in that the borderline patient displays more despair and suicidal/parasuicidal behaviors. The narcissistic patient is more preoccupied with grandiosity and envy than is the histrionic individual. The person with dependent personality disorder, while sharing the need for acceptance and reassurance, lacks the degree of emotionality seen in histrionic individuals. Somatization disorder can co-exist with HPD, but it is distinguished by the greater emphasis on physical complaints.

This disorder occurs in 2% to 3% of the general population. While women receive the diagnosis more often than do men, many clinicians believe that men are underdiagnosed. This disorder is more common in first-degree relatives of people with this disorder. Like most personality disorders, the course is variable. Some individuals experience an attenuation or softening of the core symptoms during middle age. Others may experience a complicated course, including co-morbid somatization, conversion, pain, and dissociative, sexual, and mood disorders. Two major caveats pertain to this diagnosis. The first is that emotional displays can vary from culture to culture, and what is histrionic in one culture may be identified as normal emotional expression in another. The other concerns the great co-morbidity this disorder has with BPD. Some believe that while not all borderline patents are histrionic, most HPD patients have sufficient borderline traits to merit a diagnosis of BPD.

Abstract

Histrionic personality disorder (HPD) is a personality disorder marked by excessive displays of emotionality and needs for attention. HPD owes its historical origins to early descriptions of “hysteria,” although it gradually evolved into a more circumscribed diagnosis characterized by theatrical displays and interpersonal dysfunction. HPD overlaps markedly with a number of other conditions, including somatic symptom disorder, antisocial personality disorder, and borderline personality disorder, although it is conceptually and empirically separable from them. A variety of psychotherapeutic approaches have been developed for HPD, although research on the treatment of HPD is in its infancy.

Histrionic Personality Disorder

Patients with histrionic personality disorder have an emotionally expressive style, seek excessive attention, are often dramatic, and may present with a conversion disorder. Physicians may feel flattered, captivated, seduced, or sexually aroused by these patients. Alternatively, the physician may feel overwhelmed by the patient's exaggerated or excessive emotions, embarrassed by the sexual overtures, depleted, or confounded by unexplained physical symptoms (e.g., pseudoseizures, paralysis, and mutism). These patients may unconsciously use their symptoms to elicit attention or support from the physician (Bornstein and Gold, 2008). They may also use their sexuality to recruit others to satisfy their needs to be taken care of or romantically pursued. They fear that they are not desired and will lose the care or admiration of others.

There are two different levels of functioning with the histrionic personality disorder.Kernberg (1984, 1992) describes a neurotically functioning “hysteric” who shows intact reality testing, defenses centered on repression, and stable and mature relations with others. The female hysteric has a flirtatious, clinging, childlike dependence in intimate relationships but can function at mature levels in social and work situations. Male hysterics have similar psychological conflicts but may appear as “macho” or “effeminate” (Kernberg, 1992). The hysteric of either sex often reacts to medical care with regression to a childlike, sexualized, dependent, and clinging position. They seek to gratify their wishes for dependent care by seducing or flattering others. Outside the office, they usually function well.

By contrast, a “histrionic patient” (Kernberg, 1984, 1992) can display transient losses of reality testing, defenses centered on splitting, chaotic sexualized relations with others, and a range of unexplained physical or somatic complaints. The histrionic patient is self-centered and self-indulgent, with a pervasive childlike dependence that extends from intimate relationships into all aspects of social and occupational functioning. Female histrionics typically act flirtatiously but may become indignant when a man shows sexual interest. Male histrionics also show the self-centered and dependent pattern but may also have hypochondriacal and antisocial features. Histrionics of both genders may seek medical care because of unexplained medical symptoms. They may react to medical care with regression but, unlike the hysteric, use defenses centered on “splitting”; they may see the physician as “all good or all bad” and can be extremely devaluing. They may appear severely self-centered, attention seeking, diffusely sexual, hypochondriacal, somatic, and exploitative. All of this may be coupled with an exhausting dependency on the physician.

In working with hysterics and histrionic patients, a physician needs to be friendly, neither overly warm nor reserved. Hysterics and histrionics often are helped when the physician uses parallel diagnostic inquiry when they present with somatic complaints. Parallel diagnostic inquiry is a technique in which the clinician simultaneously explores potential physical and psychological factors involved in the patient's complaints. Hysterics also may benefit from some gratification of their dependent wishes and a free discussion of their fears and emotions. They can often be reassured by an educational and informational approach to their medical illnesses and are capable of expressing gratitude to the physician. In contrast, the intense dependency of histrionics is often made worse by gratifying the patient's needs. Offering excessive emotional care may make them greedy or demanding for satisfaction of their needs. Histrionics benefit from firm, kind limit setting (especially to their sexual overtures), with neutral acknowledgment and gratification of their reasonable needs. They may be further helped by focusing on their distortions in reality perception and through interpretation of their splitting mechanisms.

Histrionic personality disorder

Histrionic personality disorder (HPD) was not included within the first edition of the APA diagnostic manual. It has been one of the more controversial of the PD diagnoses, given its close association with stereotypic feminine traits contributing to concerns regarding a potential gender bias (Oltmanns and Powers, 2012). HPD was proposed to be deleted in DSM-5 due in large part to the absence of much research specifically concerned with its etiology, pathology, or treatment (Blashfield et al., 2012; Skodol, 2012). Although HPD was recommended for deletion, attention-seeking, a trait central to the conceptualization of HPD, is included within the DSM-5 dimensional trait model (APA, 2013).

With respect to the criticism of the gender bias involved in HPD, it is not that the diagnosis is characterizing normal femininity as a PD but instead an exaggerated, stereotypic form of femininity, similar to how NPD and APD involve, in part, maladaptively extreme variants of traits associated with stereotypic masculinity. However, women are at times incorrectly diagnosed with the disorder by clinicians who do not use a semi-structured interview for its assessment (Oltmanns and Powers, 2012).

Histrionic persons tend to be emotionally manipulative and intolerant of delayed gratification. They are uncomfortable when not the center of attention, they are inappropriately sexually seductive, and they demonstrate a shallow self-dramatization (APA, 2013).

Etiology and risk factors

Histrionic personality disorder is of inconclusive causes, but there are studies that suggest multiple causes are possible. There is a strong correlation between the function of neurotransmitters and this disorder, as well as the other cluster B disorders. High levels of norepinephrine lead to anxiety, dependence, and high sociability. There is also a correlation of 0.6 that histrionic personality disorder is hereditary, in studies of twins. There are theories that authoritarian or distant attitudes, usually by the mother but sometimes both parents, may result in children developing this disorder. There may also be a relationship between this disorder and antisocial personality disorder, but this has not been proven. No specific risk factors have been identified.

Histrionic Personality Disorder

Those with histrionic personality want to be the center of attention, and are uncomfortable in situations where they are not. They can display rapidly shifting and shallow expressions of emotions, and their behavior is over-reactive and intensely expressed. They may crave novelty, stimulation, and excitement, and may constantly demand reassurance due to feelings of helplessness or dependence. The histrionic personality is over-concerned with physical attractiveness, and has little or no tolerance for frustration or delayed gratification. Their manner is seductive and flamboyant, though their expressionistic speech will most likely be devoid of depth and lack detail. The self for the histrionic personality is that “I am sensitive and everyone should admire and approve of me.” Their fictitious goal is to be the center of admiring attention without really working for it, like a child. Their methods include hypersensitivity, covert manipulation, emotional displays, and claims to be the center of attention. More common in females and in first-degree relatives, the histrionic personality’s impairments include being controlling or dependent in relationships, impressionable and easily influenced, and overly trusting. Of note in our discussion here is that the histrionic personality may somaticize a great deal as a means of gaining attention.

8.2.6 Histrionic

The histrionic personality disorder is characterized by an exaggerated display of emotions and by excessive attention seeking (American Psychiatric Association, in press). Histrionic individuals have an intense need to be the center of attention, feeling uncomfortable when not the focus of others’ attention. They use their physical appearance to draw attention, and have a seductive, sexually provocative style. Histrionic persons also have an overly dramatic, exaggerated style of expressing their emotions, but those emotions are shallow and rapidly changing. They tend to be suggestible or easily influenced by others, and tend to consider casual acquaintanceships as being much closer relationships than is actu- ally the case.

Histrionic Personality Disorder

Persons with histrionic personality disorder can be charming, expressive, and dramatic. They tend to seek attention, and they can be manipulative to maintain the interest of others. They may use behavior, including seductive sexual behavior, suicide attempts, or even physical illness, to obtain your attention. Their cognitive style can be characterized by dichotomous thinking, overgeneralization, and emotional reasoning. Their typical exaggerated emotional responses are superficial but charming.

Interpersonally, these persons feel inadequate and seek the approval or attention of others, including clinicians. Horowitz34 explained that patients with histrionic personality disorder seek attention to avoid their inner despair. However, they fear a loss of self-control when the desired attention is received. Through their demonstrations of helplessness, they provoke a rescuing response from the other person, including clinicians. Given that this response only reinforces their feelings of inadequacy, they reject the helpful response, leaving the clinician or rescuer feeling angry and helpless in return. Their personal histories will often demonstrate repeated life stories of moving from the role of victim to the aggressor and to the rescuer in their close relationships.34 They can often play out this style of interaction with clinicians.

Engaging patients with histrionic personality disorder in therapy or clinical care can be difficult. Although they present as focusing on their emotional needs, these patients use emotions in a superficial manner, and they often need some overt behavioral response to foster a sense of trust. For example, if you are working with a histrionic patient, your adherence to a previously agreed-on plan and your demonstrating this can be very important. As one histrionic patient explained, “Talk is cheap.”