Histrionic Personality Disorder

Histrionic personality disorder Graphics courtesy of My DynamicsOpens in new window

Histrionic personalities may initially seem charming, likeable, energetic, and seductive, but as time passes they are likely to be seen as emotionally unstable, immature, and egocentric. This personality style and disorder predominates in females, and presents with a caricature of femininity in dress and manner.

Clinical Presentation

The clinical presentation of the Histrionic Personality Disorder can be characterized by the following behavioral and interpersonal style, thinking style, and feeling style.

The behavioral style is characterized as charming, dramatic, and expressive, while also being demanding, self-indulgent, and inconsiderate.

Persistent attention-seeking, mood lability, capriciousness, and superficiality further characterize their behavior.

  • Interpersonally, these individuals tend to be exhibitionistic and flirtatious in their manner, with attention-seeking and manipulativeness being prominent.
  • The thinking or cognitive style of this personality can be characterized as impulsive and thematic, rather than being analytical, precise, and field-independent.

In short, their tendency is to be non-analytic, vague, and field-dependent.

Histrionic personalities are easily suggestible and rely heavily on hunches and intuition. They avoid awareness of their own hidden dependency and other self-knowledge, and tend to be “other-directed” with respect to the need for approval from others. Therefore, they can easily dissociate their “real” or inner self from their “public” or outer self.

Their emotional or affective stle is characterized by exaggerated emotional displays and excitability, including irrational outbursts and temper tantrumsOpens in new window.

Although they are constantly seeking reassurance that they are loved, they respond with only superficial warmth and charm and are generally emotionally shallow. Finally, they are exceedingly rejection-sensitive.

DSM-5 Characterization

Individuals with this personality disorder are characterized by an unremitting pattern of attention-seeking and emotionality.

  • They tend to be uncomfortable in situations where they cannot be the center of attention.
  • Their emotional reactions tend to be shallow and rapidly shifting. Typically, they draw attention to themselves with the way they dress.
  • Their manner of speech tends to be impressionistic with few details.

These individuals are easily influenced by others or circumstances. They are likely to perceive relationships as more intimate than they really are. They often engage in provocative and inappropriate seductive sexual behavior. Furthermore, they are dramatic and overly exaggerate their emotional expressions (American Psychiatric Association, 2013).

Case Example: Ms H.
Ms. H. is a 19-year-old female undergraduate student who requested psychological counseling at the University Health Services for “boyfriend problems.” Actually, she had taken a nonlethal overdose of minor tranquilizers the day before coming to the Health Services. She said she took the overdose in an attempt to kill herself because “life wasn’t worth living” after her boyfriend had left the afternoon before.

She was an attractive, well-dressed woman adorned with makeup and nail polish, which contrasted sharply with the very casual fashion of most coeds on campus. During the initial interview she was warm and charming, maintained good eye contact, yet was mildly seductive.

At two points in the interview she was emotionally labile, shifting from smiling elation to tearful sadness. Her boyfriend had accompanied her to the evaluation session and asked to talk to the therapist. He stated the reason he had left the patient was because she made demands on him which he could not meet, and that he “hadn’t been able to satisfy her emotionally or sexually.” Also, he noted that he could not afford to “take her out every night and party.”

Biopsychosocial – Adlerian Conceptualization

The following biopsychosocial formulation may be helpful in understanding how the Histrionic Personality Disorder develops. Biologically and temperamentally, the Histrionic Personality Disorder appears to be quite different from the Dependent Personality DisorderOpens in new window.

Unlike the dependent personality, histrionic personality is characterized by a high energy level and emotional and autonomic reactivity.

Millon and Everly (1985) noted that histrionic adults tended to display a high degree of emotional lability and responsiveness in their infancy and early childhood. Their temperament that can be characterized as hyper-responsive and externally oriented for gratification.

Psychologically, Histrionic Personality Disorder has the following characteristic view of self, world-view, and life goal.

  • The self-view of the histrionic will be some variant of the theme: “I am sensitive and everyone should admire and approve of me.”
  • The world-view will be some variant of: “Life makes me nervous, so I am entitled to special care and consideration.”
  • Life goal is some variant of the theme: “Therefore, play to the audience, and have fun, fun, fun.”

In addition to biological and psychological factors, social factors such as parenting style and injunction, and family and environmental factors, influence the development of the histrionic personality.

The parental injunction for the histrionic personality involves reciprocity: “I’ll give you attention, if you do X.” A parenting style that involves minimal or inconsistent discipline helps insure and reinforce the histrionic pattern.

The histrionic child is likely to grow with at least one manipulative or histrionic parent who reinforces the child’s histrionic and attention-seeking behavior.

Finally, the following sequence of self and system perpetuants are likely to be seen in the Histrionic Personality Disorder:

  • denial of one’s real or inner self;
  • a preoccupation with externals;
  • the need for excitement and attention-seeking which leads to a superficial charm and interpersonal presence;
  • and the need for external approval. This, in turn, further reinforces the dissociation and denial of the real or inner self from public self, and the cycle continues.

Treatment Considerations

The differential diagnosis of the Histrionic Personality Disorder includes the Narcissistic Personality DisorderOpens in new window and the Dependence Personality DisorderOpens in new window. It also includes the Histrionic-Borderline Disorder, which is a decompensated version of the Histrionic Personality DisorderOpens in new window, and, according to Millon (2011), the Histrionic-Antisocial Personality Disorder.

Associated diagnoses include: Persistent Depressive DisorderOpens in new window, Social Anxiety DisorderOpens in new window, and Obsessive-Compulsive DisorderOpens in new window. In addition, Major DepressiveOpens in new window and Bipolar DisordersOpens in new window are common in the decompensated Histrionic Personity Disorder.

The treatment of the Histrionic Personality Disorder may present a considerable challenge to the clinician. For the purpose of this discussion, we will limit ourselves to some general considerations about treatment goals, limits, and medications.

General treatment goals include helping the individual integrate gentleness with strength, moderating emotional expression, and encouraging warmth, genuineness, and empathy. Because the histrionic personality can present as dramatic, impulsive, seductive, and manipulative with potential for suicidal gestures, the clinician needs to discuss the matter of limits early in the course of therapy regarding professional boundaries and personal responsibilities.

Some histrionic personalities, particularly those who bear some resemblance to Hysteroid DysphoriaOpens in new window, respond to certain antidepressant agents, particularly Parnate and Nardil (Liebowitz & Klein, 1979). Otherwise, unless a concurrent acute psychotic or Major Depressive Episode is present, psychotherapy is the principal mode of treatment.

  1. American Psychiatric Association. Diagnositc and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Association, 2013.
  2. Widiger, T. A. & Bornstein, R. F. (2001). Histrionic, dependent, and narcissistic personality disorders. In H. E. Adams & P. B. Sutker (Eds)., Comprehensive handbook of psychopathology (pp. 509 – 534). New York: Kluwer Academic.
  3. Dobbert, Duane L. Understanding Personality Disorders: An Introduction. Lanham, MD: Rowman & Littlefield, 2011.
  4. Sperry, Len. Handbook of Diagnosis and Treatment of the DSM-5 Personality Disorders, 3rd ed. New York, NY: Routledge, 2016.