Histrionic Personality Disorder (HPD)

Histrionic Personality Disorder (HPD)

Histrionic Personality Disorder (HPD)

Patients with histrionic PD (HPD) have a long-standing pattern of extreme attention seeking and emotionalism that seeps into all areas of their lives. These people satisfy their need to be at center stage in two main ways: (1) Their interests and topics of conversation focus on their own desires and activities; and (2) they continually call attention to themselves by their behavior, including speech. They are overly concerned with physical attractiveness (of themselves and of others, as it relates to them), and they will express themselves so extravagantly that it can seem almost a parody of normal emotionality. Their need for approval can cause them to be seductive, often inappropriately (even flamboyantly) so. Many lead normal sex lives, but some will be promiscuous, and still others may be uninterested in sex.

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These people are often so insecure that they constantly seek the approval of other people. Dependence on the favor of others may cause their moods to seem shallow or excessively reactive to their surroundings. Low tolerance for frustration can spawn temper tantrums. They usually like to talk with mental health professionals (it is another chance to be the center of attention), but because their speech is often vague and full of exaggerations, they can prove frustrating to interview.

Quick to form new friendships, people with HPD are also quick to become demanding. Because they are trusting and easily influenced, their behavior may appear inconsistent. They don’t think very analytically, so they may have difficulty with tasks that require logical thinking, such as doing mental arithmetic. However, they may succeed in jobs that set a premium on creativity and imagination. Their craving for novelty sometimes leads to legal problems as they seek sensation or stimulation. Some have a remarkable tendency to forget affect-laden material.

HPD has not been especially well studied, but it is reportedly quite common. It may run in families. The classic patient is female, though the disorder can occur in men.

Essential Features of Histrionic Personality Disorder

These patients not only crave the limelight, but are unhappy when they are not the focus of attention. They actively attempt to draw attention to themselves with their physical appearance and mannerisms. Their manner of speaking may be overly dramatic, but what they say tends to be vague, lacking specificity. They can be gushing or effusive when expressing their emotions, which, however, tend to be superficial and fleeting. Too open to suggestion, too readily influenced, these people may interpret relationships as being intimate when they’re not—even to the extent of behaving in ways that are improperly suggestive or seductive.

The Fine Print

The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, somatic symptom disorder, other personality disorders)

Angela Black

Angela Black and her husband, Donald, had come for marriage counseling; as usual, they were fighting.

“He never listens to me. I might as well be talking to the dog!” Tears and mascara dripped onto the front of Angela’s low-cut silk dress.

“What’s there to listen to?” Donald retorted. “I know I irritate her, because she complains so much. But when I ask how she’d like me to change, she can never put her finger on it.”

Angela and Donald were both 37 years old, and they had been married nearly 10 years. Already they had been separated twice. Donald made excellent money as a corporate lawyer; Angela had been a fashion model. She didn’t work often any more, but her husband made enough to keep her well dressed and comfortably shod. “I don’t think she’s ever worn the same dress twice,” Donald grumbled.

“Yes, I have,” she snapped back.

“When? Name one time.”

“I do it all the time. Especially recently.” For several moments Angela defended herself, without ever making a concrete statement of fact.

“Res ipsa loquitur,” said Donald with satisfaction.

“Oh, God, Latin!” She nearly howled. “When he puts in his superior, gratuitous Latin, it makes me want to cut my wrists!”

The Blacks agreed on one thing: For them, this was a typical conversation.

He worked late most nights and weekends, which upset her. She spent far too much money on jewelry and clothing. She relished the fact that she could still attract men. “I wouldn’t do it if you paid more attention to me,” she said, pouting.

“You wouldn’t do it if you didn’t listen to Marilyn,” he retorted.

Marilyn and Angela had been best friends since their cheerleading days in high school. Marilyn was wealthy and independent; she didn’t care what people thought, and behaved accordingly. Usually Angela followed right along.

“Like the pool party last summer,” put in Donald, “when you took off your suits to ‘practice cheers’ for the races. Or was that your idea?”

“What would you know about it? You were working late. Besides, it was only the tops.”

Evaluation of Angela Black

Angela’s personality style had a profound effect on her marriage, though the vignette hints that her other social relationships (for example, men at the party) were affected as well. More information would be needed to establish that she had been this way throughout her adult life. However, it would seem unlikely that her way of doing business with the world had developed recently.

Angela’s symptoms included a strong need to be the center of attention (HPD criterion A1) and sexual provocation (inferred from her dancing topless—A2); excessive concern with physical appearance (A4); dramatic emotional expression (A6); suggestibility (following the lead of her friend Marilyn—A7); and vague speech (commented on by her husband—A5). I thought she might have expressed a touch of rapidly shifting emotional expression (A3), too, but maybe that’s just me. Conservatively scored, she had at least six symptoms of HPD (five are required by the DSM-5 criteria).

Her clinician should gather information adequate to determine that Angela did not have any of the major mental disorders that commonly accompany HPD. These include somatic symptom disorder (had she been in good physical health?) and substance-related disorders.

Would Angela qualify for other PD diagnoses? She was centrally focused on herself, and she liked to be admired. However, she lacked the sense of grandiose accomplishment that characterizes patients with narcissistic PD. You can often identify histrionic features in people with borderline PD. Angela’s mood was somewhat labile, but she did not report interpersonal instability, identity disturbance, transient paranoid ideation, or other symptoms that characterize borderline patients. Her easy suggestibility might suggest dependent PD, but she was so far from leaning on her husband for support that she actively fought with him. With a GAF score of 65, I’d diagnose her as follows: