by Joye C. Anestis
Perhaps it is because I grew up around theatre people, but to me histrionic personality disorder (HPD) is a fascinating mental illness. The overall descriptor of HPD is superficial emotion - folks with this illness reportedly experience superficial emotions, but act like they are experiencing deep and dramatic emotions instead. The stereotype of this illness is an overly dramatic woman who has to be the center of attention and uses her sexuality to achieve goals (think Blanche DuBois in A Streetcar Named Desire or Jenna on 30 Rock). Can you see how theatre people often get pointed to as a example of the disorder in real life? But what do we actually know about HPD? What does the scientific evidence tell us about it and about its treatment? It turns out, way less than we would hope.
A member of the Cluster B "dramatic & erratic" personality disorders, the DSM-IV-TR (2000) lists the followings symptoms of HPD (5 or more symptoms are needed to get the diagnosis):
- Uncomfortable when not the center of attention. If not the center of attention, an individual with this disorder may do something dramatic to gain attention.
- Interacts with others in an inappropriately seductive or provocative manner. This is not only done to romantic partners, but in a wide variety of inappropriate contexts, such as work.
- Emotions that rapidly shift and are shallow. Crying one minute, laughing the next, with no apparent depth to the emotion.
- Constant use of physical appearance to draw attention to self. Often these folks will dress very flamboyantly, seductively, or in other attention-getting manners. They are also very sensitive about their physical appearance and may get upset by critical comments about their appearance.
- Speech is impressionistic and lacks detail. They will state strong opinions but will be unable to explain specific & clear reasons behind these opinions.
- Is dramatic and theatrical, has exaggerated emotional expression. They may have extreme temper tantrums or sob uncontrollably about a minor incident.
- Suggestibility. They are easily influenced by others, by circumstances, or by current fads. They adopt convictions quickly.
- Believes relationships are more intimate than they actually are. They will describe a new acquaintance as a best friend, for example.
Diagnostic levels of HPD occur in 2-3% of the community (Grant et a., 2004; Samuels et al., 1994; APA, 2000) and in 10-15% of clinical samples (APA, 2000). One of the most persistent beliefs about HPD is the idea that it occurs at much higher rates in females than in males. This assumption, however, is not backed up by research. Several studies assessing the prevalence of HPD in both clinical and non-clinical samples have failed to find significant sex differences (Grant et al., 2004; Lilienfeld et al.., 1986; Nestadt et al., 1990). Younger people are at higher risk for this syndrome than older adults (Grant et al., 2004).
Despite the lack of sex differences in prevalence rates, some researchers have argued the clinicians apply the diagnosis of HPD in a biased manner based on biological sex. Ford and Widiger (1989) found that clinicians were more likely to diagnose females with HPD and males with antisocial personality disorder, regardless of their actual presentation. Even when the clinicians were presented with women who clearly met the antisocial profile, they diagnosed the women with HPD. Others have argued that the symptoms themselves are biased against women. Look at the symptoms again. Don't they sound like an extreme description of the feminine sex role? Sort of the extreme "damsel in distress" or Blanche DuBois type? Sprock (2000) found that feminine sex role-typed behaviors were rated as more representative of HPD than masculine sex role-typed behaviors. In the most rigorous test to date of sex bias in the personality disorder symptoms, Jane et al. (2007) examined the differential item functioning of the each personality disorder symptom. That means, they wanted to see if any of the symptoms of a personality disorder were endorsed at different rates by men and women with the same overall level of a personality disorder. No systematic sex bias was found for the HPD criteria.
Others have argued that the symptoms are also biased against certain racial and ethnic groups (e.g., African-American, Hispanic) but no studies have systematically examined this argument. The picture is even bleaker in terms of treating HPD...as no studies have been conducted to indicate which forms of treatment might be most effective for this condition. It seems reasonable to expect that some of the treatments known to be effective with other personality disorders might be useful in treating HPD - dialectical behavior therapy (Linehan, 1993a, 1993b), CBT (Beck, Freeman, Davis, & Associates, 2003), or SCRIPT (Cukrowicz & Joiner, 2005) - but we don't definitively know this to be true.
In my opinion, this is one of the most problematic criteria sets in all of the DSM. For one thing, the symptoms are difficult to reliably assess, even when using structured diagnostic interviews. Impressionistic speech, for instance, is a rather subjective criterion, requiring some clinical judgment when assessing it. Furthermore, and I think more problematic, none of the symptoms of HPD have been subjected to empirical study. I have not been able to come across one single study verifying the presence or empirical basis of any of these symptoms. In general, HPD is one of the most neglected syndromes in the DSM. Perhaps this is because it is rare to come across a person with only HPD and no other mental illness. The HPD symptom set is highly comorbid with the other Cluster B personality disorders (antisocial, borderline, and narcissistic; Cale & Lilienfeld, 2002; Zimmerman et al., 2005) and somatization disorder (Bornstein & Gold, 2008; Lilienfeld et al., 1986). Finally, the syndrome of HPD, on its own, is not incredibly impairing, making it rare for an individual to present for treatment of it. Some clinicians and researchers would argue that its not a mental illness at all, that this is one example where we are pathologizing just being different. But I would argue that there are instances when these symptoms can get in the way of functioning, when the lack of true social support, the inappropriate interpersonal skills, and the attention-seeking behaviors could lead to depression or other mental illnesses. But we need well-constructed research studies to help inform our conceptualization and our treatment of HPD, as well as to confirm whether or not it truly is an illness. It's unfortunate that the only conclusion we can draw about HPD right now is that we just don't know.