What is Histrionic Personality Disorder?

Histrionic personality disorder (HPD) is a type of personality disorder, characterised by intense, unstable emotions, distorted self-image, and attention-seeking behaviours. It is part of the “Cluster B” group of personality disorders, which also include borderline, antisocial and narcissistic personality disorders. People with HPD are generally described as charming, manipulative, flirtatious, seductive and impulsive.¹

This article will aim to outline HPD and explore its causes, symptoms and how the disorder can be managed. The key points of the article include:

• HPD is a psychiatric personality disorder
• People with HPD have a ‘dramatic’ personality, demonstrating exaggerated emotions and attention-seeking behaviour
• Mostly people assigned female at birth (AFAB) are diagnosed with HPD
• HPD is part of the Cluster B group of personality disorders
• It is likely that several factors can lead to the development of HPD
• There is currently no cure for HPD
• Psychotherapy is the preferred way to manage HPD

Overview

Histrionic personality disorder derives its name from the concept of Hysteria, with the foundations of modern histrionic personality traceable to Freud’s description of “hysterical neurosis”.² It is also often commonly referred to as dramatic personality disorder. 

The prevalence of HPD ranges from less than 1% to 3% of the general population and is one of the least studied Cluster B personality disorders.³ People with Cluster B personality disorders are frequently described as volatile, dramatic and erratic, and as they are so closely linked it is common for people to be diagnosed with more than one type of Cluster B personality disorder.¹

In general, people with HPD exhibit exaggerated emotions and attention-seeking behaviours, which may lead them to have frequent suicidal threats and gestures.³ Often, they use sexual behaviour to draw attention from others. They also have a higher risk of developing other mental health disorders with HPD commonly occurring alongside:^4,5

• Other Cluster B personality disorders
• Depression- may result from alienation from friends and family
• Somatization/conversion disorder- may make up physical symptoms to get attention from other people
• Anxiety disorders- there is a prevalence of around 35-52% in people with personality disorders
• Eating disorders
• Substance use disorders- 10-15% of individuals in substance abuse treatment settings have HPD

The prevalence of at least one personality disorder in the general population is around 9%, however the prevalence of HPD is much lower. People AFAB are around 4 times more likely to have HPD than people assigned male at birth (AMAB), however this may be because those AFAB are over-diagnosed due to more negative prejudices surrounding them exhibiting overtly sexual behaviour. Additionally, people AMAB are less likely to report dramatic personality traits, and so conversely may be under-diagnosed. Finally, as people with HPD usually regard their behaviour as ‘normal’, this could also lead to under-diagnosis of the disorder and may only be identified once an individual’s work/personal life is affected.⁶

Although there is no cure for HPD, most people diagnosed can lead useful and productive lives. Most people with HPD benefit from therapy and tend to have improved outcomes through the recognition of their condition. However, people with severe HPD, and where it may coexist alongside another mental disorder, may experience problems in their work and personal lives.² As personality continues to develop through adolescence, HPD is usually diagnosed after the age of 18. Mental health professionals generally decide on a diagnosis of HPD after evaluating if behaviours meet the DSM-5 criteria.¹ 

However, a diagnosis of HPD may be subject to the opinion of the mental health professional involved and therefore may be misdiagnosed.

Causes of histrionic personality disorder

The cause of HPD is not entirely understood, and it is likely that a multitude of factors may lead to the development of HPD. It probably results from a combination of both inherited and learned factors.

It is thought that one of the possible causes of HPD is childhood trauma.⁷ This builds upon the idea that pathological personality development is often dependent upon a traumatic environment experienced during childhood.  As HPD is often associated with distorted sexual behaviour, one theory is that sexual abuse may trigger HPD development. Furthermore, as learned sexual behaviour may manifest to fulfil nurturing needs not experienced in childhood, this implies that HPD development is also linked to childhood neglect. Case histories of people with HPD support this theory, but it is still unclear what forms of childhood trauma influence the development of HPD the most and its subsequent severity.⁷  

As HPD often runs in families, it is thought that there are some genetic and biological factors which influence HPD development.¹ Some studies have shown that one of the neural systems in the brain called the noradrenergic system is overactive in patients with HPD. This neural system is responsible for the release of a neurotransmitter called norepinephrine. People with HPD often have excessive emotional reactions, which may be influenced by the over-activity of norepinephrine and related neurotransmitters.

Another proposed cause of HPD is the influence of parenting styles. It is thought that parents who are inconsistent, over-indulge their children and have few boundaries may increase the likelihood of their children developing HPD. Furthermore, parents who exhibit HPD-like behaviour themselves are more likely to have children with HPD.¹ This may be because children adopt and learn from the behaviour shown by their parents, or because of previously mentioned genetic factors.

Signs and symptoms of histrionic personality disorder

There are a range of signs and symptoms that people with histrionic personality disorder may exhibit. These include:¹

• Feelings of underappreciation when not the centre of attention
• “Larger than life” presence
• Inappropriately sexual behaviours
• Rapidly shifting emotions
• Dramatic and emotionally expressive
• Public displays of emotion which may embarrass friends/family
• Easily influenced by people they admire
• Physical appearance may be used to attract the attention of other people
• Vague way of speaking
• Consider relationships with others to be closer than they actually are

Research has also shown that the signs and symptoms of people with HPD may change depending on the age of the individual. For example, the use of seduction to grab the attention of others is more commonly adopted by young adults with HPD. Conversely, older adults with HPD may use paternal/maternal seduction to gain attention.

Management and treatment for histrionic personality disorder

​​Histrionic personality disorder is usually diagnosed by a mental health professional after evaluating  relevant patterns of behaviour and symptoms.¹ It is important for HPD to be diagnosed as early as possible so the patients can benefit maximally from treatment. There is currently no cure for HPD, however it can be managed in several different ways, including:

• Psychotherapy
• Group therapy
• Cognitive behavioural therapy
• Family therapy

Psychotherapy is the preferred treatment choice for people with HPD, as it has been found to be a supportive treatment which can decrease emotional distress and improve the patients coping strategies. One form of psychotherapy called psychodynamic psychotherapy has been proven to be particularly effective. It aims to treat a patient’s dysfunctional personality by resolving underlying trauma and making the patient recognise their disordered behaviours. This can lead to patients learning new, healthier, and more adaptive behaviours.¹

Group therapy has also been shown to be effective in the management of HPD, although it is not normally recommended as the first-line treatment. As people with HPD often have problems with their interpersonal relationships, group therapy can allow patients to role-play problems at work or in their personal lives. This can allow them to understand other people’s point of view and implement healthier behaviours in real life. However, group therapists need to be aware that individuals with HPD can dominate sessions and so firm boundaries need to be set.

Cognitive behavioural therapy (CBT) aims to reduce maladaptive thoughts that people with HPD may have. The goal of CBT is to transform dysfunctional thinking into healthier and more systematic thinking, so that they can deal with problems in a more effective way.

Family therapy is also important for patients with HPD, as their abnormal behaviour often affects family members and their relationships with them. This type of therapy can teach people with HPD how to avoid and resolve familial conflict. It also allows family members to voice how they feel in response to these unhealthy behaviours in a safe setting.

Medications are not currently recommended for people with HPD because the patient may abuse the medication. However, as HPD often exists alongside another mental health disorders, patients may be receiving medication for another disorder e.g., antidepressants, anti-psychotics, and anti-anxiety medication.

FAQs

How is histrionic personality disorder diagnosed?

Histrionic personality disorder is usually diagnosed by a mental health professional using DSM-5 criteria.

Can histrionic personality disorder be prevented?

There are currently no options to prevent histrionic personality disorder. However, early diagnosis can be beneficial for patients and families. Additionally, educating people about HPD may be able to prevent mild histrionic behaviour from developing into severe HPD.

Who is  at risk of developing histrionic personality disorder?

It is thought that a multitude of factors lead to the development of histrionic personality disorder, including a history of childhood trauma, genetic factors, and parenting styles. People who suffer from another psychiatric illness are also more likely to develop histrionic personality disorder.

How common is histrionic personality disorder?

Histrionic personality disorder has a prevalence of around 1-3% in the general population. People AFAB are four times more likely to be diagnosed with histrionic personality disorder than those AMAB.

When should I see a doctor?

It is important to see a doctor if your behaviour is affecting your personal relationships and your work performance.

Summary

Histrionic personality disorder is a psychiatric illness and part of the Cluster B group of personality disorders. It is distinguished by exaggerated emotions and attention seeking behaviour. It is generally a functional psychiatric disorder but can lead to problems in the individuals personal and work life. Furthermore, HPD often co-exists alongside another psychiatric disorder, such as depression, anxiety, and substance use disorder. 

The cause of HPD is not entirely known but is thought to arise due to a multitude of factors, including childhood trauma, genetic/biological factors, and parenting styles. 

Although there is currently no definitive treatment option for HPD, it can be managed using psychotherapy, group therapy, cognitive behavioural therapy, and family therapy. Ideally, HPD should be diagnosed as early as possible so that patients can get the full benefit from therapy.