Histrionic Personality Disorder
A person with histrionic personality disorder relies heavily on the attention and approval of others to maintain their own self-esteem, and pursues this need for reassurance through seductive, overdramatic, and attention-seeking behaviour. Speech and manner tend to be theatrical and hyperbolic, and first impressions of openness and social charm are often mixed, on closer contact, with shallowness, flirtatiousness, and a manipulative quality. Genuine self-reflection beyond the most superficial level is characteristically lacking.
This has traditionally been noted as a controversial category, described in detail yet seldom actually diagnosed, and criticised for carrying overtones of sexism insofar as it can be applied as a caricature of exaggerated femininity rather than as a rigorously assessed diagnosis.
Also known as
- Hysterical personality disorder
- An older term often used interchangeably with histrionic personality disorder.
Recognition features
- Self-dramatisation and overdramatic, theatrical behaviour, often paired with hyperbolic speech and melodramatic descriptions of ordinary events
- Sexual provocativeness and egocentricity, alongside an excessive demand for praise and approval from others
- An initial appearance of openness and social skill, which on closer contact proves mixed with shallowness, flirtatiousness, and manipulativeness
- Lability of mood and a lack of capacity for anything beyond the most superficial introspection
- A marked sensitivity to separation and to any threat to the attention or approval the person depends on
Eliciting it at interview
- Observe the person's manner and speech directly during the interview for theatricality, dramatisation, and hyperbole, rather than relying solely on history
- Ask how the person typically seeks reassurance or attention from others, and how they respond when this is withheld
- Gently test the depth of self-reflection available, since a characteristic lack of insight beyond superficial description is a recognised feature
- Be alert to the diagnosis being applied inconsistently or with a gendered double standard, and apply the same threshold of genuine functional impact used for any other personality disorder
Distinguishing features
- Differs from dependent personality disorder in the direction of the person's approach to securing nurture: the histrionic person actively and dramatically pursues attention, whereas the dependent person passively relies on others to take the initiative
- Differs from a genuine link to conversion or dissociative disorders, once assumed but shown by later research not to hold in the way originally thought, despite the shared 'hysterical' label
- A short-lived histrionic presentation occurring only during a depressive or hypomanic episode does not itself amount to a personality disorder, and should be expected to resolve as the episode does
- Somatisation is often associated with this personality pattern, historically described together as a condition once termed Briquet's syndrome
Common misconceptions
- That histrionic personality disorder is essentially just an exaggeratedly feminine or dramatic personal style; the diagnosis has been criticised precisely for this kind of caricature and requires the same genuine functional impact as any personality disorder before it is applied
- That histrionic personality disorder necessarily reflects an underlying conversion or dissociative disorder; more recent research has not supported this once-assumed link
- That a briefly dramatic or attention-seeking presentation during an episode of depression or hypomania indicates this personality disorder; such short-lived features should resolve with the episode and should not be labelled as personality disorder
Related phenomena
Narcissistic Personality Disorder
Related syndromes
Practice this
A 34-year-old woman describes an ordinary work disagreement in highly theatrical, hyperbolic terms, dressed strikingly for the appointment, and repeatedly steers the conversation back toward whether you find her impressive. On closer contact her initial charm proves mixed with flirtatiousness and a degree of manipulativeness, and she becomes visibly upset when you glance at your notes rather than at her. What personality pattern is this? · A man becomes markedly more dramatic, flirtatious, and attention-seeking than usual during a hypomanic episode, a pattern his family says is completely unlike him when well. Before revealing the answer: does this amount to histrionic personality disorder? · Two patients both seem to organise their lives around other people's attention and approval. Before revealing the answer, decide what distinguishes dependent personality disorder from histrionic personality disorder. · Two patients each seem to organise much of their life around securing other people's attention and care, but in very different styles — one dramatic and demanding centre stage, the other quiet and compliant. Before revealing the answer, decide which is histrionic and which is dependent personality disorder, and what tells them apart. · Two patients each seem to crave a great deal of attention from others. Before revealing the answer, decide what would help you tell narcissistic personality disorder apart from histrionic personality disorder. · You are assessing a patient for features of histrionic personality disorder. Before revealing the answer, decide what you would specifically ask about and observe during the interview. · Explain why an initially charming, socially skilled first impression is not reassuring evidence against histrionic personality disorder, but can in fact be part of the pattern itself.
Illustration
A 34-year-old woman describes her recent break-up in vivid, theatrical detail during a routine appointment booked for an unrelated matter, dramatically declaring she 'nearly died of a broken heart,' and within minutes turns her attention to praising the doctor's tie, seeking a compliment in return before the consultation can return to its original purpose.
References
- Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 10, 'Personality Disorders'.