Histrionic personality disorder
Synonyms and keywords: HPD; melodramatic personality; overacting personality; overplayed personality; theatrical personality

# Overview
Histrionic personality disorder (HPD) is a personality disorder characterized by a pattern of excessive emotionality and attention-seeking, including an excessive need for approval and inappropriate seductiveness, usually beginning in early adulthood. The essential feature of the histrionic personality disorder is an excessive pattern of emotionality and attention-seeking behavior. These individuals are lively, dramatic, enthusiastic, and flirtatious. They may be inappropriately sexually provocative, express strong emotions with an impressionistic style, and be easily influenced by others.  Treatment is often prompted by depression associated with dissolved romantic relationships. Medication does little to affect this personality disorder, but may be helpful with symptoms such as depression. Psychotherapy may also be of benefit.

# Historical Perspective
- Histrionic Personality Disorder shares a contrasting history with Conversion disorder and Somatization Disorder, though they are linked to the ancient notion of hysteria, or wandering womb.
- Ancient Greeks thought that excessive emotionality in women was caused by a displaced uterus and sexual discontent.
- During the Middle Ages, Christian ascetics claimed the cause of women's mental problems were witchery, sexual hunger, moral weakness, and demonic possession.
- By the 19th century, medical explanations proposed a weakness of women's nervous system related to biological sex.
- Thus, "hysteria" reflected the stereotype for women as vulnerable, inferior, and emotionally unbalanced.
- The extent to which the definition of Histrionic Personality Disorder currently reflects gender bias remains the subject of a controversy.
- "Hysteria" differentiated into conversion hysteria (later to become Conversion disorder) and hysterical personality (later to become Histrionic personality disorder) in the psychoanalytic literature as well as with the writings of Kraepelin, Schneider, and others.
- The concept of hysterical personality was well developed by the mid-20th century and strongly resembled the current definition of Histrionic personality disorder.
- The first DSM featured a symptom-based category, hysteria (conversion) and a personality-based category, emotionally unstable personality. DSM-II distinguished between hysterical neurosis (conversion reaction and dissociative reaction) and hysterical (histrionic) personality. In DSM-III, the term Hysterical Personality changed to Histrionic Personality Disorder to emphasize the histrionic (derived from the Latin word histrio, or actor) behavior pattern and to reduce the confusion caused by the historical links of hysteria to conversion symptoms.
- The landmark case of Ruth E. helped to fully define and emphasize the characteristics of the current DSM-IV diagnostic. DSM-III-R attempted to reduce the overlap between Histrionic Personality Disorder and Borderline Personality Disorder by dropping three overlapping criteria and adding two criteria that emphasized histrionicity. DSM-IV dropped two more criteria that did not appear to contribute to the consistency of the diagnosis, according to research done by Bruce Pfohl.

# Causes
- The cause of this disorder is unknown but childhood events and genetics may both be involved.
- Environmental factors such as a lack of criticism or punishment as a child, or positive reinforcement only following the completion of an approved behavior are all possible causes of histrionic personality disorder. 

# Differential Diagnosis
- Manipulative behavior
- Borderline personality disorder
- Dependent personality disorder
- Antisocial personality disorder
- Narcissistic personality disorder

# Epidemiology and Demographics

## Prevalence
- The prevalence of histrionic personality disorder is 1,840 per 100,000 (1.84%) of the overall population.

## Gender
- Histrionic personality disorder is more often diagnosed in women than in men; men with some quite similar symptoms are often diagnosed with antisocial personality disorder. However, psychologists claim that the unbalanced rates of diagnosis are due to ascertainment bias found in hospital settings as well as the stigma surrounding attention-seeking and sexual forwardness in men. 

# Risk Factors
- Genetic predisposition
- Environmental factors, primarily relating to childhood experiences with lack of criticism, punishment, or reinforcement.

# Natural History, Complications and Prognosis
- People with histrionic personality disorder are often able to function at a high level and can be successful socially and at work.
- People with histrionic personality disorder often have good social skills, however they tend to use these skills to manipulate others in order to become the center of attention. 
- Histrionic personality disorder may affect a person's social or romantic relationships or their ability to cope with losses and/or failures.
- People with this disorder may seek treatment for depression when romantic relationships end, although this is by no means a feature exclusive to this disorder. They often fail to see their own personal situation realistically, instead tending to dramatize and exaggerate their difficulties.
- People with histrionic personality disorder often blame others for the responsibility for failure or disappointment.
- People with histrionic personality disorder may go through frequent job changes due to the fact that they become easily bored and have trouble dealing with frustration.
- People with histrionic personality disorder often place themselves in risky situations due to their craving for novelty and excitement.
- Histrionic personality disorder is highly reactive. If there is another major disorder present, such as delusional disorder, then emotional intensity will create anger, rage, abuse and distance in relationships.
- Associated conditions are:
- Clinical depression
- Anxiety disorders
- Panic disorder
- Somatoform disorders
- Anorexia

## Complications
- Histrionic personality disorder can impair one's ability to create social, professional, or romantic relationships.
- Histrionic personality disorder can determine how one reacts to losses or failures.
- People with histrionic personality disorder are more likely to suffer from depression than the general population.

## Prognosis

# Diagnostic Criteria
- The person's appearance, behavior, and history, and a psychological evaluation are usually sufficient to establish the diagnosis. There is no test to confirm this diagnosis. Because the criteria are subjective, some people may be wrongly diagnosed as having the disorder while others with the disorder may not be diagnosed.

## DSM-V Diagnostic Criteria for Histrionic Personality Disorder

## Diagnostic Criteria (ICD-10)
- The International Statistical Classification of Diseases defines histrionic personality disorder as characterized by:
- Self-dramatization, theatricality, exaggerated expression of emotions
- Suggestibility, easily influenced by others or by circumstances
- Shallow and labile affectivity
- Continual seeking for excitement and activities in which the patient is the center of attention
- Inappropriate seductiveness in appearance or behavior
- Over-concern with physical attractiveness

## History and Symptoms
- Literature differentiates histrionic personality disorder according to gender.
- Women with HPD can be self-centered and intensely dependent on others. They are emotionally labile and very clingy in immature relationships. Females with HPD project their own unrealistic intentions onto people with whom they are involved.  They are emotionally shallow and don't do well understanding themselves or others too deeply. Their selection of marital or sexual partners is often extremely inappropriate. Women with HPD  tend to enter into abusive relationships with partners who increase in their abusiveness as time wears on. Pathology can increase with the level of intimacy in these relationships. Women with HPD can show inappropriate and very intense anger either towards their spouse or others. They may engage in manipulative suicide threats or self-harm as an aspect of general manipulative interpersonal behavior.
- Males with HPD usually present problems of identity crisis, disturbed relationships, and lack of impulse control. They have anti-social tendencies and are inclined to exploit physical symptoms. These men are emotionally immature, dramatic, and very shallow.
- Both men and women with HPD engage in disinhibited behavior.
- The symptoms can be summarized as follows:
- Constant seeking of reassurance or approval
- Excessive dramatics with exaggerated displays of emotions
- Excessive sensitivity to criticism or disapproval
- Inappropriately seductive appearance or behavior
- Excessive concern with physical appearance
- A need to be the center of attention (self-centeredness)
- Low tolerance for frustration or delayed gratification
- Rapidly shifting emotional states that may appear shallow to others
- Opinions are easily influenced by other people, but difficult to back up with details
- Tendency to believe that relationships are more intimate than they actually are
- Threatening or attempting suicide to get attention

## Mnemonic
A mnemonic that can be used to remember the criteria for histrionic personality disorder is PRAISE ME:
- P - provocative (or seductive) behavior
- R - relationships, considered more intimate than they are
- A - attention, must be at center of
- I - influenced easily
- S - speech (style) - wants to impress, lacks detail
- E - emotional lability, shallowness
- M - make-up - physical appearance used to draw attention to self
- E - exaggerated emotions - theatrical

## Lab Findings
- There are no diagnostic laboratory findings associated with histrionic personality disorder.

## Imaging
- Imaging studies are usually not indicated in diagnosis of histrionic personality disorder.

# Treatment
The treatment of histrionic personality disorder can include:
- Family therapy
- Medications
- Alternative therapies
It is important for the therapist and family members to monitor and record all situations that trigger the HPD so that the deep underlying overload of pain can be accessed and released for therapeutic change.
Because of the lack of research support for work on personality disorders and long-term treatment with psychotherapy, the empirical findings on the treatment of these disorders remain based on the case report method and not on clinical trials. On the basis of case presentations, the treatment of choice is psychotherapy aimed at self-development through resolution of conflict and advancement of inhibited developmental lines. Group therapy is not recommended for those with HPD because it often perpetuates histrionic behavior because the person then has an audience to play off of.