What Is Histrionic Personality Disorder (HPD)?

What Is Histrionic Personality Disorder (HPD)?

Histrionic personality disorder is a mental condition characterized by a pattern of extreme emotionality and attention-seeking behavior that begins by early adulthood and is obvious in different situations.

HPD is one of 10 personality disorders recognized in the DSM-5. It is classified as one of the Cluster B disorders, which are characterized as dramatic, overly emotional, and/or erratic. The word histrionic means “dramatic or theatrical."

Histrionic personality disorder affects approximately 3.8 million adults in the United States (approximately 1.8%). The disorder is characterized by shallow emotions, attention-seeking, and manipulative behavior.

Symptoms 

In some cases, you may not realize that you have histrionic personality disorder because your way of thinking and behaving seems natural to you. And you may blame others for the challenges you face.

People with histrionic personality disorder may:

• Display exaggerated symptoms of weakness or illness and may use threats of suicide to manipulate others
• Display excessive but shallow emotions and attention-seeking behaviors (i.e., they are constantly “performing” in order to gain attention)
• Experience fleeting moods, opinions, and beliefs; they are also very suggestible and quick to respond to fads
• Need others to witness their emotional displays in order to gain validation or attention
• Use sexually provocative behaviors to control others or gain attention

Diagnosis

Since HPD can have symptoms similar to other psychiatric disorders and medical illnesses, your doctor will likely first make a differential diagnosis to rule out other disorders or medical conditions that may be causing the symptoms.

According to the DSM-5, a person must have five or more of the following signs or symptoms to be diagnosed with HPD:

• Discomfort in situations in which you're not the center of attention
• Interaction with others that's often characterized by inappropriate sexually seductive or provocative behavior
• Rapidly shifting and shallow expression of emotion
• Consistently uses physical appearance to draw attention to self
• Style of speech that is excessively impressionistic and lacking in detail
• Shows self-dramatization, theatricality, and exaggerated expression of emotion
• Is easily influenced by others or by circumstances
• Considers relationships to be more intimate than they actually are

HPD vs. BPD

There is a great deal of overlap between the features of histrionic personality disorder (HPD) and borderline personality disorder (BPD), so much so that some experts believe that HPD may not actually be distinguishable from BPD.

According to DSM-5, "although borderline can also be characterized by attention-seeking, manipulative behavior, and rapidly shifting emotions, it is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and identity disturbance".

The conditions share similarities including:

• Share the features of rapidly shifting and reactive emotions
• Are associated with impulsive behavior
• Are characterized by a very strong expression of emotion

Some clinicians argue that the qualities of these symptoms are different in HPD versus BPD—specifically that the rapidly shifting emotions in HPD are not experienced with the same depth and intensity as those in BPD. Other experts, however, have argued that HPD and BPD are not necessarily distinct disorders.

However, despite predictions that the HPD diagnosis would be dropped in DSM-5, it was not, and so it remains its own specific and unique diagnosis.

Causes and Risk Factors

Although the precise cause of histrionic personality disorder isn't known, it is thought to be caused by a combination of genetic and environmental influences. Your genes may make you vulnerable to developing a personality disorder, and a life situation may trigger the actual development.

• Genes: Certain personality traits may be passed on to you by your parents through inherited genes; these traits are sometimes called your temperament.
• Environment: Your environment involves the surroundings you grew up in, events that occurred, and relationships with family members and others.

Other factors linked to an increased risk of developing or triggering personality disorders include:

• Parenting style, particularly inconsistent or over-indulgent boundaries
• Parents who model dramatic or volatile behaviors
• A family history of psychiatric disorders, substance use, or personality disorders
• Childhood Trauma

Related Conditions

Histrionic personality disorder also tends to co-occur with other personality disorders, including:

• Borderline personality disorder (BPD) 
• Narcissistic personality disorder
• Dependent personality disorder
• Somatic symptom disorder

Treatment

Histrionic personality disorder is often difficult to treat, partly because people with the condition often seek treatment only when the disorder is causing them major problems or stress. When help is sought, treatment may include psychotherapy, medications, or a combination of the two along with lifestyle changes.

Psychotherapy

Psychotherapy can be effective in treating HPD, as it can help reduce emotional distress, improve self-esteem, and enhance the person's coping skills. Supportive psychotherapy is the preferred treatment of choice. This approach focuses on improving self-esteem, reducing emotional distress, and improving coping skills.

According to the National Alliance on Mental Illness (NAMI), there are several types of psychotherapy that may also be useful for treating personality disorders, including:

• Dialectical behavior therapy (DBT): Teaches coping strategies for regulating emotions and improving relationships
• Cognitive behavior therapy (CBT): Helps people "to recognize negative thoughts and learn effective coping strategies"
• Mentalization-based therapy (MBT): Teaches people to notice internal states and develop empathy for others

Medication

While there are no FDA-approved medications for the treatment of histrionic personality disorder, the following types of medications may be used to treat affective dysregulation, or the mood swings, anger, tearfulness, anxiety, and depression that often accompany the disorder. Any associated depression or anxiety disorders could be treated with antidepressants.

• Antidepressants: Norpramin (desipramine), Prozac (fluoxetine), Elavil (amitriptyline), Luvox CR (fluvoxamine)
• Antipsychotics: Risperdal (risperidone), Abilify (aripiprazole), Zyprexa (olanzapine), Haldol (haloperidol)
• Mood stabilizers: Lamictal (lamotrigine), Tegretol (carbamazepine), Topamax (topiramate), Valproic acid (depakene), lithium

Holistic Therapy

Mindfulness techniques, including yoga, tai chi, and biofeedback, may also help people with personality disorders control their inner feelings including impulsivity and emotional reactivity.

Coping

People with HPD often go underdiagnosed and undertreated, so perhaps the best way to improve your symptoms is to first identify them. With appropriate treatment, you can learn to manage symptoms and come up with a self-care plan to improve quality of life, including:

• Establishing consistent eating and sleeping schedule
• Exercising on a regular basis
• Avoiding drugs and alcohol
• Enlisting the help of trusted friends and family to keep you on track

For Loved Ones

If a friend or family member has histrionic personality disorder, it is important to encourage that person to seek help. Without professional treatment, it is unlikely that the symptoms and their related impacts on relationships will improve. Do your best to learn about HPD, including symptoms and treatment, so you can better understand and support your loved one.