Histrionic Personality Disorder
HISTRIONIC PERSONALITY DISORDER (HPD) INTRODUCTION
The history of Histrionic Personality Disorder dates as back as 4000 years when it was called hysteria. The word histrionic means "dramatic or theatrical." Histrionic personality disorder is classified by psychologists with the group of personality disorders characterized by overly dramatic, emotional, impulsive or erratic reactions. It is defined as a mental disorder where a person is overly emotional and exhibits attention seeking behaviour. These people are lively and dramatic and they put on a show for other people in order to gain attention. But the attention is a facade. The histrionic performer plays a big dramatic game in order to deny intimacy and split off from the real self. Individuals with HPD can be described as manipulative, vain, and demanding. However, in addition to the focus on physical appeal, there may also be a genetic association between somatisation disorder and the histrionic personality disorder.
This type of behaviour is generally established in early adulthood. Individuals who display a few histrionic characteristics but function in generally healthy interactions with others are characterized as having a Histrionic Personality Style. Individuals who exhibit serious dysfunctional characteristics are clinically diagnosed as having Histrionic Personality Disorder
CAUSES OF HPD
The cause of this disorder is unknown, but childhood events such as deaths in the immediate family, illnesses within the immediate family which present constant anxiety, divorce of parents and genetics may be involved. Individuals who have experienced pervasive trauma during childhood have been shown to be at a greater risk for developing HPD as well as for developing other personality disorders. Histrionic Personality Disorder is more often diagnosed in women than men; men with some quite similar symptoms are often diagnosed with antisocial personality disorder.
Little research has been conducted to determine the biological sources, if any, of this disorder. Psychoanalytic theories suggest that the causes are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual's personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible -rather, it is the complex and intertwined nature of all three factors that are important. If a person has this personality disorder, then there is a slightly increased risk for this disorder to be carried over to their children.
Environmental factors also play an extremely significant role which may lead to Histrionic Personality Disorder. Early family environment and relationships have always been influential in the histrionic person's self-perception and excessive need for attention. All parents adopt the style of reciprocity i.e. the parent or any other significant person all the time says, "I'll give you attention, if you do X." This trains the child to look for cues of what to do to gain approval. Most parents do some of this with few or no negative consequences. But when an exceptionally sensitive child (sensitive to others) is constantly fed with these kinds of statements, he or she can become more inclined or prone towards this fanatical search for attention that influences the development of histrionic personalities.
The child receives attention and affection when he performs in a way that meets his parents' approval, but is ignored, or even punished at other times. Hence, a lack of criticism or punishment as a child, rewarding a child only when he completes certain approved behaviours, and unpredictable attention given to a child by his or her parent(s), totally confuses the child about what types of behaviour earn parental approval. All of these problems in family relationships are troubling for a growing child. Instead of feeling loved for who he is, he learns that he is only appreciated and cared for what he does. This leaves him with the painful feeling of being unloved and hence he begins to pay especially close attention to the approval of others and to behaving in ways that elicit the longed for attention. This shift from feeling good about being ones true self to trying to become what others want in order to be loved is a life altering movement.
People with a healthy and a strong sense of self have a realistic understanding of themselves, know their strengths and weaknesses, what they like and dislike, and are aware of their values and commitments. Although they value other's opinions, they aren't at the mercy of them. These people can enter into deep relationships and make lasting commitments, but they can also be alone without feeling anxious and abandoned. Histrionic Personalities and others without this healthy sense of self tend to be unaware of their true feelings and their likes, dislikes, and values. They become dependent on others, constantly search for attention, or engage in work or other activities to enhance their shaky self-esteem since they are unable to sit even briefly with their uncomfortable feelings. This discomfort is what drives the histrionic person to constantly seek attention.
SYMPTOMS OF HISTRIONIC PERSONALITY DISORDER
People with this disorder are usually able to function at a high level and can be successful socially and professionally. Such people usually have good social skills, but they tend to use these skills to manipulate other people and become the centre of attention. Unlike many other personality disorders, histrionic personality disorder does not necessarily have a negative impact on work or social functioning. People often describe the histrionic personality as energetic, attractive, and popular. People with the disorder are also often successful in their careers.
Common symptoms of histrionic personality disorder are listed below
1) Is uncomfortable in situations in which he or she is not the centre of attention. No matter how much attention they receive, it is never enough. They seek attention compulsively and are markedly uncomfortable when not at the centre of attention. They have to be the life of the party. If they fail in achieving this pivotal role, they act out or create hysterical scenes
2) Interaction with others is often characterized by inappropriate sexually seductive or provocative behaviour. Histrionics sexualize everyone and every situation. They constantly act flirtatious, provocative, and seductive, even when such behaviour is not warranted by circumstances or, worse still, is highly inappropriate (for instance in professional and occupational settings).
3) Shifting emotions: The expression of emotions of patients with HPD tends to be shallow and to shift rapidly.
4) Consistently uses physical appearance to draw attention to themselves: While most individuals with histrionic personality disorder are concerned with dressing well and attracting attention through physical attractiveness, some use startling or provocative appearance to get the attention they need. Their self-esteem is closely tied to physical attractiveness, appearance, and fitness. The desire for attention often manifests itself in the histrionic personality's appearance; being physically fit, wearing the latest fashions, having the best hairstyle and/or make up are common to people with histrionic personalities. The histrionic personality does not find aging comfortable or pleasant.
5) Has a style of speech that is excessively impressionistic and lacking in detail: Those with HPD also have a style of thinking and speaking that differs from most of us. They tend to be highly impressionistic and lacking in details and specifics. They express strong opinions with a dramatic flair, but when asked to explain themselves, their underlying reasons are vague and without supporting facts and details.
6) Shows self-dramatization, theatricality, and exaggerated expression of emotion: Anytime they perceive that they are not commanding the attention they seek, they may do something dramatic, create a scene, or tell an exaggerated story to draw the focus of attention to themselves.
7) Is highly suggestible, i.e., easily gullible and easily influenced by others or circumstances: Considers relationships to be more intimate than they actually are.
8) Despite being overtly friendly style, histrionic individuals are actually quite unable to form healthy, intimate, lasting relationships. They try to convince others that they have so much capacity for love that one person alone can't meet it! Sustaining meaningful, intimate relationships is difficult for people with histrionic personality disorder because most people with histrionic personality disorder lack emotional depth and maturity. Their overwhelming need for attention and praise results in selfishness and a lack of regard for others which is not favourable for long-lasting intimate relationships.
In addition to the above symptoms, a person with HPD may also be naïve, gullible, restless, anxious, and may also become depressed if their needs are not met. They may go through frequent job changes, as they become easily bored and have trouble dealing with frustration. Because they tend to crave novelty and excitement, they may place themselves in risky situations. All of these factors may lead to greater risk of developing depression. In extreme cases, the threat of suicide could surface.
Personality disorders such as histrionic personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. The person's appearance, behavior, and history, along with 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. Many individuals may display histrionic personality traits. Only when these traits are inflexible, maladaptive and persisting, cause significant functional impairment or subjective distress do they constitute Histrionic Personality Disorder.
While histrionic personality disorder is easier to diagnose than some personality disorders, other medical conditions exist that can produce histrionic symptoms. Before a definitive diagnosis is made, these conditions must be ruled out:
• antisocial personality disorder.
• borderline personality disorder.
• dependent personality disorder.
• narcissistic personality disorder.
• personality changes from underlying medical conditions.
• substance abuse.
Other Personality Disorders may be confused with Histrionic Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Histrionic Personality Disorder, all can be diagnosed. Histrionic Personality Disorder has been associated with higher rates of Somatisation Disorder, Conversion Disorder, and Major Depressive Disorder. Borderline, Narcissistic, Antisocial, and Dependent Personality Disorders often co-occur.
TREATMENT OF HPD
Many people with histrionic personality disorder don't seek out treatment until the disorder starts to significantly interfere or otherwise impact a person's life.
People with histrionic personality disorder do not believe they need therapy but therapy is the preferred treatment for histrionic personality disorder, and has been used with varying degrees of success. Therapy can be greatly beneficial to an individual with HPD.
Psychotherapy (a type of counselling) is generally the treatment of choice for histrionic personality disorder. The goal of treatment is to help the individual uncover the motivations and fears associated with his or her thoughts and behaviour, and to help the person learn to relate to others in a more positive way. This psychoanalytic therapy assists patients to become aware of their own feelings. It focuses on the root of the disorder, often digging into the patient's childhood to reveal this root. Long-term psychodynamic therapy needs to target the underlying conflicts of individuals with HPD and to assist patients in decreasing their emotional reactivity.
Therapy should generally be supportive with the intention of establishing a good rapport with the patient early on. More often than not the therapist will be asked to constantly reassure and rescue the client from daily problems which is usually expressed in a dramatic fashion. Solution-focused therapy is often appropriate with this client. Most therapy approaches should be focused on reducing the short-term difficulties within the person's life rather than the long-term personality change of the individual.
Suicidal behaviour is often apparent in a person who suffers from histrionic personality disorder. The tendency of committing suicide should be assessed on a regular basis and suicidal threats should not be ignored or dismissed. Self-mutilation behaviour may also be present in this disorder and should also be taken seriously as an issue of importance to discuss within therapy.
Since the patient usually exaggerates the events and problems therapists will find that it is beneficial to take a somewhat sceptical stance. A line of reasoning leading to its logical conclusion should be followed by the therapist. This enables the client to discover the unrealistic expectations and fears associated with many of his behaviours and thoughts.
Cognitive therapy will focus on the behaviours and how to control them. While cognitive-based approaches can be a part of a larger treatment plan, they should not be the focus. Helping the client to examine interactions from a more objective point of view and emphasizing alternative explanations for behaviour is likely to be more effective for people with this disorder are often incapable of examining unconscious motivations and their own thoughts to a degree where it is helpful. Examining and clarifying a client's emotions are also important components of therapy.
Group therapy is sometimes suggested to assist individuals with HPD to work on interpersonal relationships as there is a slight possibility that psychodrama techniques or group role play can assist individuals with HPD to practice problems at work and to learn to decrease the display of excessively dramatic behaviours. Using role-playing, individuals with HPD can explore interpersonal relationships and outcomes to understand better the process associated with different scenarios.
Group therapists need to monitor the group because individuals with HPD tend to take over and dominate others. But more often than not, group or family therapy sessions are not advised because the histrionic personality's demand to be the focus of attention makes any multi-person therapy counterproductive as the individual who suffers from this disorder often draws attention to himself and exaggerates every action and reaction.
While medication is not typically used in treatment for HPD, the use of antidepressants may be used if the patient suffers from severe anxiety and/or depression. Care should be given when prescribing medications to someone who suffers from histrionic personality disorder, though, because Histrionic personality disorder patients may abuse medication or use medication for suicidal gestures.
Meditation has been used to assist extroverted patients with HPD to relax and to focus on their own inner feelings. Some therapists employ hypnosis to assist individuals with HPD to relax when they experience a fast heart rate or palpitations during an expression of excessively dramatic, emotional, and excitable behaviour
6)Living with the Histrionic
Life with the histrionic can be challenging, confusing, frustrating, and oftentimes painful. Since histrionics struggle with depth in relationships, their partners are often left questioning their failed attempts to increase intimacy or closeness. Partners of histrionics often live a life on eggshells, not knowing when they will be smothered with superficial affection or loathed for being too predictable or dependable.
For the partner, the most helpful approach to living well with a histrionic person is to offer maximal emotional support while maintaining strong personal boundaries. By adopting a loving, but objective stance, while holding the histrionic accountable for his/her behaviours, the partner gives the histrionic person the best chance of learning to trust in a relationship—not out of successful performance, but because of mutual participation and acceptance. Remaining loving and flexible, while tactfully confronting destructive behaviours in the relationship, can help the histrionic gain a realistic understanding of his or her impact on the relationship.
PREVENTION OF HPD
Although prevention of the disorder might not be possible, treatment can allow a person who is prone to this disorder to learn more productive ways of dealing with situations. Early diagnosis can assist patients and family members to recognize the pervasive pattern of reactive emotion among individuals with HPD. Educating people, particularly mental health professionals, about the enduring character traits of individuals with HPD may prevent some cases of mild histrionic behaviour from developing into full-blown cases of maladaptive HPD. Further research in prevention needs to investigate the relationship between variables such as age, gender, culture, and ethnicity and HPD.
SUBMITTED BY MRIDU RATHI
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