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Citation: Perrotta G (2021) Histrionic personality disorder: Defi nition, clinical profi les, differential diagnosis and therapeutic framework. Arch Community Med Public Health
7(1): 001-005. DOI: https://dx.doi.org/10.17352/2455-5479.000123
https://dx.doi.org/10.17352/acmphDOI:
2455-5479ISSN:
MEDICAL GROUP
Abstract
Starting from the general concept of “histrionic personality”, the present work focuses on the essential aspects of personality disorder that defi ne the clinical and
diagnostic contexts, laying the foundations for a correct differential diagnosis, without neglecting the neural characteristics developed by the scientifi c community. The
discussion ends with the best suggested therapeutic approaches.
Mini Review
Histrionic personality disorder:
Defi nition, clinical profi les,
differential diagnosis and
therapeutic framework
Giulio Perrotta*
Psychologist sp.ing in Strategic Psychotherapy, Forensic Criminologist, Lawyer sp.ed SSPL, Researcher,
Essayist, Italy
Received: 18 December, 2020
Accepted: 04 January, 2021
Published: 05 January, 2021
*Corresponding authors: Dr. Giulio Perrotta,
Psychologist sp.ing in Strategic Psychotherapy,
Forensic Criminologist, Lawyer sp.ed SSPL, Researcher,
Essayist, Italy, E-mail:
https://www.peertechz.com
Contents of the manuscript
Histrionic personality disorder is a personality disorder in
Cluster B of the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-V) [1], in which impulsivity,
high emotionality and drama predominate, along with
Borderline, Antisocial and Narcissistic Disorder. It is essentially
characterised by intense emotionality, expressed in a theatrical
manner, and by constant attempts to obtain attention, approval
and support from others through covert or overtly seductive
behaviour; in addition to the dramatic and inappropriately
seductive interpersonal style, impressionability, a tendency to
somatisation and novelty seeking characterise this disorder.
This disorder would appear to be more common among women
than men, but this could be due to cultural conditioning of the
diagnoses rather than a real difference in distribution between
the sexes [2,3].
One of the most widely accepted aetiological theories for
histrionic personality disorder is that it has a dual origin:
biological and psychosocial. From the biological point of
view, people suffering from this disorder are said to have
a temperament characterised by hypersensitivity and an
external search for gratifi cation. On the psychosocial level,
people who have developed histrionic personality disorder
often experienced diffi culties in satisfying their legitimate
needs for attention and care during childhood. Some of these
persons were appreciated by signifi cant fi gures, particularly
their parents, for their pleasant appearance and for their skills
as entertainers, rather than for their way of being, so they
learned that, in order to satisfy their affective needs, one must
use physical appearance and seductiveness. Other people with
these disorders received attention and care as children only
when they were ill, so they learned to seek care only through
physical complaints [2,4-7].
For a diagnosis of histrionic personality disorder, patients
must present a persistent pattern of excessive emotionality
and attention-seeking, characterised by at least fi ve of the
following clinical signs [3].
a) Distress when they are not the centre of attention.
b) Interaction with others that is inappropriately sexually
seductive or provocative.
c) Changeable instability and often shallow expression of
emotions.
d) Constant use of physical appearance to draw attention
to themselves.
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Citation: Perrotta G (2021) Histrionic personality disorder: Defi nition, clinical profi les, differential diagnosis and therapeutic framework. Arch Community Med Public Health
7(1): 001-005. DOI: https://dx.doi.org/10.17352/2455-5479.000123
e) Language that is extremely impressionistic and vague.
f) Dramatisation of the self, theatricality, and extravagant
expression of emotions.
g) Suggestibility (they are easily infl uenced by others or
situations).
h) Interpretation of relationships as more intimate than
they are.
In addition, symptoms must begin in early adulthood.
Comorbidities are common, especially other personality
disorders (antisocial, borderline, narcissistic) [8,9], suggesting
that these disorders share a biological vulnerability or
questioning whether histrionic personality disorder is a separate
disorder. Common are anxiety, mood, depressive, bipolar and
somatic disorders, as well as delusional and paranoid symptoms,
addictions and sexual behaviour disorders, and often simulated
attempts at suicide risk (to attract attention) [3,10-35]. In the
new nosographic formulation contained in the PICI-1 (version
TA), histrionic disorder retains its characteristics, but is better
integrated with the symptomatology shared with the other
disorders in its cluster [36-38].
Histrionic personality disorder can be distinguished
from other personality disorders based on the following
characteristics: [3].
Narcissistic personality disorder
Patients with narcissistic personality disorder also seek
attention, but unlike those with histrionic personality disorder,
they want to feel admired or elevated; patients with histrionic
personality disorder are not as demanding about the kind of
attention they receive and do not mind being thought of as cute
or silly.
Borderline personality disorder
Patients with borderline personality disorder see themselves
as bad and feel emotions intensely and deeply; those with
histrionic personality disorder do not see themselves as bad,
although their dependence on the reaction of others may result
from low self-esteem.
Dependent personality disorder
Patients with dependent personality disorder, like those
with histrionic personality disorder, try to be close to others,
but are more anxious, inhibited, and submissive (because
they are worried about rejection); patients with histrionic
personality disorder are less inhibited and more exuberant.
People with histrionic personality disorder feel
uncomfortable or unappreciated when they are not the centre
of attention. For this reason they continually try to capture
the interest of others with behaviour that is theatrical (e.g.
exaggeration of life episodes, invention of stories, dramatic
descriptions of their physical and emotional state), provocative
(e.g. instigation) or seductive (e.g. fl attery, sexual provocation,
gifts). These persons may initially fascinate new acquaintances
by their enthusiasm, hyper-sociability, tendency to involve,
display of confi dence and seductiveness. In particular, their
seductive behaviour is inappropriate in inappropriate contexts
(e.g. at work) and also towards people for whom they have no
real emotional or sexual interest (e.g. employers, friends). The
body can be used to attract the attention of others, becoming
not only seductive, but also sick. The focus on the approval
of others, rather than on one’s own internal experiences,
results in a propensity to consider oneself only in relation to
others and, therefore, to experience a poor sense of personal
identity. Dramatic and superfi cial emotional expression is
another distinctive feature of this disorder. People suffering
from histrionic personality disorder have intense and blatant
emotional displays (e.g. crying uncontrollably over a minor
event, hugging people they have only just met), which fl are
up and die quickly and do not seem to be experienced in
depth. These people can be accused of simulating feelings
that they would not authentically experience. In particular,
the communication style of people with histrionic personality
disorder is theatrical (e.g., gesticulating, use of facial
expressions), impressionistic and lacking in detail: these people
may express opinions convincingly, but the underlying reasons
are often lacking in data and details to support them. Another
characteristic feature of histrionic personality disorder is that
people consider their relationships to be more intimate than
they really are (e.g. regarding an acquaintance as a close friend,
fantasising about acquaintances in a romantic way, allowing
themselves to call people they have just met by their fi rst
name). In reality, sufferers have diffi culty in achieving genuine
emotional intimacy with the people with whom they relate. In
their relationships, they may, for example, play a part (e.g., the
victim, the princess) or try to control the other person through
emotional manipulation and seduction, without being aware
of it. They are extremely dependent on external attention,
approval and support, are very sensitive to rejection and
fearful of separation. In order to avoid relationship breakdown,
they may resort to extreme behaviour aimed at attracting the
attention of the other person (e.g. sexual promiscuity, self-
harm, suicide attempts). In relationships, they may seek out
authority fi gures to whom they attribute extraordinary gifts
and magical solutions to their problems. Another characteristic
of people with this disorder is a high degree of suggestibility:
their opinions and feelings can be easily infl uenced by the
beliefs and moods of others, by impressions and enthusiasms
of the moment, by simple circumstances. Personal values
and interests, for example, may vary with the values and
interests of the partner of the moment. They may also be
intolerant of frustration and exposed to boredom, so they may
seek immediate gratifi cation of their needs (e.g. abandoning
a project after initial enthusiasm because it is tiring) and
considerable stimulation (e.g. seeking new and exciting
activities such as promiscuous sex, neglecting a lasting
relationship and seeking excitement in a new relationship).
People with histrionic personality disorder are often concerned
about their physical appearance and take great care of it (e.g.
they spend a considerable amount of time, energy and money
on clothing and body care) as a means of attracting attention to
themselves. These people frequently seek compliments on their
003
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Citation: Perrotta G (2021) Histrionic personality disorder: Defi nition, clinical profi les, differential diagnosis and therapeutic framework. Arch Community Med Public Health
7(1): 001-005. DOI: https://dx.doi.org/10.17352/2455-5479.000123
appearance and can be easily and excessively upset by a critical
comment on it. The manifestation of histrionic personality
disorder may be infl uenced by sex-role stereotypes, whereby a
man and a woman with this disorder may embody caricatures
of masculinity (the athletic, womanizing ‘macho’) and
femininity (the over-emotional, aesthetically well-groomed
‘femme fatale’) respectively. On the other hand, this disorder
can also manifest itself in men in the form of approval-
seeking and passive behaviour [10]. A recent study has shown
that histrionic individuals, such as borderline and narcissistic
individuals, have very high levels of alexithymia and thus a low
ability to recognise their own and other people’s emotions [14].
Certain features of histrionic personality disorder can also
be found in other disorders, from which this disorder should be
distinguished. Rapidly changing emotions, attention-seeking
and manipulative behaviour, for example, are also characteristic
of borderline personality disorder, but in the latter there is
also self-destructiveness, angry breakdowns of interpersonal
relationships and more intense states of emptiness and altered
identity. Both people with histrionic personality disorder and
those with antisocial personality disorder tend to be superfi cial,
manipulative, seductive, impulsive and in search of new and
exciting situations, but the former, unlike the latter, show
more intense emotional reactions, typically do not engage in
antisocial behaviour and carry out manipulations to obtain
attention and care, rather than profi t, power and material
gratifi cation. Narcissistic personality disorder sufferers also
crave the attention of others, but whereas they usually seek
praise for their supposed superiority, histrionic personality
disorder sufferers are also willing to appear fragile and
dependent in order to gain attention. Narcissistic personality
disorder sufferers may also exaggerate the intimacy of their
relationships, but generally emphasise the social or economic
position of their acquaintances. People with dependent
personality disorder are also highly dependent on others
for praise and support, but they do not have the excessive
emotionality and theatrical style that characterises histrionic
personality disorder [10].
Sufferers of this disorder can compromise their emotional,
social and professional relationships by implementing
strategies that tend to be manipulative. The theatrical
interpersonal style may lead others to consider them superfi cial
and inauthentic. Pressing and dramatic demands for help and
care (e.g. showing fear or being very depressed, threatening
or attempting suicide), carried out when one feels that one is
not considered or has to face life’s diffi culties alone, may drive
away exasperated partners, relatives and friends. Provocative
or seductive behaviour can also be perceived by people of the
same sex as threatening to their relationship and can lead to
competitiveness or distance in the relationship. At work, this
behaviour may be inappropriate and may lead to low esteem or
devaluation at work [12].
It is useful to analyse the psychological characteristics of
individuals with histrionic personality disorder in terms of
their views of themselves and others, intermediate and deep-
seated beliefs, coping strategies and core emotions [11,14].
Self-image
Since they feel inadequate and vulnerable to being ignored,
they manifest a compensatory self-image of fashionable people
who make their mark and therefore deserve attention.
View of others
They view others favourably as long as they manage to
attract their attention, entertainment and affection. They try
to form strong alliances with others, with the condition that
they are at the centre of the group and that others play the role
of attentive audience. In contrast to narcissistic personalities,
histrionics are very involved in minute-to-minute interactions
with others and their self-esteem depends on receiving
continuous expressions of appreciation.
Intermediate and deep beliefs
Histrionics may have rules that fall under intermediate
beliefs, such as ‘you should express your feelings’, ‘you should
be funny’, ‘you should show others that they have hurt you’.
Some of their assumptions are “if I entertain or amuse others
then I am worthy”, “if I fail to capture the attention of others,
then I am worthless, others will abandon me”, “if others do not
respond, they are unfair”, “if I fail to capture their attention,
I am powerless”. Deep-seated beliefs are “I am fundamentally
unattractive” and compensatory beliefs include “I am lovable,
funny and interesting”, “I am deserving of admiration”,
“people are there to admire me and I make my bet”, “they
don’t have the right, they deny me my due”.
Coping strategies
They use dramatisation and demonstrate in every way to
keep people attached to them. When they fail to do so, they
believe they are being treated unfairly, and try to gain approval
through theatrical expressions of grief and anger: they cry,
engage in aggressive behaviour, attempt suicide, etc.
Main emotions
The most prevalent is joy, often combined with hilarity
and other high-tone emotions when successfully entertaining
people. Histrionic individuals usually experience an
undercurrent of anxiety and mild dysphoria, refl ecting fear of
rejection. When they are rejected, their emotion can quickly
change to anger or sadness.
Studies showing which treatments are effective in treating
histrionic personality disorder are currently scarce. Among
the treatments with some evidence of effectiveness are the
following. The preferred treatment is individual psychotherapy,
accompanied by pharmacotherapy if necessary. Psychodynamic
psychotherapy, postulating that the basic dynamic in people
suffering from histrionic personality disorder is the unresolved
attempt to have all their needs satisfi ed by someone else,
attempts to identify with the patient the origin of this dynamic
and the so-called neurotic strategies (e.g. seduction, illogical
thinking) used to satisfy their needs. A distinctive feature of
this type of treatment is the interpretation of the transference
(emotions and thoughts experienced in a past signifi cant
004
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Citation: Perrotta G (2021) Histrionic personality disorder: Defi nition, clinical profi les, differential diagnosis and therapeutic framework. Arch Community Med Public Health
7(1): 001-005. DOI: https://dx.doi.org/10.17352/2455-5479.000123
relationship and shifted to a current fi gure) of the patient
towards the therapist. Although the evidence for the effi cacy
of group treatments for this disorder is currently scarce,
psychodynamic group psychotherapy seems to be effective
for histrionic patients who present greater diffi culties and
suffering. The group context, in fact, would help them to
modulate both the transference with the therapist and the
search for attention, approval and care. The literature also
contains protocols for the treatment of these people as a couple.
Such treatment is usually required after strong disagreements
within the couple or because of an imminent threat of
separation. Sperry and Maniacci have developed a treatment
that integrates the systemic, psychodynamic and cognitive-
behavioural approaches and is aimed at couples consisting of
one partner with histrionic personality disorder and the other
partner with obsessive-compulsive personality disorder (this
type of couple is frequently formed because in it the partners
assume complementary roles, such as ‘support seeker’ and
‘responsibility taker’). This treatment process involves three
phases: establishing the therapeutic alliance, restoring balance
within the couple and modifying the partners’ individual
dynamics. The fi rst two phases involve both partners at the
same time, while the third is carried out in individual sessions.
In the case of histrionic personality disorder, pharmacological
therapy is essentially used to support individual psychotherapy.
This recourse occurs when the patient presents symptoms such
as depression, anxiety and physical symptoms of psychological
origin (e.g. psychogenic migraine). In particular, in the presence
of depression, cyclic antidepressants or serotoninergics
may be indicated, while in the presence of depressive
symptoms accompanied by intense sensitivity to rejection,
desperate attention-seeking, pretentiousness, hyperphagia
and hypersomnia, anti-MAO drugs are the most effective.
SSRIs such as fl uoxetine and sertraline have been shown to
be effective for people with greater diffi culties, particularly
those with emotional instability and impulsiveness. Within the
framework of cognitive behavioural therapy, several treatment
programmes have been implemented for personality disorders.
The following treatments have already shown some evidence of
effectiveness in treating histrionic personality disorder. Beck
and Freeman’s cognitive therapy for personality disorders is a
cognitive-behavioural treatment that focuses on recognising
and challenging dysfunctional beliefs about oneself, others and
the world. These beliefs are said to be generated by distortions
of reality (cognitive distortions) and to constitute cognitive
schemata (basic cognitive structures that allow experience
and behaviour to be organised). In the treatment of histrionic
personality disorder, the patient is fi rst of all helped to identify
his emotions, thoughts and the events to which they are related,
as he would fi nd it diffi cult to carry out these operations. This
work, together with the evaluation of the consequences of
one’s actions, would help the patient to lower his dysfunctional
impulsiveness. Then the therapist works with the patient to
identify and modify his dysfunctional central beliefs: “I am
inadequate and unable to manage my life”, “I must be loved
by everyone to be of value” and “The loss of a relationship
is disastrous”. The belief that one is incapable of taking care
of oneself leads people with this disorder to constantly seek
attention and care from others. The second belief induces
rejection sensitivity, approval seeking, and the urge to act
in relation to others in order to capture their attention and
approval. The belief that the interruption of an emotional
relationship can be disastrous also encourages these people
to maintain unsatisfactory and inauthentic relationships and,
therefore, maintains their sense of inability to cope on their
own and their feeling of inauthenticity. The modifi cation of
these beliefs is implemented by resorting to various techniques
(e.g. imaginative techniques, behavioural experiments,
assertiveness exercises, problem solving) that help the patient
to increase their sense of effi cacy. The therapeutic process takes
place through the so-called collaborative empiricism, whereby
it is the patient who gradually identifi es and learns to meet his
or her own needs in functional ways, rather than still expecting
others to do so or an omnipotent, saviour-like therapist to do
so. For one subtype of patients, a behavioural intervention that
can be integrated with Beck and Freeman’s therapy has also
proved effective: social skills training aimed, in particular, at
modulating emotions and impulsive behaviour and developing
empathy (by focusing on the emotions and needs of others).
Jeffrey Young’s schema-focused therapy is a treatment that
integrates the cognitive-behavioural approach with object
relations and Gestalt approaches. According to this approach,
the dysfunctional patterns of ‘emotional deprivation’ (a belief
that other people will not provide the emotional support the
person needs), ‘imperfection’ (a belief that one is imperfect,
inadequate and unpleasant or inferior to others) and ‘approval
seeking’ (a belief that one must always seek acceptance at
the expense of a real sense of self) are active in patients with
histrionic personality disorder. The central aim of this type of
therapy is the identifi cation and modifi cation of these patterns,
through cognitive, relational, experiential and behavioural
strategies (e.g. cognitive restructuring, corrective emotional
experiences, empathic confrontation, imaginative exercises,
homework) [3,10,13,39-41].
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Citation: Perrotta G (2021) Histrionic personality disorder: Defi nition, clinical profi les, differential diagnosis and therapeutic framework. Arch Community Med Public Health
7(1): 001-005. DOI: https://dx.doi.org/10.17352/2455-5479.000123
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