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Overview on Histrionic Personality Disorder
Mu Yang1,a,*
1Institute of Problem Solving, Bard College at Simon’s Rock, 84 Alford Road, Great Barrington,
America
a. myang21@simons-rock.edu
*corresponding author
Abstract: Histrionic Personality Disorder (HPD) is a mental disorder characterized by the
excessive expression of emotions and attention-seeking behavior. This paper provides an
overview of HPD, including its diagnostic criteria, prevalence, etiology, and treatment
options. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
criteria for diagnosing HPD are being talked about. The article also explores the etiology of
HPD, including the role of genetic factors and environments, and analyzes the impact of
early life experiences on the development of the disorder. Besides, the paper outlines
various treatment options for HPD, including psychotherapy and medication management,
and highlights the importance of early diagnosis and intervention in improving outcomes
for individuals with this disorder. Finally, this paper also gives some suggestions on the
field of HPD. Through this paper, people can gain a better understanding of histrionic
personality disorder. Overall, this paper provides a comprehensive overview of HPD and its
associated features, with the goal of increasing understanding and awareness of this often-
misunderstood condition.
Keywords: dramatic, psychopath, attention-seeking, need for approval/affection,
exaggerated emotions
1. Introduction
When people show excessive sadness or joy or use exaggerated body language to draw attention to
themselves, they may be suffering from HPD. Diagnostic and Statistical Manual of Mental
Disorders, Third Edition (DSM-3) initially recognized HPD in 1980. Nonetheless, identifying it has
been debatable, with some individuals proposing that it shares similarities with other Personality
Disorders (PD) like narcissistic PD and borderline PD. In DSM-5, HPD is still considered a distinct
personality disorder and is the subject of ongoing research in the fields of psychology and
psychiatry. HPD is not a popular area of personality disorder research that many people lack a basic
understanding of. This has caused problems such as inaccurate diagnoses and patients’ inability to
seek medical treatment immediately. HPD can significantly affect a person’s life and their
relationships with other people. Exaggerated emotional expressions and attention-seeking behavior
can lead to social and professional problems, and impulsive behavior can lead to financial and legal
problems [1]. However, HPD is a treatable condition, and seeking help from a mental health
professional can improve your quality of life.
Proceedings of the 4th International Conference on Educational Innovation and Philosophical Inquiries
DOI: 10.54254/2753-7064/7/20230886
© 2023 The Authors. This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0
(https://creativecommons.org/licenses/by/4.0/).
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2. Definition of Histrionic Personality Disorder
The DSM-5 describes HPD as a psychological disorder marked by overblown emotions and
behavior that seeks attention [2]. Individuals with HPD typically rely on external validation from
others instead of developing an internal sense of self-worth. They desperately crave attention and
often gain it through exaggerated or inappropriate behavior. Additionally, patients are often
unaware that there may be a problem with their behavior and thought patterns. Typically, HPD
emerges during adolescence or early adulthood. Individuals who are female have a higher incidence
of being diagnosed with HPD compared to those who are male; however, researchers suggest that
males and those assigned male at birth may be underdiagnosed. HPD is a relatively uncommon
condition, with studies estimating that around 1 percent of people may be affected [1,2].
3. Relations Between HPD and Other Mental Illness
To specify, HPD is categorized under Cluster B personality disorders, along with Borderline PD,
Antisocial Personality Disorder (ASPD), and Narcissistic PD [3]. They are often described as
unpredictable or unstable [4]. HPD individuals are typically impulsive, seductive, and flirtatious [5].
In relevant experiments and discussions about personality disorders, HPD is rarely mentioned, and
it has many similarities and connections with the same category of personality disorders as ASPD.
Figuring out this part is very important for a complete understanding of HPD [1]. Ellison M. Cale
and Scott O. Lilienfeld conducted a study to investigate the potential association between HPD and
psychosis, specifically whether HPD and ASPD might be surrogate representations of psychosis
with respect to sex-type. The researchers also evaluated whether there were any links between traits
of psychosis, HPD, and ASPD, and performance in laboratory tests for passive avoidance errors and
distraction effects based on Newman’s (1987) theory of psychotic response regulation. In the study,
75 theater actors completed self-report questionnaires, two laboratory assessments of response
regulation, and peers filled out questionnaires regarding the participants’ personality disorder
characteristics. The study’s results suggest that there is insufficient and conflicting evidence to
support the idea that HPD is a female version of psychopathy, and that ASPD is a male version of
psychopathy. The results contradict earlier studies, as the scores on the response modulation task
did not demonstrate any significant links with psychosis, HPD, or ASPD [4]. S.O. Lilienfeld, C.
Van Valkenburg, K. Larntz, and H.S. Akiskal conducted a study involving 250 patients to explore
the correlation between individuals and families with HPD, ASPD, and Somatization Disorder (SD).
The findings revealed significant overlap between the three disorders in individuals, with the
strongest relationship observed between ASPD and HPD. While families of patients with SD
reported a high prevalence of ASPD, the same was not observed in families of patients with HPD.
The researchers suggested that in males, histrionic individuals may develop ASPD, while in females,
they may develop SD. Moreover, they proposed that all three disorders may represent distinct stages
or manifestations of a common latent quality [6].
4. Etiology
The cause of HPD is unclear, but probably has multiple factors contributing to its development [6].
There is an indication that the disorder may be influenced by both genetic factors and environments
[4]. Childhood trauma has been proposed as a potential factor developing HPD [7]. Coping
mechanisms used by children in traumatic situations may lead to personality disorders. In fact,
personality disorders in childhood can result from adaptation to cope with traumatic circumstances
or environments. The likelihood of developing HPD may be influenced by parenting styles.
Parenting that lacks boundaries, is overindulgent, or inconsistent may increase the risk of
developing HPD. Additionally, parents who model dramatic or inappropriate sexual behaviors may
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also increase the risk of developing this disorder. The fact that HPD tends to occur within families
suggests that there may be a genetic susceptibility to the disorder. Having a personal or family
history of personality disorders, mental illnesses, or substance use disorders increases the risk of
developing HPD, as is the case with many psychiatric disorders. C Apt and D F Hurlbert conducted
a study to investigate sexual attitudes, behavior, and intimacy in women with HPD compared to a
well-matched control group of women without personality disorder. The study found that women
with HPD had lower sexual confidence, stronger sexual erotophobia attitudes, lower self-esteem,
and higher levels of marital dissatisfaction compared to the control group. Additionally, the women
with HPD reported more sexual attention, lower libido, greater orgasmic disturbances, and were
easier to engage in extramarital affairs than the peers. This study also provided insight into the
possible reason for the genetic predisposition to HPD mentioned in the previous paragraph and
males and those assigned male at birth may be underdiagnosed. HPD is a relatively uncommon
condition, with studies estimating that around 1 percent of people may be affected [1,2].
5. Impact of HPD on Individuals’ Daily Life
People with HPD often have a desire to be admired and noticed by others. They may engage in
exaggerated and dramatic behavior to attract attention, and they may use their appearance, including
their clothing, makeup, or body language, to attract attention. In addition, people with HPD may
have difficulty forming and maintaining lasting relationships because their emotions are often
shallow and may perceive relationships as more intimate and important than they really are. They
may become overly dependent on others for emotional approval, and may feel abandoned or
rejected when they do not receive the attention they crave. People with HPD may also have
difficulty regulating their emotions and may become emotionally unstable, experiencing sharp and
rapid mood swings. They may overreact to small things or perceived slights, and they may take
criticism and disapproval from others as a personal attack [1,2].
6. Diagnosis
A mental health expert, such as a psychiatrist or psychologist, will typically conduct a
comprehensive evaluation and assessment to diagnose HPD. Assessments may include the
following: (1) Clinical interview: The clinician will ask about the patient’s symptoms, personal
medical history, and current living conditions. They may ask about childhood experiences, family
history, and current relationships. (2) Mental health professionals rely on the DSM-5 to identify
whether an individual meets the criteria for HPD. (3) Psychological testing: Clinicians can use
psychological testing to gather additional information about an individual’s personality traits,
emotional functioning, and thinking patterns. (4) Observation: A clinician may observe an
individual’s behavior during interviews and in other settings, such as in group therapy or in
interactions with others [2].
7. Treatment
7.1. Cognitive Behavioral Therapy for HPD
HPD treatment typically includes a combination of several interventions, including lifestyle
modifications, medication, and psychotherapy. Psychotherapy is an important part of treating HPD.
Cognitive behavioral therapy (CBT) is a common approach to psychotherapy for HPD. CBT aims
to help patients recognize and modify negative thinking patterns and behaviors that contribute to
their emotional instability and the urge to seek attention. Additionally, CBT can help patients
develop coping skills and enhance self-esteem, thereby reducing their need for external validation.
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CBT aims to assist patients in managing their emotions effectively and enhancing their social
interactions [8]. A randomized controlled trial published in the Journal of Clinical Psychology
investigated the efficacy of CBT for individuals diagnosed with HPD. The study, titled “Efficacy of
Cognitive Behavioral Therapy for Histrionic Personality Disorder: A Randomized Controlled
Trial,” enrolled 50 participants with an initial diagnosis of HPD, who were randomly assigned to
receive 12 weekly sessions of CBT or treatment as usual (TAU). The main objective of the research
was to evaluate the effectiveness of CBT for HPD. The CBT intervention included modules on
emotion regulation, interpersonal skills, and cognitive restructuring. The study found that
participants who received CBT showed significant improvement in performance symptoms
compared to those who received TAU. Furthermore, the CBT group showed a significant decrease
in depression and anxiety when compared to the TAU group. However, the study did not find
significant improvements in overall functioning or quality of life in the CBT group. Ultimately the
authors concluded that CBT might be an effective treatment option for patients with HPD,
especially in addressing specific acting symptoms and reducing comorbid depression and anxiety.
However, they note that more research is needed to determine the most effective treatments for
HPD and to determine which specific components of CBT are most helpful for this population [9].
7.2. Psychodynamic Therapy for HPD
Another psychotherapy approach that has shown promise in treating HPD is psychodynamic
therapy. This approach seeks to explore the root causes of the patient’s behaviors and feelings,
which are often rooted in childhood experiences. Psychodynamic therapy can help patients gain
insight into their behavior, understand how their past experiences influence their present behavior,
and develop healthier coping strategies [8]. A case report published in the Journal of Psychiatric
Practice describes the successful treatment of a woman with HPD using a combination of
psychodynamic psychotherapy and medication. This article, “Psychodynamic psychotherapy for
histrionic personality disorder in the context of substance abuse: a case report” is a case report of a
woman receiving psychodynamic psychotherapy for HPD in the context of substance abuse. The
article mentioned the patient’s history of drug use, multiple failed relationships, and self-destructive
behavior. This patient was diagnosed with HPD and initiated psychodynamic psychotherapy, which
focuses on understanding and addressing the underlying psychological issues driving her behavior.
The therapeutic process includes the use of techniques such as interpretation, transference analysis,
and exploration of the patient’s early experiences. The patient demonstrated substantial progress in
their expressive symptoms and overall functioning after receiving treatment for 18 months.
Ultimately, it was concluded that psychodynamic psychotherapy might be an effective treatment
option for patients with HPD, especially when the disorder is complicated by substance abuse. The
authors acknowledge the need for further research to gain a better understanding of the most
efficacious treatments for HPD despite the results obtained from their study [10].
7.3. Other Treatments
Group therapy is also an effective treatment modality for HPD. Group therapy can provide a
supportive environment where individuals can learn social and communication skills, develop
healthier relationships, and improve their self-esteem. Group therapy can also provide opportunities
for individuals to practice expressing themselves in healthy ways and receive feedback from others
[8]. In addition to psychotherapy, medications can be used to treat co-occurring mental health
conditions that may exacerbate HPD symptoms [8]. One potential treatment for HPD is the use of
antidepressants and anti-anxiety medications, which can alleviate symptoms of depression and
anxiety commonly associated with the disorder. However, caution must be exercised when
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prescribing medications to people with HPD, as some medications can worsen their symptoms.
Lifestyle changes are also an important part of treating HPD. Encouraging patients to engage in
regular physical activity and develop hobbies can improve mood and reduce the need for attention-
seeking behaviors. Practicing self-care and stress-stress techniques, such as meditation or yoga, can
also help manage HPD symptoms [8]. A study published in the Journal of Neurological and
Psychiatric Disorders investigated the effectiveness of short-term psychodynamic psychotherapy
(STPP) in treating HPD. The research topic was “Efficacy of short-term psychodynamic
psychotherapy in patients with HPD: a randomized controlled trial.” The study enrolled 45
participants who were diagnosed with HPD and randomly assigned them to receive 12 sessions of
STPP or to a waitlist control group. The results showed that STPP was associated with significant
improvements in symptoms of acting, anxiety, and depression. STPP interventions include
techniques such as interpretation, exploration of early experiences, and identification of associated
patterns of maladaptation. The research showed that the participants who underwent the STPP
treatment had notable enhancements in their performance symptoms and overall personality
functioning in comparison to the waitlist control group. The authors concluded that STPP might be
an effective treatment option for patients with HPD, particularly in addressing core personality traits
and underlying psychological conflicts that lead to performative behavior. The study is not without
limitations; for instance, the sample size was relatively small, and there was no long-term follow-up
data available. The authors suggest that more studies should be conducted to evaluate the efficacy
of STPP for HPD and to investigate which particular aspects of the therapy would be most
advantageous for this group [11]. Tailoring treatment to each individual’s needs is critical, as is
identifying any co-occurring mental health conditions and addressing them appropriately.
Treatment may also need to be adjusted over time as the patient’s needs and symptoms change.
Psychotherapy, especially CBT and psychodynamic therapy, has shown promising results in
controlling HPD symptoms. Group therapy can also be an effective adjunct to individual therapy.
Although there is no universal treatment for HPD, individuals with the disorder can enhance their
quality of life and manage their symptoms with appropriate treatment.
8. Suggestions
In summary, biological, psychological, and social factors can all contribute to HPD, but more
research is needed to find out which of these factors may be key. Here are some of my suggestions
in the field of histrionic personality disorder. The first is raising awareness: there is still a lot of
stigma and misconceptions surrounding personality disorders (including HPD), and a large
percentage of people don’t even know what a personality disorder is. This can be done through
public education campaigns, media coverage and community outreach. Second, more research is
needed on HPD, especially effective treatments. More research could also help identify risk factors,
comorbidities, and long-term outcomes for people with HPD. To improve diagnosis, it is important
to note that HPD is sometimes wrongly identified as other psychological disorders, such as anxiety
or depression. Improving diagnostic criteria and training mental health professionals to recognize
the unique characteristics of HPD can help ensure that people receive appropriate treatment. HPD is
a relatively specific personality disorder, and it is useful to specify specific treatment methods based
on individual circumstances rather than general treatment. Access to treatment is therefore also
deserving of improvement: HPD patients need more access to treatment. To achieve this, it is
necessary to increase funding for mental health services, improve access to mental health care in
underserved areas, and lower barriers to treatment, such as cost or social stigma. In conclusion,
there is still much work to be done in the field of histrionic personality disorder. Raising awareness,
conducting more research, improving diagnosis, tailoring treatment, and improving access to
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treatment are all important steps in addressing this disease and improving outcomes for people with
HPD.
9. Conclusion
In conclusion, Histrionic Personality Disorder (HPD) is a relatively rare but important clinical
condition that is characterized by attention-seeking behaviors, excessive emotionality, and a
tendency to be easily influenced by others. Despite limited understanding of the causes of HPD,
studies indicate that both biological and environmental factors are likely contributors to the
development of this disorder. It is important to diagnose and treat HPD early to help individuals
manage their symptoms and improve their overall well-being. Psychotherapy, specifically CBT, has
been found to be effective in reducing HPD symptoms. In addition, medication may be used in
conjunction with psychotherapy to further improve outcomes for individuals with this disorder.
More research is necessary to establish the effectiveness of HPD treatment methods and provide a
better understanding of the disorder. Mental health professionals should be knowledgeable about
the essential characteristics of HPD and aware of the treatment options available. By providing
appropriate care and support to individuals with HPD, mental health professionals can help these
individuals to manage their symptoms and lead fulfilling lives. Increasing public awareness and
understanding of HPD can also help to reduce the stigma associated with this disorder and improve
outcomes for those affected by it.
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