Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Diagnosis is by clinical criteria. Treatment is with psychodynamic psychotherapy.
(See also Overview of Personality Disorders.)
Patients with histrionic personality disorder use their physical appearance, acting in inappropriately seductive or provocative ways, to gain the attention of others. They lack a sense of self-direction and are highly suggestible, often acting submissively to retain the attention of others.
Estimated prevalence is < 2% of the general population (1). The prevalence in females and males is similar. Prior reports of an increased prevalence among females was possibly influenced by ascertainment bias from hospital-based studies.
Comorbidities are common, particularly other personality disorders (antisocial, borderline, narcissistic) (2). Some patients also have somatic symptom disorder, which may be the reason they present for evaluation. Major depressive disorder, persistent depressive disorder, and conversion disorder may also coexist.
General references
1. Morgan TA, Zimmerman M: Epidemiology of personality disorders. In Handbook of Personality Disorders: Theory, Research, and Treatment. 2nd ed, edited by WJ Livesley, R Larstone, New York, NY: The Guilford Press, 2018, pp. 173-196.
2. Zimmerman M, Rothschild L, Chelminski I: The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry 162:1911-1918, 2005. doi: 10.1176/appi.ajp.162.10.1911
Symptoms and Signs of Histrionic Personality Disorder
Patients with histrionic personality disorder continually demand to be the center of attention and often become depressed when they are not. They are often lively, dramatic, enthusiastic, and flirtatious and sometimes charm new acquaintances.
These patients often dress and act in inappropriately seductive and provocative ways, not just with potential romantic interests, but in many contexts (eg, work, school). Because of their desire to impress others with their appearance, they are often preoccupied with how they look.
Expression of emotion may be shallow (turned off and on too quickly) and exaggerated. They speak dramatically, expressing strong opinions, but with few facts or details to support their opinions.
Patients with histrionic personality disorder are easily influenced by others and by current trends. They tend to be too trusting, especially of authority figures who, they think, may be able to solve all their problems. They often think relationships are closer than they are. They crave novelty and bore easily. Thus, they may change jobs and friends frequently. Delayed gratification is frustrating to them, so their actions are often motivated by obtaining immediate satisfaction.
Achieving emotional or sexual intimacy may be difficult. Patients may, often without being aware of it, play a role (eg, victim). They may try to control their partner using seductiveness or emotional manipulation while becoming very dependent on the partner.
Diagnosis of Histrionic Personality Disorder
Diagnostic and Statistical Manual of Mental Disorders, 5th Ed, Text Revision (DSM-5-TR) criteria
For a diagnosis of histrionic personality disorder (1), patients must have
A persistent pattern of excessive emotionality and attention seeking
This pattern is shown by the presence of ≥ 5 of the following:
Discomfort when they are not the center of attention
Interaction with others that is inappropriately sexually seductive or provocative
Rapidly shifting and shallow expression of emotions
Consistent use of physical appearance to call attention to themselves
Speech that is extremely impressionistic and vague
Self-dramatization, theatricality, and exaggerated expression of emotion
Suggestibility (easily influenced by others or situations)
Interpretation of relationships as more intimate than they are
Also, symptoms must have begun by early adulthood.
Differential diagnosis
Histrionic personality disorders can be distinguished from other personality disorders based on characteristic features:
Narcissistic personality disorder: Patients with narcissistic personality disorder also seek attention, but they, unlike those with histrionic personality disorder, want to feel admired or elevated by it; patients with histrionic personality disorder are not so picky about the kind of attention they get and do not mind being thought cute or silly.
Borderline personality disorder: Patients with borderline personality disorder consider themselves bad and experience emotions intensely and deeply; those with histrionic personality disorder do not see themselves as bad, even though their dependence on the reaction of others may stem from poor self-esteem.
Dependent personality disorder: Patients with dependent personality disorder, like those with histrionic personality disorder, try to be near others but are more anxious, inhibited, and submissive (because they are worried about rejection); patients with histrionic personality disorder are less inhibited and more flamboyant.
Differential diagnosis for histrionic personality disorder also includes somatic symptom disorder and illness anxiety disorder.
Diagnosis reference
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022, pp. 757-760.
Treatment of Histrionic Personality Disorder
Psychodynamic psychotherapy
General principles for treatment of histrionic personality disorder are the same as those for all personality disorders.
Little is known about the efficacy of cognitive-behavioral therapy and pharmacotherapy for histrionic personality disorder.
Psychodynamic psychotherapy, which focuses on underlying conflicts, may be tried. The therapist may start by encouraging patients to substitute speech for behavior, and thus, communicate with others in a less dramatic way. The therapist may also help patients realize how their histrionic behaviors are a maladaptive way to attract the attention of others and to manage their self-esteem.
