Diagnosing Histrionic Personality Disorder

Individuals with histrionic personality disorder (HPD) express emotion easily and dramatically. Regularly seen crying at weddings, their expression of affect may appear exaggerated. Individuals with HPD have shallow and superficial emotions even though these emotions are typically on full display. They use dramatic displays of shallow emotions to be the center of attention or for interpersonally manipulative ends. The histrionic individual is not comfortable unless they are the center of attention and typically use their appearance and/or sexuality to get attention.

When they talk, they speak in an impressionistic, vague, and overly general manner. Their utterances lack specificity and substance. They are easily influenced by their current surroundings and can have rapid shifts of emotion depending on the mood and affect of the person they are currently interacting with. Their social interactions are characterized by flirtatiousness, and their appearance and behavior are often sexualized. Individuals with HPD are interpersonally and emotionally manipulative.

Narrative Description of HPD

Individuals with HPD display a pattern of speech that is overly general and non-specific. When talking, they rarely, if ever, give concrete examples with appropriate detail. This is noticeable when an individual with HPD expresses a strong opinion. It is logical to hypothesize that their autobiographical memory specificity would be significantly lower than the autobiographical memory specificity seen in other personality patterns or disorders. Individuals with HPD will often report that if someone expresses discomfort, like a headache or stomach ache, or expresses any intense feeling, then the HPD individual will suddenly feel similarly. Their opinions change depending on who they are with.

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An individual with HPD might agree that political correctness has gone too far with one person and assert that political correctness has not gone far enough with a different person. They match their opinions to the opinions expressed by others. Like Woody Allen in the film Zelig, individuals with HPD lack a well-developed, grounded sense of self; rather, they adopt the attitudes, behaviors, and affects of others like a chameleon adapts its color to its environment for protection.

HPD may also function defensively or self-protectively. Individuals with HPD often consider a relationship to be more intimate than it actually is. They might call someone their best friend after having met that person just recently. Imposing an intense, "special" relationship on every friendship can be a sign of HPD.

The rapidly changing feelings and emotions of individuals with HPD are readily noticeable by an outside observer. Other people typically comment on how individuals with HPD express emotion because it is so exaggerated. Individuals with HPD may receive feedback that they are overly emotional or that their emotions do not seem real. Individuals with HPD have a longstanding pattern of this style of emotional expression. Individuals with HPD often have a reputation of being flirtatious, often reporting that other people frequently misinterpret their friendliness as a romantic or sexual invitation.

DSM Diagnosis of HPD

The DSM-IV/-5 defines histrionic PD as the presence of 5 or more of the following diagnostic criteria plus the general criteria for personality disorder:

(1) Discomfort when not the center of attention

(2) Inappropriate sexually seductive social interactions

(3) Rapidly shifting and shallow expression of emotion

(4) Use of appearance to get attention

(5) Impressionistic speech that lacks detail

(6) A dramatic, exaggerated expression of emotion

(7) Suggestible, i.e., easily influenced by others or circumstances

(8) Considers relationships to be more intimate than they are

Other Issues

Criticism of HPD includes the fact that there is little empirical research on it. Therefore, questions about its construct validity exist. It was proposed for removal in the DSM-5 but ultimately retained. It may or may not make the cut into the next edition of the DSM. Another common and major criticism of HPD is that it is a sexist diagnostic construct because the description of the longstanding pattern of behavior under the label HPD resembles the traditional female gender role stereotype.

Furthermore, the term hysteria is most commonly associated with Freud, who used it to describe women with dramatic psychosomatic problems. Empirical evidence may support the idea that HPD diagnosis reflects sexist attitudes: Women are four times more likely to be diagnosed with it than men. Its prevalence is around 2 percent in the general population but up to around 10–15 percent in clinical populations.