Which of the following best explains why it is such a challenge to treat personality disorders?
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A histrionic personality disorder, or commonly known as a dramatic personality disorder, is a psychiatric disorder distinguished by a pattern of exaggerated emotionality and attention-seeking behaviors. A histrionic personality disorder is categorized within the "Cluster B" of personality disorders. Cluster B personality disorders include conditions such as narcissistic personality disorder, borderline personality disorder, and antisocial personality disorder. These personality disorders are commonly described as dramatic, excitable, erratic, or volatile. Specifically, people with histrionic personality disorder are typically characterized as flirtatious, seductive, charming, manipulative, impulsive, and lively. This activity reviews the evaluation, treatment, and management of histrionic personality disorder and highlights the role of the interprofessional team in managing patients with this condition. Objectives:
Personality is the set of established patterns of behavior by which one relates to and understands the world around them. A personality disorder arises when one develops an inflexible and intransigent pattern of maladaptive thinking and behaving, which significantly impairs social or occupational functioning and can cause interpersonal distress.[1] Patterns of thinking and behaving must significantly deviate from cultural norms to meet the diagnostic criteria for personality disorder. Divergence from cultural expectations would manifest as disturbances with affectivity, cognition (perceives self, others, or events inappropriately), impulse control, or interpersonal functioning.[2] These disturbances are not due to another mental disorder, substance abuse, or other medical condition.[3] Histrionic personality disorder, or dramatic personality disorder, is a psychiatric disorder distinguished by a pattern of exaggerated emotionality and attention-seeking behaviors. Histrionic personality disorder falls within the “Cluster B” of personality disorders.[4] Cluster B personality disorders include conditions such as narcissistic personality disorder, borderline personality disorder, and antisocial personality disorder.[2] These personality disorders are commonly described as dramatic, excitable, erratic, or volatile.[1] Specifically, people with histrionic personality disorder typically present as flirtatious, seductive, charming, manipulative, impulsive, and lively.[5] People with histrionic personality disorder may feel underappreciated or disregarded when they are not the center of attention. These people are typically the life of the party and have a “larger than life” presence.[3] They may be vibrant, enchanting, overly seductive, or inappropriately sexual with most of the people they meet, even when they are not sexually attracted to them.[6] People presenting with histrionic personality disorder may demonstrate rapidly shifting and shallow emotions that others may perceive as insincere. Physical appearance may be used to draw attention to oneself by wearing bright-colored clothing or revealing garments.[6] Those with histrionic personality disorder may speak in a vague style that lacks in detail.[4] Furthermore, they may be dramatic and extremely emotionally expressive, even embarrassing friends and family with public displays of emotions.[3] They may be impressionable, gullible, suggestible, and easily influenced--especially by the people they admire. Additionally, they tend to consider relationships closer than they usually are. While it is unknown what explicitly causes histrionic personality disorder, it is likely a disorder that is multifactorial in its origin. Histrionic personality disorder probably develops as a conglomeration of both learned and inherited factors.[6] One hypothesis is that histrionic personality disorder may develop as a result of trauma experienced during childhood. Children may endure their trauma by coping with their environment in ways that may ultimately lead to a personality disorder.[2] Personality disorders in childhood may originate as an adaptation to cope with a traumatic situation or traumatic environment.[7] Parenting styles may also influence the likelihood of developing a histrionic personality disorder. Parenting which lacks boundaries is over-indulgent or inconsistent may predispose children to develop histrionic personality disorder.[8] Moreover, parents who role model dramatic, erratic, volatile, or inappropriate sexual behavior put their children at high risk for developing this personality disorder.[9] Because histrionic personality disorder tends to run in families, there is some consideration that there is a genetic susceptibility for this disorder.[8] As with many psychiatric disorders, having a family history of personality disorders, psychiatric illness, or substance use disorders is a risk factor for histrionic personality disorder.[6] While approximately 9% of the general population has at least one personality disorder, the prevalence of histrionic personality disorder in the general populace runs about 2 to 3 %.[1] It is possible for people to have more than one personality disorder. Women are four times more likely to be diagnosed with histrionic personality disorder than men.[1] However, research suggests that women may be overly diagnosed with this disorder compared with men due to sexual-forwardness being less socially acceptable for women.[1] Furthermore, men may be less likely to report their symptoms and thereby be under-diagnosed.[1] Histrionic personality disorder tends to be ego-syntonic, meaning people with this disorder typically consider their behavior to be normal and struggle to identify a problem.[2] This lack of insight may contribute to the underdiagnosis of this personality disorder until later in life once patterns of behavior have significantly interfered with relationships, work, or interpersonal wellness.[3] Mental health care professionals will make a diagnosis of histrionic personality disorder after evaluating for abiding patterns of behavior and symptomology.[4] Personality continues to evolve throughout development; therefore, histrionic personality disorders are typically not diagnosed until after age 18.[1] Per DSM-5 criteria, a diagnosis of a histrionic personality disorder requires a pervasive and ubiquitous pattern of consistent attention-seeking behaviors and emotional dysregulation as outlined by specific manifestations. Diagnosis requires meeting five (or more) of the following criteria:
These patients take repression and dissociation as a significant form of defense mechanism. The treatment of choice for histrionic personality disorder is psychotherapy. Supportive psychotherapy is a recommended modality of treatment for patients with histrionic personality disorder, as this approach is found to be encouraging, reassuring, and non-threatening.[5] Supportive psychotherapy aims to reduce emotional distress, improve self-esteem, and to enhance the patient’s coping skills, all through attentive and sympathetic listening.[5] Psychodynamic psychotherapy (also called insight-oriented therapy) has also proven to be a successful approach in treating patients with histrionic personality disorder.[8] The goal of this therapy is to alter an aspect of a patient’s dysfunctional personality by integrating crucial developmental milestones a patient may have missed during previous stages of emotional maturation.[4] Psychodynamic psychotherapy aims to resolve underlying, unconscious conflicts in an effort for patients to understand themselves and their behaviors better.[8] The patients are encouraged to substitute excessively dramatic speech for a more adaptive action or behavior, to promote better communication with others.[1] Through psychodynamic psychotherapy, patients learn to recognize that hyper-sexual, attention-seeking behaviors are maladaptive, and discover new, healthier ways to develop self-esteem.[4] Group therapy and family therapy are not typically recommended as the first-line modality in treating histrionic personality disorder. People with histrionic personality disorder tend to desire to be the center of attention, which may be distracting from therapeutic goals in a group setting.[5] Additionally, people with this disorder may exhibit shallow emotions appearing insincere to those groups or family members participating in therapy concurrently.[5] Histrionic patients may be inappropriately sexual with their therapists; therefore, it is critical to set firm boundaries with patients.[1] The roleplay model and assertive approaches may help in minimizing conflicts. While the gold standard for treating personality disorders is psychotherapy, patients with histrionic personality disorder may be profoundly symptomatic.[9] Patients may experience affective dysregulation, where they frequently endure mood swings, anger, tearfulness, anxiety, and depression. While there are no FDA-approved medications for the treatment of histrionic personality disorder, affective dysregulation may be treated with antidepressants, mood stabilizers, and antipsychotics.[9] Antidepressants have proven to be effective include desipramine, fluoxetine, amitriptyline, and fluvoxamine.[8] The mood stabilizers with proven therapeutic benefits include lamotrigine, carbamazepine, topiramate, valproate, and lithium.[9] Research has demonstrated that antipsychotics such as risperidone, aripiprazole, olanzapine, and haloperidol have been useful in treating affective dysregulation.[1] Patients with histrionic personality disorder may struggle with impulse control and regulation of their behaviors. Clinical trials have demonstrated that mood stabilizers specifically can target these symptoms.[9] The biofeedback mechanism may help these patients control their inner feelings. The differential diagnosis for histrionic personality disorder includes narcissistic personality disorder, borderline personality disorder, dependent personality disorder, somatic symptom disorder, and illness anxiety disorder.[1] Like histrionic personality disorder, patients with narcissistic personality disorder prefer to be the center of attention.[2] However, patients with narcissistic personality disorder want attention, which results from admiration or veneration, whereas people with histrionic personality disorder are not particular about what type of attention they garner. Patients with histrionic personality disorder are similar to those with borderline personality because both types of patients experience intense emotions; however, patients with borderline personality disorder usually dislike themselves.[5] Dependent personality disorder should be considered in the differential diagnosis for histrionic personality disorder as with both personality disorders, the patient will prefer to be around others.[6] However, patients with dependent personality disorder tend to be more submissive, and their behavior is more inhibited as they are preoccupied with fears of rejection.[5] Somatic symptom disorder and illness anxiety disorder are also included in the differential for histrionic personality disorder as patients with histrionic personality disorder may use physical symptoms and complaints to gain attention from others.[8] While there is no cure for histrionic personality disorder, many people who have histrionic personality disorder can have useful and productive lives.[10] Patients who participate in therapy tend to have better outcomes as they gain insight into their condition and function more optimally socially and occupationally.[1] However, people with severe histrionic personality disorder may experience problems at work and in social or romantic relationships.[5] People with histrionic personality disorder are at a higher risk of developing depression than the general population.[6] Additionally, people with histrionic personality disorder are at increased risk of developing substance use disorders such as cannabis use disorder and alcohol use disorder.[9] They are also prone to having somatization disorder, panic attacks, and conversion disorders. Attention seeking behavior may confer them in showing frequent suicidal threats and gestures. As with other psychiatric disorders, patient education is a crucial component of successfully managing histrionic personality disorder. Patients diagnosed with histrionic personality disorder would benefit from understanding the maladaptive characteristics of their personality to gain insight and ultimately gain some control.[2] Patients should receive information that there is no cure to histrionic personality disorder; however, medications may be used to ameliorate symptoms.[1] Mood symptoms may correlate with life events, and moods are prone to highs and lows in association with life occurrences.[3] Nevertheless, medications should not be changed each time the patient experiences alterations in moods or emotional crises.[3] Patients with histrionic personality disorder may require longer trials on medications to determine if the medication is effective.[5] Premature termination of psychiatric medications does not allow for adequate medication trials.[10] Furthermore, it requires emphasis that psychotherapy is a vital element of treatment, specifically supportive psychotherapy or psychodynamic psychotherapy.[3] To promote better outcomes for patients with histrionic personality disorder, it is vital for patients to receive an accurate diagnosis. All providers would benefit from having a greater understanding of this disorder so that patients may receive the care they need. Psychiatric disturbances can affect anyone; however, if the physician or nurse provider is not considering histrionic personality disorder as a differential diagnosis, the patient will not receive the treatment they need.[7] Once a qualified practitioner makes a diagnosis of histrionic personality disorder, a comprehensive care plan should be discussed with the patient, including access to psychiatry and psychotherapy.[1] It is paramount for patients to have a clear understanding that there is no FDA approved medications for histrionic personality disorder, and prescribing providers need to delineate treatment goals.[10] The treating psychiatrist, mental health nurse, and psychotherapist should collaborate to devise an optimal treatment plan.[10] Ideal treatment plans would include psychotherapy frequently (weekly to bi-weekly) and the use of psychiatric medications if mood symptoms are interfering with the patient’s functioning.[10] However, frequent medication changes should be avoided, drugs lethal in overdose should be avoided, and medications with addictive potential should be avoided.[7] Histrionic personality disorder management requires the efforts of an interprofessional team that includes physicians, specialists, specialty-trained nursing staff, and pharmacists, all collaborating across disciplinary lines to drive outcomes positively. [Level V] Review Questions1. Nestadt G, Romanoski AJ, Chahal R, Merchant A, Folstein MF, Gruenberg EM, McHugh PR. An epidemiological study of histrionic personality disorder. Psychol Med. 1990 May;20(2):413-22. [PubMed: 2356266] 2.Cale EM, Lilienfeld SO. Histrionic personality disorder and antisocial personality disorder: sex-differentiated manifestations of psychopathy? J Pers Disord. 2002 Feb;16(1):52-72. [PubMed: 11881161] 3.Rienzi BM, Scrams DJ. Gender stereotypes for paranoid, antisocial, compulsive, dependent, and histrionic personality disorders. Psychol Rep. 1991 Dec;69(3 Pt 1):976-8. [PubMed: 1784694] 4.Kellett S. A time series evaluation of the treatment of histrionic personality disorder with cognitive analytic therapy. Psychol Psychother. 2007 Sep;80(Pt 3):389-405. [PubMed: 17877864] 5.Novais F, Araújo A, Godinho P. Historical roots of histrionic personality disorder. Front Psychol. 2015;6:1463. [PMC free article: PMC4585318] [PubMed: 26441812] 6.Lilienfeld SO, Van Valkenburg C, Larntz K, Akiskal HS. The relationship of histrionic personality disorder to antisocial personality and somatization disorders. Am J Psychiatry. 1986 Jun;143(6):718-22. [PubMed: 3717392] 7.Apt C, Hurlbert DF. The sexual attitudes, behavior, and relationships of women with histrionic personality disorder. J Sex Marital Ther. 1994 Summer;20(2):125-33. [PubMed: 8035469] 8.Morrison J. Histrionic personality disorder in women with somatization disorder. Psychosomatics. 1989 Fall;30(4):433-7. [PubMed: 2798737] 9.Sulz S. [Hysteria I. Histrionic personality disorder. A psychotherapeutic challenge]. Nervenarzt. 2010 Jul;81(7):879-87; quiz 888. [PubMed: 20585747] 10.Hori A. Pharmacotherapy for personality disorders. Psychiatry Clin Neurosci. 1998 Feb;52(1):13-9. [PubMed: 9682928] |
