Sanctuary for the Abused
Tuesday, June 20, 2006
The Histrionic Personality Disorder (HPD)
The essential feature of the histrionic personality disorder is a pervasive and excessive pattern of emotionality and attention-seeking behavior. These individuals are lively, dramatic, enthusiastic, and flirtatious. They may be inappropriately sexually provocative, express strong emotions with an impressionistic style, and be easily influenced by others (DSM-IV™, 1994, p. 655).
The ICD-10 (1994, p. 230) describes the histrionic personality disorder as characterized by shallow and labile affect, self-dramatization, exaggerated expression of emotions, suggestibility, egocentricity, self-indulgence, and lack of consideration for others. These individuals may engage in inappropriate seductiveness and overconcern with physical attractiveness. They are easily hurt and seek continuous excitement, attention and appreciation.
Frances, et.al. (1995, p. 373) describes individuals with HPD as manipulative, vain, and demanding. However, in addition to the focus on physical appeal, the authors note that there may also be a genetic association between somatization disorder and the histrionic personality disorder. Benjamin (1993, pp. 165-166) believes that HPD falls into two subtypes: 1) those who are flirtatious and focused on physical attractiveness, and 2) those who are concerned with somatic symptoms. The DSM-IV™ Axis II HPD emphasizes the flirtatious version. However, individuals with HPD will vary in the degree to which they are sexually seductive or concerned about physical symptoms.
HPD is commonly co-morbid with conversion disorders, hypochondriasis, dissociative disorders, and affective disorders (Richards, 1993, p. 246). Kernberg (1992, p. 53) suggests that the relationship of HPD to conversion reaction and dissociative symptoms is strongest when the personality disorder is most severe.
Akhtar (1992, p. 259) notes that the current description of HPD corresponds to the previous idea of an infantile personality. These individuals had few sexual inhibitions, were impulsive, experienced identity diffusion and emotional lability, and demonstrated what the author referred to as moral defects. Yet, as described in the DSM-IV, individuals with HPD demonstrate what our society tends to foster and admire -- to be well liked, successful, popular, extroverted, attractive, and sociable (Millon & Davis, 1996, p. 366). In fact, Widiger, et.al. (Costa & Widiger, eds., 1994, p. 47) describe HPD as an extreme variant of extroversion. Extroversion involves the tendency to be outgoing, talkative, convivial, warm and affectionate, energetic, and vigorous. In a non-pathological form, extroversion is being high-spirited, buoyant, and optimistic. These factors coalesce into a personality disorder only when the needs behind the behavior are pathologically inflexible, repetitious, and persistent (Millon & Davis, 1996, p. 366). It is then that the corruptibility, manipulativeness, and disinhibited exploitation of others become factors and the personality disordered version of extroversion becomes apparent.
The literature differentiates HPD according to gender. Women with HPD are described as self-centered, self-indulgent, and intensely dependent on others. They are emotionally labile and cling to others in the context of immature relationships. Females with HPD over identify with others; they project their own unrealistic, fantasied intentions onto people with whom they are involved. They are emotionally shallow and have difficulty understanding others or themselves in any depth. Selection of marital or sexual partners is often highly inappropriate. Pathology increases with the level of intimacy in relationships. Women with HPD may show inappropriate and intense anger. They may engage in manipulative suicide threats as one aspect of general manipulative interpersonal behavior (Kernberg, 1992, pp. 58-59).
Males with HPD usually present with identity diffusion, disturbed relationships, and lack of impulse control. They are often promiscuous and bisexual. They have antisocial tendencies and are inclined to exploit physical symptoms. These men are emotionally immature, dramatic, and shallow (Kernberg, 1992, p. 59). Both men and women with HPD engage in disinhibited behavior. This is apparent in females with HPD through affective lability, manipulativeness, and intense, brief relationships. In men with HPD, disinhibition may be expressed through impulsivity, aggressive behavior, drug abuse, interpersonal exploitation, and numerous shallow sexual relationships (Frances, et. al., 1995, p. 373). If the aggressive, impulsive, and exploitative behavior become dominant in men with HPD, differentiation from the antisocial personality disorder can become problematic. There are questions raised in the literature as to whether or not HPD is a female variant of APD in men. However, as currently described in the DSM-IV™, the two are differentiated by the need to please and inclination to seek reassurance found in men or women with HPD and the more calculating and indifferent determination to exploit others found in APD. Also, a diagnosis of HPD does not require adolescent correlates of antisocial behavior as does the diagnosis of APD.
Individuals with HPD may decompensate in later adult years due to the cumulative effects of: 1) the incapacity to pursue personal, professional, cultural, and social values; 2) the frequent disruption of and failure in intimate relationships; and 3) identity diffusion. These factors interfere with ordinary social learning and consequences grow more severe with age. The usual course of untreated HPD is precarious as life opportunities are missed or destroyed (Kernberg, 1992, p. 65).
Individuals with HPD view themselves as gregarious, sociable, friendly, and agreeable. They consider themselves to be charming, stimulating, and well-liked. They value the capacity to attract people via their physical appearance and by appearing to be interesting and active people. For individuals with HPD, indications of internal distress, weakness, depression, or hostility are denied or suppressed and are not included in their sense of themselves (Millon & Davis, 1996, p. 369).
For individuals with HPD, vanity and seductiveness function to bolster and maintain self-esteem; they often become overinvested in how they look and dread aging (McWilliams, 1994, pp. 312). Growing old violates the view of themselves as glamorous and attractive people who are admired by others.
The HPD self is experienced as a small, fearful, and defective child who has to cope in a world dominated by powerful others (McWilliams, 1994, p. 310). For example, one professional man, diagnosed with HPD, repeatedly dreamed that he was a Volkswagen Beetle trying to keep up with larger, more powerful cars on an area freeway.
Individuals with HPD are consumed with attention to superficialities and spend little time or attention on their internal life. Because they know themselves so little, they often have no sense of who they are apart from their identification with others. They are able to change their attitudes and values depending upon the views of significant others in their lives. These individuals also fail to attend the details and specifics of their experiences. They have, accordingly, memories that are diffuse and general with a tremendous lack of detail (Will, Retzlaff, ed., 1995, p. 99).
View of Others
Individuals with HPD experience others as powerful and capable in relation to their own sense of being a small, fearful, and defective child (McWilliams, 1994, p. 310). This view of themselves as less powerful allows these individuals to absolve themselves from responsibility for their own behavior and to engage in manipulative behavior with others to force attention and care-taking They will behave in a seductive and enticing manner until they are denied what they are seeking. Individuals with HPD become intensely angry toward others they see as withholding.
Individuals with HPD focus on others to the point that they obtain their own identity from those to whom they are attached. Yet the attention they focus on others does not allow them to gain understanding of others or to become effectively empathic. Their intense observation skills are dedicated to determining what behaviors, attitudes, or feelings are most likely to result in winning the admiration and approval of others. Essentially, these individuals watch other people watch them. Their actual focus is on how they are doing and how they are being received by others. As a result, they are not particularly effective in understanding how others are feeling. Individuals with HPD are inclined to define relationships with or connections to others as closer or more significant than they really are. They do not see when they are being humored or placated by people who may have lost patience with their relentless need for attention and the failure to relate in a genuine way. Others may eventually withhold their own efforts to relate to individuals with HPD once they become aware that there is no real attempt to connect -- rather there is a continuing demand to be attended to and admired. Basically, it is analogous to how well the actor or actress actually "knows" their audience beyond reading whether or not the performance is being well received.
The HPD failure to view others realistically is reflected by their difficulties in developing and sustaining satisfactory relationships. Individuals with HPD tend to have stormy relationships that start out as ideal and end up as disasters (Beck, 1990, p. 214). These individuals are unable to tolerate isolation; when alone, they feel desperate and are unable to wait for new relationships to develop gradually (Horowitz, Horowitz, ed., 1991, p. 4). They will idealize the significant other early in the relationship and often see the connection as more intimate than it really is. If the significant others begin to distance themselves from the incessant demands, individuals with HPD will use dramatics and demonstrativeness to bind these people to the relationship. They will resort to crying, coercion, temper tantrums, assaultive behavior and suicidal gestures to avoid rejection (Beck, 1990, p. 51).
Even though individuals with HPD will attempt to bind others to them, they are often dissatisfied with single attachments. They tend to be lacking in fidelity and loyalty; they are seductive, dramatic, and capricious in personal relationships (Millon & Davis, 1996, p. 357). Their interpersonal dependency is not expressed through faithfulness and commitment. They start relationships well but falter when depth and durability are needed. There is a paradox in HPD relationships of coercive dependency and infidelity.
On the surface, in HPD relationships, there is warmth, energy, and responsiveness. Covertly, this behavior is accompanied by a "secretly disrespectful agenda of forcing delivery of the desired nurturance and love. . .manipulative suicidal attempts are examples of such coercions" (Benjamin, 1993, p. 173). Individuals with HPD have a strong fear of being ignored; they long to be loved and taken care of by someone who is both powerful and able to be controlled through the use of charm and seductiveness. They become helpless and childlike when faced with potential rejection (McWilliams, 1992, p. 307).
All people have dependency needs. It is the way these needs are expressed that differentiates personality-disordered individuals. Individuals with HPD tend to express dependency needs in a more uncontrolled, unmodulated, and exploitative manner (Bornstein, Costello, ed., pp. 122-123). Pathological manifestations of dependency needs include intense fears of abandonment, passive, helpless behaviors in intimate relationships, and phobic symptoms aimed at minimizing separation (Bornstein, Costello, ed., pp. 130-132). These behaviors lead to interpersonal conflict, rejection, and isolation which triggers even more pathological expression of the maladaptive responses.
Parents with HPD are inclined to use manipulative behaviors to focus their childrens‘ attention on parental needs and to evade arduous parental responsibilities while maintaining the appearance of being loving and involved. This can result in exploitation of and failure to protect children from emotional, physical, or sexual abuse.
Benjamin (1993, p. 174) notes that both borderline personality disordered and histrionic personality disordered individuals engage in coercive dependency; however, the coercion and dependency appear simultaneously in HPD and switch from one to the other in BPD. Individuals with HPD mask their control and contempt in a complex combination of neediness and attractiveness.
Issues With Authority
Individuals with HPD will engage in illegal behavior with little internal moral restraint. They are often able to evade negative consequences through the appeal of their interpersonal behavior. They are not inclined to be assaultive, argumentative, or aggressive with authority figures. They are engaging, responsive, and enthusiastic. They frequently tell people they see as powerful, i.e., in authority, how wonderful, effective, competent, etc. they are. For individuals with HPD, misinformation in the service of making someone else happy is fine; that is, they are quite at ease with evasion and dishonesty.
Individuals with HPD are overreactive, volatile, provocative, and engaging in their behavior. They are intolerant of inactivity, impulsive, emotional, and responsive. They have a penchant for momentary excitements, fleeting adventures, and ill advised hedonism (Donat, Retzlaff, ed., 1995, p. 47). The HPD behavioral style is charming, dramatic, expressive, demanding, self-indulgent, and inconsiderate (Sperry, 1995, p. 97). They tend to be capricious, easily excited, and intolerant of frustration, delay, and disappointment. The words and feelings they express appear shallow and simulated rather than real or deep (Millon & Davis, 1996, pp. 366-367).
These individuals can be quite effective in situations where a first impression is important and vague expression of ideas is preferred over precision. They are less effective where performance is measured by objective measures of competence, diligence, thoroughness, and depth. Acting, marketing, politics, and the arts are fields where individuals with HPD will do well and manage competition effectively (Richards, 1993, p. 246).
The body, erotically or via illness, is often used by individuals with HPD to attract the attention of others (Horowitz, Horowitz, ed., 1991, p. 5). They will engage in inappropriately exaggerated smiles and continuous elaborate hand gestures. Movement and expressions are designed to have a pleasing effect (Turkat, 1990, pp. 72-73).
Individuals with HPD are fraudulent insofar as their inner emptiness is in contradiction to the impressions they seek to convey to others. They hide their true cognitive sterility and emotional poverty (Millon & Davis, 1996, p. 370). HPD cognition is global, diffuse, and impressionistic; these individuals appear incapable of sustained intellectual concentration; they are distractable and suggestible (Beck, 1990, p. 215). They avoid introspective thought. They are attentive to fleeting and superficial events but integrate their experience poorly with a cursory cognitive style. They lack genuine curiosity and have habits of superficiality and dilettantism. They avoid potentially disruptive ideas and urges by dissociating from thoughts, people, and activities that threaten their view of themselves or the world (Millon & Davis, 1996, p. 369).
Individuals with dependent personality disorder and histrionic personality disorder share important traits: they both turn to others for protection and the rewards of life; they are socially affable and share an intense need for attention and affection. Individuals with HPD have a more vigorous and manipulative style; these people will take the initiative in assuring that attention is forthcoming. They will actively solicit the interest of others through a series of seductive behaviors (Millon & Davis, 1996, p. 357).
Individuals with HPD express their emotions intensely yet remain unconvincing. They appear warm, charming, and seductive, yet their feelings appear to lack depth and genuineness (Beck, 1990, p. 213). They have an infantile quality in their emotional expression. They experience exaggerated feelings that change frequently. They become so involved in their emotional dramas that they are unaware of or are uninformed about the world they live in. They cannot stand frustration, disappointment, or delayed gratification (Oldham, 1990, pp. 143-144).
Individuals with HPD are subject to distortion in their emotional reasoning. They accept their emotions as evidence of truth rather than just a statement about their current emotional state (Will, Retzlaff, ed., 1995, p. 99).
People with HPD experience recurrent flooding of affect. Somatic preoccupations and sudden enraged, despairing, or fearful states may occur. Patience is rare and these individuals may use alcohol or other drugs to quickly alter states of negative feeling (Horowitz, Horowitz, ed., 1991, p. 4).
HPD defenses include dissociative mechanisms. Individuals with HPD regularly alter and recompose themselves to create a socially attractive but changing facade. They engage in self-distracting activities to avoid reflecting on and integrating unpleasant thoughts and feelings (Kubacki & Smith, Retzlaff, ed., 1995, p. 168). Repression is also a HPD defense; frequent splitting off from conscious awareness of self results in an intrapsychic impoverishment; psychological growth is precluded. These individuals remain immature and childlike in their behavior. Through repression, individuals with HPD remain unaware that their thoughts and feelings are attached to their behavior. Accordingly, they claim innocence when their conduct results in interpersonal conflict (Kubacki & Smith, Retzlaff, ed., 1995, p. 171).
Millon (Millon & Davis, 1996, pp. 369-370) also noted the HPD defense mechanisms of dissociation and repression. Individuals with HPD are attuned to external rather than internal events. They dissociate entire segments of memory and feelings that prompt discomfort. They, in particular, must keep away from awareness the triviality of their entire being, its pervasive emptiness and paucity of substance (Millon & Davis, 1996, pp. 369-370).
McWilliams (1994, pp. 304-307) describes the organizing defenses of HPD as repression, sexualization, and regression. Individuals with HPD will also behave in a counterphobic manner; they approach what they fear. However, they may become helpless and childlike when faced with potential abusers.