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Rorschach Correlates of the DSM-IV

Histrionic Personality Disorder
Mark A. Blais & Mark J. Hilsenroth
Published online: 10 Jun 2010.

To cite this article: Mark A. Blais & Mark J. Hilsenroth (1998) Rorschach Correlates of the DSM-IV
Histrionic Personality Disorder, Journal of Personality Assessment, 70:2, 355-364, DOI: 10.1207/
s15327752jpa7002_12

To link to this article: http://dx.doi.org/10.1207/s15327752jpa7002_12

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 Histrionic Personality Disorder
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Mark J . Efilsenroth

Hysteria is one of the oldest docurnenrrci medical disorders. Descriptions of hqs-

teria haye been found in bnth ancient Greek an&E p y p t m rned~calwritings I Veith.
1977). Hysteria was the first psychiatric condition ro draw h e attentlor> of Freud
(Ereues & Freud. i 899'1 057) and p:cvided a starting p i n t f ~ the
r devel:p-nenr of
 356 BLAIS. WLSENROTW. FOWLER

psychoanaIys:s. Psychoanalytic formu!ations of hysteria and later, hysterical char-

acter, have focused on the presence of repressed sexuality, excessive and shallow
emotionality, and an overdeveloped fantasy life (Fenichei. 1945; Shapim, 1965).
Although the concept has undergone considerrible alterstion, Histrionic Personal-
:ty Disorder (HPD) continues to be par: of the officiai Diagnostic and SmlstEcaT
Manuad ofhfenta! Disorders (4th ed. [DSM-I\?; American Psychiatric hssocia-
tmn, 1994) nomenclature. The core features of DS144-it' HPD are "pervasive and
excessive emotionality 2nd attention-seeking behavror" (p. 655).
The Rorschach Inkblot Test (Rorschach. 1421/!942) has also had a long asso-
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ciation with hysteria. We have available to us Rorschach's own interpretation of the

protocol of a 30-year-old woman diagnosed with hysterical neurosis. In his inter-
pretation, he noted a coarctated record (low Rj, suggestive of repression. and a
"marked tendency rowzrd color answers, that 1s: more extratensive than intrcver-
sive features" (Rorschach, 1923/1942. p. i43:1. W r i t i ~ gyears Iaaer, Schrrfer (1938)
also considered repression, indicated by low R and few M {i-eurraanMovement), and
emotionaIity, indicated by the sum of G (Color! exceeding M (Human Movement),
to be the principal Rorschach signs of hystericaE neurosis.
The rational linking of Rorschach C responses an3 hysteria Is quite understand-
able. Starting with Rorschach's original work, C responses have been conceptually
related te affective expression arid responsiveness (Lerner, 199 1j. Likewise exces-
sive and undercontrolied ernotionaiity have been a central diagnostic feature of
hysteria since before Freud's writings (Pfohi, 1991) and continue to be important
features in the current conceptuaIizatian of FIPD. The prominence of excessive
emotionality in the DSM-iVcunceptualization of EIPD suggests that Rorschach as-
sessment data may be usefu: in the diagnosis oi'this disorder. Unfortunately, ern-
pirical data on the behzviorai correlates of Rorschach C responses are limited (Ex-
ner, 19933. There are data suggesting that mdividcaEs with high C responses zre
more easily hypnotized (Brennen & Richard, E 943). Also Exner end Armburster
(1979, cited in Exner, 1993) found C respomes to be correIated with a sensation-
seeking scale. Clearly. empirical data are needed tc?heip establish the validity of the
association of Rorschach C responses to affectivity.
The role played by dependency in HPD conrinues to be con~oversial.Some
theorists c o ~ s i d e dependency
r to be a primary motivation for PIPD patients (Mil-
Ion: 1990). However. none of the DSM-Ii? criteria directly measure dependency
(such a crirerka was present in DSiLI-111-I?; "Constantly seeks or demands reassmr-
ance. approval, or praise," but was dropped ii-on: the B S k H V ; PPfbhl. 199!). Ror-
schach assessment data might be able to shed light on this controversy. The Ror-
schach Texture (Tj response has been associated with dependency since it was
intmduced by KIopfer. The interpretation of T (scored as cF in KIopfer9ssystem)
centered on immature dependency. ''cF responses represent a relativeiy crude con-
tinuatlon of an early need for closeness, a need to be hejd and fondied and a longing
for an infantile sort of dependence on others"' (KIopfer: Ainsworth, KIopfer, &
 Halt, 1956. p. 271 ). Empirizzl!g., Marsh and VigLione iiS93; found a slgnificac:
correlation between 7 and touching behavior. Weber, M e I q , and Gacono i i991 i
i'ounb that interpersonally detached ~nparlentconducr-disordered adolescents pro-
ctuced significanily less Tthan did a group of dysthymic adolescents. Sindariy \ t r y
low T has beel; repeatedly o b s e r d In the Rorschach records of indi\~iduaisuith
antisocial personality disorders (Gaconii & MeIny. I99 l : Gacona, Meloq. & Berg.
1992). I: has also been found [hat peopie w!id>e h 7 a t e d T responses ha\.e a greater
need for inaerperscrnai closeness than do peopie with few T responses cExner 5r
Bryant, f 974.cited In Exmer. 1993).111 summarizing the d i ~ w s eempirical data on
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T,Exner :/I9931wmte, "The data concernlrrp Tare quite c o r n p e h g . People who

eievate fbr Thave greater needs for closeness.. . . The! apparently experience ione-
l i n e s or stronger than usual needs ro be dependelnt 01: others" ,:p. 385;.
The purpose iaf this study was to expiore the extent to which select Rorschzh
variables were empiricaIIy associated with the DSIWI\.'HPD criteria a n t twn seif-
rep:.,r: measures of Hysteria. the MMPI-2 Hysteria fH? ! scale ard %hehfh?PI HIS-
trionic Perbonaiity Disorder (MMPI-HPD:! scale (More!, LVaugh. & BlzshfieId.
1985).This srudy is distincr:w ic chat it represents :he first efforr to emp;:icoIl~ es-
tablish the relarlon be:~!een Rorschazh variabies and the DS?f-lt' HPD c:Itene.
Also, this approach to studymp HPD mag. prowde important insights n r o the ur:-
derlying ps>cholagicai charazteristics of the i).S.+-ii' PIPD and :hereb;: increase
our clinical understandmg of patients presenting wirh this disorder. The Rorschach
varkbles studied were R (Number c ~ Responses
f !, u+tich has been linked to repres-
eon: FC+CF+C(Form Color+ Color Form i Color:) as a measure ofe;noiionality:
7 (Texture) as ar: indicator of immature dependenq and nunurance needs. and O x
Denial (DEN! scale of the Lerner a:ld Lerner !19YC1) Defense S a l e to measure tHe-
fewsive sryje.

METHOD

Subjects

The subjects f j r this study were drawn from an archivai search of fiies at a
un:versirl;-based outpatient psychdog. rI:nic. This review included approxi-
marely 809 case fiies covering a ?-year period. A number of pre~iousstudm have
,i\ utilized char: information to retrospectiwlx rate patients iclr AXISI1
sLICceSSfK1-~.

diagnostic crireria (Fyer. Frances. S;ull!van. Hurt?& Carkin. 1988, McCann, i 991;
More?.. 1985'1.The selection of cases proceeded in rhree phases. Ir: the firs! phase.
317 cases were idei:tifkd as havir,g been diagnosed with a persona!i:) discrrder.
The original clinicai diagnases were rendered by a team consisting of an ad\mced
clinical psychology doctoral student and a supervisrng licensed clinizd psycholo-
gist on completion of the c!inii's iniake and assessment procedure.
 In h e second phase of selection, the chart material for these 217 patients was
rated for the presence or absence of DSM-111-R and DSM-IVpersondity disorder
(PD) diagnoses. The presence or absence of a PI4 was determined through a retro-.
spective review of the patient records, ~ l h i c hincluded an evalua6ot: report, session
notes from the first IS weeks of therapy, and ?-month treatment reviews when
available. Information regarding patient ~dentity,dizgnosis, and test data (includ-.
ing all Rorschach data) were appropriately masked from the reviewers. Raters in
this phase of the stody were four advanced docroral students in an American Psy-
choiogicd Association-approved clinical psycho?ogy program. The raters had re-
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ceived speciai training ir. the diagnosis of DSh4-111-R and DSM-IV Axis 11disor-
ders. Intert-ater rehability -was established by independent ratings of a randonly
selected pool of 3 1 patients and the obtained kappa value was .90 for the presence or
absence of a BSAI-PV personality disorder. respect:uely. Of the 2 17 patients re-
viewed in this manner. 79 were fs-und to meet DSh4-[\.'criteria for an Axis I1 disor-
der and had completed the Rorschach with [he EoEIcwing distribution: Antisocial
QANPD) = 16, Borderline (BPD', = 23, Histrionic (HPD) = 5 , Narcissistic iKPD,! =
12, Cluster A PD = 10, and Cluster C PD = 13.
The 79 patients identified through this retrospective case review made up our
sample. The sample was 5 1 % male patients and Dad anlean age of 28gears iSD = 89
at the time of their clinic ir,take. They averaged I4 years of education (SD = 2) and
;hex mean Wechsler fuli-scale IQ (Wechsler. I981) was 186 iSD = i 3). Forty-five
parients were single, 9 were married, 24 had been divorced. and 1 widowed. In the
third phase, the records :>fthese 79 patients were again independentiy rated on ail of
the DS!WlVCluster B PD sympton criteria (ANPD, BPD, HPD. and NPD! using
the same case material and methodology outlined earlier. Again interrater reliabii-
ity was established by independent ratings of a randomly sejected pool of 25 pa-
tients. Interrarer agreement for the presence or absence of indjvidlaal DSM-IVClus-
terB symptom criteria were: .80 (BPD), "86(ANPD),.90(HPDi, and .90(NPD).

Rorschach

As stated earher, rhe Rorcchach Structural Summary scores of R, C F t F C + C , and

1,a h g wnh the content scare of DEN, have been hqpothesnred to have utnlity rl:
dd'ferentiatmg HPD from the other fiucier B P h . The concert wore of DEN, as zt
measure of the defense denrai. n a \ asses& by :he terner Defense Scale (LDS,
Lernel-. 199:) The LDS 1%a Rorschach scoring systenl f ~ a rs w x m g pnminve de
fenses as the) 3re represented in huinar, and quasl-human and In some clrcum-
stances h m a n detali responses ( E L (ffj, and Nd) In order to use a s m g k bararrabk,
DEN. In the analyses. these scores were first weighted using acontmuum from high
to low denla1 i 1-21 and then collapsed mtcl an everall derived score iHlisenroth.
Ebbbard. h'ash. & Handier. 1993) For example, ~ f t h e r were
e three In\tances of de-
 niai an an ~ndividuai'spratclcol. one bejng a Le; ei l 2nd rhe other I L ~ Ubeing both
Levei 3s. the individual would receiie a toral denial scare of ?. ;1 I 3 --t 3 = ?:.

Procedure

The Rorschach was ciriginai!? admxistered and scored foihving the procedures of
Exrler (1986. E493';, excepr for the DEN scale. which was scored acc0r3:ng t:! t e r -
ner i:99 1 'i. Ail Rorschach p;otocois here rescored. Hind to previous scores and pa-
?ient diagnoses.. by rhe second aurhor. 1n;errate: relinhilitj (\Veirrer. 199I ! was ob-
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tamed O!; having the third author score. b i d tc! the fksr c o d e ~ ' sscures and patient
diagnosis, 20 randomly seiected protclcois. The rnatexmcer agreement for the Srruz-
rural Summa;?. Rorschach variables (R. FC+CF+C II was 86%. and 12XCi- for the
LDS xntenr score. DEN. Ail 79 Rorschach protocols utilized in this stuciy were re-
\ , i e w d fi9r \ aiidiry and none were found to h2i.e ;'eu,er than I-% reqwnses and n
tan:hric r h v e !.0.
A subsampie of 61 patients also completed the MMPi-2 t Butcher. Dahlsrrcm.
Graham. TeIkgen, B Kae~rmer,1989:. For these indi\.iduals the hIiL2PI.-2Hhs-
teria i E 1 !~and Ii:strinnjc Personailry Disorder scaies ihiISIPI-3-EP3 ! were scored
and included in the studq. iColiigan. More\;. 8 Crffxcl. 1993: More? e: ai.. 1985).
Both ;he overlapping and nonoveriappinp vers~onsr;f the MMPI-7-HPD scaies
were included in the a~alyses.

Staa~sticaiAnalyses

The CEcster B [A~atisocial~ Borderhe, H~snionic.and Narciiiistic i symptorn rar-

i n g ~were summed to produce total scores ( m a ; nunber oi'cr~teriltn e t ; 5 x each of
the CIusrer B PDs. Second. the Rorschach variclbkes wrereconelated u.~thrhe rorai
number c!f Rorschach responses ( R )and both T and FC-. CF + C were fcsund to be
sigrmifica~tlycorrelated with R 9< .C)S Therefore, the effect of R was partided ogt
of ali analyses utilizing these IWO :.ariabBes. Third, correiations u w e ohrained ibr
the Rarschiich variables, ihe C:r?ster I3 PD total scores. aad t h MBfPI--2 NJ, and
HPD scales. Fourth. c:melatrons were cornpuled for the Rorschach variabies and
the eight individual HPD criteria. -4s the distributions c.f a zurnber of the Rorschach
variables were skewed. Speamiar, rho c:~rreia?ionsccorrecteb for ties! \yere corn-
puted and used for 311 con~parisorss

RESULTS
 TABLE 1
Spearman Correlations for the Rorschach, Mmnesota Multiphasic
Personality Inwentoy-2 (MMPI-21, and Diagnostic and SWsficaI
kBanuai of Mer~daiBisor&rs-W Cluster B PBs

ANPD total -.I0 -.I6 -.08 -20

BPD total .06 .I 3 .16 .I5
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IIPD total .35* .08 .3y -.I2

WPD totar .06 .O? .04 -.05
fi" .02 .30* 3~3 -
EIPD-O~ .1C: .09 .20 -
HPD-N 0" .15 .02 .j8 -

Nore: W = 79. ANPD = Antisocial; BPD = Borderline; HPD = Histrionic lots1 scores;
NPD = Narcissistic: HJ = MMPI-2 Hystena scak; HPD-0 =. MMP1.--2His:rionk PD scale
owrlapping version: HPD-NO = MMPI-2 Histrionic PD scale non-overiappirag version.
"n = 62. '?he effect of ii was partraled onf of anaiyses employing this uliririsie.
* p < .a.

TABLE 2
Spearman Correlations for the Rorschach Variables
and the Dmgnostrc and Statisticab Manual sf Mental Disorders-!hi
(DSM-IVj Histrionic Personality B~sorder( W D )Criter~a

Korschuch Vuxiub[es

DSM-[I.' I I P D Crireric FC+ CF+ DEN T"

--

I Center of at?entlon .I6 nq * .35**

2 Sexually seductke .42** .1J
., ..
.LL

3 Shailow emotrons .-79** .C2 .Oh

?i**
.--. .GI "05
4 Uses appearance
5 Impressiomstic speech .36** .19 ,1;1**
6 Self-dramatization .I 8 .bJ .45**
7 Hrghig suggestible .06 .II .06
8 More intimate .16 .I? .25*

Note .V = .79. DEX = Denial.

%e effect of R was prrrtiaied out of analyses ernpioyiig this \&able.
* p < .m.
**p < .oi.
 abie, DEN. was significantly related to the MMPI-2 H\ scak whnle nc! s p i f i c a n t
relaelons were noted for the MhlPI-2-RPD scales.
Table 2 prcvides the Spearman rho correlations among the Rorschach vari-
ables and the eight individual DSM-IY HPD criteria. Tahte 2 slio\vs :hat se! en of
the eight HPD criteria ha3 at least one slgcificanr correia:ior? w:th the Rorschach
kariables. Thad significant correlations to four cr~ieria(HPD 1 . 5 %6.and 3 i and
both FC+CFt.C were nHsc correlated with four criteria (HPD7 , 3 . A. and 5 ) . DE?:
was significantly correlated with FBPD criterior: I . Only the HPD anterron 7 "ls
s~rggesribie. . . " failed to demonstrate a significant correlation to the Rorschach
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variables.

This scud! ao:nght to empirjcnliy explore the associations among the DSAl-IVHPD
crirena. select Rorschach variables. and rwo self-repon measures of hystecia. Our
findrngs support both the ab3I:r~of Rorschach assessment data ro dentif) diagnos-
tic feat.ures of the DSM-I\' HPDs anci to provde insights into the jeeper psycho-
iogicd motiva:ions of the D.W-WHPD. Our fimdrngs indicate chat the Rorszhach
vmsbles of FC+CF-C and Tare signlhcanrly and differenr:a!:l:\. reiated to HPD In
cornparison to other DSits-I\'Cluster B PDs. These corre'lattonal data suggest that
Rorschach assessment may be useful in differeidating HPD from ocher Cluster B
PDs. Also. the Rorschach variables drmcwstrared nxulripse significan~c o r e k i o n s
to the nci~vadualHPD criteria The patrerrr of rnulr~plecorrelar~cma c m s the indi-
zlduai criteria suggests that the qualities identified by the Rorschach variables a x
c e ~ t r afeatares
l of the DSrbl-ii; HPD. In fact only one of the eight HPD criteria ::7.
'2s suggestible . .. "! failed to be signif~cnnrlycorreiated with the IYxschxh \!xi-
abies. Et is possible that rhts criterion is difficult ~dentifythrough a chart re\,iew.
thereby ascirunti~gfor the negaci7e finding. Conyerse!>, it mi!!. be rhar this aspect
of HPD is easier to identify through clinical iilterweu and ob3erva:ion rather rhan
through Rorschxh assessment.
Despite the recent revisions. the research is mixed as to ~vherhe:i l r not :he dryer-
gence of HPD and Xarcissistlc PD has been significantly :rnproired iBlzis. Hilsen-
roth, & Castlebury. 1997; Blais & Norman. B999i. Given this. cIinicians wiI! con-
tinue to need data obtained from nlrrltlpIe assessment methods to clarify such
rncmcluste: differerrtiaf diagnoses. Our findings suggest that Rorschach asszssmenr
data can aid i n the differentiation of fhese DSM Ciuster & PDs !see Hiisenroth,
Handlerl & Bizis, 9%. f x eiaboration on this methoddogicai point). For exam-
~ i ea, preplderance of C and I responses is, the Rorschach protomis of patients
suspected of having aCluster & PD nrighr direct the cimcian towrird a diagnosis of
HPD or indicate the presence of histriocic features. Used in this manner. Rorschach
 assessment data. as part of a multimethod emluation, could prove quite vaiuabie in
improving the differential diagnosis of DSM-6V PDs.
Furthermore, Rorschach data can provide important. insights into the nature and
characteristics of the DSA.f-Ik7PDs. For example, our findings suggest that HPD is
associated with greater affectivity (CF-+CF+C)snd more Ioneliness and depend-
ency ( T ) than were the other Cluster B PDs. The finding that T was strongly associ-
ated with the HPD total score is very informative and of theoretical importance. De-
pendency has been proposed by some PD theorists 10 be a prlnary motivation of
HPD patients (MiILon, 1998). Interestingly, the two highest cor;cEatbons for T and
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the indvidcaal HPD cnaeria were found for Criteria I (is uncornfaxible when not
the center of attention j and 6 (shows self-dramatizatior~,theatricalilty ,and exagger-
ated expressions of emotion), both of which are clearly interpersonal in focus.
These data lend support to ihe idea that dependency needs mstivahe some of the
HPD patient's interpersonai behaviors. This Rorschach-based insight into HPD
suggests that the addition of criteria directly measuring dependency needs wouid
improve the construct validity of the DS!bl-IC: PIPD criteria see.
The Rorschach variables were not significantly associated with either the over-
Iappx~goornonoverlapping version of the MMP1-2 HPD scale. Hcswever. DEN was
significantly associated with the MMPI-2 My scale. This is also an important find-
ing, as psycholoplcd denial is one of the rwo primary characteristics measured by
the MMPI E+ scaie (Duckworth; 1999;Greene. 1991). This finding prcvides solid,
cross-method evidence of validity for this Rorschach content scale. Furthermore, if
denial is an important pychoIogicai feature of E-IPD, as recent research suggests it
is (Blais, Conboy, Wilcox, & Norman, i996), then this finding raises questions
about how w d l this feature is captured by the current DS4-IV HPD criteria.
Rorschach C responses were signif~carntlycorreiated with a number of HPD critena
reflecting behav~oralexpressions of emotion. For example, HPD 3 ""dspiays ... shal-
jowl expression c?f emotion" [kmericaa Psychiatric Association, 1994, p. 658) and 2
"interactions .. . characterized by .. . sexual$ sednztive w pxwocraGve behavior"
(American Psychiatric Association. 1993, p. 657). Tkese data provide some much
needed empirical sapport for the rational linking of C responses with affectivity.
This study demonstrates the abiiity of projective test data tc! identify behavioral
markers sf the D S A W V I I P Dand p a i n s to the potential of Rorschach data for im-
proving PD diagnoses. Furthennore, our data ilIustrated how Rorschach research
can be used to inform, clarify, and tc some exgent guide the development of a de-
scriptive and behavional diagnostic system such as the DSIM-I\/

ACKNOWLEDGMENTS

We thank Frank CasiBebnry, Myra Christensen, Susan Church. Karen Toman, and
Gre;a Smith for thelr varrous contributions ro rhrs study
 RORSCK4CI-I CORKELtlTES OF HFD 363

AE earher version ~f this :nanusirjpt wac presented at the 15th Iriternar~onai

Congress of Rorschach and Projecuvs Methods. Boston. 3uIq 1996

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inpamat Psychlatry Servxe
Massachsetts General H a s p a l
55 Frat (;tree:
Bosion, M.4 021 14

Received August i 4, I996

Revised March 5. !997