Histrionic Personality Disorder

1
 CHAPTER I

INTRODUCTION

In life, a person from an early age has a tendency or habit to use a pattern

that is relatively similar in responding to a problem he is facing which, when

considered further, the way or method of solving it appears as something that has

a special pattern and can be identified as a feature or sign in recognize that

someone. This phenomenon is known as character or personality

Personality disorders must be distinguished from personality traits.

Personality traits are patterns of behavior that last a long time, relate to the

environment and oneself, and emerge in the form of social and personal contexts.

Personality traits are also flexible and the clinical picture does not meet diagnostic

criteria or guidelines, and is milder than personality disorders. When this behavior

pattern becomes significantly maladaptive and causes serious impairment in

personal and social functioning, it is called a personality disorder. 1,2

In an individual with a personality disorder, there is dysfunction in family

relationships, work, and social functioning. According to Kurt Schneider, a person

with a personality disorder is someone who makes it difficult and detrimental to

himself and society because of these constitutional personality traits (not acquired

after the individual has developed or not due to significant stress). Constitutional

means the result of bodily and psychological interactions. Thus, things that can

cause personality disorders are sought in these two elements since childhood,

namely, especially heredity, developmental disorders of the nervous system and

hormones as well as environmental influences in childhood. 1,2

2
 Symptoms of personality disorders are alloplastic (i.e. able to adapt and

change the external environment) and ego-syntonic (i.e. acceptable to the ego),

those with personality disorders do not feel anxious about their maladaptive

behavior because the person does not routinely feel the pain of what society

perceives as a symptom, they are often perceived as unmotivated for treatment

and unresponsive to recovery. 1,2

One of the existing personality disorders is histrionic personality disorder.

According to the DSM-V, limited data from studies in the general population

suggests a prevalence of around 2 to 3%. The main hallmarks of histrionic

personality disorder are excessive and diffuse self-dramatization, excessive

emotionality, and attention-seeking. Some people tend to express themselves in

very dramatic ways. Taken to extremes, these tendencies form the basis of

histrionic personality disorder. 1,2

About 2-3% of the population, more women than men, suffer from

histrionic personality disorder. His trademark is behaving to attract attention,

often exaggerating his thoughts and feelings. Happy to sulk, cry, and accuse

others of not paying attention to it. 2,3

3
 CHAPTER II

LITERATURE REVIEW

A. Histrionic Personality

Personality disorders are inflexible and maladaptive personality traits that

cause significant dysfunction or subjective suffering. In the 5th Diagnostic and

Statistical Manual of Mental Disorders (DSM-V), personality disorder is defined

as a long-lasting pattern of behavior and internal experiences that deviates

markedly from one's cultural expectations, is pervasive, has onset during

adolescence or young adulthood, is stable from time to time, and cause

unhappiness and deterioration. 1,2

Literally, the word histrionic comes from the Latin, namely "histrionicus"

which means "pertaining to be an actor". The main hallmarks of histrionic

personality disorder are excessive and diffuse self-dramatization, excessive

emotionality, and attention-seeking. Behind it all, sufferers are often unable to

maintain deep and lasting relationships. This personality disorder tends to occur

among people who have experienced separation from their partner and is

associated with depression and poor physical health. 1,2

Consciously, histrionic patients want to be seen as attractive, charming,

warm, intuitive, sensitive, and generous. In addition, these patients also appear

exhibitionist, seeking attention, seductive, manipulative, and often over-

dramatized, easily hurt, do not think about the feelings of others, and whimper

with episodes of crying or anger. These patients have the capacity to experience

one emotional state after another at a very rapid pace. In a way, their experience

4
of affectivity is similar to that of small children who can quickly switch from

laughing to crying

The histrionic patient presents himself to the world in three domains. The

first is 'dramatic', which includes exhibitionism, exaggeration, emotionally

unstable, very passionate, and very generous. The second is 'manipulative' in

which the interpersonal world is controlled and gratification is taken from there,

such as seeking attention, not being promiscuous in social matters, being

demanding, easily hurt, not thinking about others, and being dependent. The third

is related to the aspect of 'ego functioning', usually histrionic patients are often

impulsive, scattered, disorganized, easily bored, rarely punctual, and difficult to

trust. 3,4

They tend to magnify their thoughts and feelings, making things sound more

important than they really are. Seductive behavior is often found in both men and

women. They may think that by acting on their sexual impulses they can reassure

themselves that they are attractive to the other sex.

The dramatic type histrionic personality suppresses feelings, colors, and

attention. Such individuals process their world effectively, appreciate the effects

of emotions, and express their emotions easily and openly. They experience life

through sensation and romance, deliberately making themselves physically

attractive, consciously dressing with the opposite sex in mind and being attractive,

charming, or even seductive. Many are highly intuitive with a quick sense of what

to talk about and how others want to be treated. Most trust others easily and

readily involve themselves in a relationship.3,4

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 The kind of friendly (ougtoing) focuses more on being friendly than

"appearing". Possessing great self-confidence in terms of influence and appeal,

this type of individual goes out of his way to be popular and naturally knows how

to make others like him. They are usually described as warm, lively, dramatic,

passionate, or provocative. Most see themselves as cheerful and optimistic

individuals. Their joy in life is contagious, inspiring others to be just as happy.

Many act and think like teenagers, even at an older age. Most are open to new

possibilities and find great pleasure in encountering new experiences.3,4

Sperry stated that individuals with histrionic personality disorder typically

become angry, depressed, or jealous when not being the center of attention, while

individuals with the outgoing type enjoy praise and flattery without relying on it.

He also enjoys entertaining others, but can give up the stage to be part of the

audience. Interpersonally, the histrionic individual relies on a blanket of sexual

charm.3,4

This is in contrast to the friendly type, which is charming, attractive, and

refined with more merit. Emotionally histrionic individuals are often fickle with

their rapidly changing moods. On the other hand, friendly types have more precise

emotional control. Physical attractiveness through designer grooming, clothing,

and accessories is of the utmost importance to histrionics. Friendly types also

have such attraction though they don't extend to obsessive disorder. 5,6

Individuals with cognitive impairment are global, mixed-up, and

impressionistic (providing general ideas rather than specific facts or detailed

information), while normal types are more constructive in detailed judgments and

qualify, because of their emotional authenticity. In contrast to the disturbed

6
individual, who constantly engages in theatrical and dramatic expression, the

normal type is not too extravagant without a desire to take on a leading role.

While disturbed individuals are easily swayed by the influence of others, normal

types are able to make their own decisions, even at the risk of losing attention and

approval. Finally, individuals with the disorder perceive relationships as more

intimate or intimate than they really are, while the normal type is anchored in a

more intact self. thus providing the opportunity for a greater sense of continuity

and a deeper self-awareness into the nature of personal relationships. 5,6

B. Etiology

Millon et al. mentioning the etiological dynamics experienced by a person so that

he has a histrionic personality disorder: 7, 8

1. Genetics

2. Female gender, male is synonymous with antisocial personality disorders.

3. Childhood trauma, shaped through the relationship between the opposite sex of

parents, childhood experiences and developmental consequences for psychosexual

development and character formation that exist today.

4. Low mental function at the oral stage, from high mental function at the oedipal

stage of development, where the growth of a sense of sexual desire is an

unconscious attitude towards parents of the opposite sex.

5. Problems with object relations.

6. Not forming a strong super ego.

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7. Sometimes the same behavior is rewarded, sometimes not (inconsistently so

children experience frustration to get their parents' attention and exaggerate

behavior to get protection, praise, affection).

8. Barriers to identity development.

9. Cognition and ego defense mechanism systems combine to protect oneself.

10. Rejecting situations that should provide knowledge for them thereby limiting

their opportunities to face intellectual challenges.

11. There is modeling from family members. 7,8

C. Histrionic Personality Characteristics

Patients with histrionic personality disorder exhibit high attention-seeking

behavior. People with histrionic personality disorder tend to express their emotions

excessively. They tend to magnify their thoughts and feelings, making things sound

more important than they really are. They show temper tantrums, fear, and accusations

when they are not the center of attention or are not getting praise or appreciation.5,6

Flirting behavior is common in both sexes. Sexual fantasies about people involved

with the patient are frequent, but the patient is inconsistent about verbalizing these

fantasies and may be coy or flirtatious instead of sexually aggressive. In fact, histrionic

patients may have psychosexual dysfunction: women may be anorgasmic, and men may

be impotent. They may exercise their sexual impulses to reassure themselves that they

are attractive to the other sex. Their need for security is endless. However, their

relationships tend to be superficial, and patients can fail, be self-absorbed, and fickle.

Their strong dependence causes them to be very trusting and gullible.5,6

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 The main defenses for patients with histrionic personality disorder are repression

and dissociation. Thus, these patients are unaware of their true feelings and unable to

explain their motivations. Under stress, the reality test is easy to be disturbed.8,9

a. Self dramatization

The style of speech, physical appearance, and general behavior of these

patients is dramatic and exhibitionistic. The pattern of language tends to use

superlative words. Patients often exaggerate in order to dramatize a point and

do not care about the truth if a distortion better accompanies the drama. These

patients are often attractive and look younger than their age. In both sexes,

there is a strong attraction to style and fashion. Women often dramatize

femininity while men dramatize masculinity.8,9

b. Emotionality

Although the histrionic patient has difficulty feeling deep feelings of love and

intimacy, the outward appearance is quite the opposite. This patient is very

attractive and relates to others warmly, although he is emotionally unstable

and easily changed. He takes relationships for granted, even though he

actually feels comfortable. In a relationship where the patient does not get

emotional contact, he feels rejection and failure and often blames other

individuals and shows obvious disappointment which can progress to

depression or anger which can be expressed as temper tantrums. The

relationship with these patients can change rapidly, from loving a person to

hating him as children can go from crying to laughing in a short period of

time.8,9

c. Stimulate

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 These patients create impressions by using the body as an expression of love,

but this is simply the result of a desire to be perceived as accepted, admired

and protected rather than to feel intimacy or sexual desire. The patient will

respond competitively antagonistically to other people using the same

equipment to get attention.8,9

d. dependent

Male patients more frequently display pseudo-independent behavior, which

can be recognized as a defense due to an emotional response of excessive fear

or anger. Whereas female patients show themselves as very dependent and

helpless people, who expect doctors to guide them in every action. He is also

possessive in relationships. This patient requires great attention from all

around him and is unable to entertain himself. Boredom is a constant problem

for these patients as they consider themselves boring.8,9

e. Suggestible

Although suggestible, patients are sometimes only suggestive of suggestions

that they think are true.8,9

f. Marriage and sexual problems

In female patients it may be anorgasmic and males tend to be impotent.8,9

g. Somatic disorders

Somatic complaints involving multiple organ systems usually begin during

the patient's teenage years and continue throughout life. Symptoms are

dramatically described and include headache, back pain, conversion

symptoms, and in women often with pelvic pain and menstrual

disturbances.8,9

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D. Histrionic Personality Clinical Manifestations

a. Theatrical Histrionic

Highly dramatic, romantic, and attention-seeking, theatrical histrionic is a

summary of basic histrionic patterns. Described by Fromm's "marketing orientation,"

such individuals essentially live as commodities, market themselves as chameleons to

social demands, and change the characteristics they display to suit the audience and the

circumstances. For them, nothing is intrinsic. Instead, the self is under social economic

requirements - transformed, synthesized, manufactured, and packaged to optimize their

attractiveness in a given market segment.

Style is not only valued over goods but also valued as an exception to goods. As a

result, theatrical histrionics exists largely without depth, since having an inner identity

limits potential maneuvers. In fact, reading other people's motives and reflecting back

on themselves what is attractive, pleasing, and seductive is their most important

endeavor. 10,11

b. Infantile Histrionic

The infantile histrionic, similar to Kernberg's infantile personality, represents a

mixture of borderline and histrionic personalities. As previously stated, many histrionic

individuals have strong dependency problems. By prematurely sexualizing relationships

and drawing powerful others into their orbit, histrionic individuals experience more

indulgence and less frustration. Therefore, they do not need to develop a full-fledged

sense of identity whose shape starts with what analysts call the reality principle, the

awareness that life is intrinsically so frustrating that some common physical tool,

namely the ego, would be needed to deal with it. 10,11

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 Thus, the life of the histrionic individual is continually dominated by a need to be

the center of attention, a constant search for sensation, and primitive regression into

fantasy, all of which conform to the pleasure principle. In the more primitively

organized histrionic infantiles, the expression of these characteristics is even more

severe. Due to their lack of identity formation their attachment to their significant other

is highly dependent and demanding. Most are constantly looking for reassurances to

maintain their stability and vacillate between over-indulgence and deep depression

when approval does not come. Without the self-awareness to restrain or regulate their

most basic urges, their emotions change quickly, easily, and unpredictably. drastically

change from very much in love to very angry to very guilty, all of them may be

expressed simultaneously. In more agreeable situations, they may act in a childishly

pleasant or charming manner but become moody or sullen the next moment. Many

complain that they are either unloved or treated unfairly, attitudes which quickly

escalate into tantrums when anyone disagrees with them. 10,11 attitudes that quickly

escalate to tantrums when anyone disagrees with them. 10,11 attitudes that quickly

escalate to tantrums when anyone disagrees with them. 10,11

c. Vivacious Histrionic

Vivacious histrionics (exuberant histrionics) synthesize histrionic allure with

energy levels of the hypomanic type. The result exudes charm, charm, antics, high

spirits and intensity. More than just friendly and passionate, vivacious histrionic is

interpersonally cheerful, optimistic, spontaneous, and impulsive in expression, and

without consideration of the consequences in the future. Driven by a need to feel joy

and arousal, many easily become infatuated with attaching themselves to someone and

then moving on to others in short succession.12,13

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 In behavior, their movements are fast and lively. Comes and goes with attention.

Although they are only superficial thinkers, their ideas often flow so quickly and easily

that others become swayed by their excitement. Those who are more normal walk

around, solve problems, start projects, and persuade others to join in with the energy

and friendliness of a natural salesperson. But others pursue temporary desires without

accomplishing anything, leaving broken promises, empty wallets, and disappointed

partners. Not surprisingly, many vivacious histrionics also have narcissistic traits. 12,13

d. Appeasing Histrionics

The appeasing subtype combines histrionic, dependent, and compulsive features.

Approval is their main mission in life: You have to like them; you have to be their

friend. To achieve this goal, they constantly compliment, flatter, please, approve, and

make you feel that they would do anything for you: "You are so smart! You have done a

perfect job! You look so beautiful! How can I help you?" ?" Whenever they feel

indifference, they quickly add to the action, positioning their judgment back in a

positive direction. As a result, they present an image of absolute goodwill, one for

whom rewards are of moral importance. When a mismatch occurs, they quickly begin to

smooth things over again, even when they have to make sacrifices, compromise their

own will, or agree on important points. 12,13

Rather than attacking those who cannot be reconciled, they choose to feel the

wound, portraying themselves as innocent victims trapped in a cruel world, martyrs who

suffered the outrageous spears and arrows of fate, always feeling deserving of sympathy

and compassion. The implication of such a conciliatory lifestyle is compensation for a

substantial void. Behind their friendly smiles lies the emptiness of the histrionics, the

guilt of compulsions, and the inferiority and helplessness of dependents. Most feel that

13
they are problematic individuals who are unloved and inadequate. Therefore, they

become eager to please others, always alert to even the most subtle symptoms of when

and where respect and approval may be obtained. 12,13

Developmentally more advanced than basic histrionics, these individuals have

internalized the punishing parental voice that falls with criticism and rebuke. Like

hyperconform compulsives, these individuals satisfy their tormentors, consciously

anticipate their needs, and offer only good intentions and gestures in return for anger

and hostility. In essence, they become so kind and sweet that they can make even the

superego of a sadist feel guilty. 12,13

e. Tempestuous Histrionic

The tempestuous (turbulent) variant combines negativistic histrionic personality

traits. Such individuals can best be described as highly moody and emotionally volatile.

During the better periods, they exhibit only histrionic traits, display attractive faces,

superficially become sociable predictors, talk to others, and add in return their own

independent emotional expressions. Like the theatrical histrionics, they are quickly

bored, overly dramatic, hyperreactive to outside stimuli, and impulsive seekers of

sensation. When combined with borderline traits, the result is emotional overdrive.

12,13

Like the borderline individual, the temperamental histrionic is hypersensitive to

criticism, intolerant of frustration, and socially immature—characteristics that almost

ensure that the good times last. Most alternate between periods of extreme emotional

excitement and acting out impulsively, followed by bouts of anger that turn into

depressive-like symptoms of exhaustion and changes in eating and sleeping patterns.

While the normal individual develops a strong sense of self-identity that encapsulates

14
and hides basic drives and regulates emotions, the tempestuous histrionic is not only

more thinly layered than the basic histrionic pattern but somehow fragmented like a

borderline. 12,13

As a result, they are more susceptible to uncontrolled displays of raw and rapidly

changing emotions. When offended, they lose control, reacting like a storm and rioting

at even the slightest provocation. Deprived of attention, they may frantically seek

approval, become argumentative, moody, or despair when approval does not come

immediately. Over time, these individuals may gradually become less histrionic and

become more angry and critical of others, feeling bad for other people's good fortune.

They also may develop a preoccupation with body function and health, and dramatically

display their illness or complain endlessly about illness to regain lost attention and

support.

f. Disingenuous Histrionic

The disingenuous subtype synthesizes both histrionic and antisocial traits. A

slightly different picture is created, depending on the relative influence of histrionic and

antisocial traits. At first, they make a favorable first impression and appear young,

sociable and sincere, displaying a spontaneity and charm so that others quickly weaken

their guard. But the combination of histrionic and antisocial traits makes the

disingenuous subtype more manipulative than the basic histrionic pattern and for

purposes other than concern and approval. 13,14

For some, their histrionic nature serves only as a useful method of making

acquaintances and opening doors but overlays and temporarily conceals underlying

antisocial characteristics, including a willingness to break social conventions, break

promises and destroy loyalties, act irresponsibly, and sometimes exploded with anger

15
and physical confrontation. For some, antisocial influences stop here with traits that are

perceived as the result of normal delinquency. However, others combine histrionic and

more psychopathic characteristics. These individuals synergize skills, charms, and

histrionic social skills that are more adaptive to reading the motives and desires of

others with calculated malicious intent. 13,14

Clearly, this variant is more egocentric, deliberately insincere, and perhaps more

aware of their manipulation than the basic histrionic pattern. They often seem to enjoy

conflict, deriving some degree of satisfaction or pleasure from the resulting tension and

stress. Because antisocial individuals usually interpret kindness as weakness, their

friendly, histrionic nature sometimes makes them fear that others will come to see them

in exactly the same way. If they feel this is true, they may reciprocate the wrong

impression by becoming predators (people who exploit others). 13,14

E. Diagnosis and Differential Diagnosis

Diagnosis

In interviews, patients with histrionic personality disorder were generally

cooperative and willing to provide a detailed history. Their mannerisms and

dramatic emphasis on speech are unheard of, they can mispronounce frequently,

and their language is very colorful. Shows of affection are common, but if forced

to deal with certain feelings (such as anger, sadness, and sexual desire), they may

respond in surprise, anger, or denial. Cognitive examination results are usually

normal, although lack of persistence may be demonstrated on arithmetic or

concentration tests.15,16

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 People with histrionic personality disorder display a high degree of

attention-seeking behavior. They tend to exaggerate their thoughts and feelings

and make things sound more important than they really are. They exhibit temper

tantrums, cry, and accuse, if they are not the center of attention or do not receive

praise or approval. 15,16

Seductive behavior is common in both sexes. Sexual fantasies about the

person involved with the patient are also common, but the patient is inconsistent

in verbalizing these fantasies and may act coy or flirtatious rather than sexually

aggressive. In fact, histrionic patients can have psychosexual dysfunction: Women

can be anorgasmic and men can be impotent. The need to be reassured is

relentless: they may act on their sexual impulses to convince themselves that they

are attractive to the opposite sex. However, their relationships tend to be shallow,

and they can be arrogant, preoccupied with themselves, and fickle. their need to

depend makes them overly trusting of others and gullible. 15,16

The main defenses for patients with histrionic personality disorder are

repression and dissociation. In this regard, the patient is not aware of his true

feelings and cannot explain his motivation. Under pressure, reality testing is easily

disrupted. 15,16

To diagnose histrionic personality disorder in clinical practice, a diagnostic

guideline is needed, which are included in the Diagnostic and Statistical Manual

of Mental Disorder V (DSM V) and PPDGJ III. 15,16

Diagnostic criteria for histrionic personality disorder according to DSM V,

as indicated by five (or more) of the following:17,18

1. Uncomfortable in situations where he is not the center of attention

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 2. Interactions with others are often characterized by sexually seductive

or inappropriately provocative behavior

3. Shows rapid shifts and shallow expressions of emotion

4. Constantly uses physical appearance to draw attention to himself

5. Has a style of speech that is very impressionistic and not detailed

6. Shows self-dramatization, theatricality, and exaggerated emotional

expression

7. Easily suggested, easily influenced by other people or circumstances

8. Presumes the relationship is more intimate than it really is.2

Diagnostic criteria for histrionic personality disorder based on PPDGJ-

III:17,18

 Personality disorder with the following characteristics:

a. Self-dramatization of emotions such as theatrically exaggerated

b. Suggestive, easily influenced by other people or by circumstances

c. Superficial and labile affective state

d. Constantly seeking excitement, appreciation from others, and activities in

which the patient is the center of attention

e. Inadequate "stimulating" (seductive) appearance or behavior

f. Too concerned with physical attractiveness.

 Diagnosis requires at least 3 of the above. 17,18

Differential Diagnosis

It is difficult to distinguish histrionic personality disorder from borderline

personality disorder, but within borderline personality disorder, suicide attempts,

identity diffusion, and brief psychotic episodes are more common. Although both

18
conditions can be diagnosed in the same patient, the clinician must separate the

two. Somatization disorder (Briquet's syndrome) may coexist with histrionic

personality disorder. Patients with brief psychotic disorder and dissociative

disorder may also have a histrionic personality diagnosis. 17,18

F. Management

Psychotherapy

Patients with histrionic personality disorder are often unaware of their true

feelings. Clarification of internal feelings is of therapeutic importance.

Psychoanalytically oriented psychotherapy, both individual and group, may be the

treatment of choice for histrionic personality disorder.

a. Cognitive-behavioral therapy

To help individuals recognize and change ways of thinking that arise from

feelings and behavior. 19,20

b. Group therapy

Used to help individuals with histrionic personality disorder work in interpersonal

relationships. 19,20

c. Expressive Psychodynamic therapy

This therapy can help the sufferer to be more aware of what he is feeling. 19,20

Pharmacotherapy

Pharmacotherapy may be an adjunct to therapy if the blood is related to symptoms

(such as the use of antidepressants for depression and somatic complaints,

antianxiety agents for anxiety and antipsychotics for delirium and illusions). 19,20

19
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 CHAPTER III

CLOSING

The main hallmarks of histrionic personality disorder are excessive and

diffuse self-dramatization, excessive emotionality, and attention-seeking. Behind

it all, sufferers are often unable to maintain deep and lasting relationships. This

personality disorder tends to occur among people who have experienced

separation from their partner and is associated with depression and poor physical

health.

Consciously, histrionic patients want to be seen as attractive, charming,

warm, intuitive, sensitive, and generous. In addition, these patients also appear

exhibitionist, seeking attention, seductive, manipulative, and often over-

dramatized, easily hurt, do not think about the feelings of others, and whimper

with episodes of crying or anger.More women than men are usually diagnosed

with this disorder.

21
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