CASE REPORT

HISTRIONIC PERSONALITY DISORDER

PSYC71F22S011

SUBMITTED TO MAM NAJMA

ASMA IRFAN

M.PHILL-II
Case Summary

S.B was 17 years old boy . He belonged to a middle class family. His developmental milestones
were not so delayed. He was studying in private education institute when he was 13 years old.
The child came with the presenting complaints to feel underappreciated or disregarded when he
is not the center of attention. vibrant, enchanting, overly seductive, or inappropriately sexual
with most of the people he meet, even when he is not sexually attracted to them. demonstrate
rapidly shifting and shallow emotions that others may perceive as insincere. Physical appearance
used to draw attention to himself by wearing bright-colored clothing or revealing garments,
speak in a vague style that lacks in detail. For this purpose of assessment different psychological
tools had administered which included Behavioral observation, Functional Checklist, Mental
Status examination (MSE) Brief histrionic personality scale (BHPS) ,The 11-item scale (each
item with a score from 1 to 4) runs from 11 to 44. The BHPS was psycho-metrically validated with
a student sample. The average score was 25.5 points (standard deviation 4.6 points). Moreover,
other assessment techniques have also been employed such as clinical observation and clinical
interview. The presenting complains and their durations as well as results of psychological tests
applied showed the client was suffering.Psychological interventions include Rapport Building,
Psycho Education, Positive Reinforcement, art and craft therapy, behavioral modification, play
therapy were applied. Seven sessions were conducted with the child. After treatment some
improvement was observed in his symptoms. He started behaving decent and tending to avoid
extremes.

Demographic Information:

Name: S.B
Age: 17years
Gender: Male
Education: Class 12
Marital status: Single
Family: Nuclear
Occupation: Student
Siblings: 2 sisters and 1 brother
Parents: both alive
Birth order: 3rd born
Religion: Islam
Residence: Sargodha
Past psychiatric history of client: problem from social behaviour.
Source and Reason of Referral:

The client was referred by his teacher in college by personally contacting and was referred by
administration of the institute for the purpose of assessment, diagnosis and treatment.

Table

Presenting complaints of clients as reported by his teacher were given below:

Symptoms Presenting complaints

Impressionist speech ‫دھیان نہ رکھنا‬

Sensitive to physical attention ‫آنکھ مال کر بات نہ کرسکنا‬

Uncomfortable in situations of less attention ‫عملی مھارت میں کمزورھے‬

Suggestible personality ‫بولنے میں مسائل ھیں‬

Intimate in dealings ‫حافظُٰہ کمزور ھے‬

Self dramatization ‫بولنے میں تاخیر‬

Exaggerated emotions . ‫روزمرہ کے کام میں مسائل کا آنا‬

Initial observation

Client was 17 years old boy. His hygienic condition was good and he was maintaining overly
display of posture. His hair was finely combed. He was wearing a different dress. His mood was
normal and he had smiling face. He had problem in talking normally and he did not maintain
proper eye contact. His behavior was cooperative. His speech content was tangential. His hands
were continuously in movement and he was little bit nervous.

Past personal history

Patient was a history of school life with inappropriate social life and have not healthy
relationship with peer group . even in family his different sort of interests isolated his from
siblings as an avoidant child and annoying kid.

History of present illness

Client had moderate level of Histrionic personality disorder. His daily life functioning was
affected because of inability of daily tasks, social dealings and daily .

Family psychiatric history

There was no family psychiatric history reported.

General home atmosphere:

His general home atmosphere was very comfortable and cooperative. He had a great bond and
closely attached with his father and elder sister. His mother was also very supportive and
attached with him. His family spends certain hours daily just to sit with him and give him
attention.

Presenting complaints diagram:

Intimate in
dealings
Self
dramatization
Suggestible
personality

Histrionic
Exaggerated Personalit
emotions .
y Disorder Uncomfortable in
situations of less
attention
 Impressionist
Sensitive to
speech physical
attention

Family history:

Client belongs to a middle class family. He had two elder sisters. Among siblings he was
youngest. He had strong relationships with his parents and siblings who were supportive and
caring to him. His family members were very cooperative.

S2 S1
A.H

Genogram:

Keys Name:
F Father
M Mother
S1 Elder Sister
S2 Elder sister
 Male
Female
Strong relation
Normal relation
Weak relation

Psychological Assessment

Following psychological assessment methods and tools were administered to test his functioning:

 Clinical Interview
 Clinical observation
 Brief Mental Status Examination
 Brief histrionic personality disorder (BHPD)

Clinical interview

Clinical interview is a flexible research method that uses open ended question to obtain a lot of
information from the clients. The purpose of conducting this interview was to know the cause of
his problems by getting the history of clients from his early life to present state of life. Though
the interview his psychiatric, medical, developmental, educational, personal and family history
was taken. His complaints and problems were explored through the interview. If the client was
uncooperative, so we conduct interview from his parents. They willfully discussed his problems.
Along with taking history from his past life events, his current life issues were explored through
the unstructured interview.

Subjective Rating of Problematic Behavior

The rating of behaviors was as follow:

 Behavior Ratings Scores

I like it when I know someone 4 4

desires me sexually

I’m very interested in material 3 7

things like cars, shoes, etc.

I get frustrated when people 2 9

don’t notice me

I know how to make people 2 11

like me right away

A lot of people find me 2 13

sexually appealing

I find it exciting to flirt with 3 16

others

- I tend to be the "life of the 3 19

party"

- I’d prefer not to commit to 4 23

just one romantic partner

- I flirt even with people who 3 26

I’m not attracted to

- I always seem to have new 4 30

friends

- I like to be the center of 3 33

attention

Ratings of the Test

Tests were administered on the child for the purpose of assessment. The results of these tests
were as follow:

BHPS Score Interpretation

11 to 29 No noticeable histrionic features

points

30 to 34 Noticeable histrionic personality features but not necessarily at a

points clinical level

35 to 44 Clinically significant histrionic personality feature

points

Mental Status Examination

The mental status examination is structured assessment of patient’s behavioral and cognitive
functioning. It includes descriptions of the patient’s appearance and general behavior, level of
consciousness and attentiveness, motor and speech activity, mood and affect, thought and
perception, attitude and insight, the reaction evoked in the examiner, and finally higher cognitive
abilities. The specific cognitive function of alertness, language, memory, constructional ability,
and abstract reasoning are the most clinically relevant. An MSE is conducted by a therapist who
observes and asks specific questions about the behavior of the person being interviewed.
Diagnostic and therapeutic decisions are based on the findings of MSE.

 Appearance
 Client was wearing a uniform. His hairs were well combed and his hygiene condition was
good.

 Attitude
He was nervous and little shy. But overall his attitude was positive and he was cooperative.

 Behavior
His behavior was different than normal child. He was moving his hands frequently.

 Speech
He had limited speech, low tone and quite poor speech.

 Affect and mood

He was quite nervous and smiling at a same time.

 Thoughts
His thoughts were disorganized.

 Perceptions
No hallucination and delusions were present during the interview.

 Orientation
He was well orientation in place, object and person.

 Memory and concentration

His memory was intact.

DSM-5 Level Self Rated Level 1 Cross Cutting Measures- child

There is no set test to determine whether someone has histrionic personality disorder. Previously,
a number of pointers were specified in an earlier edition of the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders in order to help clinicians
make a diagnosis3). At least five of the following traits needed to be recorded for a diagnosis to
be indicated:

 A compulsion to be the center of attention that results in discomfort if unmet

 Inappropriate sexual, seductive or provocative behavior when interacting with others
 Shallow, rapidly shifting emotions
 The use of physical appearance to draw others’ attention
 Dramatic, impressionistic speech that lacks detail
 Exaggerated, theatrical emotional expression
 Easily influenced by others or situations
 Assumes relationships are more intimate than they are

Unstructured or semi-structured interviews may also be carried out as part of the diagnostic
process; these usually involve investigation into the patient’s concerns without a set series of
questions, allowing for free-flowing conversation.

Often, an element of the diagnostic process is the self-report inventory, which usually takes the
form of a short questionnaire designed to provide insight into the patient’s state of mind. The
subject is required to answer questions pertaining to their lifestyle, symptoms, values and more,
which are then assessed and scored by the healthcare professional to indicate the nature of the
condition.

Quantitative interpretation

Table 2

Scoring of Level 1 Cross Cutting Measures by his parent

Item no Domain Rating

1 Somatic symptoms 2
2\ Sleep problems 1
3 Inattention 0
4 Depression 1
5 Anger 2
6 Irritability 2
7 Mania 2
8 Anxiety 2
9 Psychosis 0
10 Repetitive thoughts and 2
behavior
11 Substance use 1
12 Suicidal ideation 2

Qualitative interpretation

Client scored higher on domain of inattention.

Qualitative interpretation:

The chronological age of the child was 11 years but his functional level was less than this his age
fellow. The child functional level predicts that he was poor in all areas but his cognitive was also
poor. He could not properly give attention to the classroom tasks and his attention span was low.
He did not listen attentively and could not follow the given instructions. His developmental
milestones were delayed that’s he faces difficulty in organizing a task and almost he had avoid
some tasks and daily activities.

Qualitative Analysis:

The chronological age of the child was 17 years but his emotional level was less than his age
fellows. The child functional level predicts that he was poor in all areas but he was poorer in self
maintenance than other areas. He was comparatively somehow better in self help skill but he was
dependent on appraisal for the completion of some activities. Such as takes off clothes, wash
face and hands, button and unbutton own clothes, pull off socks, unfasten snaps or clothing,
comb or brush hairs. According to BHPS his functional level on self help is equal to five or six
year’s old child. In social skills he was somehow poor because due to lack of intrest other than
himself and no exposure he was unable to perform some activities such as jump backward, walk
on tip toe put together three pieces of puzzles. In language skills he was somehow better but up
till now his speech is not fully developed as he was facing stereotypical problems. In general
socialization he was better as he was having smiling face and shake hand. He was poorer in
academic tasks and due to lack of cognitive skills and he can’t retain any information in the
memory for the future use.

Diagnosis

On the basis of observation and assessment and according to DSM-5 criteria child was
suffering from Histrionic Personality Disorder.

Case Formulation:
According to DSM-5 criteria and clinical assessment, he had moderate level of Histrionic
Personality Disorder. Factors that were cause, maintaining the disorder and played role for his
protection was as follow;
Histrionic personality disorder is not caused by one particular event or experience. A number of
different risk factors can increase your risk of developing this disorder, such as:

 Being rewarded for attention seeking behavior as a child

 A family history of personality disorders, anxiety, or depression
 Learning behaviors from a parent or caregiver with histrionic personality disorder
 A lack of criticism or punishment as a child
 Unpredictable attention from your parents
 Previously experiencing depression or anxiety
 A genetic susceptibility to personality disorders
.

Prognosis:

While there is no cure for histrionic personality disorder, he have histrionic personality disorder
can have useful and productive lives. Patient who participate in therapy tend to have better
outcomes as they gain insight into their condition and function more optimally socially and
occupationally. However, with severe histrionic personality disorder he may experience
problems at work and in social or romantic relationships.

Management Plan and Treatment.

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. Supportive psychotherapy aims to reduce emotional distress, improve self-esteem,
and to enhance the patient’s coping skills, all through attentive and sympathetic listening.
Psychodynamic psychotherapy (also called insight-oriented therapy) has also proven to be a
successful approach in treating patients with histrionic personality disorder.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. Psychodynamic psychotherapy aims to resolve underlying, unconscious conflicts in
an effort for patients to understand themselves and their behaviors better. The patients are
encouraged to substitute excessively dramatic speech for a more adaptive action or behavior, to
promote better communication with others. Through psychodynamic psychotherapy, patients
learn to recognize that hyper-sexual, attention-seeking behaviors are maladaptive, and discover
new, healthier ways to develop self-esteem.
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. Additionally, people with this disorder may exhibit shallow emotions appearing insincere
to those groups or family members participating in therapy concurrently. Histrionic patients may
be inappropriately sexual with their therapists; therefore, it is critical to set firm boundaries with
patients. 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. 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. Antidepressants have proven to be effective include desipramine,
fluoxetine, amitriptyline, and fluvoxamine. The mood stabilizers with proven therapeutic
benefits include lamotrigine, carbamazepine, topiramate, valproate, and lithium. Research has
demonstrated that antipsychotics such as risperidone, aripiprazole, olanzapine, and haloperidol
have been useful in treating affective dysregulation 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.
The biofeedback mechanism may help these patients control their inner feelings.

Therapeutic Interventions

Following techniques were used for the modification of child behavior and to achieving his
goals:

 Group therapy: This is a type of psychotherapy in which a group of people meets to

describe and discuss their problems together under the supervision of a therapist or
psychologist. Group therapy may be of particular benefit to people with HPD, especially
if it’s with other people with HPD. It can help someone with HPD see their own behavior
reflected back at them.
 Psychodynamic psychotherapy: This type of therapy focuses on the psychological roots
of emotional distress. Through self-reflection and self-examination, the person
undergoing therapy looks into problematic relationship patterns in their life.
 Supportive psychotherapy: This type of therapy aims to improve symptoms and
maintain, restore or improve self-esteem and coping skills. Supportive psychotherapy
involves the examination of relationships and patterns of emotional response or behavior.
 Cognitive behavioral therapy (CBT): This is a structured, goal-oriented type of
therapy. A therapist or psychologist helps you take a close look at your thoughts and
emotions. You’ll come to understand how your thoughts affect your actions. Through
 CBT, you can unlearn patterns of negative thoughts and behaviors and learn to adopt
healthier thinking patterns and habits.

While there’s currently no medication that can treat personality disorders, there is medication for
depression and anxiety, which people with histrionic personality disorder may also have.
Treating these conditions can make it easier to treat histrionic personality disorder.

Patient education:

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. Patients should receive information that there is no cure
to histrionic personality disorder; however, medications may be used to ameliorate
symptoms. Mood symptoms may correlate with life events, and moods are prone to highs and
lows in association with life occurrences.Nevertheless, medications should not be changed each
time the patient experiences alterations in moods or emotional crises.Patients with histrionic
personality disorder may require longer trials on medications to determine if the medication is
effective. Premature termination of psychiatric medications does not allow for adequate
medication trials. Furthermore, it requires emphasis that psychotherapy is a vital element of
treatment, specifically supportive psychotherapy or psychodynamic psychotherapy.

Reporting Child Progress

Child progress will be reported verbally to the teacher.

Related Services

We can take help from class teacher. Psychiatrists and speech therapist.

Behavior Pre and Post Rating:

 BehavioUR Pretest posttest

I like it when I know someone 4 3

desires me sexually

I’m very interested in material 3 4

things like cars, shoes, etc.

I get frustrated when people 2 3

don’t notice me

I know how to make people 2 2

like me right away

A lot of people find me 2 1

sexually appealing

I find it exciting to flirt with 3 1

others

- I tend to be the "life of the 3 2

party"

- I’d prefer not to commit to 4 2

just one romantic partner

- I flirt even with people who 3 3

I’m not attracted to

- I always seem to have new 4 4

friends

- I like to be the center of 3 4

attention

Limitations

There were following limitations in the present case history:

 There was not proper setting for conducting an interview.
The time too short for the assessment and psychological interventions.
Due to Preboards test and school functional activities child was not available most of the time.
Due to short time no work done on the communication of the child.

Suggestions

There are some suggestions that are very useful for the progress of child:

There should be a medical doctor and physician in the school for daily checkup of the
children.
The school functions should not disturb the children daily routine and activities.
Individualized training program should be continued.

Guidelines for the parents and teachers

 Involve the child in group activities and motivate him to participate in conversation.
 Reinforce the child even on a very small effort or attempt.
 Try to make child independent in some daily routine self- help related activities.
 Try to give quality time and attention to the child.
 Continue to practice the activities suggested by psychologist and speech therapist.

Session Report

Session 1

First session was based on 45 minutes which started from the rapport building with the
child. After interacting with the child and to reach the problem of the child. It is very important
to make a good confidential relationship with your child. It was quiet difficult to engage her in
interview because she was very shy and lack of confidence. Provide the safe environment,
assuring confidentiality, genuineness, acceptance and empathy, help to develop the trusty
therapeutic and good rapport. The client attitude was anxious in the starting but after rapport
building she became calm and cooperative.

2nd Session Goals

In the 2 nd session some assessments were administered on the child and ensure that child
remain engaged in session. Mental status examination,BHPS was applied. His performance was
good and he was cooperative and calm.

3rd Session Goals

In the 3rd session some tests were applies on the child to reduce the problematic behaviors.
Verbal behavior therapy was applied. Physical and occupational therapies were also applied on
child. Positive reinforcement was also give to the child for the behavior modification. His
behavior was calm and cooperative.

4th Session Goals

In the 4 th some other interventions were applied on child like psycho education and verbal
behavioral therapy. Work on his concentration and communication. Also work on the speech of
the child engaged her in the different activities like art and drawing. He performed her
interestingly and very well.

5th Session Goals

In the 5 th session to keep the child engaged in different activities at the end of the session.
Repeat the previous therapies and noticed the improvement of the child. His performance was
better than the previous session. Keep him appreciate and encourage, motivate then terminate the
session.
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