BORDERLINE PERSONALITY

DISORDER/HISTRIONIC PERSONALITY
DISORDER PRESENTATION

BY
ENOCH KOJO FORSON
EF/CHP/21/0022
 ORDER OF PRESENTATION

• PERSONALITY DISORDERS

• BORDERLINE PERSONALITY DISORDER (BPD)

• HISTRIONIC PERSONALITY DISORDER (HPD)

• HPD VERSUS BPD (SIMILARITIES AND DIFFERENCES)

• REFERENCE
 WHAT ARE PERSONALITY DISORDERS

• “A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the
expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is
stable over time, and leads to distress or impairment”. (AMERICAN PSYCHIATRIC ASSOCIATION, 2013, P.690).

• These personality disorders are grouped into 3 clusters (cluster a, b & c)

• BORDERLINE PERSONALITY DISORDER and HISTRIONIC PERSONALITY DISORDER are in cluster b

which are generally characterized by i.e. dramatic, emotional and or erratic episodes. (AMERICAN PSYCHIATRIC
ASSOCIATION, 2000)
 BORDERLINE PERSONALITY DISORDER
(BPD)
According to Paris (2005), people with borderline personality disorder display great instability,
including major shifts in mood, an unstable self-image, and impulsivity. these characteristics
combine to make their relationships very unstable.

• BORDERLINE PERSONALITY DISORDER is one of the most common personality

disorders observed in clinical settings (Lenzenweger, Lane, Loranger & Kessler, 2007).

• The ICD-10 identifies this disorder as emotionally unstable personality disorder.

 DIAGNOSTIC CRITERIA

According to the APA (2013), its diagnosis is indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment.

2. A pattern of unstable and intense interpersonal relationships characterized by alternating

between extremes of idealization and devaluation.

3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

 CONT’D

4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,
substance abuse, reckless driving, binge eating).

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

7. Chronic feelings of emptiness.

8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper,
constant anger, recurrent physical fights).
 ASSOCIATED FEATURES SUPPORTING DIAGNOSIS
According to the DSM 5, the following are the associated features supporting the diagnosis of BPD.

• Individuals with borderline personality disorder may have a pattern of undermining themselves at the moment a goal
is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of
how well therapy is going; destroying a good relationship just when it is clear that the relationship could last).

• Some individuals develop psychotic-like symptoms (e.g., hallucinations, body-image distortions, ideas of reference)
during times of stress.

• Individuals with this disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession) than
in an interpersonal relationships.

• Premature death from suicide may occur in individuals with this disorder, especially in those with co-occurring
depressive disorders or substance use disorders.
 CONT’D

• Recurrent job losses, separation or divorce are common among such people.

• Physical and sexual abuse, neglect, hostile conflict, and early parental loss are more
common in the childhood histories of those with borderline personality disorders.

• Common co-occurring disorders include depressive and bipolar disorders, substance use
disorders, eating disorders (notably bulimia nervosa), posttraumatic stress disorder, and
attention-deficit/hyperactivity disorder.

• Borderline personality disorder also frequently co-occurs with the other personality
disorders.
 CULTURE-RELATED DIAGNOSTIC ISSUES

According to the DSM 5, the pattern of behavior seen in BPD has been identified in many settings around

the world.

• Adolescents and young adults with identity problems (especially when accompanied by substance use)

may transiently display behaviors that misleadingly give the impression of borderline personality

disorder.

• Such situations are characterized by emotional instability, “existential” dilemmas, uncertainty, anxiety-

provoking choices, conflicts about sexual orientation, and competing social pressures to decide on
 ETIOLOGY
• According to Linehan (2001), this disorder results from a combination of INTERNAL FORCES
(difficulty identifying and controlling one’s arousal levels and emotions) and EXTERNAL FORCES (an
environment in which a child’s emotions are punished or disregarded),

1. Sufferers who are particularly impulsive apparently have lower brain serotonin activitY (Norra,
Mrazek, Tuchtenhagen, Gobbele, Buchner, Sass, & Herpertz, 2003). (INTERNAL FORCE)

2. According to Paris (1991), some sociocultural theorist suggest that cases of borderline personality
disorder are particularly likely to emerge in cultures that change rapidly. (EXTERNAL FORCE)

3. Gunderson (2001) and Guttman (2002), also argue that early parental relationship ie parental neglect
or rejection, verbal abuse, lack of acceptance, multiple parent substitutes, divorce, death or traumas
such as physical or sexual abuse. (EXTERNAL FORCE)
 EPIDEMIOLOGY

• The average population prevalence of Borderline Personality Disorder is estimated to be 1.6% but may be

as high as 5.9%.

• The prevalence of Borderline Personality Disorder is about 6% in primary care settings, about 10%

among individuals seen in outpatient mental health clinics, and about 20% among psychiatric inpatients.

• The prevalence of borderline personality disorder may decrease in older age groups.

American Psychiatric Association, 2013

 TREATMENT / MANAGEMENT

• Sperry (2003), argued that psychotherapy can eventually lead to some degree of improvement
for people with borderline personality disorder.

• According to Heard and Linehan (2005) Dialectical Behaviour Therapy (DBT) has received
growing research support and is now considered the treatment of choice in many clinical circles.

• Pharmacotherapy treatment such as antidepressant, antianxiety and antipsychotic drugs have

also helped calm the emotional and aggressive storms of some people with borderline
personality disorder (Agronin, 2006)
 HISTRIONIC PERONALITY DISORDER
(HPD)

• Histrionic personality disorder is a mental condition characterized by a pattern of extreme

emotionality and attention-seeking behavior that begins by early adulthood and is obvious in
different situations (Angstman & Rasmussen, 2011).

• The word histrionic means “dramatic or theatric”.

• People with histrionic personality disorder are inclined to express their emotions in an
exaggerated fashion, for example, hugging someone they have just met or crying uncontrollably
during a sad movie (Svrakic & Cloninger, 2005).
 CONT’D

According to the APA (2013), it has pervasive pattern of excessive emotionality and attention seeking,
beginning by early adulthood and present in a variety of contexts.

Approval and praise are the life’s blood of these individuals; they must have others present to witness their
exaggerated emotional states.

Vain, self-centered, demanding, and unable to delay gratification for long, they overreact to any minor event
that gets in their way of their quest for attention. some make suicide attempts, often to manipulate others.

LAMBERT, 2003
 DIAGNOSTIC CRITERIA
According to the APA (2013), its diagnosis is indicated by five (or more) of the ff:

1. Is uncomfortable in situations in which he or she is not the center of attention.

2. Interaction with others is often characterized by inappropriate sexually seductive or provocative
behavior.
3. Displays rapidly shifting and shallow expression of emotions.
4. Consistently uses physical appearance to draw attention to self.
5. Has a style of speech that is excessively impressionistic and lacking in detail.
6. Shows self-dramatization, theatricality, and exaggerated expression of emotion.
7. Is suggestible (i.e., easily influenced by others or circumstances).
8. Considers relationships to be more intimate than they actually are.
 ASSOCIATED FEATURES SUPPORTING
DIAGNOSIS
According To The DSM 5, Associated Features Supporting The Diagnosis Of Histrionic Personality Disorders
Include;

 Individuals With Histrionic Personality Disorder May Have Difficulty Achieving Emotional Intimacy In Romantic
Or Sexual Relationships.

They May Seek To Control Their Partner Through Emotional Manipulation Or Seductiveness On One Level,
While Displaying A Marked Dependency On Them At Another Level.

 Individuals With This Disorder Often Have Impaired Relationships With Same-sex Friends Because Their
Sexually Provocative Interpersonal Style May Seem A Threat To Their Friends’ Relationships.

These Individuals May Also Alienate Friends With Demands For Constant Attention.

They Often Become Depressed And Upset When They Are Not The Center Of Attention.
 CONT’D
 These individuals are often intolerant of, or frustrated by, situations that involve delayed gratification,

and their actions are often directed at obtaining immediate satisfaction

 Longer-term relationships may be neglected to make way for the excitement of new relationships.

 The actual risk of suicide is not known, but clinical experience suggests that individuals with this
disorder are at increased risk for suicidal gestures and threats to get attention and coerce better
caregiving.

 Histrionic Personality Disorder Has Been Associated With Higher Rates Of Somatic Symptom Disorder,
Conversion Disorder (Functional Neurological Symptom Disorder), And Major Depressive Disorder.

 Borderline, Narcissistic, Antisocial, And Dependent Personality Disorders Often Co-occur.

 CULTURE-RELATED DIAGNOSTIC ISSUES

According to the DSM 5, norms for interpersonal behavior, personal appearance, and emotional
expressiveness vary widely across cultures, genders, and age groups.

Before considering the various traits (e.g., emotionality, seductiveness, dramatic interpersonal
style, novelty seeking, sociability, charm, impressionability, a tendency to somatization) to be
evidence of histrionic personality disorder, it is important to evaluate whether they cause
clinically significant impairment or distress.

(American Psychiatric Association, 2013).

 ETIOLOGY

While it is unknown what explicitly causes histrionic personality disorder, it is likely a disorder that is
multifactorial in its origin.

According to Lilienfield, Van Valkenburg and Akiskal (1986), histrionic personality disorder probably develops as
a conglomeration of both learned and inherited factors.

Cale and Lilienfield (2002) hypothesized that histrionic personality disorder may develop as a result of trauma
experienced during childhood. They say, children may endure their trauma by coping with their environment in ways
that may ultimately lead to a personality disorder.

 Personality disorders in childhood may originate as an adaptation to cope with a traumatic situation or traumatic
environment ( Apt & Hurbert, 1994).
 CONT’D
parenting styles may also influence the likelihood of developing a histrionic personality disorder. parenting style which
lacks boundaries, is over-indulgent or inconsistent may predispose children to develop histrionic personality disorder
(Morrison, 1989).

Sulz (2010), argues that parents who role model dramatic, erratic, volatile, or inappropriate sexual behaviors put their
children at high risk for developing this personality disorder.

 According to Morrison (1989), Histrionic Personality Disorder tends to run in families, there is some consideration that
there is a genetic susceptibility for this disorder.

As with many other psychiatric disorders, having a family history of personality disorders, psychiatric illness, or substance
use disorders is a risk factor for histrionic personality disorder (Lilienfield, Van Valkenburg & Akiskal, 1986).
 EPIDEMIOLOGY

According to the DSM 5 (2013), the prevalence of histrionic personality disorder in the general
populace runs from 1% to 2%.

Women are four times more likely to be diagnosed with histrionic personality disorder than
men. however, women may be overly diagnosed with this disorder compared with men due to
1. sexual-forwardness being less socially acceptable for women.

2. Men may be less likely to report their symptoms and thereby be under-diagnosed.

(Nestadt, Romanoski, Chahal, Merchant, Gruemberg & Mchugh,1990).

 CONT’D

Histrionic personality disorder tends to be ego-syntonic, meaning people with this disorder
typically consider their behavior to be normal and struggle to identify it as a problem (Cale &
Lilienfield, 2002).

Rienzi & Scrams (1991), says this lack of insight may contribute to the under diagnosis of this
personality disorder until later in life when once patterns of behavior have significantly
interfered with relationships, work, or interpersonal wellness.
 TREATMENT / MANAGEMENT

According to Novias & Godinho (2015), 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. They say, supportive psychotherapy aims to
reduce emotional distress, improve self-esteem, and to enhance the patient’s coping skills, all
through attentive and sympathetic listening.

The roleplay model and assertive approaches may help in minimizing conflicts. This is
because histrionic patients may be inappropriately sexual with their therapists; therefore, it is
critical to set firm boundaries with patients (Nestadt et al, 1990). 
 CONT’D

 Morrison (1989) had argued that psychodynamic psychotherapy (insight-oriented therapy) has
also proven to be a successful approach in treating patients with histrionic personality disorder.

the goal of this therapy according to Kellet (2007) 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.

Through psychodynamic psychotherapy, patients learn to recognize that hyper-sexual, attention-

seeking behaviors are maladaptive, and discover new, healthier ways to develop self-esteem
(Kellet, 2007).
 CONT’D
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 (novias & godinho, 2015).

Patients may experience affective dysregulation, where they frequently endure mood swings,
anger, tearfulness, anxiety, and depression.

Research has demonstrated that antipsychotics such as risperidone, aripiprazole, olanzapine,

and haloperidol have been useful in treating affective dysregulation (Nestadt et al, 1990).

 clinical trials have demonstrated that mood stabilizers specifically can target these symptoms
(Sulz, 2010).
 HPD & BPD
DIFFERENTIAL DIAGNOSIS

• Borderline Personality Disorder Is Distinguished By;

1 Self-destructiveness

2. Angry Disruptions In Close Relationships,

3.Chronic Feelings Of Deep Emptiness And Loneliness.

(American Psychiatric Association, 2013, P. 666)

 REFERENCE
1. AMERICAN PSYCHIATRIC ASSOCIATION. (2013). DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (5TH ED.).

WASHINGTON, DC: AUTHOR

2. CALE, E.M,, LILIENFELD S.O. HISTRIONIC PERSONALITY DISORDER AND ANTISOCIAL PERSONALITY DISORDER: SEX-

DIFFERENTIATED MANIFESTATIONS OF PSYCHOPATHY? J PERS DISORD. 2002 FEB;16(1):52-72. [PUBMED]

3. LAMBERT, M. T. (2003). SUICIDE RISK AND MANAGEMENT: FOCUS ON PERSONALITY DISORDERS. CURR. OPIN. PSYCHIAT., 16(1), 71-76

4. NESTADT G, ROMANOSKI AJ, CHAHAL R, MERCHANT A, FOLSTEIN MF, GRUENBERG EM, MCHUGH PR. AN EPIDEMIOLOGICAL STUDY

OF HISTRIONIC PERSONALITY DISORDER. PSYCHOL MED. 1990 MAY;20(2):413-22.

5. RIENZI, B.M, SCRAMS DJ. GENDER STEREOTYPES FOR PARANOID, ANTISOCIAL, COMPULSIVE, DEPENDENT, AND HISTRIONIC

PERSONALITY DISORDERS. PSYCHOL REP. 1991 DEC;69(3 PT 1):976-8. [PUBMED]

6. SVARKIC, D. M., & CLONINGER, C. R. (2005). IN B. J. SADOCK & V. A. SADOCK (EDS.), KAPLAN & SADOCK’S COMPREHENSIVE TEXTBOOK

OF PSYCHIATRY (P. 2063-2104). PHILADELPHIA: LIPPINCOTT WILLIAMS & WILKINS.

 REFERENCE CONT’D
7. PARIS, J. (2005). BORDERLINE PERSONALITY DISORDER. CANAD. MED. ASSOC. J.,172(12), 1579-1583.

8. LENZENWEGER, M. F., LANE, M.C., LORANGER, A. W., & KESSLER, R.C. (2007). DSV-IV PERSONALITY DISORDERS IN THE NATIONAL

COMORBIDITY SURVEY REPLICATION. BIOLOGICAL PSYCHIATRY 62(6), 553-564.

9. GUNDERSON, J. G. (2001). BORDERLINE PERSONALITY DISORDER: A CLINICAL GUIDE. WASHINGTON, DC: AMERICAN PSYCHIATRIC

PUBLISHING.

10. GUTTMAN, H. A. (2002). THE EPIGENESIS OF THE FAMILY SYSTEM AS A CONTEXT FOR INDIVIDUAL DEVELOPMENT. FAM. PROCESS,

41(3), 533-545.

11. NORRA, C. S., MRAZEK, M., TUCHTENHAGEN, F., GOBBELE, R., BUCHNER, H., SASS, H., & HERPERTZ, S. C. (2003). ENHANCED

INTENSITY DEPENDENCE AS A MARKER OF LOW SERONTONERGIC NEUROTRANSMISSION IN BORDERLINE PERSONALITY DISORDER. J.

PSYCHIATR. RES., 37(1), 23-33.

12. PARIS, J. (1991). PERSONALITY DISORDERS, PARASUICIDE, AND CULTURE. TRANSCULT. PSYCHIATR. RES. REV., 28(1), 25-39.