Histrionic Personality Disorder

Disease class: Personality Disorders

Personality disorder cluster: B (dramatic) 

Commonly known as:

• HPD

 

Aetiology / Risk factors

• Severe psychological trauma in childhood, particularly:
• Sexual abuse
• Physical abuse
• Emotional abuse
  
• Neglect
• Loss of a close friend or relative
• Severe physical illness
  
• Inheritance of high-risk genes from parents
  

 

Symptoms and signs

• Anxiety 
• Depression
• Self-harm
• Suicidal ideation
• Attempted suicide 
• Recreational drug use
• Hypersexuality  
• Psychosis
• Medically unexplained physical symptoms  
• Alexithymia (lack of insight into their own emotions) 
• Impulsivity
• Hypersensitivity to criticism
• Irritability
• Attention seeking behaviour 
• Co-dependence
• Fear of abandonment
• Lack of self identity (to quote many patients: "I feel like a blank piece of paper, which nobody ever wrote on.")
  
• Abnormally flirtatious or charismatic behaviour
• Reckless, high-risk behaviour
  
• Criminal activity
• Lack of concern for the feelings and rights of others
  

 

Age of onset

• Signs and symptoms of emerging PDs can be observed throughout childhood and adolescence, with a marked increase in severity between 14-18. 
• Personality disorders are never officially diagnosed in children, as the personality usually changes dramatically during the course of normal development.
• In some children, a diagnosis of Conduct Disorder may be made. CD is often called a precursor to Antisocial Personality Disorder, because of the similarities in the conditions. Most children with CD become less antisocial with normal development, but 25-40% of CD cases later meet the diagnostic criteria for ASPD in adulthood.
  

 

Common co-morbidities

• Eating disorder 
• Substance misuse disorder
• Anxiety disorder
• Depressive disorder 

 

Stigmatising factors

Patients with personality disorders (particularly "psychopaths" and "narcissists") are frequently vilified in the media. Stigma has increased as public awareness of "borderline PD" has increased. Many healthcare workers, including mental health specialists, describe strong feelings of fear or frustration when engaging with most PD patients. For these reasons, a diagnostic label of "personality disorder" may have a negative impact on a patient's self-esteem.

The following stigmatising features can be demonstrated in a significant proportion of the PD population:

• A widespread belief that PDs are 'incurable' or that 'every personality is fixed': Severe dysfunction often persists until the patient reaches their 40s. Significant progress is only seen once the patient develops a sincere and strong commitment to change themselves.
  
• An adversarial affect: PD patients often display aggression, hostility, unpredictability, irrationality, impulsivity, hypersensitivity, and similar traits.
  
• Intentional use of deceptive psychological manipulation techniques. For example: crying loudly, threatening, lying.
  
• Symptoms and signs which are self-inflicted (self-harm; suicide attempts; substance misuse; factitious disorder; malingering) or medically unexplainable (somatic symptom disorder).
  
• Self-destructive behaviours: Gambling, unsafe sexual practices, criminal activities.
• Non-compliance with medication, therapies and other interventions.
• A subconscious resistance to change and fears of 'getting better', becoming 'normalised', or losing support from healthcare providers.
  

 

Management 

PD patients often seek help for physical complaints (e.g. self-harm; suicide attempts; substance misuse; malingering; factitious disorder; somatic symptom disorder). 

Medical doctors have a legal and ethical obligation to investigate them each time they present to healthcare settings (within reason). After excluding any harmful 'organic' diseases, competent doctors should consider possible mental health disorders and document their objective findings thoroughly.

Diagnosis and stigmatisation

Patients with likely PDs often lack an official diagnosis, even if their healthcare providers strongly suspect it. PDs must be diagnosed by specialists after weeks or even months of regular assessment. They can be notoriously to diagnose, for reasons including:

• The huge variety of clinical presentations: 
• Many PD patients demonstrate a 'classic' set of signs, symptoms and risk factors. Experienced clinicians can recognise likely PD in some patients in a matter of minutes. However, many PD patients lack these common features or mimic other conditions. 
• They often lack insight into their condition.
• They often complain of physical problems rather than psychological ones. 
• Substance misuse is common within this group, and it is impossible to make a fair and accurate diagnosis until they are clean and sober.
  
• At first presentation, some patients with EUPD can be indistinguishable from patients with bipolar disorder. This has been demonstrated in studies with experienced psychiatrists.
  
• Frequently poor engagement with healthcare services: frequent incidents of hostility towards healthcare staff, premature self-discharge from hospital or missed appointments (DNA: Did Not Attend).
• Concealment of essential information: signs, symptoms, risk factors, etc. May be intentional or involuntary (e.g. fluctuating emotional states; dissociation; repression of traumatic memories).
  
• Difficulties in defining 'disordered' personalities: There is a broad spectrum of healthy personalities in the population and there is a risk of 'over-medicalising' uncommon, but healthy variations.

Diagnostic labels can be difficult to remove, once mentioned to the patient or entered into medical records. Various euphemisms are often used to convey that a patient may have HPD. For example: in the National Health Service, many patients with undiagnosed HPD are described as "cluster 8" patients. This is because "Care cluster 8" refers to "Non-psychotic, chaotic and challenging disorders", most commonly, EUPD. 

 

Risk management

•  Patients should be assessed for risk of suicide or self-harm and monitored carefully.

 

Medication

Patients with PDs are often prescribed antidepressants, anxiolytics, anti-psychotics, painkillers, hypnotics, sedatives, and other medications. These are often unnecessary, or even harmful.

As a general rule of thumb for non-specialists, PDs usually benefit more from therapy than medication, whereas bipolar disorder usually benefits from medication more than therapy.

 

Therapy

• DBT: Dialectical Behavioural Therapy. This is the most well-known and well-regarded class of therapy available for HPD patients.
  
• CBT: Cognitive-Behavioural Therapy. This is cheaper, faster, more cost-effective, and more available than DBT. Unfortunately, the nature of HPD makes CBT relatively ineffective in this group, especially if it is not delivered through a guided 1-on-1 course.
• Psychodynamic psychotherapy. This involves a long period of very deep guided introspection and analysis of subconscious processes. This option is relatively expensive, difficult to access and promotes a high degree of dependence on the therapist until completion. 
• Counselling: Relatively cheap and accessible. This usually involves talking about concerns and traumatic events at a superficial level. Counsellors are often self-employed and they are subject to less regulation than other clinicians. 
• There is a risk to the mental health of both the patient and the therapist, if the therapist lacks the skill or knowledge to safely manage PDs.
  

 

Prognosis

• Severe dysfunction often persists until the patient reaches their 40s. Significant progress is only seen once the patient develops a sincere and strong commitment to change themselves.

 

Compare with:

• Bipolar disorder
• Attention deficit hyperactivity disorder
• Other cluster B (dramatic) personality disorders:
  
• Antisocial Personality Disorder
• Emotionally Unstable Personality Disorder
• Narcissistic Personality Disorder
  
• Conduct disorder (a similar disorder of childhood)