Understanding Histrionic Personality Disorder
(Formerly Known as Hysteria)
Gary D. Hanson, M.A.

Twenty-seven-year-old Christy sought pastoral counseling at the request of her husband because of disillusionment over her marriage, now in its fourth year. Her church counselor was already aware of Christy because the church's worship leader had threatened to resign several times over her emotional outbursts from being turned down for a lead in the latest dramatic presentation or a special music solo.

Christy's husband, Tom, had expressed an urgent concern to their pastor after a recent event when Christy forgot their infant daughter and left her with a day care provider while Tom was out of town on a business trip. Christy had entered a modeling contest at a local mall, and as she basked in the attention of the local talk show cameras, the thought of her daughter, now in the care of a disgruntled day care employee, completely slipped her mind. This event—just one in a series of similar incidents—had triggered yet another bitter argument over Christy's lack of attention to her daughter and to Tom himself. Reluctantly, Christy agreed to discuss her issues with a pastoral counselor.

During the initial interview Christy was warm and charming. She maintained good eye contact and was dressed attractively and a bit provocatively. Struck by Christy's rapid changes in emotion, the counselor noticed that one minute she was smiling with elation, the next erupting into tearful sadness. The picture Christy painted of her life was one of extremes. She just didn't understand why her "fabulously handsome" husband could not understand her need for self-expression and her gift of adding life to any social setting. Christy "absolutely adored" her "precious" daughter who was an "angel" in her eyes, but who seemed to take after her father in being demanding of Christy's attention. As Christy moved from excited speech regarding her personal accomplishments to tears over her lack of understanding from her husband and daughter, she frequently used a compact mirror, stopping at one point to touch up her eye makeup before continuing the discussion.

"When she (Christy) doesn't receive the attention she craves, she can quickly lose her charming style and become angry, pouty, rude, or condescending."

From Christy's outward appearance, she could pass as a fashion model, actress, or TV talk show host. She is attractive, gregarious, energetic, and has a dramatic flair that often makes her the life of the party. She is acutely attuned to her surroundings, an astute judge of the likes and dislikes of others, and a ready resource for the latest fashion trends. But that is only one side of the story.

Sometimes Christy's style turns out to be more of a curse than a blessing. Although she impresses people positively upon a first meeting, she never develops any deep, committed relationships, and her shifting moods eventually start wearing on those around her. Her consuming need for approval and desperate striving to draw out affection are just too much. And no matter how much attention she receives it is never enough. Her thirst is unquenchable but her efforts persistent. When she doesn't receive the attention she craves, she can quickly lose her charming style and become angry, pouty, rude, or condescending. These shifting moods leave her family, friends, and acquaintances hurt, bewildered, put off or mistrusting and cause them to keep their distance—the very thing Christy fears the most.

In addition to creating interpersonal problems, Christy's need to constantly evoke attention has another downside. She is constantly under pressure to perform and she is emotionally susceptible to the approval or disapproval of everyone she meets.

None of Christy's traits or attributes are negative in and of themselves. In fact, most of them are very enjoyable in moderation. But when they all come together in one person in a pronounced way, they cause serious problems and reflect a personality maladjustment known as Histrionic Personality Disorder (HPD).
While both men and women develop Histrionic Styles, they show them somewhat differently. Men with this disorder often dress and behave in a "macho" manner and seek attention by bragging about their "manly" activities. Women, on the other hand, tend to choose very feminine clothes and attract attention through charming, seductive, or helpless behaviors.

Histrionic Personality Disorder has a long history dating back some 4,000 years when it was called hysteria. Today, the histrionic personality can be thought of as ranging from acceptable, mildly dramatic behavior, to unhealthy, potentially risky behaviors or characteristics. Individuals who display a few histrionic characteristics but function in generally healthy interactions with others are characterized as having a Histrionic Personality Style. Individuals who exhibit serious dysfunctional characteristics are clinically diagnosed as having Histrionic Personality Disorder. Here are some of the main characteristics and personality dynamics of Histrionic Personalities.

The Search for Attention and Admiration

The central conflict of persons with Histrionic Personality Disorders is their unresolved childhood need for affection, approval, and admiration. For some reason, histrionic persons have failed to develop a solid sense of themselves and their significance and worth. Unconsciously they feel empty, inadequate, or unlovable. Consequently, they are constantly turning to others for affirmation, attention, and rewards. In the process, they develop a highly tuned sensitivity to the moods and thoughts of those they wish to impress. They learn to quickly determine what actions or antics will succeed in getting others to respond to them in a positive way. But no matter how much attention they receive, it is never enough. It is like pouring water through a sieve.

"Histrionic personality disorder has a long history dating back some 4,000 years ago when it was called hysteria."

Problems With Intimacy and Commitment

Underneath their overtly friendly relational style, histrionic individuals are actually quite unable to form healthy, intimate, lasting relationships. Some histrionic individuals try to convince others that they have so much capacity for love that one person alone can't meet it! Some are sexually unfaithful to their mates. Others are simply driven to always be with others and don't enjoy spending much quality time with their spouse.
This was true of Christy. Her husband was repeatedly frustrated when he attempted to plan and enjoy an intimate dinner just for two. Tom's efforts usually ended in explosive arguments when Christy complained that she would rather have had friends come along, and accused Tom of not appreciating her and stifling her social life.
Fluctuating Behavior

The histrionic person's effort to act in ways calculated to gain attention and admiration creates an extremely unstable pattern of behaviors and fickle emotions. Anytime they perceive that they are not commanding the attention they seek, they may do something dramatic, create a scene, or tell an exaggerated story to draw the focus of attention to themselves. Since histrionic individuals are essentially using others to build up their own fragile feelings about themselves, they must be constantly on the lookout for ways of getting the attention they so badly crave. But this leaves them without a solid, consistent sense of who they are and with a persistently unpredictable way of being. They are more concerned about getting attention from others than they are about being true to themselves.

Impressionistic Thoughts and Speech

Those with HPD also have a style of thinking and speaking that differs from most of us. They tend to be highly impressionistic and lacking in details and specifics. They express strong opinions with a dramatic flair, but when asked to explain themselves, their underlying reasons are vague and without supporting facts and details. When describing another person, for example, they may say, "He's incredible," "He's huge," or "I hate her." They are strong on impressions but weak on details, facts, and carefully thought out plans and logic. They also tend to play hunches and adopt convictions quickly since their feelings and opinions are so easily influenced by others and by current fads. They may consider relationships to be more intimate than they actually are, describing almost every acquaintance as "my dear," or "my dear friend."

The following section clarifies the major differences between someone with a Histrionic Personality Style and someone with an actual Histrionic Personality Disorder. Many of us share some of the characteristics of a Histrionic Style, to a slight or moderate degree, but few of us show the excesses of those with a Histrionic Personality Disorder. These traits only reach the level of a personality disorder when they are so frequent and inflexible that they create serious problems or impairments in relationships, or sufficient distress to make the person unhappy in life.

Comparison of the Histrionic Personality Style
and Histrionic Personality Disorder*

Personality Style Personality Disorder
Enjoy compliments and praise Constantly seeks or demands reassurance, approval, or praise
Attentive to appearance and grooming, enjoys clothes, style, and fashion Overly concerned with physical attractiveness
Charming, engaging, and appropriately attractive in appearance and behavior Sexually seductive in appearance and behavior
Lively and fun-loving, often impulsive, but can delay gratification Expresses emotion with inappropriate exaggeration; self-centered and little tolerance for delayed gratification
Enjoy being the center of attention, and can rise to the occasion when all eyes are on them— enjoying acting or drama Uncomfortable in situations where they cannot be the center of attention—have an intense need to be acting all the time
Sensation oriented, emotionally demonstrative, and physically affectionate; react emotionally, but appropriately Display strong but rapidly shifting and shallow emotions
Utilize a style of speech that is appropriately global and specific Utilize a style of speech that is excessively impressionistic and lacking in detail

 

False Assumptions About Life

Along with their distinctive emotional, relational, and intellectual styles, histrionic individuals tend to hold a certain set of largely unconscious assumptions or beliefs about themselves and what they need to do to have a good life. They believe, for example, that to have meaningful relationships with others means they must be the center of the group with others playing the role of attentive audience. They believe things like: "Unless I captivate people, I am nothing." "If I can't entertain people, they will abandon me." Or, "If I can't captivate people, I am helpless or no good!"

Because of their unrealistic views of themselves and life, people with histrionic personalities are constantly setting themselves up for failure, rejection, and frustration. No one can always be the center of attention! When they aren't, they either conclude that they are worthless or that other people are bad for not constantly affirming them. So they either feel depressed or resort to crying, tantrums, assaultive behaviors, or even suicidal gestures to get their way, gain attention, or to punish a perceived offender. Tom wept as he described his many attempts to show Christy love and affection only to be chastised and ridiculed for his efforts or incorrect timing.

Since histrionic individuals believe it is necessary to be loved by virtually everyone for everything they do, they also have an exaggerated fear of rejection. Any hint of rejection is devastating, even when the person doing the rejecting is not actually important to the histrionic person! Feeling basically inadequate, yet desperate for approval, they feel they can never relax and leave the gaining of approval to chance or the good will or love of others.

Causes and Dynamics

Researchers have found that histrionic adults tended to display a high degree of vacillating or erratic emotions from infancy and early childhood. They are also more likely to be hyper responsive and to look to others for gratification from the time they are quite young. This suggests some physiological predisposition to a hysterical style. These inborn tendencies alone, however, are insufficient to cause someone to develop a Histrionic Personality Disorder. The histrionic person's self-perception and excessive need for attention have nearly always been deeply influenced by their early family environment and relationships. Something happened in those relationships to program them for an exaggerated search for attention.

Although every person is different, one parenting style often experienced by the potentially histrionic personality is characterized by reciprocity. That is, the parent or other significant person communicates, "I'll give you attention, if you do X." This, of course, trains the child to look for cues of what to do to gain approval. All parents do some of this with few or no negative consequences. But when a child with an especially strong inborn sensitivity to others grows up in a home with a constant diet of these messages, he or she can become programmed for the excessive search for attention that influences the development of histrionic personalities.

"The histrionic person's self-perception and excessive need for attention have nearly always been deeply influenced by their early family environment and relationships."

This parenting style is closely related to conditional love and approval. The child receives attention and affection when he performs in a way that meets his parents' approval, but is ignored, or even punished at other times. Christy, for example, described her family of origin as "the perfect family." But her counselor noticed that she emphasized the praise she received when she performed for her parents in social settings in contrast to their general lack of attention and support in any other area of life.

Another parenting style that can lead to the development of histrionic patterns is one of minimal or inconsistent discipline combined with rewards for attention-getting antics. On the one hand, the child is not taught to take responsibility and reflect on his misbehavior or the needs of others. On the other, his attention-getting behavior gets frequent attention.

All of these problems in family relationships are troubling for a growing child. Instead of feeling loved for who he is, he learns that he is only appreciated, cared for, or affirmed for what he does. This leaves him feeling empty and unloved. Since those feelings are so painful he begins to pay especially close attention to the approval of others and to behaving in ways that are calculated to elicit the longed for attention.

This shift from feeling good about being ones true self to trying to become what others want in order to be loved is a life altering movement. People with a healthy sense of self have a strong inner sense of who they are, what they like and dislike, and their values and commitments. They value other's opinions but they aren't at the mercy of them. They have a realistic understanding of themselves and know their strengths and weaknesses. These people can enter into deep relationships and make lasting commitments, but they can also be alone without feeling anxious and abandoned.

Histrionic Personalities and others without this healthy sense of self tend to be unaware of their true feelings and their likes, dislikes, and values. They become dependant on others, constantly search for attention, or engage in work or other activities to shore up their shaky self-esteem since they are unable to sit even briefly with their uncomfortable feelings. This discomfort is what drives the histrionic person to constantly seek attention.

Spiritual Issues

In a real sense, the histrionics' constant search for attention and affection represents a core struggle of our fallen human race. We all tend to want to earn love and acceptance, rather than accept it as a gift from God and others. We don't want to fully face the depth of our sinfulness and needs, and our inner hurts and pain. And we find all kinds of ways to avoid facing ourselves honestly. But histrionic personalities have exaggerated struggles in these areas and their struggles impact their spiritual lives as well as their emotions and relationships.

For them, even relating to God—the most true and faithful source of love and acceptance—presents a great challenge because they are too terrified to look within and face themselves. They are afraid to see how unlovable they feel inside the recesses of their minds. But until they face those feelings they have trouble letting God into those needy recesses. Yet that is the place that we must all begin our spiritual journey.

People with histrionic personalities can also have problems in their relationships with God because they want to be the center of attention. Obviously, this doesn't work with God! He calls us to be humble servants, not admired stars. And as Elijah learned, despite His power and majesty, God often speaks in a whisper (I Kings 19:12). This is a difficult combination for these individuals. They will give their all to gain the attention and acceptance they long for, but they expect to be the center of attention in return.

Treatment

Unfortunately, most people with histrionic personalities are poorly motivated to change. They have such a lifelong pattern of avoiding emotional pain through massive repression and temporary attention getting maneuvers that they rarely seek help unless they are experiencing a deteriorating relationship, depression, or some other troubling social or emotional problem. And once they receive a little relief from their presenting problem, they tend to go on their way rather than facing their deeper emotional, spiritual, and relational struggles. If they will stay in therapy, however, they can get a great deal of help.

The ultimate need of histrionic individuals in therapy is to change their deeply ingrained tendency to try to fulfill all their needs by looking to others for attention rather than develop a solid sense of their own self-worth or self-esteem. To do this, histrionic individuals need to feel accepted and relatively safe and comfortable with their therapist. Gradually, they can begin to observe their pattern of avoiding their inner emotional anxiety by frantically looking for attention. In this process they need to learn to sit with their emotional discomfort instead of running from it.

As people with histrionic personalities learn to bear and face their fears of abandonment and inner emptiness they can increasingly focus on their internal world rather than on ways of trying to elicit attention from others. Since histrionic individuals avoid introspection by focusing on the outside world, this can be frightening and difficult. It is essential, however, to learn to see the futility of their relational and coping style in order to think more clearly and be less impulsive and more centered. In the process, they will gain insights into their unrealistic assumptions about themselves and life. They will come to see how they concluded they had to be the center of attention to feel good about themselves and they will realize that belief is an emotionally destructive idea.

Living With the Histrionic

Life with the histrionic can be challenging, confusing, frustrating, and oftentimes painful. Since histrionics struggle with depth in relationships, their partners are often left questioning their failed attempts to increase intimacy or closeness. While the histrionic will attempt to draw a partner into a rescuing, admiring role in order to ward off the anxiety of potential rejection, they may just as quickly display scorn or contempt for the same partner once they tire of their present life's routine.

"For the partner, the most helpful approach to living well with a histrionic person is to offer maximal emotional support while maintaining strong personal boundaries."

Partners of histrionics often live a life on eggshells, not knowing when they will be smothered with superficial affection or loathed for being too predictable or dependable. This is turn can begin to undercut the partner's self-esteem. By definition, the anonymous people in the "audience" of the histrionic person are less interesting or exciting than the "beautiful" person holding center stage! This impact can be both subtle and cumulative, eventually leaving the partner of the histrionic filled with uncertainty and self-doubt. It can also leave partners resentful because they feel that they can never provide enough attention or admiration to fill the histrionic's emptiness.

In the face of the histrionic's compulsive optimism, denial, disassociation, and evasion, the partner who raises the issues of life's negative consequences and inevitable pain, can expect to be the brunt of the histrionic's wrath.

For the partner, the most helpful approach to living well with a histrionic person is to offer maximal emotional support while maintaining strong personal boundaries. By adopting a loving, but objective stance, while holding the histrionic accountable for his/her behaviors, the partner gives the histrionic person the best chance of learning to trust in a relationship—not out of successful performance, but because of mutual participation and acceptance.

It is also important to sensitively encourage behaviors that are mature, responsible, and based in reality if the histrionic is to emerge from his or her position of childlike powerlessness. Remaining loving and flexible, while tactfully confronting destructive behaviors in the relationship, can help the histrionic gain a realistic understanding of his or her impact on the relationship.

Frequently Asked Questions About Histrionic Personality Disorder

  1. Are there medications for HPD? There are no medications that specifically treat the common symptoms of HPD. When histrionic individuals are also suffering from depression or anxiety, medication may help reduce those symptoms.
  2. Isn't Histrionic Personality Disorder just a form of pride that should be confessed? While the histrionic individual often displays very prideful behavior, his or her motivations and actions are actually masked cries for love and help, and they often grow out of very low self-esteem. While pride is an issue we all struggle with, the most urgent need for the histrionic personality is to learn an appropriate sense of self-assurance—the self-assurance that can best be nurtured through experiences of unconditional Christlike love. In fact, Christ is an excellent model for relating to individuals with histrionic personalities. He displayed a firm love that was at the same time unconditional and uncompromising.
  3. Where can I learn more? Additional assistance can be obtained through Internet sites and support groups specializing in personality disorders, including histrionic, borderline, or narcissistic.

*Adapted from Sperry, L., 1995. Handbook of Diagnosis and Treatment of the DSM-IV Personality Disorders. New York: Brunner/Mazel

Gary D. Hanson, M.A., a Christian counselor with masters degrees in Marriage and Family Therapy and Business Administration. Mr. Hanson offers individual and family counseling and consults with the business community. Gary and his wife, Joy, are the parents of two children and live in Plymouth, Minnesota.

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