Objectives

• What are the DSM-IV criteria for the histrionic personality?

• The dramatic and outgoing personalities are normal variants of the avoidant. Describe their characteristics and relate them to the more disordered criteria of the DSM-IV.

• Explain how different personality styles combine to form each of the subtypes of the histrionic personality.

• What is the historical significance of hysteria and its contribution to the development of the histrionic personality?

• Modern psychodynamic theorists distinguish between the hysterical and the histrionic personalities. Explain that distinction.

• How do the defense mechanisms of repression, sexualization, dissociation, and projection work in the histrionic personality?

• Are histrionics likely to be good sexual partners?

• Explain what is meant by the statement: "Histrionics have an impressionistic cognitive style."

• Explain how early family dynamics led to the development of the histrionic personality.

• Do histrionic and antisocial personality disorders have common etiology?

• Histrionics share characteristics with other personality disorders. List these other disorders and explain the distinction between each and the histrionic.

• List therapeutic goals for the histrionic personality.

At some point in your academic career, you may have encountered a classmate or two who invariably claimed the center of attention. Typically dramatic and often seductive, these individuals made every attempt to impress the teacher and classmates with witty remarks and suggestive behaviors. Perchance you may have noticed that their interaction with other classmates involved a frequent interrupting or reframing of discussions to sustain themselves as the focus. Anything falling short of others' admiration or reverence toward themselves would inevitably invoke feelings of resentment and depression. Yet, these negative moods would have been fleeting as their relentless striving for approval prompted a more suitable affect. In addition, you would have noted to yourself how easily influenced they were, especially as you witnessed their opinions and behaviors conform on a whim to suit whomever they sought to interact with. Once in conversation, they communicated with flamboyant headlines at the expense of substantive details. This bold pattern of expression was usually perpetuated by their physical appearance, whether it was their hairstyle, make-up, clothing, or a memorable combination of the sort. In the end, you would have felt these people were the "life of the party."

The pattern displayed by these individuals is that of the histrionic personality. Yvonne (see Case 9.1) clearly illustrates such a pattern. To her, attention bestows its narcotizing effects as it is something she "can't do without" (see criterion 1). Bolstering her sense of worth, Yvonne can readily interact with others whose attention she's captured. Without it, she feels subpar and scrambles to redirect all interests back to her. Over the years, she has developed ingenious ways of doing so with a sensitivity to the qualities and behaviors that others might find interesting and attractive. Indeed, most of Yvonne's strategies are seductive or sexually provocative (see criterion 2); her repertoire of behaviors contributes to her success as an exotic dancer. Such behaviors are conducive to her profession and are not considered pathological when in that environment. However, her chronically seductive maneuvering outside of work is inappropriate and ill-suited. For example, she throws out double entendres in the clinical interview but then retreats to the safer interpretation if pursued. Her purpose in the interview should be to report her own experience, not charm or attract the interviewer. Nonetheless, Yvonne is just being herself.

As males are the stereotypical antisocial personality, females are that of the histrionic personality. In many ways, Yvonne seems to epitomize this female stereotype. Her tendency to hyperemotionalize overshadows her rationale as she exhibits an ever-changing stream of consciousness and its respective, uncensored emotional expressions (see criterion 3). Her emotional life has the trappings of depth and seems vividly alive but, on deeper inspection, lacks authenticity. Always a little exaggerated and theatrical (see criterion 6), her emotional shifts are sometimes so rapid and overplayed that the observer may wonder whether Yvonne's feelings are genuine or else wonder about the underlying conflicts and insecurities her never-ending kaleidoscope of affect conceals. On reflection, Yvonne seems too concerned with her own universe. She talks freely but, for the most part, she tends to avoid serious matters, causing her words to lack detail and substance (see criterion 5).

Like most histrionics, Yvonne uses her physical appearance to direct attention toward herself (see criterion 4). Although the case talks more about her gesture and speech than her dress, her job as an exotic dancer can be seen as an exaggeration of this characteristic. On any day ripe with social opportunity, Yvonne probably tries to look flashier, sexier, and more colorful than everyone else, for these are the qualities that she believes will win friends and influence people. Though Yvonne is right some of the time, her interpersonal postulate comes at a substantial cost. She tends to confuse attraction and intimacy (see criterion 8), apparently because she has as little insight into others as she has into herself. She openly states, "Most guys just want me for my body," for example, yet she also says, "I think I find it easy to get to know others, and that's why I get so

CASE 9.1

Yvonne is a 23-year-old, single female referred for psychological assessment by her gynecologist. She is outgoing and effusive, "dressed to kill," and yet coquettishly reluctant to disclose the nature of her difficulties.1 When directly asked, she avoids open discussion and seems to free associate to any number of topics, some happy, some sad, but all tangential to the clinical interview. She talks a lot, but doesn't really say much. She states, for example, that she is on a first-name with her physician, that she has been a dancer since she was a little girl, and that she is "blessed" with countless good friends.

After a period of direct questioning, Yvonne reveals that she has been experiencing debilitating pain continually for over half a year. "I just lay in bed and feel like I will absolutely expire!" she exclaims, closing her eyes and dropping her head forward to feign death. Extensive medical testing reveals no sufficient basis for her complaint.

During the clinical interview, Yvonne's nonverbal affectations are numerous. Her head is cocked slightly down, eyes wide with invitation. Her facial expressions, intended to underscore the meaning of her words, are exaggerated far beyond those of normal persons. She skips quickly from one topic to another. Apparently theatrical by nature, she measures the reaction of her audience and adjusts her performance accordingly. She periodically throws out double entendres, but retreats to the safer, more demure meaning if others begin to act on her suggestions. At times, she seems to parade through a succession of persons to find the one that best fits the role of therapy client.

Despite Yvonne's interpersonal intensity, her history seems mostly unremarkable. She describes a happy and well-adjusted family, though she admits some conflict with her mother. Her two brothers, much older than she, still treat her like a baby. She remains very close to her parents, especially her father, and calls home on a daily basis. At present, she is not involved in a serious relationship, but notes with a giggle that "most boys find me very attractive." Nevertheless, she feels that she has been unlucky in love, and openly admits that most guys "just want me for my body." "I think I find it easy to get to know others," she says, "and that's why I get so bored with people so fast." Instead, she prefers the excitement of new experiences, including occasional episodes of intoxication and substance abuse.

Currently, Yvonne works as a dancer at an adult club, but asserts forcefully that she is different from the other girls, an artist plying her trade. When asked what drew her to this mode of expression, she says she likes the attention and the money, "two things I can't do without." She expresses disgust with both the after-hours practices of the other dancers and with the clientele. Her family believes that she is teaching ballet. The source of her pain remains uncertain.

!Numbers mark aspects of the case most consistent with DSM criteria, and do not necessarily indicate that the case "meets" diagnostic criteria in this respect.

Histrionic Personality Disorder DSM-IV Criteria

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(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

Reproduced with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

bored with people so fast." This boredom results from her innate disinterest in detail and preference for headlines. As in life, headlines are fleeting and so, too, is the shelf life of her interpersonal relationships. In fact, she becomes bored because she has little substance of her own through which to connect with others. Yvonne knows many people, but she doesn't know anyone deeply, and that likely includes not knowing herself. In this sense, her cascade of exaggerated emotions serves as a distraction from the emptiness of her experience.

With this portrait of Yvonne, we are now in a position to examine additional issues that form the plan of this chapter. First, we compare normality and abnormality and then move on to variations of the basic histrionic theme. After that, biological, psy-chodynamic, interpersonal, and cognitive perspectives on the histrionic personality are described. These sections form the core of what is scientific in personality. By seeking to explain what we observe in character sketches like Yvonne's, the goal is to move beyond literary anecdote and enter the domain of theory. As always, we present history and description side by side, noting the contributions of past thinkers, each of whom tends to bring into focus a different aspect of the disorder. Developmental hypotheses are also reviewed but are tentative for all personality disorders. Next, the section "Evolutionary Neurodevelopmental Perspectives" shows how the existence of the personality disorder follows from the laws of evolution. Also included are comparisons between the histrionic and other theory-derived constructs, as well as a discussion of how histrionic personalities tend to develop Axis I disorders. Finally, we survey how the disorder might be treated through psychotherapy, again organizing our material in terms of classical approaches to the field: the interpersonal, cognitive, and psychodynamic perspectives.

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