The Psychodynamic Perspective

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Although the preceding contributions anticipate the modern view, arguably the most important historical development came in 1895 with the publication by Breuer and Freud on unconscious mechanisms in hysteria, stimulated by the famous case of Anna O. Both were fans of hypnosis, used to gain insight into Anna's unconscious conflicts, including her dislike for her father and her love for Breuer, who then left the case to Freud. Eventually, the two formed the theory that hysterical symptoms resulted from early sexual molestation, leaving memories so distressing that they were intentionally forgotten and could only be fully remembered under hypnosis. Once such symptoms were recalled fully to consciousness, Freud found that they vanished, never to return. These findings became the basis for a momentous development, the first theory of neuroses, which holds that behind every neurotic conflict lays a forgotten childhood trauma. Such experiences are said to be repressed. Making the unconscious conscious is still one of the primary goals of psychotherapy. The idea that the mind can somehow forget things that it really knows has provided both enlightenment and perplexity to psychologists ever since.

Eventually, Freud made yet another discovery, even more important. He discovered that, far from being completely trustworthy, the hypnotic recollections of his hysterics instead reflected the presence of unconscious wishes, fantasies superimposed on memory. Hysterical symptoms could now be seen, not as resulting from childhood trauma, but rather as reflecting unconscious instincts threatening to break into consciousness awareness. The effect on psychoanalytic theory was broad and transforming. With hysterical wishes obviously formed during early development while relating to the opposite-sex parent, the discovery of childhood sexuality and the consequent development of psychosexual stages and their associated character types were now on the horizon. In fact, without this insight, there might be no field of personality disorders, as there would be no characterology from which the study of personality disorders could emerge. Eventually, the importance of wishes led Freud to dreams as the "royal road to the unconscious" and to the use of free association as the technique that defined psychoanalysis as an applied science. Even into the 1950s, analytic theorists would continue to regard conversion hysteria as the cornerstone on which the whole of classical psychoanalysis was constructed (Fenichel, 1945).

Modern psychodynamic theorists have sought to distinguish between the hysterical character and the histrionic personality as presented in various editions of the DSM. Most analysts see the two as existing on a spectrum of severity. Kernberg (1992), for example, places the hysterical personality at a higher level of functioning and the histrionic personality at a lower, infantile level of functioning. The higher level hysteric, Kernberg states, is more socially adaptive, with more genuine, authentic, and predictable emotions. Affective control, he elaborates, is lost only in connection to others with whom there exist intense sexual or competitive conflicts. Gabbard (1994, pp. 559-560) paints a similar picture: Histrionics are more florid, more labile, more impulsive, and more sexu-alized and seductive; hysterical personalities, in contrast, are more subtle in their exhibitionism and express sexuality in a more coy or engaging manner. Whereas hysterical personalities can be successful, even ambitious, at work, Gabbard states, histrionics fail due to aimlessness, helplessness, and dependence. Finally, hysterical personalities tolerate separation from love objects, but histrionic patients are overcome with separation anxiety. We have contrasted Yvonne across the normal and pathological ends of this continuum. Again, she falls more toward the pathological side.

Although the analytic account of these personalities continues to evolve, adult traits nevertheless are recognized in a variety of historical works. Freud (1931/1950) developed a conception of the erotic character, for whom the desire for love and the possible loss of love are key themes. W. Reich (1933, pp. 204-205) provided a more detailed description, including "coquetry in gait, look or speech" in women and "softness and excessive politeness" and femininity in men. Reich also noted fickleness, suggestibility, a tendency to change emotions quickly and unexpectedly, being excited one moment but quickly disappointed the next, and a tendency to confuse fantasy with reality. In terms of defenses, he regarded histrionics as only thinly armored, with few of the sublimations and reaction formations common in the compulsive, in many ways the histrionic's theoretical opposite. Fenichel (1945, p. 528) amplified Reich's conceptions, noting that hysterical characters sexualize all their relationships and act as if entertaining an audience in an attempt to "induce others to participate in [their] daydreaming."

The psychoanalytic school of thought has historically based the framework of a histrionic personality around female stereotypes, hence, the abundance of female-typed descriptors evidenced here and in forthcoming paragraphs. However, modern-day schools of thought, including that of the psychoanalytic, recognize the prevalence of histrionic personality patterns among both males and females. Arriving at this equitable plateau has, nonetheless, become a welcomed reality as the science of psychology continues to build on the works of its forerunners.

The defensive style of the histrionic personality has been an especially fertile area of psychodynamic investigation. Across the decades, psychodynamic theorists have been repeatedly astonished by their use of massive repression, which Freud called a splitting of consciousness. Histrionics specialize in actively excluding most of what is factual, detailed, and precise from conscious awareness (see Shapiro, 1965). Instead, they possess a need to keep it simple; for them, the devil is in the details, literally. In contrast to compulsives, who isolate similarities and differences, ponder small points, and agonize over the possibilities to the point of indecision, histrionics are sensitive only to the overall emotional tone; they pick up vibrations and give off vibrations, but everything else is excluded from awareness as being too dangerous for consideration. We've noted this already in Yvonne at the beginning of the interview, where she seems to have a problem focusing on reporting her actual problems.

Given this need to repress, histrionics do not routinely startle you with their abstract power or their ability to see compelling connections among ostensibly diverse phenomena. Instead, they create a barrier between themselves and the world, filtering what is logical and reasonable and letting in only what is affectively charged, a style most of us would consider grossly superficial. By refusing to reflect on their own goals, attitudes, and identity, histrionics free themselves from worry and are thereby excused from the existential albatross the rest of us bear. Histrionics repress the emptiness of the marketed self, the conflicts their sexualized relationships create in others, and even their own unfulfilled desires. In essence, they lack the fervor for intense personal growth.

In addition to repression, hysterical personalities make use of sexualization, dissociation (considered in a subsequent section), and projection. Sexualization, in particular, serves complex adaptive and defensive purposes. W. Reich (1933), in fact, regarded hypersexuality as the defining characteristic of these personalities, suggesting that seduction is used as a defense against the fear or threat of masculine aggression. In other words, frightened by the possibility of violence, the histrionic summons another drive in the aggressor, replacing hostility with attraction. In part, this explains a curious paradox in their behavior: Histrionics exude sexual potential but are simultaneously intensely frightened and repelled by actual sexual activity (Easser & Lesser, 1965).

In fact, histrionic personalities are often shocked when asked to confront their provocative sexual messages. Apparently, conscious awareness of the instrumental use of the physical body is completely incompatible with a self-image of sweet innocence, an example of massive repression in action. Histrionics are more likely to turn the tables, projecting hypersexual interest onto their accuser and deflecting attention from themselves. With righteous indignation, they may maintain that they cannot express how hurt they are by such a suggestion, thereby leaving their prospective suitors feeling angry, confused, or even amazed. For Yvonne, this tendency is perhaps seen with her insistence that she is "not like the other girls," as she insists forcefully that she is an artist, dancing presumably for the aesthetic value. Histrionics may also use sexualization to distract themselves from feelings of anxiety or emptiness or to compensate for their perception that women lack power in a male-dominated world. By evoking sexual desire in others, by creating demand but rarely satisfying it, histrionics level the interpersonal playing field. Whatever the reason, their pervasive use of sexuality has caused many analytic writers to remark that these personalities display a false maturity, effectively, a false presentation of self. Rather than join the mature world, histrionics remain childlike with superficial efforts to disguise their seductive wiles.

Within psychodynamic circles, the development of the hysterical character remains controversial. Freud suggested fixations revolving around the opposite-sex parent, a doctrine reinforced by Fenichel (1945) but questioned by later writers (Marmor, 1953; Sperling, 1973). Ironically, it would seem that psychodynamic thinkers are still debating the very issue on which psychoanalysis itself was founded. Current thinking is that low-functioning hysterics display predominantly oral concerns, and high-functioning hysterics display issues related to the oedipal stage of development, during which a growing sense of sexuality creates an unconscious desire for the opposite-sex parent. Accordingly, the more primitive DSM-IV histrionic personality should be plagued by oral dependency, together with more profound disturbances in object relationships and interpersonal conduct. In contrast, hysterical personalities should be relatively more intact and experience greater overall success in most areas of functioning (Blacker & Tubin, 1991). The difference is one of degree: Analysts speak of a spectrum running from the relatively more oedipally fixated "good hysteric" to the more primitive and orally fixated "bad hysteric" (Zetzel, 1968).

In contrasting the oral and oedipal hysteric (Blacker & Tubin, 1991; Easser & Lesser, 1965; McWilliams, 1994), the most important tasks are to account for the presence of excessive dependency together with massive repression. Whereas the message from caretakers to the future dependent personality is, "We will do for you, because you cannot do for yourself," the analytic perspective sees the mothering of future histrionics as often inadequate, cold, and insensitive. Feeling afraid, isolated, unsafe, or unappreciated, the little girl must seek some source of nurturance beyond the primary caretaker. Eventually, she turns strongly to her father while devaluing her mother, thereby refusing a normal female identification. Males are strong and exciting, and females, including herself, come to be seen as weak and wanting. The part of her personality that might have developed a genuinely full and female selfhood given an adequate female role model is thus left to atrophy (McWilliams, 1994). Without any realistic anchor, it becomes caricatured into a loose set of behaviors that conform to social stereotypes about what elicits male desire (Blacker & Tubin, 1991). The conflict with her mother that Yvonne acknowledges, together with her closeness to her father and brothers, might fit this pattern, though more exploration would be needed.

At the same time that the little girl is turning to her father, she finds attention-getting efforts to win his approval are made more effective by nuances of seduction. Subtle sexual overtones thus begin to catalyze relationships. Awareness of this attraction is mutually threatening to both father and daughter and must be forcefully repressed, though comments may be made on the little girl's beauty, cuteness, sweetness, or innocence (McWilliams, 1994). As a result, a pattern of repressed sexual desire and sexual manipulation takes form and continues throughout life. Naturally, this also leads to conflicts between mother and daughter, whereby the mother is devalued. In effect, the future histrionic or hysteric, now "Daddy's cute little girl," learns to throw herself at male figures with the false maturity of hypersexualization, but at the same time develops a shallow or superficial sense of self that betrays her lack of an adequate female role model. We can easily imagine, for example, that at the beginning of therapy, Yvonne might state simply, "My mother and I have never been close," which might evolve into, "My mother was a cold person who was frightened by my relationship with my father."

The consequences of such a dynamic are easily seen by returning to the fundamental principles of psychoanalysis. Recall that in normal development, mental life is at first dominated by the id, which operates on the pleasure principle: I want what I want, and I want it now. Because the demands of the id almost always run into frustration, the ego emerges to coordinate its demands with the constraints of the external environment. Based on the reality principle, the ego operates as the executive branch of the personality. At first, the ego is free to consider any available route to satisfaction. Eventually, however, parental figures and other role models forbid some actions and idealize others. Thus, the superego develops, consisting of the conscience and the ego ideal, that is, what one should and should not do and become. Frozen in developmental

Focus on Sexuality

Histrionic Personality and Sex Personality and Sexual Well-Being

Histrionic personalities demonstrate, usually in a mildly caricatured form, what our society fosters and admires in its members: to be popular, extroverted, attractive, and sociable. Interpersonally, they use seductive maneuvers to attract the attention they crave.

But do they follow through and sustain that initial impression? Are they good lovers? Apparently, the answer is no. Apt and Hurlbert (1994) studied a sample of women who had been diagnosed as histrionic using the MCMI-II and compared them to a matched sample of other nonhistrionic women in a series of measures of sexual behaviors and attitudes. Histrionic women were found to have significantly lower sexual assertiveness, greater ero-tophobic attitudes toward sex, lower self-esteem, and greater marital dissatisfaction; they were found to be more preoccupied with sexual thoughts; and they reported having lower sexual desire and more sexual boredom. They also reported a greater incidence of orgasmic dysfunction and indicated a greater likelihood of entering into an extramarital affair. Despite such negative findings, histrionics reported greater sexual self-esteem.

Although the results of this particular study referred to histrionic women, there is no reason to believe that histrionic men are any more sexually competent. In fact, a similar pattern of high sexual self-esteem and difficulties has been identified for males and labeled sexual narcissism by the same authors (Hurlbert & Apt, 1991).

time, histrionics do not develop a strong superego because they have few qualms about transgressing commitments or manipulating those around them.

Consider Monique (Case 9.2), who has a lot going for her, but she cannot seem to remain monogamous. Like Yvonne, she seems to have a need for stimulation. New relationships excite her, though she quickly becomes bored, to the point that she feels the need to "return to partying and drinking." Now that her writer husband has settled down, she feels the urge to return to the same pattern that produced her two previous divorces, the desire to begin a secret and exciting affair. When she presents for therapy, she exhibits many of the classical symptoms. Her emotions run the gamut from laughter to sadness. She sexualizes her interaction with the interviewer by deliberately creating sexual imagery. Her need for attention is consistent with her social butterfly, cheerlead-ing history, becoming pathological in her depressive reaction when her girlfriend was voted homecoming queen and again in her interest in extramarital relationships. The impressionistic cognitive style of the histrionic is evident in her description of her high school years, and a theatrical, exaggerated emotionality can be seen in the dramatic flourish that accompanies it. Finally, there is evidence that she considers relationships to be more intimate than they really are. She married her first husband after having known him only three weeks, though, "It felt like we'd known each other all our lives." She probably feels the same way about her lovers, something that justifies each affair and contributes to its beginning.

If Monique's superego development were more robust, such desires would either be inhibited or never reach consciousness. Moreover, if her ego identity were more solidly anchored, she would long ago have developed goals that would further define her place in the world and give meaning to her existence, and she probably would not have a history of nontraditional life choices or alcohol abuse. Like other histrionics, Monique has short-circuited her natural developmental process. By sexualizing relationships prematurely, histrionics lure powerful others toward them so they may ease their way, reward their desires, and reduce their frustrations. Like other histrionics, Monique has no desire to develop a deep, abiding, solid sense of identity. Thus, histrionics remain, as W. Reich (1933) noted, "thinly armored," with only a veneer of selfhood to cover the drives and dependencies of an infantile id. As such, they continue to be dominated by the pleasure principle, as expressed through their need to be the center of attention; persistent stimulus-bound and sensation-seeking behavior; dramatic, theatrical displays; and even primitive regressions into fantasy, called primary process thinking. When anxiety threatens, their thin self tends to fragment or dissociate under the strain, regresses into primitive fantasy, or redirects stress somatically into the body, where it reappears as symptoms not easily accounted for by a legitimate medical condition, possibly Yvonne's situation.

The development of the higher functioning hysterical personality is similar to that of the histrionic, in that both have oral-dependency concerns. However, the hysteric runs into difficulties mainly during the oedipal phase, that is, at the point in development when budding sexuality creates an unconscious desire for the opposite-sex parent. At this stage, children naturally begin to compete with the same-sex parent, who becomes a rival. Some unusual circumstance, however, is required to intensify the dynamic and produce lasting personality traits. Zetzel (1968), for example, found that many of her hysteric patients had experienced real separation or loss of the opposite-sex parent during this period, presumably intensifying their unconscious wish to possess their parent-lover, thereby making resolution of the conflict more problematic. This provides a second pathway leading to the development of the hysterical personality.

Monique, an attractive and vivacious woman, sought therapy hoping to prevent the disintegration of her third marriage.1 As she describes her problem, her emotions run the gamut from laughter to sadness. Whenever in a relationship, she would eventually become "bored," (laughter) start showing interest in "more exciting males," and eventually return to partying and drinking. "Can you imagine me in a s-e-x-u-a-l affair?" she asks the interviewer playfully with a feigned innocence. As a recovering alcoholic, Monique thought she might be "on the brink," but wanted to take a good look at herself before ruining her marriage to the loving husband who had bonded so well with Jacqueline, her daughter from her first marriage.

Monique's history foreshadows her current situation. She is four years older than her sister, her only sibling. Her father, a wealthy businessman and gifted salesman, regarded the girls as "display pieces," trotting them out at social gatherings so that others could admire the successful family man. Her mother was an emotional but charming woman who took great pains that the children grew up "beautiful and talented." Both entered childhood pageants and talent shows. Monique's most precious memory is running into her father's arms after winning one such contest at age 8.

During the teen years, Monique was very popular, a social butterfly who dated often and never wanted for attention from the opposite sex. She busied herself with a variety of extracurricular activities, including the high school choir and artwork for the school paper. In her junior and senior years, she made the varsity cheerleading team. She describes these years with a flourish as "just the most wonderful and exciting and stimulating time that a person could ever, ever have." She does, however, recount becoming depressed and lying in bed for days when her best girlfriend was voted homecoming queen. "She wasn't nearly as cute as me," Monique states solidly.

After high school, Monique decided on art school instead of a traditional college. As a freshman, she married a fellow student, a handsome boy three years older with good grades but a reputation for causing trouble. Though they had known each other for only three weeks, "It was like we'd known each other all our lives ... I could tell we were meant!" she states. She recounts the course of subsequent events as if building up the plot of a soap opera, introducing dramatic pauses at just the right points. Both craved excitement and eventually decided on an open marriage. She is still not certain her first husband is Jacqueline's real father. Seven months later, they were divorced. Three years later, she married an older man in his forties who gave both mother and daughter a "comfortable home and lots of love and attention." Again, however, she eventually became bored and started several affairs, but broke off each one for fear her husband would find out. Eventually he did, and they were divorced. For the next four years, she was on her own, partying, using drugs, and drinking heavily. Her mother and sister took care of Jacqueline.

Her wild days came to an end, however, when she met her present husband, a talented writer. But now that she has settled down, Monique again feels herself at the threshold of destroying the relationship, either by her own potential infidelity or by the distraction of alcohol abuse.

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.

1 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.

For subjects who received adequate mothering, oral issues are absent and object relations are relatively intact. In other words, adequate mothering leads to trust and relatively solid ego development. Such hysterics have a solid female role model, do not devalue the mother or turn strongly to the father for nurturance prior to the development of their adolescent sexuality, and, therefore, do not sexualize their adult relationships as overtly. Instead, they are more subtle, the expression of their sexuality is more constructive, and they exhibit fewer psychological symptoms under conditions of stress. Subjects following the first pathway fall victim to a developmental double whammy: With the father already idealized and no good female role model with which to identify and sublimate their blooming sexuality, the desire to possess the father is more easily magnified. Communications that before were sexualized mainly through reinforcement and shaping are now fueled unconsciously by real sexual force.

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    What is the psychodynamic perspective behind hypersexual disorder?
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    Which of the following statements might a psychodynamic theorist make about personality disorders?
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