The essential features of this personality disorder are excessive emotionality and attention-seeking behavior. These individuals are uncomfortable when not the center of attention and characteristically engage in overly dramatic, excessive, exaggerated, and affected emotional displays for which the primary goal is to secure attention and admiration from others. They may present themselves in a sexually seductive, flirtatious, and provocative manner and are concerned with their physical appearance. Their dress and speech are often flamboyant to maximize the attention they receive. They frequently have a long history of drawing attention to themselves and of engaging in excited emotional displays with overstated theatricality as if they are playing to an audience. Their speech is often vague, excessively impressionistic, and lacking in detail.
When they are not successful at maintaining the social spotlight, people with Histrionic Personality Disorder typically respond with anger and frustration. In the clinical setting, they may try to sexually engage the clinician with dramatic stories of their sexual escapades. In general, they try to sexualize the professional relationship and keep it superficial. During the early course of treatment, one of our older patients wore provocative outfits to her sessions, flirted openly and regularly, and shared details of her sexual prowess and current conquests. In later sessions, however, she revealed that she derived little real joy from sex, had been celibate for several years, and was scared of intimacy.
Underneath their bubbly, outgoing, and superficially charming facade, people with Histrionic Personality Disorder tend to be shallow, self-centered, and have a strong need for social approval. They are adept at forming new relationships and often create positive first impressions, but lasting and deep relationships are less likely to occur. Their relationships usually crumble because they turn out to be superficial, are one-sided, and lack true intimacy. Their emotional expressions are shallow, frequently changing, and overblown. They often become needy, dependent, childlike, and demanding with others, which can result in their rejection. They are easy suggestible and influenced by others, likely as an attempt to secure affection. Sadly, they tend to perceive their relationships to be more intimate than they actually are, and often provide exaggerated accounts of their social successes. Their flamboyancy and superficial charm were demonstrated by one of our patients, an elderly woman, who had some occupational success as a greeter for a large retail store. Whereas she described providing dramatic and theatrical welcomes that reportedly thrilled visitors to the
Table 3.3 DSM-IV-TR Diagnostic Criteria for Histrionic Personality Disorder (Code: 301.50)
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 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
Source: From Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, American Psychiatric Association, 2000, Washington, DC: Author. Copyright 2000 by American Psychiatric Association. Reprinted with permission.
store, her social life, in reality, was replete with failed relationships and superficiality. The DSM-IV-TR diagnostic criteria for Histrionic Personality Disorder are shown in Table 3.3.
Criterion 2 (interaction with others is often characterized by inappropriate sexually seductive or provocative behavior) may be a poor fit for many in later life because of the reduced number of potential sexual partners, especially among older women who greatly outnumber older men. Nonetheless, older adults may still meet this criterion if they are inappropriately provocative and seductive despite any real intention of creating a sexual relationship. Criterion 7 (is suggestible, that is, easily influenced by others or circumstances) may be problematic especially when cognitive impairments are present (e.g., poor planning and impaired judgment) and in cases where very frail older adults do not have much actual control over their environments. Being easily influenced ("going with the flow and not causing any problems") may, in fact, be encouraged and rewarded in some long-term care settings. Care must be taken to evaluate whether the suggestibility reflects a lifelong deficit or is an expectable reaction to their present circumstances (cognitive and social).
Theorized Pattern in Later Life and Possible Impact of Aging Older adults with Histrionic Personality Disorder are often described by their adult children as "acting like spoiled children." Their self-centeredness and shallowness do not appear to diminish with age. Older individuals with this disorder are particularly intolerant of the physical changes that come with age (e.g., wrinkles, hair loss, sagging body parts) since their self-worth is based largely on superficial characteristics such as physical appearance. Because of their lifelong reliance on their physical attributes to attract attention, older histrionics may respond to normal physical changes by becoming excessive users of plastic surgery and other antiaging techniques. One of our older patients spent down her entire savings on surgery to prevent becoming "an icky old lady."
Similarly, we have seen many cases in which older individuals with Histrionic Personality Disorder have a poor adjustment to aging when their flirtatious and seductive style becomes less rewarded. Comorbid depression frequently occurs. Because seductiveness has been part of their social role for so long, aging individuals with Histrionic Personality Disorder are often baffled about how to relate to others without "attracting them." They often perceive the reductions in their sex appeal as catastrophic because they have established little other means to garner attention and affection from others.
Retirement may be a particular source of distress for the older histrionic type especially if the person used the work environment as the stage on which to perform. In cases in which the histrionic person married and maintained the relationship, widowhood may be notably damaging because the individual will have great difficulties cultivating new relationships and sources of support. Increased dependency (due to physical or cognitive problems) is likely to also result in significant prob lems for the aging histrionic. Whereas they may be perceived initially as warm, friendly, and entertaining by other residents and caregiving staff, their self-centeredness will eventually be discovered, resulting in negative responses and shunning. The resulting petulance and irritability on the part of the histrionic individual often makes matters worse.
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