Tuesday, 8 April 2008

Histrionic Personality Disorder

Note to Skank:

Individuals with Histrionic Personality Disorder exhibit excessive emotionalism--a tendency to regard things in an emotional manner--and are attention seekers. They have an overwhelming desire to be noticed, and often behave dramatically or inappropriately to get attention.

Behaviors may include constant seeking of approval or attention, self-dramatization, theatricality, and striking self-centeredness or sexual seductiveness in inappropriate situations, including social, occupational and professional relationships beyond what is appropriate for the social context.

They may be lively and dramatic and initially charm new acquaintances by their enthusiasm, apparent openness, or flirtatiousness. They commandeer the role of "the life of the party". Personal interests and conversation will be self-focused. They use physical appearance to draw attention to themselves. Their style of speech is excessively impressionistic and lacking in detail.

They may do well with jobs that value and require imagination and creativity but will probably have difficulty with tasks that demand logical or analytical thinking.

Histrionic personality disorder does not usually affect the person's ability to function adequately in a superficial work or social environment. However, problems often arise in more intimate relationships, where deeper involvements are required.

Symptoms

* Excessive dramatics with exaggerated displays of emotion

* Self-centeredness, uncomfortable when not the center of attention

* Tendency to believe that relationships are more intimate than they actually are

* Constantly seeking reassurance or approval

* Displays rapidly shifting and shallow expressions of emotions

* Overly concerned with physical appearance / Consistently uses physical appearance to draw attention to self

* Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior

* Excessive sensitivity to criticism or disapproval

* Has a style of speech that is excessively impressionistic and lacking in detail

* Opinions are easily influenced by other people, but difficult to back up with details

* Low tolerance for frustration or delayed gratification

* Have difficulty maintaining relationships, often seeming fake or shallow in their dealings with others

People with this disorder are usually able to function at a high level and can be successful socially and at work. They may seek treatment for depression when romantic relationships end. They often fail to see their own situation realistically, instead tending to overdramatize and exaggerate. Responsibility for failure or disappointment is usually blamed on others.

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Frances, et.al. (1995, p. 373) describes individuals with HPD as manipulative, vain, and demanding.

Akhtar (1992, p. 259) notes that the current description of HPD corresponds to the previous idea of an infantile personality. These individuals had few sexual inhibitions, were impulsive, experienced identity diffusion and emotional lability, and demonstrated what the author referred to as moral defects. Yet, as described in the DSM-IV, individuals with HPD demonstrate what our society tends to foster and admire -- to be well liked, successful, popular, extroverted, attractive, and sociable (Millon & Davis, 1996, p. 366). In fact, Widiger, et.al. (Costa & Widiger, eds., 1994, p. 47) describe HPD as an extreme variant of extroversion. Extroversion involves the tendency to be outgoing, talkative, convivial, warm and affectionate, energetic, and vigorous. In a non-pathological form, extroversion is being high-spirited, buoyant, and optimistic. These factors coalesce into a personality disorder only when the needs behind the behavior are pathologically inflexible, repetitious, and persistent (Millon & Davis, 1996, p. 366). It is then that the corruptibility, manipulativeness, and disinhibited exploitation of others become factors and the personality disordered version of extroversion becomes apparent.

Women with HPD are described as self-centered, self-indulgent, and intensely dependent on others. They are emotionally labile and cling to others in the context of immature relationships. Females with HPD over identify with others; they project their own unrealistic, fantasied intentions onto people with whom they are involved. They are emotionally shallow and have difficulty understanding others or themselves in any depth.

Individuals with HPD may decompensate in later adult years due to the cumulative effects of:
1) the incapacity to pursue personal, professional, cultural, and social values;
2) the frequent disruption of and failure in intimate relationships; and
3) identity diffusion.
These factors interfere with ordinary social learning and consequences grow more severe with age. The usual course of untreated HPD is precarious as life opportunities are missed or destroyed

Self-image

Individuals with HPD view themselves as gregarious, sociable, friendly, and agreeable. They consider themselves to be charming, stimulating, and well-liked. They value the capacity to attract people via their physical appearance and by appearing to be interesting and active people. For individuals with HPD, indications of internal distress, weakness, depression, or hostility are denied or suppressed and are not included in their sense of themselves (Millon & Davis, 1996, p. 369).

For individuals with HPD, vanity and seductiveness function to bolster and maintain self-esteem; they often become overinvested in how they look and dread aging (McWilliams, 1994, pp. 312). Growing old violates the view of themselves as glamorous and attractive people who are admired by others.

Individuals with HPD are consumed with attention to superficialities and spend little time or attention on their internal life. Because they know themselves so little, they often have no sense of who they are apart from their identification with others. They are able to change their attitudes and values depending upon the views of significant others in their lives. These individuals also fail to attend the details and specifics of their experiences. They have, accordingly, memories that are diffuse and general with a tremendous lack of detail (Will, Retzlaff, ed., 1995, p. 99).

View of Others

Individuals with HPD focus on others to the point that they obtain their own identity from those to whom they are attached. Yet the attention they focus on others does not allow them to gain understanding of others or to become effectively empathic. Their intense observation skills are dedicated to determining what behaviors, attitudes, or feelings are most likely to result in winning the admiration and approval of others. Essentially, these individuals watch other people watch them. Their actual focus is on how they are doing and how they are being received by others. As a result, they are not particularly effective in understanding how others are feeling.

Individuals with HPD are inclined to define relationships with or connections to others as closer or more significant than they really are. They do not see when they are being humored or placated by people who may have lost patience with their relentless need for attention and the failure to relate in a genuine way. Others may eventually withhold their own efforts to relate to individuals with HPD once they become aware that there is no real attempt to connect -- rather there is a continuing demand to be attended to and admired.

Relationships

The HPD failure to view others realistically is reflected by their difficulties in developing and sustaining satisfactory relationships. Individuals with HPD tend to have stormy relationships that start out as ideal and end up as disasters (Beck, 1990, p. 214). These individuals are unable to tolerate isolation; when alone, they feel desperate and are unable to wait for new relationships to develop gradually (Horowitz, Horowitz, ed., 1991, p. 4). They will idealize the significant other early in the relationship and often see the connection as more intimate than it really is. If the significant others begin to distance themselves from the incessant demands, individuals with HPD will use dramatics and demonstrativeness to bind these people to the relationship. They will resort to crying, coercion, temper tantrums, assaultive behavior and suicidal gestures to avoid rejection (Beck, 1990, p. 51).

Even though individuals with HPD will attempt to bind others to them, they are often dissatisfied with single attachments. They tend to be lacking in fidelity and loyalty; they are seductive, dramatic, and capricious in personal relationships (Millon & Davis, 1996, p. 357). Their interpersonal dependency is not expressed through faithfulness and commitment. They start relationships well but falter when depth and durability are needed. There is a paradox in HPD relationships of coercive dependency and infidelity.

Individuals with HPD have a strong fear of being ignored; they long to be loved and taken care of by someone who is both powerful and able to be controlled through the use of charm and seductiveness. They become helpless and childlike when faced with potential rejection (McWilliams, 1992, p. 307).

HPD Behaviour

Individuals with HPD are overreactive, volatile, provocative, and engaging in their behavior. They are intolerant of inactivity, impulsive, emotional, and responsive. They have a penchant for momentary excitements, fleeting adventures, and ill advised hedonism (Donat, Retzlaff, ed., 1995, p. 47). The HPD behavioral style is charming, dramatic, expressive, demanding, self-indulgent, and inconsiderate (Sperry, 1995, p. 97). They tend to be capricious, easily excited, and intolerant of frustration, delay, and disappointment. The words and feelings they express appear shallow and simulated rather than real or deep (Millon & Davis, 1996, pp. 366-367).

These individuals can be quite effective in situations where a first impression is important and vague expression of ideas is preferred over precision. They are less effective where performance is measured by objective measures of competence, diligence, thoroughness, and depth. Acting, marketing, politics, and the arts are fields where individuals with HPD will do well and manage competition effectively (Richards, 1993, p. 246).

The body, erotically or via illness, is often used by individuals with HPD to attract the attention of others (Horowitz, Horowitz, ed., 1991, p. 5). They will engage in inappropriately exaggerated smiles and continuous elaborate hand gestures. Movement and expressions are designed to have a pleasing effect (Turkat, 1990, pp. 72-73).

Individuals with HPD are fraudulent insofar as their inner emptiness is in contradiction to the impressions they seek to convey to others. They hide their true cognitive sterility and emotional poverty (Millon & Davis, 1996, p. 370). HPD cognition is global, diffuse, and impressionistic; these individuals appear incapable of sustained intellectual concentration; they are distractable and suggestible (Beck, 1990, p. 215). They avoid introspective thought. They are attentive to fleeting and superficial events but integrate their experience poorly with a cursory cognitive style. They lack genuine curiosity and have habits of superficiality and dilettantism. They avoid potentially disruptive ideas and urges by dissociating from thoughts, people, and activities that threaten their view of themselves or the world (Millon & Davis, 1996, p. 369).

Individuals with dependent personality disorder and histrionic personality disorder share important traits: they both turn to others for protection and the rewards of life; they are socially affable and share an intense need for attention and affection. Individuals with HPD have a more vigorous and manipulative style; these people will take the initiative in assuring that attention is forthcoming. They will actively solicit the interest of others through a series of seductive behaviors (Millon & Davis, 1996, p. 357).

Affective Issues

Individuals with HPD express their emotions intensely yet remain unconvincing. They appear warm, charming, and seductive, yet their feelings appear to lack depth and genuineness (Beck, 1990, p. 213). They have an infantile quality in their emotional expression. They experience exaggerated feelings that change frequently. They become so involved in their emotional dramas that they are unaware of or are uninformed about the world they live in. They cannot stand frustration, disappointment, or delayed gratification (Oldham, 1990, pp. 143-144).

Individuals with HPD are subject to distortion in their emotional reasoning. They accept their emotions as evidence of truth rather than just a statement about their current emotional state (Will, Retzlaff, ed., 1995, p. 99).

People with HPD experience recurrent flooding of affect. Somatic preoccupations and sudden enraged, despairing, or fearful states may occur. Patience is rare and these individuals may use alcohol or other drugs to quickly alter states of negative feeling (Horowitz, Horowitz, ed., 1991, p. 4).

Defensive Structure

HPD defenses include dissociative mechanisms. Individuals with HPD regularly alter and recompose themselves to create a socially attractive but changing facade. They engage in self-distracting activities to avoid reflecting on and integrating unpleasant thoughts and feelings (Kubacki & Smith, Retzlaff, ed., 1995, p. 168). Repression is also a HPD defense; frequent splitting off from conscious awareness of self results in an intrapsychic impoverishment; psychological growth is precluded. These individuals remain immature and childlike in their behavior. Through repression, individuals with HPD remain unaware that their thoughts and feelings are attached to their behavior. Accordingly, they claim innocence when their conduct results in interpersonal conflict (Kubacki & Smith, Retzlaff, ed., 1995, p. 171).

Millon (Millon & Davis, 1996, pp. 369-370) also noted the HPD defense mechanisms of dissociation and repression. Individuals with HPD are attuned to external rather than internal events. They dissociate entire segments of memory and feelings that prompt discomfort. They, in particular, must keep away from awareness the triviality of their entire being, its pervasive emptiness and paucity of substance (Millon & Davis, 1996, pp. 369-370).

Alcohol & Drug Addiction

These individuals are prone to alcoholism and drug addiction and are quite adept at denying the related behaviors. They seek easy escape from pain, deny negative consequences, and fail to observe or accept responsibility for the impact of their behavior on others.

Richards (1993, pp. 227-239) believes that individuals with personality disorders have an increased inclination to use drugs and alcohol as alternative solutions to life problems. Faulty adaptation to normal stressors and frequent failures in self-regulation can be attributed to deficiencies or disturbances in the personality. This accounts for continued addiction even in the face of catastrophic negative consequences.

For individuals with HPD, the shallowness and absence of internal integration are mirrored in a superficial involvement in the details of life; they have little ability to understand and integrate emotional experiences across situations. Alcohol and drugs serve as an alternative to personality integration and increased maturity. This is particularly effective for individuals with HPD because drug use facilitates dissociative behavior. Not only will they use drugs and alcohol for self-regulation and as a self-soothing alternative to facing life problems, they will view themselves as victims to their addiction. They often cycle rapidly between the role of enraptured drug user and the victimized person suffering from the illness of addiction (Richards, 1993, pp. 240-247).

Millon & Davis (1996, p. 378) state that individuals with HPD may become involved in drug or alcohol abuse because the substances can free them to act out in ways that are congenial to their inclination to be stimulus-seeking. Through drugs and alcohol, these individuals are able to transform themselves; they gain feelings of well-being, bolster a flagging sense of self-worth, and perhaps even come to feel omnipotent. Drugs and alcohol can disinhibit controlled HPD impulses so that there need be no assumption of personal responsibility or guilt for behavior.

Individuals with HPD are vulnerable to addiction via their immaturity, inclination to avoid unpleasantness, and stimulus-seeking behavior. They define themselves as victims to their addiction and describe themselves as powerless, not over addiction, but in relation to recovery. These individuals usually have little experience in recognizing and tolerating the painful in life. They do not define reality as a positive force; they are much more inclined to prefer the fantasies they have about both themselves and others.

Richards (1993, p. 278) notes that individuals with HPD will demand to be special in treatment. They are inclined to become the star patient in a treatment group or the problem child due to relapse. They may also, consciously or not, view service providers (or their group) and their drug(s) of choice as jealous lovers fighting over them and for their allegiance. This is a situation these individuals tend to relate to with relish (Richards, 1993, pp. 247-248).

Dual Diagnosis and the Histrionic Personality Disorder

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