INTRODUCTION:

The word personality describes deeply ingrained patterns of behavior and the manner in which individuals perceive, relate to, and think about themselves and their world. Personality traits are conspicuous features of personality and are not necessarily pathological, although certain styles of personality may cause interpersonal problems. Personality disorders are rigid, inflexible and maladaptive, causing impairment in functioning or internal distress.

A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible. It has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment.

DEFINITION:

Personality means that habitual patterns and qualities of behavior of any individual as expressed by physical and mental activities and attitudes, distributive individual qualities of a person. Histrionic personality disorder is characterized by constant attention seeking, emotional overreaction, and suggestibility. A person with this condition tends to over-dramatize situations, which may impair relationships and lead to depression.¹

CAUSES:

· Genetics/Hereditary

· Neurochemical/Physiological

· Psychoanalytical

· Environmental influences

Genetic/Hereditary:

Twin studies has aided in breaking down the genetic vs. environment debate. A twin study conducted by the department of Psychology at Oslo University attempted to establish a correlation between genetic and Cluster B personality disorders. With a test sample of 221 twins, 92 monozygotic and 129 dizygotic twins researchers interviewed the twins with the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and concluded that there was a correlation of 0.67 that Histrionic Personality Disorder is hereditary.²

Neurochemical/Physiological:

Studies have shown that there is a strong correlation between the function of neurotransmitters and the Cluster B personality disorders such as HPD. Individuals diagnosed with HPD have highly responsive noradrenergic systems which is responsible for the synthesis, storage, and release of the neurotransmitter, norepinephrine. High levels of norepinephrine lead to anxiety-proneness, dependency, and high sociability.³

Psychoanalytic theory:

Psychoanalytic theories incriminate authoritarian or distant attitudes by one (mainly the mother) or both parents, along with conditional love based on expectations the child can never fully meet. Using psychoanalysis, Freud believed that lustfulness was a projection of the patient's lack of ability to love unconditionally and develop cognitively to maturity, and that such patients were overall emotionally shallow. He believed the reason for being unable to love could have resulted from a traumatic experience, such as the death of a close relative during childhood or divorce of one's parents, which gave the wrong impression of committed relationships. Exposure to one or multiple traumatic occurrences of a close friend or family member's leaving (via abandonment or mortality) would make the person unable to form true and affectionate attachments towards other people⁴.

Environmental influences:

HPD persons often fail to see their own situation realistically, instead tending to overdramatize and exaggerate. They tend to crave novelty and excitement, they may place themselves in risky situations. All of these factors may lead to greater risk of developing depression. It occurs more frequently in women than in men, although some feel it is simply more often diagnosed in women because attention seeking and sexual forwardness are less socially acceptable for women than for men.

INCIDENCE:

The disorder occurs more frequently in women, although this may be because it is more often diagnosed in women than men. Data from the 2001-2002 National Epidemiologic Survey on alcohol and related conditions estimate that the prevalence of histrionic personality disorder is 1.84 percent.¹

HPD is diagnosed four times as frequently in women as men. It affects 2–3% of the general population and 10–15% in inpatient and outpatient mental health institutions⁵

CLINICAL MANIFESTATION:

· Individual are lively, excessive dramatics with exaggerated display of emotions.

· Enthusiastic and flirtations.

· Inappropriately seductive appearance or behavior

· Low tolerance of frustration or delayed gratification.

· Rapidly shifting emotional states that may appear shallow to others.

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

· Makes rash decisions.

· Project their own unrealistic fantasized intensions into people with whom they are include.

· Selection of marital or sexual partners is highly inappropriate.

· Make identity diffusion,

· Antisocial tendency are inclined to exploit physical symptoms.

· Affects person’s social and romantic relationships or their ability to cope with losses or failures.

· Failure or disappointment is usually blamed on others.

· Over involvement

· Aggressiveness

· Egocentricity

· Self indulgence

· Persistent manipulation behavior in achieving the needs

· A style of speech that is excessively impressionistic and lacking in detail

MNEMONIC:

A mnemonic that can be used to remember the characteristics of histrionic personality disorder is shortened as "PRAISE ME":^3,6

· Provocative (or seductive) behavior

· Relationships are considered more intimate than they actually are

· Attention-seeking

· Influenced easily by others or circumstances

· Speech (style) wants to impress; lacks detail

· Emotional lability; shallowness

· Make-up; physical appearance is used to draw attention to self

· Exaggerated emotions; the atrical

TYPES:

Millon's subtypes:

Theodore Millon identified six subtypes of histrionic personality disorder. Any individual histrionic may exhibit none or one of the following:⁷

DIAGNOSIS:

· Observation of appearance and behavior

· Collection of history

· Psychological evaluation

Diagnostic classification as follows

DSM-IV-TR:

The previous edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM IV-TR, defines histrionic personality disorder (in Cluster B) as:⁵

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:

· Is uncomfortable in situations in which he or she is not the center of attention

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

· Displays rapidly shifting and shallow expression of emotions

· Consistently uses physical appearance to draw attention to self

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

· Shows self-dramatization, theatricality, and exaggerated expression of emotion

· Is suggestible, i.e., easily influenced by others or circumstances

· Considers relationships to be more intimate than they actually are

The DSM-IV requires that a diagnosis for any specific personality disorder also satisfies a set of general personality disorder criteria.

ICD-10:

The World Health Organization's ICD-10 lists histrionic personality disorder as:⁸

A personality disorder characterized by:

· Shallow and labile affectivity,

· Self-dramatization,

· The atricality,

· Exaggerated expression of emotions,

· Suggestibility,

· Egocentricity,

· Self-indulgence,

· Lack of consideration for others,

· Easily hurt feelings, and

· Continuous seeking for appreciation, excitement and attention.

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

TREATMENT:

· Psychotherapy based on the case report method aimed at self development through resolution of conflict

· Functional analytic psychotherapy

· Family therapy based on manifestation

Psychotherapy:

The recommended form of treatment for histrionic personality disorder is psychotherapy. Therapy with people with this diagnosis is often challenging because they may exaggerate their symptoms or ability to function. They may also be emotionally needy and challenge the boundaries set up by the therapist. Therapy should generally be supportive and solution-focused. Because depression can be associated with failed romantic relationships, patients with histrionic personality disorder often seek treatment when they are experiencing symptoms of depression. Depression can be treated through psychotherapy and psychotropic medications.²

Functional analytic psychotherapy:

Another way to treat histrionic personality disorder after identification is through functional analytic psychotherapy. The job of a Functional Analytic Psychotherapist is to identify the interpersonal problems with the patient as they happen in session or out of session. Initial goals of functional analytic psychotherapy are set by the therapist and include behaviors that fit the client's needs for improvement. Functional analytic psychotherapy differs from the traditional psychotherapy due to the fact that the therapist directly addresses the patterns of behavior as they occur in-session⁹

The in-session behaviors of the patient or client are considered to be examples of their patterns of poor interpersonal communication and to adjust their neurotic defenses. To do this, the therapist must act on the client's behavior as it happens in real time and give feedback on how the client's behavior is affecting their relationship during therapy. The therapist also helps the client with histrionic personality disorder by denoting behaviors that happen outside of treatment; these behaviors are termed "Outside Problems" and "Outside Improvements”. This allows the therapist to assist in problems and improvements outside of session and to verbally support the client and condition optimal patterns of behavior”. This then can reflect on how they are advancing in-session and outside of session by generalizing their behaviors over time for changes or improvement".⁹

Coding client and therapist behaviors:

This is called coding client and therapist behavior. In these sessions there is a certain set of dialogue or script that can be forced by the therapist for the client to give insight on their behaviors and reasoning”. Here is an example from “the conversation is hypothetical. T=therapist C=Client This coded dialogue can be transcribed as:⁹

· ECRB – Evoking clinically relevant behavior

· CRB1 – In-session problems

· CRB2–In-session improvements

· TCRB1–Clinically relevant response to client problems.

· TCRB2–Responses to client improvement.

“(ECRB) T:Tell me how you feel coming in here today (CRB2) C: Well, to be honest, I was nervous. Sometimes I feel worried about how things will go, but I am really glad I am here. (TCRB2) T: That’s great. I am glad you’re here, too. I look forward to talking to you. (CRB1) C: Whatever, you always say that. (Becomes quiet). I don’t know what I am doing talking so much. (TCRB1) T: Now you seem to be withdrawing from me. That makes it hard for me to give you what you might need from me right now. What do you think you want from me as we are talking right now?”.⁹

Functional ideographic assessment template:

Another example of treatment besides coding is Functional Ideographic Assessment Template. The functional ideographic assessment template, also known as FIAT, was used as a way to generalize the clinical processes of functional analytic psychotherapy. The template was made by a combined effort of therapists and can be used to represent the behaviors that are a focus for this treatment. Using the FIAT therapists can create a common language to get stable and accurate communication results through functional analytic psychotherapy at the ease of the client; as well as the therapist.⁹

Family therapy:

Family therapy is a form of psychotherapy that seeks to reduce distress and conflict by improving the systems of interactions between family members. While family therapists often seek to have all family members (affected by the problem) in the room, that is not always possible or necessary. What distinguishes family therapy from individual counseling is its perspective or framework, not how many people are present at the therapy session. This type of counseling views problems as patterns or systems that need adjusting, as opposed to viewing problems as residing in the person, which is why family therapy is often referred to as a “strengths based treatment.”

NURSING MANAGEMENT:

Nurses responsibility for HPD as follows,¹⁰

· Establish and maintain therapeutic nurse patient relationship

· Promote effective communication strategies and healthy interactions

· Provide safe and calm environment

· Provide immediate/positive feedback for acceptable behaviors

· Try alternatives of socially and legally acceptable methods of dealing in handling frustration

· Provide emotional support and counsel the client. Prepare schedule of activities and ask the client to stick on it.

· Assist the client to understand the relationships realistically

· Encourage to take sufficient time in taking decisions.

· Observe the clients behavior, watch for social tendency, explain to them the harmful effects of such tendency, and make him to understand and not to commit or execute the plan of action.

· Advice him to the privacy and healthy manner to express the feelings related to sex appropriately

· Encourage the client to share their emotional feelings appropriately with the people who exhibit concern

· Motivate him to involve in socially approved activities

· Enhance realistic thinking

· Set Limitations for behavioral activities or tendencies

· Teach adaptive coping strategies to overcome aggression.

CONCLUSION:

Although Histrionic personality disorder may start in childhood, noticeable symptoms arise in late adolescence and early adulthood. People with a histrionic personality can typically function at a high level and achieve success educationally, socially, and professionally. However, those with very severe symptoms may find it difficult to live up to their potential at work or in school. Proper treatment and continued care for histrionic personality disorder may prove helpful.

REFERENCES:

1. https://www.psychologytoday.com/intl/conditions/histrionic-personality-disorder

2. Torgersen et al. A Twin studies of Personality Disorder Comprehensive Psychiatric journal. November 2000. Retrieved 13 march 2018.

3. https://en.wikipedia.org/wiki/Histrionic_personality_disorder

4. Pfohl, B. (1995). Histrionic personality disorder. The DSM IV Personality Disorders, 173–192.

5. Chapter 16: Personality Disorders, DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Publishing. 2000

6. Pinkofsky, HB (September 1997). Mnemonics for DSM-IV personality disorder, Psychiatric services. Washington, D.C. 48 (9): 1197–1198. doi: 10.1176/ps.48.9.1197. PMID 9285984.

7. Millon, Theodore (2004). Personality Disorders in Modern Life. John Wiley and Sons, Inc., Hoboken, New Jersey. ISBN 0-471-23734-5.

8. Chapter V: Mental and behavioral disorders (F00-F99), International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10). World Health Organization. 2010. (F60.4)

9. Callaghan G.M.; Summers C.J.; Weidman M., The treatment of histrionic and narcissistic personality disorder behaviors: A single-subject demonstration of clinical improvement using functional analytic psychotherapy Journal of contemporary psychotherapy. (2003) 33 (4): pp.321–339.

10. K.P. Neeraja. Essentials of mental health and psychiatric Nursing , Jaypee brothers medical publishers (P) Ltd, New Delhi. 2009 ; First edition: pp. 454–456

Received on 13.06.2018 Modified on 25.08.2018

Int. J. of Advances in Nur. Management. 2018; 6(4): 329-333.

DOI: 10.5958/2454-2652.2018.00075.6

Subtype	Description	Personality Traits
Appeasing histrionic	Including dependent and compulsive features	Seeks to placate, mend, patch up, smooth over troubles; knack for settling differences, moderating tempers by yielding, compromising, conceding; sacrifices self for commendation; fruitlessly placates the unpalatable.
Vivacious histrionic	The seductiveness of the histrionic mixed with the energy typical of hypomania. Some narcissistic features can also be present	Vigorous, charming, bubbly, brisk, spirited, flippant, impulsive; seeks momentary cheerfulness and playful adventures; animated, energetic, ebullient.
Tempestuous histrionic	Including negativistic features	Impulsive, out of control; moody complaints, sulking; precipitous emotion, stormy, impassioned, easily wrought-up, periodically inflamed, turbulent.
Disingenuous histrionic	Including antisocial features	Underhanded, double-dealing, scheming, contriving, plotting, crafty, false-hearted; egocentric, insincere, deceitful, calculating, guileful.
Theatrical histrionic	Variant of “pure” pattern	Affected, mannered, put-on; postures are striking, eye catching, graphic; markets self-appearance; is synthesized, stagy; simulates desirable/dramatic poses.
Infantile histrionic	Including borderline features	Labile, high-strung, volatile emotions; childlike hysteria and nascent pouting; demanding, overwrought; fastens and clutches to another; is excessively attached, hangs on, stays fused to and clinging.