Histrionic personality disorder (HPD) exists along a continuum of severity, as do many other disorders. The presence of traits at one end of the continuum is critically important to the actor depending upon these characteristics to maintain the ‘Hollywood’ persona, while the person at the far end of the spectrum may resemble someone in a manic or hypomanic phase of bipolar disorder. Persons with a true HPD are lively, dramatic, and often charming in small doses. They crave attention, repeatedly draw the focus of conversation back to themselves, make grand entrances often at inopportune times, and are prone to exaggeration of behavior, emotion, and interpretation.
HPD patients are arousal oriented; they crave stimulation, and often respond to minor stimuli with eruptions of inappropriate laughter or irrational, angry outbursts. Their interpersonal relationships are often severely impaired; they frequently rapidly exhaust their partners with their neediness. Others generally perceive them as shallow, lacking in genuineness, demanding, and overly dependent. Rejection from others may lead to depression and suicidal ideation.
Although this chapter will focus on patients who meet the defining criteria for HPD, the concepts may also be applied to patients who demonstrate histrionic features superimposed upon another disorder, such as borderline or narcissistic personality disorders. This chapter offers models to assist clinicians in understanding the conceptualization cognitive and developing effective treatment strategies.
In the early days of psychoanalytic development in Vienna, Austria, Breuer, Freud, and others conceptualized hysterical reactions as conversion disorders consisting of ‘repressed’ conflicts that manifested in physiological symptoms of blindness, paralysis, or seizures. Campbell's psychiatric Dictionary (1996) offers 24 terms related to the term ‘hysteria,’ a construct that is the precursor to the contemporary diagnosis of HPD. Campbell's offers the additional explanation for hysterical conversion reactions that includes the need to ‘flee into illness when libidinal cathexis exceeds a certain amount’ (Campbell, 1996, p. 344). The confounding factor of conversion disorder components of hysteria raises additional questions as to whether hysteria is a symptom, a disease, a personality type, or a pattern of behavior (Slavney, 1990). The only point of agreement to date is that HPD is infinitely more complicated than mere hysterical reaction.
The use of the term ‘hysteria’ has varied widely over its 4000-year history and has often been a source of controversy (summarized by Veith, 1963; Halleck, 1967). The Ancient Egyptians originally postulated that the womb, when not properly anchored might wander, lodge against other organs, such as the brain, and produce all manner of ‘highly emotional symptoms.’ By definition, therefore, hysteria became known as a disease specific to women. In the mid-nineteenth century, it was suggested that men could also manifest hysteria, as the result of psychological predispositions and psychosocial stressors (Briquet, 1859).
In studies in hysteria, Freud presented his major ‘discovery’ of a case of male hysteria; for Freud and the early twentieth century psychoanalytic community, the term hysteria generally referred to conversion disorders rather than a dramatic, excitable, and emotional personality style. As early as 1923, Schneider supplanted the term hysteria with ‘attention-seeking’ as he believed the latter was more accurate and less morally judgmental. This definition of attention-seeking behavior has become the core criteria for HPD. Histrionic individuals are viewed from a more positive frame as ‘enthusiastic,’ ‘motivating,’ and ‘exciting.’ Attractive individuals with these characteristics may be sought after in their younger years. As they grow older and their physical appeal fades, most adapt to the decreased amount of attention they receive. However, a person with HPD has less flexible ability to adapt to the changes associated with later life and may exhibit frantic, infantile, or indiscriminately immature behaviors in attempt to maintain youthful attention and attractiveness (Millon, 1996). Both males and females with HPD eventually develop a caricaturized facade of femininity or masculinity. This facade has been unwittingly reinforced through the positive or flattering attention of others, which is the life blood of their self-esteem (Horowitz, 1991).
The prevalence of HPD has been estimated at 2.1% of the general population with reliable diagnostic criteria and strong construct validity (Nestadt et al., 1990). As is generally the case with personality disorders, people usually do not seek treatment with HPD as their presenting problem; instead they complain of periods of intense dissatisfaction, depression, or anxiety. Common comorbid conditions, in addition to depressive disorders, include the full range of anxiety disorders. These individuals are also vulnerable to substance misuse disorders, the development of somatoform disorders, and eating disorders. Because individuals with this disorder often experience periods of intense dissatisfaction and depression, they are at high risk for making dramatic suicide attempts, placing themselves at risk for accidental completion. In fact, one study found the reason for inpatient admission for 80% of HPD inpatients was related to expressions of suicidality. However, most of the attempts were not life-threatening and had generally occurred after disappointment or anger (A. T. Beck et al., 2003). Owing to their dependence on the attention of other people, they are especially vulnerable to separation anxieties and may seek treatment when they become intensely upset over the breakup of a relationship.
As discussed above, the strongest indication of HPD is an overly dramatic self-presentation. These patients express emotion in an exaggerated or unconvincing manner, as if they are playing a role. In fact, when talking with these patients, the clinician may have a sense of watching a performance rather than a genuine display of emotion. Histrionic patients can appear quite warm, charming, and even seductive; yet their charm begins to seem superficial after a short period of time. This is due in part to their dramatic expression of each issue or problem with equal levels of intensity, and the use of theatrical intonation with dramatic nonverbal gestures and facial expressions. In addition, it may be noted that they present their symptoms, thoughts, and actions as if they were external entities involuntarily imposed upon them. They tend to throw up their hands (literally) and proclaim, ‘These things just always seem to be happening to me!’ Histrionic patients often use strong, dramatic words, include much hyperbole in their speech, and have a proclivity for meaningless generalizations.
Persons with this disorder often dress in ways that attract attention, wearing striking or provocative styles in bright colors, exaggerated use of cosmetics, and dramatic use of hair coloring. Not surprisingly, given the desire to maintain a youthful, attractive appearance, some HPD individuals also have eating disorders (Tomotake and Ohmori, 2002).
The patient with HPD is often conceptualized as a female who resembles the woman in The Perils of Pauline from silent movie days. She is vain, shallow, self-dramatizing, immature, overly dependent, and selfish. Although less commonly diagnosed in males, this disorder is often associated with homosexuality or theatrical narcissism. These gender differentials may reflect societal expectations rather than true gender differences in the prevalence of the disorder. In fact, it has been suggested that HPD is a distortion of sex roles in general, including extreme presentations of masculinity as well as femininity (Kolb, 1968; MacKinnon and Michaels, 1971; Malmquist, 1971). Research has attempted to determine if HPD is a female variant of male-typed personality disorders, such as antisocial personality disorder, but results thus far are weak and inconsistent (Cale and Lilienfeld, 2002a).
It is interesting to consider the evolution of hysteria and HPD as diagnoses in the Diagnostic and Statistical Manual (DSM). The DSM I (American Psychiatric Association, APA, 1952) differentiated between ‘psychoneurotic’ hysteria and ‘personality trait disturbances’ (APA, 1952, pp. 31, 32, and 34). Hysterical neurosis was further delineated into conversion reaction and dissociative reaction as opposed to hysterical personality. The criteria cited for emotionally unstable personality actually most closely resembled the eventual criteria for HPD.
It was not until DSM II that the term histrionic was first used. The criteria for hysterical personality disorder reflected clusters of behaviors and traits characterized by excitability, emotional instability, over-reactivity, and self-dramatization, attention-seeking, and often seductive behavior (APA, 1968, p. 43). Histrionic personality was officially codified with the advent of DSM III, which eliminated the diagnoses of hysteria and hysterical personality. The classification was further refined in DSM III-R (1987) with the elimination of manipulative suicidal attempts, gestures, and threats from HPD to better distinguish it from borderline personality disorder features. Finally, DSM IV (APA, 1994) and the more recent text revision, DSM IV-TR (APA, 2000) retain the criteria of a highly excitable individual who seeks attention, has global impressionistic thinking and emotional reasoning, and whose mood is labile, displaying dramatic crying spells, frightening suicidal gestures, infidelity, or even aggressive behavior.
Early dynamic descriptions of disorders that resembled personality disorders of today emphasized unresolved oedipal conflicts as one of the primary determinants of disrupted lifelong behavior patterns. Later dynamic theorists focused on the presence of a more pervasive and primitive disturbance arising during the oral, anal, or trust building stages of development (Halleck, 1967). Other hypotheses involved theories of family triangulation: a high degree of affection from father, and a low degree of affection from mother predisposed a woman to develop oedipal conflicts and resulted in the development of a hysterical personality (Mehlman, 1997). The resultant hysterical female was fixated at the genital level and suffered from a surplus of sexual energy (Reich, 1991). The use of their sexuality was their ‘armor’ in the service of defending the ego. Early psychoanalysts believed that penis envy, castration anxiety, and failure to resolve the repression of oedipal conflicts generated the hysterical symptoms. Debates continued in the psychoanalytic community as to whether the primary fixation involved in the hysterical personality is oral or phallic in nature (Marmor, 1953). As recently as 1991, several theorists were differentiating between the hysterical personality and another group of ‘hysteroids’ who use the same behavioral mechanisms but are functioning at pregenital or psychotic levels (Easser and Lesser, 1965).
More recent psychodynamic theorists suggest three subgroups: (1) hysterical character neurosis arising from classic triadic oedipal conflicts; (2) hysterical personality disorder evolving from the initial phallic phase and related to dyadic mother–child concerns; and (3) borderline personality organization with hysterical features, employing more primitive pre-oedipal defenses, more oral than phallic in nature (Baumbacher and Amini, 1980–81). In an attempt to offer a more integrative conceptualization, Horowitz (1991), saw the patterns of the hysterical personality as a function of the individual's style of information processing. The processing is viewed as a function of the individual's schema and lack of a broader behavioral repertoire (Horowitz, 1991). Gabbard (2000), summarized the differences between hysterical personality disorder and HPD: ‘… persons who have a true hysterical personality disorder may be much more subtly dramatic and exhibitionistic, and their sexuality may be expressed more coyly and engagingly’ (p. 520). He further suggests that the individual diagnosed as hysterical as opposed to those diagnosed as histrionic would be more functional by virtue of their more controlled expressions of their disorder (Gabbard, 2000).
Essentially, the psychoanalytic viewpoint today views hysterical patients as being able to assess their behavior more realistically. HPD patients find their active seductiveness as more egosyntonic and they are less able to accurately assess their behavior.
Early factor-analytical research provided some support for the psychodynamic conceptualization of the hysterical personality (Lazare et al., 1970). Traits such as the tendencies to be overly emotional, sexually provocative, exhibitionistic, and egocentric strongly clustered together. Dependency fell into an intermediary position. Unexpectedly, suggestibility and fear of sexuality failed to correlate with these other variables, whereas, aggression, obstinacy, rejection of others, and oral expression did cluster with the hysterical traits (Lazare et al., 1970). The authors concluded that this lent support to the notion that the hysterical personality reflected a more primitive conflict than the HPD as described by Kernberg in 1967.
A basic premise of cognitive therapy is that events are filtered through maladaptive schema, or hypothetical structures in the mind, which give rise to dysfunctional beliefs and automatic thoughts that are distorted in some predictable manner. These thoughts are presumably the precipitant of negative affective states, including sadness, anxiety, and anger. Therefore, as premised by Epictetus thousands of years ago, a situation in of itself is neither good nor bad, right nor wrong; one's perception and interpretation of the situation, however, makes it so.
Schemas govern information processing by serving as filters through which incoming information is perceived. Schemas influence what one attends to. Patients with personality disorders in particular selectively attend to information that fits with their beliefs and discount or selectively ignore information inconsistent with the same beliefs. Their interpretation of events is particularly impaired because they have significant difficulty employing metacognitive strategies to evaluate the validity of their perceptions. Others’ statements and behaviors may be grossly misperceived and may go uncorrected. For example, the boyfriend of an HPD patient said, ‘I need some time this weekend to get some stuff done.’ The patient interpreted this statement as meaning, ‘I have found someone prettier and I'm rejecting and abandoning you.’
Core beliefs about the self, world, and others may stem from early interactions in the family of origin; children glean such ideas from their parents, siblings, peers, and significant others. Beliefs are affected by early attachment and individuation difficulties. Individuals, who may have a genetic tendency toward developing histrionic traits, acquire a number of powerful, compelling dysfunctional beliefs about sexuality, masculinity, femininity, and relationships. They begin to believe that they are (and must be) exciting/excited and the center of attention. They also begin to focus unduly, and respond dysfunctionally to internal emotional events.
Millon (1981) and Millon and Davis (1996) have presented a biosocial learning theory view of personality disorders and HPD in particular. The HPD is viewed as ‘The Gregarious Pattern’. The individual with HPD craves affection, attention, and the approval of others. It is not simply ‘nice to be noticed,’ but rather a critical component of social interaction with high focus on shifting the attention of others to themselves. Initially, others may be drawn to the HPD individual. The positive attention and affection by others is often fleeting, though, as others may quickly perceive them to be demanding, capricious, disingenuous, and dependent. Moreover, their labile affect is often perceived as insincere, exaggerated, and shallow (A. T. Beck et al., 1990).
HPD patients are typically hypervigilant for signs of rejection or disapproval, which others may or may not have actually intended or transmitted. They perceive withdrawal or uninterest as disastrous, and react with a great deal of distress. They respond to this internally driven crisis with behavioral escalation, making increasingly frantic efforts to invite or seduce others to notice and approve of them—and/or rapidly disintegrating into despair and hurt, along with righteous indignation at the perceived snub, alienating others and evoking true rejection. The activation of their schema ‘I must be noticed’ is most likely outside of their conscious awareness. It is the immediate cognitive affective response that is most salient at the moment.
HPD individuals typically have many dysfunctional beliefs: ‘I must be noticed and admired to be happy’, ‘I have to be entertaining, lovable, and interesting’—they seek to be glamorous, impressive, or dramatic because at heart they believe that there is something lacking in or defective about them. This negative view of the self is reflected in their conditional assumption, ‘If I can't entertain people, they will abandon me,’ ‘Unless I captivate people, I am nothing’, ‘If others won't take care of me, I'll be helpless.’ They also hold dysfunctional beliefs about others: ‘People have no right to deny me,’ ‘If people don't respond to me in the way that I need them to, they are bad,’ (A. T. Beck and Freeman, 1990, p. 50). However, because of their characteristic dissatisfaction with any single partner and lack of loyalty having once acquired the attentions of the ‘desired’ one with whom they had previously believed they simply could not live without, they are soon off flirting with others, leaving their partners feeling confused, frustrated, and angry.
Histrionic individuals are given to global impressionistic thinking, and make the common cognitive distortion of emotional reasoning. A common belief is, ‘If I feel hurt, the other person must have intentionally mean to hurt me—and I should punish him.’ Thus, simply feeling hurt becomes justification for dramatic behavior. Conversely, a mere smile from a stranger can engender a feeling of warmth that becomes justification for impulsive indiscretion (A. T. Beck et al., 2003). This maladaptive pattern is likely to make histrionic individuals interpersonal relationships rather stormy and unsatisfying. The mere perception that they are unable to attract attention may be sufficient to initiate suicidal or parasuicidal cognitions and behavior.
The overly expressive affect of HPD portrays a superficial gaiety, mirth, and carefree attitude, which belies an ominous undercurrent of anxiety and a pervasive fear of rejection. In addition, hypersensitivity to the perception of rejection leaves the HPD individual prone to extremes of emotional lability. A lifelong fundamental need to elicit attention and affection from others generally produces an individual who is acutely sensitive to the cues and to what they perceive are the feelings and desires of others. Because of their tendency to get bored easily, individuals with HPD may impulsively seek out stimulation with illegal substances and/or alcohol abuse and the type of rash sexual indiscretions that their significant others might find particularly objectionable.
Although a dramatic portrayal of the self can serve as useful cues to the presence of HPD, a dramatic style alone certainly does not necessarily indicate that a patient has HPD. It is important to ask for details of the types of activities the patient most enjoys: Does he or she especially enjoy being the center of attention? Does he or she show a craving for activity and excitement? It is crucial to explore interpersonal relationships in depth. Details should be obtained as to how previous relationships started, what happened, and how they ended. Clinicians should be alert for women with overly romantic views of relationships, hoping or expecting that ‘Prince Charming’ will ride along on his white horse. Do the patients’ relationships start out as idyllic and end up as disasters? How stormy are their relationships and how dramatic are the endings? How do they handle anger, fights, and disagreements? The clinician should ask for specific examples and look for signs of dramatic outbursts, temper tantrums, and the manipulative use of anger.
Many of the characteristics of histrionic personality are generally considered to be negative traits and it is certainly not productive to ask people if they are shallow, egocentric, vain, and demanding. However, it may be possible to obtain some relevant material regarding these factors by asking patients how other people tend to view them, or through information obtained directly from significant others or family members. The therapist may ask the patient what complaints other people have made about them, while exploring previous relationships that did not work out. As with any patient, clinicians should inquire about suicidal ideation or threats, and should determine whether there is currently a risk of a suicide. Histrionic patients may demonstrate a dramatic or manipulative quality to the threats or attempts.
Instruments such as the Millon's Multiaxial Clinical Inventory (Millon, Millon and Davis, 1994) or the Structured Clinical Interview for DSM III-R (SCID; Spitzer et al., 1992) can be helpful in diagnosing these patients. However, diagnosis is usually readily obtained with a thorough history taking and additional collateral interview.
The following suggestions for assessing personality disorders were suggested by Jackson (1998):
Take a full detailed history, including a mental status exam to rule out organic disorders that mimic personality disorders.
Take every precaution to ensure that an Axis I disorder is not generating a pseudopersonality disorder picture (e.g., substance misuse or mania).
Arrange for a single interview with a significant other who has known the patient for a period of years. This person should be reliable and know the client very well.
Make every effort to focus on the positive. In Adlerian terms this is referred to as determining the ‘worthy purpose’ of a person's symptoms as well as determining those areas of strength that will serve them in therapy.
Ongoing sessions should be used to further the therapist's understanding of the disorders as well as deepen the comprehension of the person's themes and schema (A. T. Beck et al., 1990).
Some diagnostic signs that may signal the possible presence of Axis II pathology, including HPD, include the following:
The patient reports the problem as being pervasive, long-standing, and dysfunctional. A significant other reports, ‘Oh, he/she has always done that, since he's a little boy/girl’, or the patient may report, ‘I've always been this way’.
The patient is not compliant with the therapeutic regimen. While this noncompliance (or ‘resistance’) is common in many clinical problems and for many reasons, ongoing noncompliance should be used as a signal for further exploration of Axis II issues.
Therapy seems to have come to a sudden inexplicable stop. The clinician working with the Axis II patient can often help the patient to reduce the problems of anxiety or depression only to be blocked in further therapeutic work by the personality disorder.
The patient seems entirely unaware of the effect of their behavior on others. They report the responses of others, but fail to address any provocation or dysfunctional behavior that they might exhibit.
There is a question of the motivation of the patient to change. This problem is especially true for those patients who have ‘been sent’ to therapy by family members or the courts.
The patient gives lip service to the therapy and to the importance of change but seems to manage to avoid changing. He or she may exert more energy to avoid or avert changing than it would take to actually follow through with the recommendations.
The patients’ personality problems appear to be acceptable and natural for them. For example, a depressed patient without an Axis II diagnosis may say, ‘I just want to get rid of this depression. I know what it is like to feel good, and I want to feel that way again.’ The Axis II patient may see the problems as them, perhaps stating, ‘This is how I am’ and ‘This is who I am’ (Freeman and Diefenbeck, 2005).
Robin was a 39-year-old, single, white female who was occasionally employed as a waitress in a local sports bar. Her parents divorced when she was 5 years old. She was an only child. She was referred for a psychological evaluation by her family physician after she had roller-skated into his office in a bikini and tee shirt and burst into tears claiming to be terrible depressed, needing medication, all the while lamenting a recently ‘lost love.’ Her physician referred Robin for therapy.
Robin breezed into her initial session 35 minutes late. She was tall, in good physical condition, and wore pigtails with shocking pink ribbons that were more appropriate at an earlier stage of her development. As she entered the office she enthusiastically proclaimed. ‘I guess you are the one who is going to fix me!’ Then, she abruptly burst into tears as she reported living alone for the first time in her life after her recent break up with her latest boyfriend, who had tired of her chronic infidelity. ‘What will I do now? I'll just die if I'm alone.’ However, almost instantaneously, she brightened and related, ‘He just didn't understand that men find me so attractive and I just can't hurt their feelings! I mean, you have to admit I am pretty striking!’ Then, she tearfully confided that she had recently contracted genital herpes and dreaded, not the medical consequences, but that the disease would restrict her sexual activity, but only if her partners would have to be made aware of the problem.
Although Robin's father left her and her mother when she was 5 years old, he had visited her monthly, accompanied by a series of what Robin termed ‘flashy bimbos’ whom she perceived to be competition for her father's attention. ‘My Daddy was gorgeous. They could just stick their breasts in his face and he'd fall at their feet. How could he ever see me past them?’ Robin attributed her parent's divorce to her mother's fading attractiveness. ‘I can't really blame him for leaving her. I mean she really turned into a drudge.’
Robin related a series of relationships with men that began when she was 12 years old. She perceived a pattern wherein she would ‘fall madly in love with the perfect guy’ usually significantly older than she, until she either found someone who was even more perfect or she was caught cheating on ‘Mr Perfect.’ ‘I feel like I make a truly spiritual connection, like I have met my soul mate. I have to follow my soul don't I?’ She related how she had met a member of European royalty while working as a waitress. The gentleman was described as someone who couldn't resist her, proposed at their first meeting, and pronounced her to be ‘Baroness’ of some place in Europe. ‘We stayed together for what seemed like forever.’
She admitted that her most recent break-up had her seriously concerned because of her age and the fact that this was the first time anyone had broken up with her (‘And I wasn't even cheating on him!’), rather than the other way around. This was also the first time in her life that she had ever lived alone. Moreover, she was greatly distressed because she believed that her medical status impeded her ability to secure her next partner through the only means she could fathom, seduction. She sobbed. ‘This means that I can't ever have another relationship with a man and that I will always be alone.’
Patients such as Robin may very quickly seek the therapist's approval and work to get him or her on her side. They may have more difficulty working with same-sex clinicians if they perceive their therapists as not being able to give them what they believe they need—approval by a member of the opposite sex. They may also see a same sex therapist as a competitor. Patients such as Robin may attempt to forge a special closeness with their therapists, by, for example, asking personal questions, insisting on getting direct ‘advice,’ asking for special favors. The therapist in this situation interrupted these behaviors each time they presented in the sessions. In addition the use of a female co-therapist on occasion as a ‘consultant’ was extremely beneficial in that adding the component of trust in a same sex therapist challenged the beliefs from her family of origin regarding the powerlessness and lack of intellectual ability in women.
The structure of cognitive psychotherapy for personality disorder patients is much more complex than the treatment for patients with Axis I disorders alone. Special care must be taken to evaluate and understand the underlying schematic structures as multidimensional forces pressing on the person's cognitive, behavioral, and affective interpretation of any and all stimuli. Suggested modifications of treatment include increased focus on the therapeutic relationship, increased emphasis on developmental events, individualized variations in session structure, and utilization of specialized strategies to alter dysfunctional beliefs and compensatory behavioral strategies (J. Beck, 1998).
The full range of cognitive and behavioral techniques, as outlined by J. Beck (1995) are applicable to HPD patients. In fact, using a variety of techniques will ensure that therapy remains interesting, and therefore important to the person with HPD. As with most of their patients, cognitive therapists help HPD patients collaboratively set incremental, short-term goals, which are meaningful to the patients. Encouraging the patient to write each goal to increase commitment, reduce premature termination, and produce stronger shifts in cognition (Cialdini, 2001). Generated goals are specific, measurable behavioral tasks that serve to challenge maladaptive cognitions while progressively moving the patient closer to their long-term goals (Bordin, 1979; A. T. Beck et al., 2003). Therapists also formulate in their own minds several important goals for them to work toward with their HPD patients: learning to slow down, interrupt their impulsive behavior, and modify their global emotional reasoning style.
At each session, patients and therapists collaboratively set an agenda and orient the session toward helping patients solve their problems. Behavioral skills training and cognitive restructuring are important components of the problem-solving process. A particularly useful technique is behavioral experimentation outside of the therapy office. Using a collaborative style, the therapist and the patient design experiments to test a new behavior or cognitive response. One patient, for example, experimented with trying not to be the center of attention at a party honoring another person—and with the therapist's advanced help, was able to give herself significant credit for acting in this way. HPD patients view these experiments as opportunities to ‘act’ and to prove that they possess the information and experience required for successful completion. If the experiment is set up correctly, that is with high possibility for a positive outcome, the patient will be excited about the results and want to share their excitement in great detail.
On the other hand, some experiments, especially if they are not well planned, can fail. The HPD patient may express significant emotion toward the therapist, including anger, devastation, and embarrassment. The patient may be quick to say ‘I told you so,’ and insist that the experience is further evidence of their inadequacy and helplessness. In these situations the therapist must be prepared to use techniques to de-escalate the patient and move forward without responding defensively to the display of emotion and blame from the patient. Indeed, maintaining this stable, reliable, and flexible presence with the patient is one of the most critical techniques involved in their treatment.
It is important for the therapist to use HPD patients’ own words when summarizing or reflecting. HPD patients have heightened sensitivity and may perceive approximate statements as uncaring or lacking understanding and may take offense. However, patient wording and examples may not always be in good taste, and if therapists are uncomfortable with this language, they should sensitively address the issue. However, in most cases, it is appropriate and powerful to use the patient's language or metaphors as often as possible.
HPD patients bring the same distorted beliefs that they have about other people to the therapeutic experience. Therefore, therapists must always be aware of a potentially negative potential impact of their own behaviors with the patient. HPD patients may expect their therapists to be as equally impressionistic and intuitive as they are in the treatment, expecting the therapist to ‘read their minds’ without the patients offering the necessary objective data. They are particularly vulnerable to making false attributions of thoughts, actions, attitudes, and emotions to the therapist because of limited flexibility in their thinking and relating. These patients are frequently very sensitive to the slightest negative nuance or suggestion within the relationship, and they respond quickly and intensely when they perceive a slight, a challenge, a disagreement, or a loss. For example, if a therapist is a few minutes late for a session, the patient may think that the therapist is devaluing her, and she may become quite angry. Therefore it is essential in the process of trust establishment and maintenance that the therapist to monitor themselves and to be alert for patients’ negative reactions. When therapists notice that patients have become distressed in the session, it is important for them to elicit patients’ thinking and help them test and adaptively respond to it. Therapists can then help patients generalize what they learned from this therapeutic experience to experiences with other people outside of therapy.
Therapists must also be aware of their countertransference. They may feel inclined to unduly ‘rescue’ their distressed patients and therefore must resist the temptation to inadvertently reinforce the patient's voiced helplessness, childish pleas of incompetence, or highly sexualized style. These behaviors should be sensitively discussed and their associated underlying beliefs elicited and evaluated. It is also helpful to discuss the negative outcomes of other situations where the patient had tried to elicit rescue, parenting, or sexual responses.
Elaine was a 27-year-old woman who sought therapy for depression. She had legally changed her name to ‘Elan’, which she thought better suited her approach to life. Her presenting problem was that she stated that she said that she ‘simply loved sex’ and was ‘incredibly promiscuous’ and then ‘felt very guilty and depressed’ about her actions. She would often have sex with three different men in one evening. She reported that she would come home from work and be in her apartment and begin to feel ‘jumpy.’ This was a signal to go to a bar at about 6:00 p.m., pick a man up and come back to her apartment and have intercourse. She would then tell him that he had to leave before her roommate came home. (She had no roommate.) She would later feel terribly guilty, extremely depressed, and suicidal. She might, however, feel ‘jumpy’ once or twice more that evening and the scene would repeat itself.
She discussed with her therapist the details of her experiences. Eventually she wanted to ‘thank’ him for helping her stop her active sexual behavior and offered to have a romantic evening, with dinner and an implication of sex with him. When he asked her what it would mean to her if he accepted her offer, she responded that it would show her that he cared about her and would continue to help her. The therapist helped her recognize that her offer would actually have an opposite effect—he would no longer be able to help her therapeutically. The therapist and the patient worked together to further conceptualize her goals regarding sexual communication and behaviors, as well as the usual consequences that the behaviors resulted in for her. In order to respond in this adaptive way, the therapist had to examine and respond to his own countertransference and develop strategies to deal with it appropriately.
Psychodynamic treatment goals include the gradual uncovering of the HPD patients’ underlying conflicts and the development of insight into the highly exaggerated behavior. The primary focus of therapy is to ‘address the resistance before attempting to interpret the underlying content’ (Gabbard, 2000, p. 529). Issues of interpersonal style, family relationships, behavioral repertoire, and schema are brought out by examining current relationship situations and exploring where the patient first learned the behavior described. It has been hypothesized that HPD families of origin are high in control, highly intellectual-cultural, and low in cohesion (Baker et al., 1996). The parents in these families were most likely self-absorbed with difficulty expressing sincere, deep, and genuine emotion. If this hypothesis holds true, uncovering the schema related to the use of superficiality, every ‘man’ for himself and ‘I must be first, needed, etc.’ would assist the patient in normalizing their development and choosing a healthier alternative.
The most useful technique for uncovering these schema is the use of Socratic questioning. Using this technique early in therapy acclimates the patient to the style and encourages self-exploration. As the therapy moves forward it is much more powerful for the patient to uncover latent or inactive schema rather than the therapist providing expert intellectual interpretation that actually reinforces the family of origin dynamic. As the patient uncovers their own dynamics the experience increases the feeling of independence, reduces dependent behavior, increases the use of problem-solving skills, reduces impulsive conclusion formation, and reinforces more adaptive thinking.
Transference and countertransference are essential components of treating the HPD patient. A particularly difficult issue is dealing with erotic transference. There are several issues involved in self-monitoring of seductive or erotic countertransference issues: (1) there is the need for therapists to examine, understand, and accept their countertransference; (2) therapists must accept the erotic transference as an important element in treatment; (3) therapists must be able to accept their own sexual reactions and feelings and not exploit the patient; (4) the sexual transference has multiple meanings and each of them must be explored as a potential source of resistance; (5) the transference will be microcosmic of the patient's relationships, both past and present, and clinicians should use this information to explore the use of seduction as a means of communication, protection, and/or avoidance; (6) therapists must be tuned in to their own reactions, and not attribute all sexual feelings as emanating from the patient; and (7) the therapist must use caution when asking the patient to describe sexual situations, being careful that there is a genuine need to know the details; only when it serves to advance the therapy—and not when it is possibly a voyeuristic opportunity (Gabbard, 2000).
There are few randomized controlled trials of psychotherapy for specific personality disorders. A survey of the outcome research literature suggests that most outcome studies have been conducted on samples with different types of personality disorders represented. A recent meta-analysis (Leichsenring and Leibling, 2003) indicated that both dynamic and cognitive behavior therapies are generally effective in treating personality disorders. There are no controlled trials of HPD alone. However, HPD patients were included in a study that randomized 81 patients to an average of 40 sessions of dynamic therapy, brief adaptive therapy, or a waiting-list control (Winston et al., 1994). The patients who received dynamic therapy and brief adaptive therapy, which included some with HPD, improved significantly on all measures compared with waiting-list controls. These gains were maintained at 1.5 years follow-up. Two uncontrolled studies used some behavioral techniques in treating hysteria with some fairly positive results (Kass et al., 1972; Woolson and Swanson, 1972). Individuals with HPD who were being treated with cognitive-behavioral therapy for anxiety disorders responded better than others in the frequency of panic attacks (Turner, 1987; Chambless et al., 1992).
The person with HPD truly suffers from the consequences of their maladaptive perceptions, behaviors, and emotional lability. While these patients desire to have others perceive themselves as friendly, fun-loving, and agreeable, they have a genuine fear of rejection that plays heavy on their psyche and reinforces their desperate attempts to avoid being thought of in a negative light. These patients have a fragile sense of self-esteem that manifests in expressions of helplessness and dependency. Given these feelings of dependency and helplessness, it is imperative that the therapist maintains a collaborative style with the patient but allow them to experience and reinforce their own ability to use adaptive problem-solving techniques. These patients tend to befriend and flatter the therapist and are often difficult when they display a seductive style or make overt sexual advances to the therapist. Therapists must be adept at self-monitoring their countertransference and avoid becoming trapped by the patient into repeating dysfunctional patterns from the family of origin.
As with most patients with personality disorders, these patients generally seek therapy for reasons other than their pervasive personality style, which is seen as egosyntonic. These patients respond well to therapists who are able to maintain a stable, flexible, and dependable therapeutic relationship. The use of techniques, such as behavioral experiments, evaluation of cognitions, Socratic dialog to uncover schema related to family of origin issues, or lessons learned early in life can be very beneficial.