Living With Histrionic Personality Disorder

"I constantly seek attention and manipulate people to receive [their attention] without realizing it. It feels like I can never have enough attention," Itzel Sparrow, 18, said. "I could play the victim, start a fight, fake an episode or even threaten to self-harm for attention."

Sparrow was diagnosed with histrionic personality disorder (HPD) when he was 17 years old and confirmed his diagnosis again at 18 after his partner recommended therapy. HPD greatly affects his relationships and his day-to-day living. 

"I tend to have multiple favorite people that I obsess and center my life around," Sparrow said. "I feel emotions very intensely when I'm around these people. I have extremely paranoid delusions out of jealousy and fear when I feel like I'm losing them."

Histrionic personality disorder is part of cluster B personality disorders; others include borderline personality disorder (BPD), narcissistic personality disorder (NPD) and antisocial personality disorder (ASPD). Approximately 9 percent of the population has at least one personality disorder, while the prevalence of histrionic personality disorder is around 2 percent to 3 percent.

Although there is a greater number of individuals with HPD compared to BPD, misdiagnosis is common due to similarities in the cluster B category. However, there are different characteristics in an individual's sense of self and relationships between the two personality groups.

A diagnosis of histrionic personality disorder

Histrionic personality disorder is distinguished by patterns in behavior and physical appearance involving emotionality, impulsivity and attention. Individuals living with HPD often feel they aren't receiving enough attention. They then behave in ways that are extreme to receive attention through physical appearance, dramatic gestures and speech, manipulation and exaggeration.

Although it may seem obvious through behavior, diagnosis of the condition comes through a formal psychiatric evaluation. For an HPD diagnosis, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) states an individual must meet five or more out of the following criteria:

• Uncomfortable when they're not the center of attention.
• Seductive or provocative behavior.
• Shifting and shallow emotions.
• Use their appearance to draw attention.
• Impressionistic and vague speech.
• Dramatic or exaggerated emotions.
• Suggestible and easily influenced by others.
• Consider relationships more intimate than they are.

"By assessing a person's appearance, behavior and history, one can establish a diagnosis," said Sasha Hamdani, a board-certified psychiatrist. "As of right now, there is no genetic data or test to confirm this diagnosis. Also, due to the subjective nature of the criteria, and the fact that people's moods can appear volatile and variable during the diagnostic process, misdiagnosis is common."

Although the cause of HPD is unknown, studies indicate this personality disorder tends to be genetic, with other factors such as childhood trauma, childhood environment and parenting styles.

The differences between HPD and BPD

Histrionic personality disorder and borderline personality disorder—both classified as cluster B personality disorders—have similarities in behavior and symptoms. However, there are differences, particularly with interpersonal relationships, self-image, impulse and cognition.

The prevalence of individuals with BPD is an estimated 1.6 percent of the population—20 percent of the psychiatric inpatient population—in comparison to 2 to 3 percent of the general population with HPD.

Although individuals with borderline personality disorder experience patterns of wildly unstable and intense relationships, individuals with histrionic personality disorder emphasize a need for attention in their relationships, resulting in unstable interpersonal connections.

Individuals with HPD emphasize their physical appearance and use an exaggerated identity to receive attention, for instance, by wearing revealing, bright-colored or flamboyant styles of clothing.

Self-image and perception are important characteristics for those with HPD and BPD. Individuals with borderline personality disorder experience identity disturbance, such as a persistent unstable sense of self, much like people with histrionic personality disorder. However, individuals with HPD emphasize their physical appearance and use an exaggerated identity to receive attention, for instance, by wearing revealing, bright-colored or flamboyant styles of clothing.

Individuals with HPD may experience impulsivity like individuals with BPD. While borderline personality disorder and histrionic personality disorder are similar, BPD is characterized by an intense negative view of self as well as much more rapid and intense emotional variations than HPD.

According to studies, individuals with borderline personality disorder are more likely to receive treatment and utilize resources compared to individuals with other personality disorders. As a result, it has been much easier for BPD to be more extensively studied.

Debunking misconceptions about histrionic personality disorder 

Although HPD is diagnosed more often in women, findings reflect a greater prevalence of women in clinical settings, potentially skewing such data. Indeed, in more recent studies, the prevalence of histrionic personality disorder in men and women is similar. Because of the mirrored symptoms shared among the disorders, Hamdani said HPD is commonly mistaken for attention-deficit hyperactivity disorder (ADHD), bipolar disorder and other personality disorders.

"Primarily due to the lack of awareness about this diagnosis, symptoms are easily confused with other things," Hamandi explained. "Due to their inappropriate appearances, exaggerated behaviors and emotions, and constant craving of stimulation, their presentation may get confused for BPD, ADHD or even bipolar disorder. This can also be mistaken for narcissistic personality disorder and antisocial personality disorder due to persistent manipulative behavior to achieve their wants."

Sparrow has felt firsthand the stigma that comes with such symptoms.

'People don't know that [wanting] attention, being egoistic and dramatic are signs of mental illness. Even after realizing our actions hurt others, it takes effort to control the disorder.'

"It isn't 'Every woman on social media,' or the 'Bimbo personality disorder,'" Sparrow said. "People don't know that [wanting] attention, being egoistic and dramatic are signs of mental illness. Even after realizing our actions hurt others, it takes effort to control the disorder."

Sparrow also highlights the perception of hypersexuality and impulsivity of those living with histrionic personality disorder.

"Our hypersexuality is seen as 'hot' or 'sexy,' but in reality, it affects my everyday life and is pretty painful," he said.

Like most mental illnesses, individuals with HPD are expected to stop and change their behavior without professional assistance.

"People with HPD are not aware of their abusive behaviors," Sparrow indicates. "It isn't as easy as 'Just stop being a bad person.'"

Are there treatment options for histrionic personality disorder? 

Studies highlight the importance of receiving an accurate diagnosis to determine treatment and access available resources. Supportive psychotherapy is used for individuals with HPD to reduce emotional distress, improve self-esteem and enhance coping skills. Psychodynamic psychotherapy is also used to help individuals set goals in emotional maturity and also aims to resolve underlying issues to better behavior.

Although there are no FDA-approved medications for histrionic personality disorder, it may be treated with antidepressants, mood stabilizers and antipsychotics especially if there are other psychiatric conditions present.

"People often come for treatment secondary to a fallout in a relationship that drives them into depression," Hamdani explained. "Historically, this tends to be medication-resistant, although there is limited data showing antidepressants may help with acute episodes of low mood or mood stabilizers to help with volatility. In general, the more comprehensive and appropriate treatment is therapy and increased awareness of symptomatology."