Histrionic personality disorder

Personality disorders are enduring patterns of thinking, feeling and relating to others that differ markedly from cultural expectations, are inflexible and cause significant difficulties. They usually become noticeable by early adulthood.

In histrionic personality disorder, a person may feel uncomfortable when they're not the center of attention and may use dramatic expression, appearance or behavior to draw others in. Emotions can seem intense but shift quickly. Relationships may feel very close at first but turn out to be less intimate than the person believes.

HPD is part of a group of personality disorders sometimes described as "dramatic, emotional or erratic," which also includes borderline and narcissistic personality disorders. These conditions can overlap.

Having histrionic traits, such as being expressive, sociable or enjoying attention, is not the same as having a disorder. Many outgoing people have a dramatic personality without any clinical problem. A diagnosis applies only when these patterns are pervasive, rigid and cause real distress or impairment, and it should only be made by a qualified professional.

Signs of histrionic personality disorder may include:

• Feeling uncomfortable or unappreciated when not the center of attention
• Attention seeking behavior, such as dramatic stories, emotional displays or provocative behavior
• Rapidly shifting and sometimes shallow-seeming emotions
• Using physical appearance to draw attention
• Speech that is impressionistic and lacking in detail
• Theatrical or exaggerated expression of emotion
• Being easily influenced by others or by circumstances
• Believing relationships are more intimate than they are

People with HPD may also experience frustration when they don't receive attention, difficulty with delayed gratification and a tendency to seek novelty and excitement. Underneath, many feel insecure, lonely or worried about being overlooked.

These traits can strain friendships, romantic relationships and work. Because the label "histrionic" is sometimes used casually or dismissively, it's important to remember that people with this condition are often struggling.

The exact causes of histrionic personality disorder aren't fully understood. Like other personality disorders, it likely results from a combination of factors:

• Temperament and genetic influences, such as a tendency toward emotional intensity
• Early relationships in which attention or approval felt unpredictable or conditional
• Childhood experiences of neglect, trauma or inconsistent caregiving
• Learning that dramatic behavior was the most reliable way to get needs met
• Cultural and social factors that shape how emotions and attention are valued

Patterns that develop in childhood often make sense as a way of coping with an environment. In adulthood, they can become rigid and cause problems even when circumstances change.

HPD is thought to be diagnosed more often in women, although some researchers suggest this may partly reflect how symptoms are perceived and assessed. It can occur alongside depression, anxiety, other personality disorders and substance use.

HPD shares features with other personality disorders, and they can co-occur.

Borderline personality disorder involves intense emotions and unstable relationships, but it is typically marked by a strong fear of abandonment, unstable sense of self, impulsivity and, for some, self-harm or suicidal behavior. Emotional dysregulation in borderline personality disorder tends to involve more pain and inner turmoil.

Narcissistic personality disorder also involves a need for attention, but it centers on admiration, a sense of superiority or entitlement and difficulty with empathy. People with HPD may be more concerned with being noticed and liked than with being seen as superior.

Because these conditions overlap and can be stigmatized, a careful assessment by a clinical psychologist or psychiatrist is important. The aim is not to apply a label, but to understand what drives the person's difficulties and what will help.

People with HPD often seek help for other reasons, such as depression, anxiety, relationship problems or a crisis. Therapy is the main form of treatment.

Approaches that may help include:

• Psychodynamic therapy, exploring underlying needs, feelings and relationship patterns
• Cognitive behavioral therapy (CBT), identifying and changing beliefs such as "I'm worthless unless people notice me"
• Schema therapy, addressing long-standing patterns rooted in early experiences
• Dialectical behavior therapy (DBT) skills, for emotional dysregulation and impulsivity
• Group therapy, which can offer real-time feedback in relationships

Therapy works best when it builds a stable, trusting relationship and focuses on the person's goals, such as more satisfying relationships or less emotional distress. There is no medication specifically for HPD, but a psychiatrist may treat co-occurring depression or anxiety.

A clinical psychologist, psychiatrist or psychologist with experience in personality disorders can provide assessment and treatment. At a first appointment, you'll be asked about your relationships, emotions, history and what brought you in. A diagnosis is usually made over time, not in a single conversation.

Change is possible. Many people learn to understand their emotions, communicate needs more directly and build relationships that feel more secure. Family members and partners can also benefit from support, both to understand the condition and to set healthy boundaries.

If you or someone close to you is in emotional crisis or having thoughts of self-harm or suicide, seek help right away: call or text 988 in the US, call Samaritans on 116 123 in the UK and Ireland, or call 911 or your local emergency number.