HISTRIONIC PERSONALITY DISORDER A pervasive pattern of instability of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts: -Uncomfortable when not the centre of attention -Inappropriately seductive or provocative behaviour with others -Rapidly shifting and shallow expression of emotions -Always uses physical appearance to draw attention to self -Style of speech is excessively impressionistic but lacking in detail -Self-dramatization, theatricality, and exaggerated expression of emotion -Suggestible -Considers relationships to be more intimate than they actually are Associated with higher rates of somatic symptom disorder, conversion disorder (functional neurological symptom disorder), and major depressive disorder. Co-occurrence of BPD, NPD, ASPD and dependent personality disorder is also possible. Onset can be as early as childhood with greater risk for those experiencing childhood pervasive trauma. Can also be a product of social environment whereby person was reinforced to develop histrionic personality

OTHER ASSOCIATED FEATURES SUPPORTING THE DIAGNOSIS OF HPD Difficulty achieving emotional intimacy in romantic or sexual relationships with tendency to act out a role with others. Seek to control their partner through emotional manipulation or seductiveness on one level, while displaying a marked dependency on them at another level Impaired relationships with same-sex friends. Also tend to alienate friends with demands for constant attention. Easily bored and frustrated when there is delay of gratification Increased risk for suicidal gestures and threats to get attention and coerce better caregiving National Epidemiologic Survey on Alcohol and Related Conditions suggest prevalence of 1.84% Cultural factors important to be considered when making diagnosis Some studies indicate equal prevalence in male and females. In clinical settings however, diagnosis were made for mostly females

ETIOLOGY OF HISTRIONIC PERSONALITY DISORDER Psychoanalytic theory  Emotional displays and seductiveness result from parental seductiveness  Father’s sexual attention towards daughter  Conflicting family attitudes towards sexuality  Negative attitudes towards sex while simultaneously acknowledging titillation Theory untested due to difficulty in empiricising psychoanalytic theory Question posited in academic knowledge of HPD:  Is histrionic personality a sex-typed variant of antisocial personality?

DIFFERENTIAL DIAGNOSIS FOR HPD Personality change due to another medical condition Traits that emerge are attributable to the effects of another medical condition on the central nervous system To be distinguished from actual HPD Other personality disorders and personality traits Must be vigilant in observing criteria met for other personality disorders HPD can be similar to BPD, NPD, ASPD, dependent personality disorder, in some characteristics Must not be confused with histrionic traits as the disorder is persistent, maladaptive, inflexible and causes significant impairment to the person Substance use disorders BPD symptoms should be distinguished from symptoms that arise from substance use that is persistent

MNEMONIC FOR HPD – PRAISE ME P - provocative (or seductive) behavior R - relationships, considered more intimate than they are A - attention, must be at center of I - influenced easily S - speech (style) - wants to impress, lacks detail E - emotional lability, shallowness M - made-up (physical appearance get attention) E - exaggerated emotions (theatrical)

TREATMENTS FOR HPD Psychodynamic therapy – clarify symptoms, modify defensive processes to modify behaviour and relationship management Cognitive behaviour therapy - help people with BPD recognize and change both their beliefs and the ways they act that reflect inaccurate or negative opinions of themselves and others Medication - no drugs have actually been specified for the treatment of borderline personality disorder. But to alleviate symptoms, patients may be treated with antidepressants if depression is present. Pharmacological treatment is also considered necessary if HPD is in occurrence with other disorders Group psychotherapy - symptom reduction using a therapeutic community Family therapy Meditation/hypnosis

CASE STUDY Scott seeks attention every opportunity he gets - interferes with his ability to function in his job as manager Interrupts his subordinates from working to discuss his personal life - interferes with the overall productivity of the office. Wants to be more of a close friend and even family member, to the dismay of his subordinates. This Expectation of a close bond leads Scott to display rapidly shifting emotions, from exuberant and hopeful, to depressed and hopeless Feels as if the entire office should be focused on his problem and that others’ problems pale in comparison, such as his birthday being of more importance than a coworkers cancer scare. Easily suggestible and is often the victim of pyramid schemes and persuasive coworkers. Shows a pattern of theatric behavior, including different characters, voices, and personalities, in which he uses as distractions on a daily basis. MICHAEL SCOTT (The Office – TV Series)

NARCISSISTIC PERSONALITY DISORDER A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts: -Grandiose sense of self-importance -Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love -Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). -Wants excessive admiration from others -Sense of entitlement -Interpersonally exploitative -Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others -Is often jealous of others or believes others are jealous of him/her -Displays arrogance and haughtiness Very sensitive to criticism or defeat Impaired interpersonal relationships Sometimes avoid participating in events that may diminish their achievement or in which defeat is highly possible

OTHER ASSOCIATED FEATURES SUPPORTING THE DIAGNOSIS OF NPD Associated with social withdrawal, depressed mood, and persistent depressive disorder (dysthymia) or major depressive disorder in times of sustained feelings of shame or humiliation Sustained periods of grandiosity may also be associated with a hypomanic mood Can also be associated with HPD, BPD, ASPD and paranoid personality disorders Also associated with anorexia nervosa and substance use disorders

Development - Particularly common in adolescents- - May not necessarily continue as such - NPD individuals will have special difficulties due to the disorder as they grow older Prevalence -Based on DSM-IV definitions, range from 0% to 6.2% in community samples - Of those diagnosed, 50%-75% are male

DIFFERENTIAL DIAGNOSIS FOR NPD Mania or hypomania Grandiosity may emerge as part of manic or hypomanic episodes To be distinguished from actual NPD by examining other criteria in the person Other personality disorders and personality traits The most useful feature in discriminating NPD from HPD, ASPD, and BPD is the grandiosity characteristic of NPD Relative stability of self-image as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns also help distinguish NPD from BPD Excessive pride in achievements, a relative lack of emotional display, and disdain for others' sensitivities distinguish from HPD NPD does not necessarily include characteristics of impulsivity, aggression, and deceit while emphasizes on attention that is admiring from others Different from OCD as OCD relies on self-criticism while NPD focuses on self- perfection Does not have suspiciousness or social withdrawal like in paranoid or schizotypal personality disorder Not to be confused with the traits of high-achieving people Substance use disorders NPD symptoms should be distinguished from symptoms that arise from substance use that is persistent

ETIOLOGY OF NPD Kohut’s Self-Psychology Model  Characteristics mask low self-esteem  In childhood, narcissist valued as a means to increase parent’s own self-esteem  Not valued for his or her own competency and self worth  People with high levels of narcissism report cold parents who overemphasized child’s achievement Social cognitive model  Narcissist has low self esteem  Sense of self depends on “winning”  Interpersonal relationships are a way to bolster sagging self esteem rather than increase closeness to others  Lab studies reveal cognitive biases that maintain narcissism

MNEMONIC FOR NPD - SPECIAL S – Special (believes they are) P – Preoccupied with fantasies of success, etc E 3 – Envious (of others), Entitled, Excessive admiration needed C -- Conceited I -- Interpersonally Exploitive A -- Arrogant L -- Lacks Empathy

TREATMENTS FOR NPD Brief hospitalization– for NPD patients who are quite impulsive or self-destructive, or who have poor reality-testing Cognitive-behavioral therapy or schema-focused therapy- repairing narcissistic schemas and the defective moods and coping styles associated with them. Encourages patients to confront narcissistic cognitive distortions. Psychoanalytic psychotherapy- actively interpret the patient’s narcissistic defenses while at the same time illuminating the patient’s negative transferences through direct confrontation Medication - no psychiatric medications are specifically approved for the treatment of NPD. Medications that may be considered include antidepressants (specifically, selective serotonin reuptake inhibitors [SSRIs]), antipsychotics, and mood stabilizers. Group psychotherapy - long-term group therapy can benefit patients with narcissism by providing them with a safe haven in which they can explore boundaries, receive and accept feedback, develop trust, and increase self-awareness

CASE STUDY Feels she is not receiving the attention and recognition she feels she deserves. Has desire to be "worshipped," and adored. Feels she is entitled to special treatment and when this fails to occur within her career or social life, she becomes explosive and stubborn. Seems to have no empathy regarding others, and on the rare occasions empathy is displayed by Jenna, it is not genuine empathy, but a means to an end. Severely jealous of her co-star in her current television series, and is constantly looking for ways to undermine him. Dreams of unparalleled success and believes she is the most beautiful, talented woman to grace this planet. Rest of society fails to agree with her assessment of herself, and this causes much frustration for Jenna. Reacts very unfavourably to even the slightest criticism, as she believes herself to be perfect and unique. JENNA MARONEY 30 Rock (TV Series)