It is not unusual for histrionic personality disorder to pass within a family. However, it is not clear whether histrionic tendencies are genetically inherited or the result of family modeling. The individual may have inborn temperamental traits that may make them more vulnerable to developing histrionic traits, as other traits may make others more vulnerable to developing other personality disorder traits. “Researchers have found that histrionic adults tended to display a high degree of vacillating or erratic emotions from infancy and early childhood. They are also more likely to be hyper responsive and to look to others for gratification from the time they are quite young. This suggests some physiological predisposition to a hysterical style. These inborn tendencies alone, however, are insufficient to cause someone to develop a Histrionic Personality Disorder” (Hanson, 2012). The individual’s sense of self and profound exaggerated need to be the focus of others is strongly impacted by the early developmental experiences within the original family community. Histrionic parents are often erratic and dramatic raising children, which may promote second-generation histrionic tendencies (OutoftheFog.net, 2012). “Discussion of the family-of-origin patterns and their impact on the couple’s relationship can be quite useful to the couple by helping them understand the specific learned patterns they have acquired. This is often beyond each partner’s conscious awareness and helps them realize how much their relational problem is not of their making, although they can still take responsibility for it” (Sperry, 2004, page 158).
Sperry and Maniacci (1998) describe a histrionic partner as a girl that came from a family dynamic with a cold and masochistic mother. The mother resents being a mother and a woman “so much so that she overindulged her daughter as compensation for not being able to love and nurture her. Her father was described as charming, indulgent, and seductive at times, while controlling and rejecting at other times. The end result was that the histrionic girl-in-training came to believe that her father loves her more than he loved his wife. Thus, she learned to get her own way by playing each parent against the other by being coy, seductive, pretending she was ill, or having temper tantrums. Adulthood for the histrionic female became a search for a strong idealized father-husband who would take care of her” (Goldberg, 1975; Martin & Bird, 1959) (page 187-88). Hanson (2012) discussed a specific parenting style that potentially promotes histrionic personality disorder. The process of reciprocity becomes distorted, when an important person such as the parent expresses the reward of attention for some specific behavior. The child learns to discover ways to get approval. This is a relatively normal process within parent-child relationships, but “when a child with an especially strong inborn sensitivity to others grows up in a home with a constant diet of these messages, he or she can become programmed for the excessive search for attention that influences the development of histrionic personalities.” Love and approval are highly conditional. Attention and affection are the rewards for pleasing parents, but being ignored or punished are the consequences for disappointing them.
Hanson described, “Christy, for example, described her family of origin as ‘the perfect family.’ But her counselor noticed that she emphasized the praise she received when she performed for her parents in social settings in contrast to their general lack of attention and support in any other area of life.” Inconsistent discipline along with rewarding attention seeking behavior can also promote histrionic traits. Inconsistent responses absolve the child from having to take responsibility and consider missteps and how others are affected negatively. The attention seeking behavior, on the other hand is rewarded with praise and attention. The child is noticed and subsequently feels valued and loved not for his or her intrinsic worth or inherent qualities, but for what he or she does. The better and more frequent the performance the better and more frequent is the attention. The child does not feel loved and often feels empty. Unable to get unconditional love, the child becomes driven to seek opportunities to gain approval and attention as the best he or she can do. “This shift from feeling good about being ones true self to trying to become what others want in order to be loved is a life altering movement. People with a healthy sense of self have a strong inner sense of who they are, what they like and dislike, and their values and commitments. They value other's opinions but they aren't at the mercy of them. They have a realistic understanding of themselves and know their strengths and weaknesses. These people can enter into deep relationships and make lasting commitments, but they can also be alone without feeling anxious and abandoned.”
When someone is left with such an unhealthy sense of self, he or she gets out of tune with his or her actual emotions, needs, values, and likes and dislikes. “They become dependant on others, constantly search for attention, or engage in work or other activities to shore up their shaky self-esteem since they are unable to sit even briefly with their uncomfortable feelings. This discomfort is what drives the histrionic person to constantly seek attention” (Hanson, 2012). The therapist can explore with Hunter or Xandes their family experiences to see if these dynamics occurred. Unfortunately, as with many histrionics, the individual may not be willing to consider or able to be introspective sufficiently for this to happen. Instead, Hunter or Xandes is more likely to tell some cute story about a dance recital or the like. If asked if her behavior is coy with a current partner as the “strong idealized father-husband,” she is unlikely to see it and more prone again to divert with some other story. If the histrionic instincts are not too powerful or manifested around some other traits, the therapist can help the individual examine how his or her behavior became compulsive, how the partner is a foil in his or her psychodynamic drama, and then, to adapt their interactions productively.
CULTURE , GENDER, AND HISTRIONICS
If Hunter or Xandes were men instead of women would their behavior be more socially acceptable? Or, would they be seen as manifesting somewhat extreme but not out of bounds male behavior? There are also other cultural differences, which may contribute to a higher prevalence of this diagnosis. Gay men have been diagnosed as histrionic, although their behavior is considered an expression prevalent or acceptable in their culture. The set of behaviors constitutes a norm of behavior within their community (Hempstead, 2009). Would that mean that if Hunter or Xandes were gay men instead of straight women, that they would be seen as a relatively normal subset of the homosexual population community? On a blog (Gothamwhore.blogspot.com, posted 2-3-07) was a post titled “Gay Personality Disorder.” The writer commented on finding very interesting a posting on Wikipedia on Histrionic Personality Disorder. It was a common professional description of the disorder.
"In psychiatry, histrionic personality disorder (HPD), or hysterical personality disorder, is a personality disorder which involves a pattern of excessive emotional expression and attention-seeking, including an excessive need for approval and inappropriate seductiveness, that usually begins in early adulthood. The essential feature of the histrionic personality disorder is a pervasive and excessive pattern of emotionality and attention-seeking behavior. These individuals are lively, dramatic, enthusiastic, and flirtatious. They may be inappropriately sexually provocative, express strong emotions with an impressionistic style, and be easily influenced by others." The writer follows with a provocative and perhaps, devastating sarcastic comment. “Hi. Thanks for describing almost every gay man I know. Well, in particular, every gay slashie I know. That's an actor /slash/ singer /slash/ dancer /slash/ model /slash/ waiter. A pentuple-threat! Or no threat at all, depending on your perspective.” The cultural norms of the gay community would cause their behavior that is considered pathological in the straight world, to be more or less acceptable within a range of normal expression in the LGBT world. Further implications abound. Heterosexual couple therapy versus male homosexual couple therapy with a partner with this pattern of behaviors may be fundamentally conceptualized differently. And what about a female homosexual- lesbian couple that includes such a partner? The therapist may avoid a pathology dilemma (to pathologize or not to pathologize?) by examining family-of-origin along with various cultural influences (including straight or gay culture). Then therapy would address the functionality of the behaviors (histrionic, flamboyant, charming, or “gay”) in the couple's relationship. The therapist can avoid the therapeutic traps of cultural determinism (“that’s how it, I am”) and cultural relativism (“you cannot understand because you’re not me- it’s relative to my distinct cultural experience”) by focusing on how the pattern of behaviors work or do not work for intimacy, trust, and the partnership. “So, how does that work for you? In the relationship?”
HISTRIONIC OR NARCISSISTIC PERSONALITY DISORDER AND GENDER
Since Xandes and Hunter are heterosexual women, the therapist should be aware of social expectations and acceptance of gender-based patterns of behavior. As it is with dependent personality disorder, the professional assumption is that histrionic personality will be seen more often in women. Women are four times more likely to receive this diagnosis than in men. On the other hand, narcissistic personality disorder is diagnosed more often in men than women. However, narcissistic personality disorder shares many diagnostic similarities with histrionic personality disorder. “This has led to some theories that Histrionic Personality Disorder is just a feminine manifestation of Narcissistic Personality Disorder” (OutoftheFog.net, 2012). While narcissistic personality disorder is a psychological pathology, narcissism is often tolerated and admired in success personalities- especially male personalities in the arts, sports, politics, and business. Whether or not flamboyance and charm is accompanied by performance and skills that serve some bottom line productivity may be a more perceptive delineation between narcissism and histrionics. While some narcissists may be as compulsive about being the center of attention, they often offer some substantial reward in terms of finance, status, power, or other quantifiable benefit to others. Histrionics however only offer transitory entertainment or superficial ego boost that eventually costs to sustain or retain, rather than reward others.
A major percentage of colleagues, subordinates, superiors, and partners or spouses of both narcissists and histrionics eventually find both their patterns of behavior disturbing and disrespectful. They are often punished being in a relationship with them. However, in relationships with the narcissistic the cost is more likely to be considered worthwhile because of tangible rewards. Thus, vulnerability to coveting rewards or a lack of other options for otherwise psychologically healthy individuals may cause them to excuse mistreatment and stay in the relationship. On the other hand, the lack of tangible rewards and the availability of more fulfilling relationship options for individuals would empower them to cast aside the temporary blindness caused by histrionic charm to terminate the relationship. Or, separation happens when the shame and self-loathing of being dismissed becomes greater in balance against the reflected aura of histrionic energy. Male narcissism often fits well in gender politics or the social or cultural dynamics of power, domination, manipulation, and control. Historical patterns and models have been supported for men to use a variety of skills: intellectual, physical, creative, and relational to gain and hold power and control. These skills can and have sometimes evolved or moved into the realm of narcissism. Men who did not risk narcissistic behavior often risked failing to gain or hold power and control- perhaps, failing as in the male role as expected by society and culture. Women however who exercised such skills crossed into male territory, often at substantial risk to being punished as un-feminine. Women on the other hand have been guided to gain influence over the men who have gained and hold power and control, rather than seeking power and control directly. Gaining influence through performance has can evolve or move for women into the realm of histrionics. Men who are similarly extravagant while unsubstantial would be dismissed as lightweights, cultural misfits, or perversions of the male gender role. They would more likely also be punished socially and economically. Greater probability of men diagnosed with narcissistic personality disorder and of women diagnosed with dependent personality disorder or histrionic personality disorder may have less to do with innate gender differences but with social guidance and sanctions towards and against specific gender roles.
Yet, despite greater and lesser tolerance of stereotypical behavior by gender, “the common stereotypes usually associated with histrionic personality, e.g., flirtatious, bubble-headed females or Don Juan-like and macho males are not borne out in clinical practice or in research studies. Although women may be diagnosed with histrionic personality disorder more than males, ‘the sex ratio is not significantly different than the sex ratio of females within the respective clinical setting’ (American Psychiatric Association, 2000, p.712, represented with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, copyright 2000 American Psychiatric Association). Furthermore, cultural norms vary widely regarding emotionality, impressionability, and charm, such that histrionic behavior may be more common in some cultures, among both men and women, than in others. For example, Hispanics tend to be more emotionally expressive that the British (McGoldrick, 1998). With regard to obsessive-compulsive personality disorder, the disorder appears to be diagnosed about twice as often among men (American Psychiatric Association, 2000). However, certain obsessive traits, such as being hard working, punctual, and attentive to detail are noted as often among professional women as among professional men. Perhaps, the changing gender roles resulting in women becoming more empowered and having new options for recognition and attention is part of the reason behind the apparent decline in the number of histrionic-obsessive couples noted in the clinical practice today… In Western culture, the female partner is stereotypically more emotional and males are stereotypically more controlled” (Sperry, 2004, page 170-71). With conflicting research and social/cultural findings, the therapist therefore must consider individuals and the couple carefully while being cognizant of cultural and personal stereotyping that may influence diagnosis and subsequently, treatment.