From “hysteria” to histrionic personality disorder

Historically, what we now call HPD belongs to the long history of hysteria, gradually recoded into personality categories over the twentieth century. The disorder appears as a specific entity in the DSM-III, in 1980.

The DSM describes it as an enduring pattern of excessive emotionality and attention-seeking, beginning in adulthood and present across contexts. The criteria include, in particular:

• discomfort when the person is not the centre of attention;
• interactions often marked by seductiveness or provocation;
• shifting emotions perceived as shallow;
• the use of appearance to draw attention;
• speech that is highly subjective and emphatic, yet short on detail;
• theatricality or dramatisation of affect;
• marked suggestibility;
• a tendency to consider relationships more intimate than they are.

These criteria do not describe an “essence” of the person, but a relational style that becomes problematic when it makes interactions rigid, narrows the options and generates suffering.

Prevalence, comorbidities and life trajectories

Epidemiological studies place the prevalence of HPD in the general population at around 1 to 3%, with several pieces of work converging on an estimate of roughly 1.8% over a lifetime.

Clinically, the following are frequently found:

• mood disorders: major depressive episodes, anxiety;
• somatic or somatoform disorders: chronic pain, multiple physical complaints;
• addictions, notably to substances.

Several studies also show over-use of healthcare: frequent visits to the doctor or to A&E, repeated consultations, sometimes with a sense of mutual incomprehension between patient and clinician.

A category shaped by gender: bias and controversy

HPD is one of the diagnoses most criticised for its gender bias. Early experimental work showed that, given an identical clinical description, clinicians were more inclined to diagnose “histrionic” in a woman and “antisocial” in a man.

Other work and feminist analyses have pointed out that several HPD criteria closely resemble stereotypes of “excessive” femininity: seductiveness, emotional expressiveness, concern with appearance. Yet population studies suggest that, when assessment is carried out systematically, the gap between men and women is far less marked, and even absent in some samples.

For practice, this calls for wariness of the temptation to pathologise normative feminine behaviour, and for one uncomfortable question:

• Is what I find “excessive” in this person genuinely dysfunctional, or simply out of step with my own gender norms?

A systemic reading: the relationship as stage and as regulator

From a systemic standpoint, HPD makes a great deal of sense if we consider that the other person — partner, family, group — becomes an external regulator of emotions. The “need to be at the centre” is not only a demand for admiration: it is often an attempt to feel that one exists, is safe, is regulated.

The work of Babl and colleagues (2023), who followed 159 patients with HPD in clarification-oriented psychotherapy, shows just how central relational processes — the quality of the patient-therapist relationship, mutual adjustments — are to the evolution of symptoms.

Clinically, loops of this kind are found:

1. The person intensifies emotional expression, seductiveness or “drama” in order to elicit closeness or reassurance.
2. Those around them respond, at least at first, with attention, care, sometimes admiration.
3. Through repetition, that intensity becomes exhausting for the partner, the family or the care team, who end up withdrawing or armouring themselves.
4. This withdrawal is experienced as confirmation of “not mattering”, of not being loved, which revives the need to capture attention — often with even greater intensity.

Body, somatisation and the silent call

Several studies report a high association between histrionic traits and somatoform symptoms: chronic pain, multiple complaints, repeated consultations with no clear organic explanation.

What is interesting, from a systemic perspective, is that the bodily symptom can become a legitimate vehicle for attention, especially in contexts where direct emotional expression is poorly tolerated. And that, if it is reinforced by responses heavily focused on illness — care, worry, increased availability — it can become part of relational loops in which the body “speaks” what cannot be said otherwise.

This obviously does not mean that people “invent” their symptoms, but that the relational and cultural context weighs on the way suffering finds expression.

Bringing in the system: couple, family, institutions

Current models of systemic therapy and of couple and family therapy remind us that personality disorders are also disorders of interaction. Involving the system makes it possible:

• to make the feedback loops visible — the more one dramatises, the more the other withdraws;
• to support the partner or the family so that they can step out of the positions of rescuer, of over-adaptation or, conversely, of outright rejection;
• to co-construct other ways of saying “I need you” than crisis, seductiveness or the bodily symptom.

In closing: moving the spotlight

Histrionic personality disorder is less the story of a “fake” or “manipulative” person than that of an externalised apparatus of affective regulation, often built in contexts where the attention of others was scarce, conditional, or obtained at the price of a performance.

The current scientific data:

• confirm the existence of a subgroup of patients with this style of functioning, associated with real suffering and frequent recourse to healthcare;
• highlight significant gender bias in the diagnosis;
• suggest that the most promising approaches are those that combine work on schemas, relational processes and, ideally, involvement of the system: couple, family, institution.

Staying on the side of understanding interactions, rather than moral judgement, not only allows us to support these people better; it also gives back to those close to them — partners, families, teams — a capacity to act: changing the dance, rather than designating one dancer as “the problem”.

This shift of the spotlight is taken up and illustrated in the video below — in French.