Charles Aznavour sang: “I am a histrionist .. but the genius was born with me…”. Sometimes it happens that the theme of the ” histrionic ” does not turn into music – using the term art in the aforementioned piece of music seems excessive to me – and is included in the context of pathology.
What characterizes histrionic personality disorder , fascinating in the term but intense source of discomfort for the subjects who suffer from it and for those who have to interact with them for various reasons?
Surely in the histrionic subject at an interpersonal level an intense emotionality emerges – often “dysregulated”, a characteristic that however also belongs to many other personological problems – expressed with theatrical modalities (this element is the most characteristic of the histrionic disorder and justifies its name) and constant attempts to gain attention, approval and support from others. More or less explicit seductive conduct is used for this purpose and in any case inadequate to the context.
The histrionic type is found more frequently in the female sex but in reality it is also present among men in a non-negligible percentage: a man and a woman with histrionic disorder can respectively represent caricatures of masculinity (“machismo” and dongiovannismo) and femininity (a “femme fatale”, super-emotional and extremely refined from an aesthetic point of view).
The central nucleus of histrion , at a relational level, concerns the continuous search for being at the center of attention and extreme discomfort when this does not happen: in order to achieve the purpose of being considered and arousing the interest of the other, histrionic subjects narrate themselves by exaggerating life episodes, inventing stories that did not happen, or in any case unlikely, presented as real and coloring everything with an extreme level of theatrical or seductive dramatization. Initially the histrion can even arouse curiosity and charm in the listener.
The nuclear element of the histrionic is to focus attention on activating the interest of the other towards oneself at the expense of decoding one’s own internal experiences: one considers oneself as a function of others experiencing a sense of fragility of one’s own identity. It is precisely this fragility that the histrionic tries to mask with an emotional expressiveness that is both dramatic and fatuous, considering relationships as more intimate than they are (in reality, the difficulty consists precisely in reaching a authentic emotional intimacy). THE
Dependence on the attention of others leads the histrionic subject to be particularly sensitive to refusals and separations not decided by him. It may happen that the histrionic , in order to avoid the interruption of a relationship, may resort to extreme gestures aimed at attracting the attention of others, arriving at carrying out self-harm or demonstrative suicide attempts.
A further element that is found is the high suggestibility of these subjects: opinions and feelings can be easily influenced by the beliefs and moods of others or by impressions and enthusiasm of the moment. For example, personal interests or the pattern of values can vary according to the values and interests of the partner of the moment.
The histrionic can show himself intolerant to frustrations and subject to frequent states of boredom: for this reason he is inclined to seek immediate gratification for his own needs or stimulations of particular emotional intensity. Often those who have a histrionic disorder are intensely concerned about their physical appearance – precisely as a tool to attract attention – showing themselves particularly disturbed in case of criticism and willing to make many efforts to take care of it, up to showing symptoms of dysmorphophobia or eating disorders .
The reason for histrionic disorder is not yet known, as is the case with other personality disorders . The most likely hypothesis is that there is a concomitance of factors: from the biological point of view, a set of “innate” temperamental traits characterized by hypersensitivity and a tendency to the external search for gratifications has been observed.
From a psychosocial point of view, it is observed among people who have developed a histrionic disorder to have experienced in childhood difficulties in satisfying the legitimate needs for attention and care. In some cases the subjects have been appreciated by the parental figures for their appearance and for their skills as entertainers, rather than for their way of being, learning the idea, which will prove dysfunctional over time and a source of great suffering, which , to satisfy one’s emotional needs and formulate requests, one must employ the physical aspect and seductiveness thus behaving as a histrionist. In other situations we observe subjects who in childhood received attention and care only when sick, thus learning to seek care only through physical complaints. What follows?
The histrionicsby continuously implementing manipulative strategies, they manage to compromise their sentimental, social and professional relationships, creating the conditions for the appearance of other psychopathological pictures. Theatrical modalities can lead others to consider them superficial and inauthentic and to activate suspicious or devaluing responses. The dramatic requests for help and excessive caring, activated when there is the feeling of not being considered or having to face the difficulties of life without the desired support, can lead to the removal of people considered significant. Excessive seductiveness can be perceived by people of the same sex as a threat to their relationship as a couple and activate competitive patterns of competitiveness or distance in the relationship.histrionic subject , of little consideration and devaluation on a professional level.
As happens in personality disorders, even the histrionic is unlikely to ask for help for his disorder, of which in the vast majority of cases he is not aware of it. Treatment is often sought for mood disorders or anxiety states that arise as a result of the considerable difficulties encountered in the path of life. When these symptoms are particularly disabling, it is possible to resort to drug therapy which, however, cannot be separated from psychotherapeutic treatment.
In the field of cognitive-behavioral therapy, some treatment programs for personality disorders have been developed. Beck and Freeman’s model focuses on recognizing and questioning dysfunctional beliefs about oneself, others and the world. These beliefs would be generated by distortions of reality (cognitive distortions) and would constitute cognitive schemes (basic cognitive structures that allow us to organize experience and behavior).
In the case of histrionic disorder therapy , the patient is helped to identify their emotions, thoughts and events to which they are related, hypothesizing a difficulty of the subject in carrying out these operations. This work, together with the evaluation of the consequences of their actions, would help the patient to lower their dysfunctional impulsivity. In a second moment, the therapist collaborates with the patient in order to analyze and modify the central dysfunctional beliefs such as: “I am unable to manage my life”, “You have value if you are loved by everyone”, “Losing a relationship is a drama for which there is no remedy ”.
The belief that they are unable to take care of themselves would lead the histrionic subject to constantly seek attention and care from others. Believing that the interruption of an emotional relationship can be disastrous would push histrionic people not to end unsatisfactory and inauthentic relationships, fueling the sense of inability to do it alone and the feeling of inauthenticity. We try to change these beliefs by employing different techniques including imaginative techniques, behavioral experiments, assertiveness or problem solving exercises that improve the patient’s sense of self-efficacy.
The therapeutic process is implemented through a collaborative empiricism in which it is the patient himself who gradually identifies and learns to satisfy his own needs in a more functional way, rather than waiting for others to do it or for an idealized therapist to do it as a saving and omnipotent.
In some histrionic subjects the integration of Beck and Freeman therapy with social skills training aimed at modulating emotions and impulsive behaviors and improving empathic skills by training the focus of the histrionic subject on emotions and needs has proved effective of the other.
Jeffrey Young’s schema-focused therapy is a treatment that integrates the cognitive-behavioral approach with object relations and Gestalt approaches. According to this approach, dysfunctional patterns “emotional deprivation” (belief that other people will not provide the emotional support they need), “imperfection” (belief that they are imperfect) would be active in the patient with histrionic personality disorder , inadequate, unpleasant and inferior to others) and “seeking approval” (belief that one must always try to be accepted, sacrificing the real sense of self). The identification and modification of these patterns is the aim of the therapy.
As always, reading the intervention protocols is different from treating histrionic disorder , a term that appears “light” in the range of psychopathological nomenclature: in reality it is a difficult disorder to treat precisely because the inauthenticity of relationships brings the patient not to build a valid therapeutic alliance and the therapist to experience feelings of poor tolerance of the case.
I would conclude by telling patients not to despair of receiving a valid form of help, which takes time but is possible, and for future therapists to invest in valid professional training. I can only ask experienced therapists for advice on how to approach the histrionic patient .
