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Introduction

Histrionic personality disorder (HPD) is a chronic, enduring psychiatric condition characterized by a consistent pattern of pervasive attention-seeking behaviors and exaggerated emotional displays. The condition is usually life-long and treatment-resistant, with onset typically in late adolescence or early adulthood. Individuals with HPD are often described as seductive, self-indulgent, flirtatious, dramatic, extroverted, and animated.[1] They may feel underappreciated or disregarded when they are not the center of attention.[2] Individuals with HPD can be vibrant, enchanting, overly seductive, or inappropriately sexual.[3] They may typically demonstrate rapidly shifting and shallow emotions that others may perceive as insincere.

The roots of histrionic behavior can be traced back to ancient times when Greek and Roman physicians observed individuals who displayed excessive theatricality and emotional expression. These individuals were described as “hysterical”—a term derived from the Greek word “hystera,” meaning uterus—as these behaviors were believed to be exclusive to women and were caused by disturbances in the uterus.[4] In the late 19th century, during the era of psychoanalysis, Sigmund Freud contributed to the understanding of histrionic behavior. He proposed the concept of “hysteria” as a psychological disorder primarily affecting women and characterized by emotional excesses and attention-seeking behavior. Freud’s theories, although controversial and often criticized, laid the groundwork for the exploration of histrionic symptoms and behaviors.[5]

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HPD was formally recognized as a distinct diagnostic category in the mid-20th century. In 1980, the Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (DSM-III) included HPD as a diagnosable condition. The DSM-III identified key criteria, including a pervasive pattern of excessive emotionality, a need for attention, and exaggerated behaviors. Since its inclusion in the DSM-III, HPD criteria have undergone refinements in subsequent editions. The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV, 1994) and the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision (DSM-IV-TR, 2000) maintained the core diagnostic criteria, emphasizing attention-seeking behavior and self-dramatization, while also considering cultural context and gender differences. HPD is still recognized as a distinct diagnosis in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Text Revision (DSM-5-TR, 2022).

Clusters of Personality Disorders in DSM-5-TR

The DSM-5-TR divides personality disorders into clusters A, B, and C, each encompassing a distinct set of personality disorders with commonalities regarding symptoms, behaviors, and underlying psychological patterns.[6][7]

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Cluster A: Cluster A encompasses personality disorders with odd or eccentric characteristics. These include paranoid, schizoid, and schizotypal personality disorders. Individuals within this cluster exhibit social withdrawal, mistrust, and difficulties forming close relationships.[8]

Cluster B: Cluster B encompasses personality disorders with dramatic, emotional, or erratic behaviors. This cluster includes HPD along with antisocial, borderline, and narcissistic personality disorders. Individuals within this cluster typically display impulsive actions, emotional instability, and challenges in maintaining stable relationships.[9]

Cluster C: Cluster C encompasses personality disorders with anxious and fearful characteristics. These include avoidant, dependent, and obsessive-compulsive personality disorders. Individuals within this cluster tend to experience significant anxiety, fear of abandonment, and an excessive need for control or perfectionism.[10] Despite the historical context of using the “cluster” system, limitations exist when approaching personality disorders.[11] While the diagnosis of HPD provides a framework for understanding and studying these behaviors, ongoing debates in psychology and psychiatry revolve around the nature and validity of personality disorders, including HPD. Our understanding of histrionic traits and behaviors continues to evolve.[12]

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