Histrionic Personality Disorder in Children and Teenagers

The American Psychiatric Association (APA) defines Histrionic Personality Disorder (HPD) as a personality disorder characterized by a pattern of excessive attention seeking emotions, including an excessive need for approval and inappropriate seductive behaviour. Many teenagers experience emotional outbursts, overreact to things, seek attention, dress inappropriately, and engage in risky behaviours; however, these teen histrionic behaviours are not the same as HPD.

Teenagers with HPD lack a sense of self and self worth and constantly need the approval of others. If the teen is not the focus of attention, he/she will feel unappreciated and will do whatever is necessary to be the centre of attention, even if it means using extreme and inappropriate behaviours. Those with HPD are said to be lively, dramatic, vivacious, enthusiastic, and self centred.

Causes of HPD

Whilst there is no direct cause of HPD, it is thought to be due to one of the three factors:

  • Genetic – children of parents with HPD have a slightly higher risk of developing the disorder
  • Neurochemical – research has found that those diagnosed with HPD have highly responsive noradrenergic systems which is responsible for synthesis, storage and release of a neurotransmitter norepinephrine. High levels of norepinephrine leads to anxiety proneness, dependency and high sociability.
  • Environmental – think ACEs. Children/teenagers who experienced severe childhood trauma such as abuse, neglect and/or abandonment are at an increased risk of developing HPD. For example, lack of caregiver attention can lead child/teenager to develop strategies of attention seeking and shallow interaction

Of interest, more females (65 percent) are diagnosed with HPD compared to males (35 percent) and HPD is diagnosed more frequently in Hispanic and Latin American cultures and less frequently in Asian cultures.

Diagnosis of HPD

Whilst the symptoms of HPD, do not fully develop until age 15 years old, it is highly likely that parents, family, teachers would have observed many of these traits well before the age of 15. For a diagnosis of HPD in a teenager, he/she must have five or more specific character traits present for at least one year. The mnemonic PRAISE ME succinctly breaks down these symptoms/character traits:

  • Provocative, seductive behaviour
  • Relationships are considered more intimate then they actually are
  • Attention seeking, constantly seeks approval/reassurance
  • Influenced easily by others/circumstances
  • Speech style – wants to impress but seems almost childlike because he/she either cannot introspect well enough to give aa better description or is too distracted or disinterested to bother. The Diagnostic Statistical Manual of Mental Disorders (DSM 5) and World Health Organization (WHO) identify the use of statements such as “it was just like you know, weird” “because it’s yucky” as classic HPD
  • Emotional lability, shallowness
  • Make up – overly concerned with appearance which is used to draw attention to self
  • Exaggerated emotions, theatrical: “drama queen”

Of course, one of the challenges, is that these criteria are entirely subjective, therefore before a diagnosis of HPD is made, the psychiatrist should also review the teenager’s history (medical, social, family), behaviour and appearance.

It is not unusual for a teenager with HPD to also have another mental disorder(s). This is known as dual diagnosis and can include:

  • Anxiety/panic disorders
  • Major depressive disorder
  • Substance use disorder
  • Borderline personality disorder
  • Eating disorders
  • Attachment disorder
  • Somatoform disorder
  • Antisocial personality disorder

Potential Problems for a Teenager living with HPD

  • Increased risk of depression, anxiety disorder (see above)
  • Difficulty functioning in school and social settings
  • Unable to maintain long-term relationships/friendships due to attention seeking behaviours e.g. plays the victim or diva
  • Engage in risky behaviours e.g. self-harm, alcohol, drugs, unprotected intercourse
  • Seductive, manipulative, extroverted behaviours may place teen in unsafe situations e.g. online sexual predators, affair with adult teacher, etc.
  • May threaten and/or attempt suicide to get attention
  • May become involved with inappropriate people

Treatment

There is no cure for HPD, however, with appropriate treatment, behaviours and emotional responses can be managed and most teenagers will live happy, productive lives. Treatment includes:

  • Psychotherapy
  • Talk therapy
  • Medications may be given if teen also has an anxiety or panic disorder or major depressive disorder

Initially, treatment is slow and on-going as the teenager may be emotionally needy and challenge the boundaries of therapist/client. Therapy aims to help the teenager understand the motivations/fears behind his/her thoughts and behaviour and how to form more positive and mutually beneficial relationships.

What Can Parent(s) Do?

Dealing with a teenager with HPD is not easy. Patience and understanding is key to helping the teenager continue to move forward and develop the skills and strategies to manage his/her behaviours and reactions. Helpful suggestions include:

  • Be actively involved in treatment plan and follow the therapists suggestions
  • Ensure treatment plan is followed, including follow up appointments, medications taken (f prescribed)
  • Help teen manage their thoughts, be supportive and responsive, not reactive
  • Understand the difference between positive and negative attention seeking behaviour
  • Establish daily routine, set boundaries, give teen household tasks to do
  • Talk with family, siblings, school
  • If teen has another mental disorder, ensure that treatment plan is also followed
  • Speak with counsellor or social worker for resources and information on HPD
  • Consider joining a support groups for parents
  • Monitor behaviours e.g. alcohol, drugs, smoking
  • Help teen to not get stuck in negative thoughts
  • Encourage teen to journal, express gratitude, practice mindfulness, relaxation techniques
  • Work together as a family to support teen, consider family therapy and/or individual therapy too
  • Remain calm, do not berate or humiliate teen, be supportive, respectful, non-judgmental and most importantly, be there and show love

In my next Blog #38

I will discuss gaming disorder in children and teenagers

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