The Dual Diagnosis Pages: "From Our Desk"
Article posted 25 March, 2000

Dual Diagnosis and the Histrionic Personality Disorder (HPD)

Table of Contents

  • The Histrionic Personality Disorder
  • Treating the The Histrionic Personality Disorder
  • Dual Diagnosis Treatment: Treating the Addicted Histrionic Personality Disorder
  • For references, see the Bibliography page

    Cluster B:
    The Histrionic Personality Disorder (HPD)

    Essential Feature

    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 (DSM-IV™, 1994, p. 655).

    The ICD-10 (1994, p. 230) describes the histrionic personality disorder as characterized by shallow and labile affect, self-dramatization, exaggerated expression of emotions, suggestibility, egocentricity, self-indulgence, and lack of consideration for others. These individuals may engage in inappropriate seductiveness and overconcern with physical attractiveness. They are easily hurt and seek continuous excitement, attention and appreciation.

    Frances, et.al. (1995, p. 373) describes individuals with HPD as manipulative, vain, and demanding. However, in addition to the focus on physical appeal, the authors note that there may also be a genetic association between somatization disorder and the histrionic personality disorder. Benjamin (1993, pp. 165-166) believes that HPD falls into two subtypes: 1) those who are flirtatious and focused on physical attractiveness, and 2) those who are concerned with somatic symptoms. The DSM-IV™ Axis II HPD emphasizes the flirtatious version. However, individuals with HPD will vary in the degree to which they are sexually seductive or concerned about physical symptoms.

    HPD is commonly co-morbid with conversion disorders, hypochondriasis, dissociative disorders, and affective disorders (Richards, 1993, p. 246). Kernberg (1992, p. 53) suggests that the relationship of HPD to conversion reaction and dissociative symptoms is strongest when the personality disorder is most severe.

    Akhtar (1992, p. 259) notes that the current description of HPD corresponds to the previous idea of an infantile personality. These individuals had few sexual inhibitions, were impulsive, experienced identity diffusion and emotional lability, and demonstrated what the author referred to as moral defects. Yet, as described in the DSM-IV, individuals with HPD demonstrate what our society tends to foster and admire -- to be well liked, successful, popular, extroverted, attractive, and sociable (Millon & Davis, 1996, p. 366). In fact, Widiger, et.al. (Costa & Widiger, eds., 1994, p. 47) describe HPD as an extreme variant of extroversion. Extroversion involves the tendency to be outgoing, talkative, convivial, warm and affectionate, energetic, and vigorous. In a non-pathological form, extroversion is being high-spirited, buoyant, and optimistic. These factors coalesce into a personality disorder only when the needs behind the behavior are pathologically inflexible, repetitious, and persistent (Millon & Davis, 1996, p. 366). It is then that the corruptibility, manipulativeness, and disinhibited exploitation of others become factors and the personality disordered version of extroversion becomes apparent.

    The literature differentiates HPD according to gender. Women with HPD are described as self-centered, self-indulgent, and intensely dependent on others. They are emotionally labile and cling to others in the context of immature relationships. Females with HPD over identify with others; they project their own unrealistic, fantasied intentions onto people with whom they are involved. They are emotionally shallow and have difficulty understanding others or themselves in any depth. Selection of marital or sexual partners is often highly inappropriate. Pathology increases with the level of intimacy in relationships. Women with HPD may show inappropriate and intense anger. They may engage in manipulative suicide threats as one aspect of general manipulative interpersonal behavior (Kernberg, 1992, pp. 58-59).

    Males with HPD usually present with identity diffusion, disturbed relationships, and lack of impulse control. They are often promiscuous and bisexual. They have antisocial tendencies and are inclined to exploit physical symptoms. These men are emotionally immature, dramatic, and shallow (Kernberg, 1992, p. 59). Both men and women with HPD engage in disinhibited behavior. This is apparent in females with HPD through affective lability, manipulativeness, and intense, brief relationships. In men with HPD, disinhibition may be expressed through impulsivity, aggressive behavior, drug abuse, interpersonal exploitation, and numerous shallow sexual relationships (Frances, et. al., 1995, p. 373). If the aggressive, impulsive, and exploitative behavior become dominant in men with HPD, differentiation from the antisocial personality disorder can become problematic. There are questions raised in the literature as to whether or not HPD is a female variant of APD in men. However, as currently described in the DSM-IV™, the two are differentiated by the need to please and inclination to seek reassurance found in men or women with HPD and the more calculating and indifferent determination to exploit others found in APD. Also, a diagnosis of HPD does not require adolescent correlates of antisocial behavior as does the diagnosis of APD.

    Individuals with HPD may decompensate in later adult years due to the cumulative effects of: 1) the incapacity to pursue personal, professional, cultural, and social values; 2) the frequent disruption of and failure in intimate relationships; and 3) identity diffusion. These factors interfere with ordinary social learning and consequences grow more severe with age. The usual course of untreated HPD is precarious as life opportunities are missed or destroyed (Kernberg, 1992, p. 65).

    Self-Image

    Individuals with HPD view themselves as gregarious, sociable, friendly, and agreeable. They consider themselves to be charming, stimulating, and well-liked. They value the capacity to attract people via their physical appearance and by appearing to be interesting and active people. For individuals with HPD, indications of internal distress, weakness, depression, or hostility are denied or suppressed and are not included in their sense of themselves (Millon & Davis, 1996, p. 369).

    For individuals with HPD, vanity and seductiveness function to bolster and maintain self-esteem; they often become overinvested in how they look and dread aging (McWilliams, 1994, pp. 312). Growing old violates the view of themselves as glamorous and attractive people who are admired by others.

    The HPD self is experienced as a small, fearful, and defective child who has to cope in a world dominated by powerful others (McWilliams, 1994, p. 310). For example, one professional man, diagnosed with HPD, repeatedly dreamed that he was a Volkswagen Beetle trying to keep up with larger, more powerful cars on an area freeway.

    Individuals with HPD are consumed with attention to superficialities and spend little time or attention on their internal life. Because they know themselves so little, they often have no sense of who they are apart from their identification with others. They are able to change their attitudes and values depending upon the views of significant others in their lives. These individuals also fail to attend the details and specifics of their experiences. They have, accordingly, memories that are diffuse and general with a tremendous lack of detail (Will, Retzlaff, ed., 1995, p. 99).

    View of Others

    Individuals with HPD experience others as powerful and capable in relation to their own sense of being a small, fearful, and defective child (McWilliams, 1994, p. 310). This view of themselves as less powerful allows these individuals to absolve themselves from responsibility for their own behavior and to engage in manipulative behavior with others to force attention and care-taking They will behave in a seductive and enticing manner until they are denied what they are seeking. Individuals with HPD become intensely angry toward others they see as withholding.

    Individuals with HPD focus on others to the point that they obtain their own identity from those to whom they are attached. Yet the attention they focus on others does not allow them to gain understanding of others or to become effectively empathic. Their intense observation skills are dedicated to determining what behaviors, attitudes, or feelings are most likely to result in winning the admiration and approval of others. Essentially, these individuals watch other people watch them. Their actual focus is on how they are doing and how they are being received by others. As a result, they are not particularly effective in understanding how others are feeling. Individuals with HPD are inclined to define relationships with or connections to others as closer or more significant than they really are. They do not see when they are being humored or placated by people who may have lost patience with their relentless need for attention and the failure to relate in a genuine way. Others may eventually withhold their own efforts to relate to individuals with HPD once they become aware that there is no real attempt to connect -- rather there is a continuing demand to be attended to and admired. Basically, it is analogous to how well the actor or actress actually "knows" their audience beyond reading whether or not the performance is being well received.

    Relationships

    The HPD failure to view others realistically is reflected by their difficulties in developing and sustaining satisfactory relationships. Individuals with HPD tend to have stormy relationships that start out as ideal and end up as disasters (Beck, 1990, p. 214). These individuals are unable to tolerate isolation; when alone, they feel desperate and are unable to wait for new relationships to develop gradually (Horowitz, Horowitz, ed., 1991, p. 4). They will idealize the significant other early in the relationship and often see the connection as more intimate than it really is. If the significant others begin to distance themselves from the incessant demands, individuals with HPD will use dramatics and demonstrativeness to bind these people to the relationship. They will resort to crying, coercion, temper tantrums, assaultive behavior and suicidal gestures to avoid rejection (Beck, 1990, p. 51).

    Even though individuals with HPD will attempt to bind others to them, they are often dissatisfied with single attachments. They tend to be lacking in fidelity and loyalty; they are seductive, dramatic, and capricious in personal relationships (Millon & Davis, 1996, p. 357). Their interpersonal dependency is not expressed through faithfulness and commitment. They start relationships well but falter when depth and durability are needed. There is a paradox in HPD relationships of coercive dependency and infidelity.

    On the surface, in HPD relationships, there is warmth, energy, and responsiveness. Covertly, this behavior is accompanied by a "secretly disrespectful agenda of forcing delivery of the desired nurturance and love. . .manipulative suicidal attempts are examples of such coercions" (Benjamin, 1993, p. 173). Individuals with HPD have a strong fear of being ignored; they long to be loved and taken care of by someone who is both powerful and able to be controlled through the use of charm and seductiveness. They become helpless and childlike when faced with potential rejection (McWilliams, 1992, p. 307).

    All people have dependency needs. It is the way these needs are expressed that differentiates personality-disordered individuals. Individuals with HPD tend to express dependency needs in a more uncontrolled, unmodulated, and exploitative manner (Bornstein, Costello, ed., pp. 122-123). Pathological manifestations of dependency needs include intense fears of abandonment, passive, helpless behaviors in intimate relationships, and phobic symptoms aimed at minimizing separation (Bornstein, Costello, ed., pp. 130-132). These behaviors lead to interpersonal conflict, rejection, and isolation which triggers even more pathological expression of the maladaptive responses.

    Parents with HPD are inclined to use manipulative behaviors to focus their childrens' attention on parental needs and to evade arduous parental responsibilities while maintaining the appearance of being loving and involved. This can result in exploitation of and failure to protect children from emotional, physical, or sexual abuse.

    Benjamin (1993, p. 174) notes that both borderline personality disordered and histrionic personality disordered individuals engage in coercive dependency; however, the coercion and dependency appear simultaneously in HPD and switch from one to the other in BPD. Individuals with HPD mask their control and contempt in a complex combination of neediness and attractiveness.

    Issues With Authority

    Individuals with HPD will engage in illegal behavior with little internal moral restraint. They are often able to evade negative consequences through the appeal of their interpersonal behavior. They are not inclined to be assaultive, argumentative, or aggressive with authority figures. They are engaging, responsive, and enthusiastic. They frequently tell people they see as powerful, i.e., in authority, how wonderful, effective, competent, etc. they are. For individuals with HPD, misinformation in the service of making someone else happy is fine; that is, they are quite at ease with evasion and dishonesty.

    HPD Behavior

    Individuals with HPD are overreactive, volatile, provocative, and engaging in their behavior. They are intolerant of inactivity, impulsive, emotional, and responsive. They have a penchant for momentary excitements, fleeting adventures, and ill advised hedonism (Donat, Retzlaff, ed., 1995, p. 47). The HPD behavioral style is charming, dramatic, expressive, demanding, self-indulgent, and inconsiderate (Sperry, 1995, p. 97). They tend to be capricious, easily excited, and intolerant of frustration, delay, and disappointment. The words and feelings they express appear shallow and simulated rather than real or deep (Millon & Davis, 1996, pp. 366-367).

    These individuals can be quite effective in situations where a first impression is important and vague expression of ideas is preferred over precision. They are less effective where performance is measured by objective measures of competence, diligence, thoroughness, and depth. Acting, marketing, politics, and the arts are fields where individuals with HPD will do well and manage competition effectively (Richards, 1993, p. 246).

    The body, erotically or via illness, is often used by individuals with HPD to attract the attention of others (Horowitz, Horowitz, ed., 1991, p. 5). They will engage in inappropriately exaggerated smiles and continuous elaborate hand gestures. Movement and expressions are designed to have a pleasing effect (Turkat, 1990, pp. 72-73).

    Individuals with HPD are fraudulent insofar as their inner emptiness is in contradiction to the impressions they seek to convey to others. They hide their true cognitive sterility and emotional poverty (Millon & Davis, 1996, p. 370). HPD cognition is global, diffuse, and impressionistic; these individuals appear incapable of sustained intellectual concentration; they are distractable and suggestible (Beck, 1990, p. 215). They avoid introspective thought. They are attentive to fleeting and superficial events but integrate their experience poorly with a cursory cognitive style. They lack genuine curiosity and have habits of superficiality and dilettantism. They avoid potentially disruptive ideas and urges by dissociating from thoughts, people, and activities that threaten their view of themselves or the world (Millon & Davis, 1996, p. 369).

    Individuals with dependent personality disorder and histrionic personality disorder share important traits: they both turn to others for protection and the rewards of life; they are socially affable and share an intense need for attention and affection. Individuals with HPD have a more vigorous and manipulative style; these people will take the initiative in assuring that attention is forthcoming. They will actively solicit the interest of others through a series of seductive behaviors (Millon & Davis, 1996, p. 357).

    Affective Issues

    Individuals with HPD express their emotions intensely yet remain unconvincing. They appear warm, charming, and seductive, yet their feelings appear to lack depth and genuineness (Beck, 1990, p. 213). They have an infantile quality in their emotional expression. They experience exaggerated feelings that change frequently. They become so involved in their emotional dramas that they are unaware of or are uninformed about the world they live in. They cannot stand frustration, disappointment, or delayed gratification (Oldham, 1990, pp. 143-144).

    Individuals with HPD are subject to distortion in their emotional reasoning. They accept their emotions as evidence of truth rather than just a statement about their current emotional state (Will, Retzlaff, ed., 1995, p. 99).

    People with HPD experience recurrent flooding of affect. Somatic preoccupations and sudden enraged, despairing, or fearful states may occur. Patience is rare and these individuals may use alcohol or other drugs to quickly alter states of negative feeling (Horowitz, Horowitz, ed., 1991, p. 4).

    Defensive Structure

    HPD defenses include dissociative mechanisms. Individuals with HPD regularly alter and recompose themselves to create a socially attractive but changing facade. They engage in self-distracting activities to avoid reflecting on and integrating unpleasant thoughts and feelings (Kubacki & Smith, Retzlaff, ed., 1995, p. 168). Repression is also a HPD defense; frequent splitting off from conscious awareness of self results in an intrapsychic impoverishment; psychological growth is precluded. These individuals remain immature and childlike in their behavior. Through repression, individuals with HPD remain unaware that their thoughts and feelings are attached to their behavior. Accordingly, they claim innocence when their conduct results in interpersonal conflict (Kubacki & Smith, Retzlaff, ed., 1995, p. 171).

    Millon (Millon & Davis, 1996, pp. 369-370) also noted the HPD defense mechanisms of dissociation and repression. Individuals with HPD are attuned to external rather than internal events. They dissociate entire segments of memory and feelings that prompt discomfort. They, in particular, must keep away from awareness the triviality of their entire being, its pervasive emptiness and paucity of substance (Millon & Davis, 1996, pp. 369-370).

    McWilliams (1994, pp. 304-307) describes the organizing defenses of HPD as repression, sexualization, and regression. Individuals with HPD will also behave in a counterphobic manner; they approach what they fear. However, they may become helpless and childlike when faced with potential abusers.

    Table of Contents

    Treating the Histrionic Personality Disorder

    The Histrionic Personality Disorder Coming Into Treatment

    Individuals with HPD may enter treatment via the criminal justice system or through self-referral. Because of their interpersonal skills and inclination to seek approval through pleasing others, they may initially look like the proverbial "dream client." However, these individuals usually are seeking relief from a crisis in their lives and the accompanying depression. Once the depressed mood is lifted, motivation for change is eliminated or greatly reduced. Turkat (1990, pp. 74-75) is pessimistic about achieving fundamental change in the histrionic personality structure because once the motivation for therapy is gone, change is usually unwanted and treatment is terminated.

    Even so, individuals with HPD often have substantial strengths that can be utilized to make progress in treatment. It is not particularly necessary to achieve depth of character or durability in the face of tedium or long-term responsibility. These individuals can thrive in settings and activities that are in harmony with their personalities so long as their value system is not corrupted and they do not engage in illegal behaviors that will ultimately result in negative consequences in the criminal justice system.

    Medication Issues

    Individuals with HPD should be treated for any concurrent Axis I disorder. When this is not needed but cluster symptoms are noted (affective instability or cognitive disorganization) the use of serotonergic blockers can be helpful (Sperry, 1995, p. 111).

    As with all of the personality disorders, the specific features of HPD can affect compliance with medication. Individuals with HPD may respond to the side effects of various medications with an intense and dramatic overreaction (Ellison & Adler, Adler, ed., 1990, p. 59). Also, medication may not be needed by these individuals but may well be requested. Drug-seeking behavior is a significant issue in the histrionic personality disorder. Refusal to prescribe medication may result in a dramatic scene with the service providers attempting to set limits.

    Treatment Provider Guidelines

    Early in treatment individuals with HPD may see the service provider as "the all-powerful rescuer who will make everything better." The style of histrionic clients can be very appealing; dramatic renditions of experience can be quite absorbing and amusing (Beck, 1990, pp. 220-221). These individuals often attach easily to service providers, but the attachment is shallow. They are often more concerned with an impressive appearance than substantive identification and resolution of problems. They seek interventions that relieve acute emotional distress and initial motivation and cooperation may be followed by poor dependability (Donat, Retzlaff, ed., 1995, p. 51).

    Treatment may be viewed by individuals with HPD as an opportunity to socialize. Treatment providers are seen as valued sources of admiration, attention, and support (McCann, Retzlaff, ed., 1995, p. 147). On the other hand, individuals with HPD are prone to impulsivity and angry tirades with explosive comments. Most of this is outside of awareness and confrontation usually results in denial, resistance, and an unwillingness to be introspective (Craig, Retzlaff, ed., 1995, p. 80). Treatment must involve confrontation of and management of demands for social contact outside of the treatment setting, sexually provocative behavior, and continuous avoidance of relevant issues. Clear treatment goals, focusing, and limit-setting are important for clients with HPD (McCann, Retzlaff, ed., 1995, pp. 147-148).

    It is difficult to fully understand clients with HPD because of suppression, repression, and dissociation. These individuals may be aware of their problems but they have difficulty recognizing the manifestations of, or the reasons for, abnormality in their behavior. Unable to accept responsibility for their failures, they tend to blame others (Kantor, 1992, p. 249). The best contribution treatment providers can make to clients with HPD is the confidence that they have the capacity to make competent adult decisions and are capable of accepting responsibility for their own behavior.

    Countertransference Issues

    Treatment providers may be drawn into a countertransference position of being entertained and enjoying the excitement generated by clients with HPD. These individuals will often communicate to treatment providers that they are idealized, all-knowing persons who have helped their HPD clients to make large and significant strides in treatment in a short amount of time (McCann, Retzlaff, ed., 1995, p. 147). It may be enticing to believe in this rendition of the clinicians' therapeutic effectiveness only to discover that there is little genuine treatment progress.

    Boundaries and professionalism are imperative conditions to a therapeutic experience in treatment for clients with HPD. These individuals are likely to attempt to insure good caregiving by dressing attractively and keeping treatment providers entertained with amusing renditions of their life experiences. Treatment providers must manage the seductiveness and their own attraction to such appealing clients (Benjamin, 1993, p. 182). For clinicians who are staid and undramatic, these clients can be so emotionally and sexually exciting that they find themselves fantasizing right along with their clients (Kubacki & Smith, Retzlaff, ed., 1995, p. 171).

    On the other hand, individuals with HPD can interact with others in a way that actually robs the others of their self-esteem. This happens via the continuous pressure to view these individuals as attractive and appealing. This moves others, including treatment providers, into the admiring observer position. By definition, the anonymous people in the audience are less interesting or exciting people than the beautiful people holding forth on the center stage. The impact is both subtle and cumulative, leaving the people interacting with individuals with HPD inexplicably unsure of themselves. Service providers need to be aware of the potential for esteem-devaluation or their own defenses will be triggered.

    Countertransference with clients with HPD may also include defensive distancing and infantilization. It can be difficult to attend respectfully to what feels like pseudoaffect; the self-dramatizing quality invites ridicule (McWilliams, 1994, pp. 314-315).

    Treatment Techniques

    Assessment of individuals who may have a histrionic personality disorder should include the following questions:

    Assessment of individuals who may have HPD must include exploration of substance abuse issues. These individuals are prone to alcoholism and drug addiction and are quite adept at denying the related behaviors. They seek easy escape from pain, deny negative consequences, and fail to observe or accept responsibility for the impact of their behavior on others. These factors foster both entry into and maintenance of addiction. In a case example, a male histrionic personality disordered professional engaged in mutual alcoholic behavior with his wife until he wanted out of the marriage. At that time, he hospitalized his wife after she had a black-out but continued to deny his own drinking problem which was considerably more severe than his wife's level of addiction.

    A special therapeutic emphasis for individuals with HPD is attention to the fears related to the loss of an exciting lifestyle, a sense of never ending youthfulness, and evasion of the harder issues of adulthood. In a sense, individuals with HPD attempt to live life like the prototypic American movie, i.e., a happy ending so matter how severe the adversity or obstacles. Working with HPD clients can feel like being Scrooge before his conversion; the reflection of life's negative consequences and inevitable pain are almost unseemly in the face of HPD compulsive optimism, denial, dissociation, and evasion. Yet, it is important to foster behaviors that are mature, responsible, and based in reality if these individuals are to emerge from their position of childlike powerlessness and the growing negative consequences for their vocational, interpersonal, marital, and parental failures.

    Treatment Goals

    Adler (Adler, Ed., 1990, pp. 26-32) proposes that treatment goals for all personality disorder treatment include: preventing further deterioration, establishing or regaining an adaptive equilibrium, alleviating symptoms, restoring lost skills, and fostering improved adaptive capacity. Goals may not necessarily include characterological restructuring. The focus of treatment is adaptation, i.e., how the individual responds to the environment. Treatment interventions teach more adaptive methods of managing distress, improving interpersonal effectiveness, and building skills for affective regulation. It is also important to remember that many individuals with personality disorders do not complete treatment with the same service provider. For individuals with HPD, treatment must necessarily involve pressure to delay gratification and essentially grow-up. These clients need to learn to regard themselves as agents of action rather than merely the recipients of the actions of others. There is, however, a reason why individuals with HPD have little interest in learning to think clearly, focus, and hold steady under pressure. A basic dynamic of HPD is the excessive, unresolved effort to have all their needs met by someone else and they fear that if they were to become skilled in these matters, no one would take care of them anymore (Benjamin, 1993, p. 185). Addressing these fears with a positive frame would mean developing treatment goals that include integration of gentleness with strength, moderating emotional expression, and encouraging warmth, genuineness, and empathy (Sperry, 1995, pp. 105-106). Further, many individuals with HPD have the habit of not knowing facts that are emotionally distressing. They use an array of avoidant control processes: suppression, repression, disavowal, denial, and behavioral avoidance. Treatment helps them to focus sustained attention on topics that contain irrational beliefs, conflicting motives, contradictions in the sense of self, and unresolved dilemmas. Service providers must assist individuals with HPD to focus attention on topics that are usually avoided and unresolved (Horowitz, Gabbard & Atkinson, Eds, 1996, pp. 979-981). Individuals with HPD need to learn to live with reality on its terms rather than on their terms; see reality as it is; cope with reality as they find it; increase self-reliance; gain self-confidence; increase courage; and increase genuine self-esteem (Sperry & Carlson, 1993, p. 415).

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    Dual Diagnosis Treatment: Treating The Addicted Histrionic Personality Disorder

    Cluster B: Incidence of Co-Occurring Substance Abuse Disorders

    Cluster B has the highest incidence of co-occurring substance abuse disorders of the three DSM-IV personality disorder clusters (Nace, O'Connell, Ed., 1990, p. 184).

    Richards (1993, pp. 227-239) believes that individuals with personality disorders have an increased inclination to use drugs and alcohol as alternative solutions to life problems. Faulty adaptation to normal stressors and frequent failures in self-regulation can be attributed to deficiencies or disturbances in the personality. This accounts for continued addiction even in the face of catastrophic negative consequences.

    For individuals with HPD, the shallowness and absence of internal integration are mirrored in a superficial involvement in the details of life; they have little ability to understand and integrate emotional experiences across situations. Alcohol and drugs serve as an alternative to personality integration and increased maturity. This is particularly effective for individuals with HPD because drug use facilitates dissociative behavior. Not only will they use drugs and alcohol for self-regulation and as a self-soothing alternative to facing life problems, they will view themselves as victims to their addiction. They often cycle rapidly between the role of enraptured drug user and the victimized person suffering from the illness of addiction (Richards, 1993, pp. 240-247).

    Millon & Davis (1996, p. 378) state that individuals with HPD may become involved in drug or alcohol abuse because the substances can free them to act out in ways that are congenial to their inclination to be stimulus-seeking. Through drugs and alcohol, these individuals are able to transform themselves; they gain feelings of well-being, bolster a flagging sense of self-worth, and perhaps even come to feel omnipotent. Drugs and alcohol can disinhibit controlled HPD impulses so that there need be no assumption of personal responsibility or guilt for behavior.

    Drugs of Choice for the Histrionic Personality Disorder

    Peele (1989, p. 149) believes that all addictions accomplish something for the addict. They are ways of coping with feelings with which addicts cannot otherwise manage; they block out sensations of pain, discomfort, or negative affect. Further, addictive involvements make people less aware of themselves and others. Hoskins (1989, p. 11) notes that addictive behavior may look insane to an outsider, but there in an internal logic for the addict that is based on fear and a childlike view of the world and leads to an addictive life style. Drug use is neither a result nor a cause of the development of this life-style; it is just another example. Addiction fits the person; that is why is it so hard to eliminate it from the person's life (Peele, 1989, p. 156).

    For individuals with HPD, the coping patterns of dissociation, denial, evasion, and stimulus seeking all lend themselves to addiction. Drugs of choice for these individuals include antianxiety agents and stimulants but are often greatly influenced by what is fashionable to use within their social context. Not only are they influenced by others concerning drug of choice, they are likely to follow others in their choice of places and circumstances to use, route of administration, and even which treatment centers to attend. These individuals rarely use in an asocial context. They use drugs and alcohol as part of their interpersonal interaction. Accordingly, they may use drugs or alcohol as a significant role in their sexual and romantic behavior (Richards, 1993, pp. 247-248).

    Hoskins (1989, p. 61) believes that relationship addictions serve as the glue which holds together all other addictive patterns. He states that no matter what addictions individuals may have, controlling, fix-oriented relationships are a central life pattern. Relationship addiction may prove to be the most dominant and enduring feature in the lives of addicts. This is certainly a major factor for individuals with HPD. Their behavior, whether addictive or not, is controlled by their interactions with others. They have little ability or inclination to be self-directed. Overall, even abstinence can be the behavior or choice when supported by the social network within which these individuals find themselves. If the powerful psychological addiction is to relationships rather than the drug of (apparent) choice, it is possible that these individuals are less addicted than they initially appear to be. Integration into an abstinence-based social context, e.g. AA or NA, may be quite effective in facilitating long-term abstinence.

    For individuals with HPD, it is important to watch for an emerging sexual addiction with abstinence from drugs and alcohol. This alternative addiction may become apparent in the context of AA or NA involvement and subvert recovery.

    Dual Diagnosis Treatment for the Histrionic Personality Disorder

    Salzman (Mule, ed., 1981, pp. 346-347) believes that the inner forces that initiate and sustain addiction are immaturity and inappropriate, magical coping techniques. Dual diagnosis treatment must involve recognition of these tendencies that foster addictive behavior, i.e., immaturity, escapism, and grandiosity. New ways must be learned for dealing with feelings of powerlessness and helplessness other than compulsivity. Peele (1985, p. 156) proposes that a nonaddicted lifestyle must include the awareness that negative feelings, insoluble problems and a sense of inadequate rewards will never disappear entirely. To move beyond addiction, individuals must: 1) be willing to tolerate the uncertainty of life; 2) believe they have the strength to withstand uncertainty and discomfort; and, 3) believe they can generate positive rewards for themselves (Peele, 1985, p. 156).

    Individuals with HPD are vulnerable to addiction via their immaturity, inclination to avoid unpleasantness, and stimulus-seeking behavior. They define themselves as victims to their addiction and describe themselves as powerless, not over addiction, but in relation to recovery. These individuals usually have little experience in recognizing and tolerating the painful in life. They do not define reality as a positive force; they are much more inclined to prefer the fantasies they have about both themselves and others.

    Accordingly, dual diagnosis treatment for individuals with HPD must address:

    Richards (1993, p. 278) notes that individuals with HPD will demand to be special in treatment. They are inclined to become the star patient in a treatment group or the problem child due to relapse. They may also, consciously or not, view service providers (or their group) and their drug(s) of choice as jealous lovers fighting over them and for their allegiance. This is a situation these individuals tend to relate to with relish (Richards, 1993, pp. 247-248).

    Confrontation usual to substance abuse treatment can often be useful with this client population. If it is not well tolerated, look for a co-occurring borderline personality disorder. Abstinence as a prerequisite of treatment may be possible but should not be used when there is a co-occurring personality disorder. Substance use should be confronted but not result in termination from treatment. These individuals may well be able to utilize the experience for recovery. Once again, their inclination to please others may work on their behalf in a recovery-oriented context.

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    Sharon C. Ekleberry, 2000