User:Connguyen/sandbox

History
The history of Histrionic Personality Disorder stems from the word “hysteria”. Hysteria can be described as an exaggerated or uncontrollable emotion that people, especially in groups, experience. The history and beliefs of hysteria has varied throughout time. Take for example, female hysteria. It wasn’t until Sigmund Freud who studied histrionic personality disorder in a psychological manner. “The roots of histrionic personality can be traced to cases of hysterical neurosis described by Freud.” He developed the psychoanalytic theory in the late 19th century and the results from his development led to split concepts of hysteria. One concept labeled as hysterical neurosis (also known as conversion disorder) and the other concept labeled as hysterical character (currently known as histrionic personality disorder). These two concepts must not be confused with each other, as they are two separate and different ideas.

Histrionic Personality Disorder is also known as and what you used to be hysterical personality. Hysterical personality has evolved in the past 400 years and it first appeared in the DSM II (Diagnostic and Statistical Manual of Mental Disorders, 2nd edition) under the name hysterical personality disorder. The name we know today as histrionic personality disorder is due to the name change in DSM III. Renaming hysterical personality to histrionic personality disorder is believed to be because of possible connotations to the roots of hysteria, such as sexual longings, demon possessions, etc.

Histrionic Personality Disorder has gone through many changes. From hysteria, to hysterical character, to the development of hysterical personality, to what it is listed as in the most current DSM, DSM-V. “Hysteria is one of the oldest documented medical disorders.” Hysteria dates back to both ancient Greek and Egyptian writings. Most of the writings related hysteria and women together, similar to today where the epidemiology of histrionic personality disorder is generally more prevalent in women and also frequently diagnosed in women.

Ancient Age

 * Ancient Egypt – first description of the mental disorder, hysteria, dates back to 1900 BC in Ancient Egypt. Biological causes of this mental disorder, such as the uterus movement in the female body was seen as the cause of hysteria. Traditional symptoms and descriptions of hysteria can be found in the Ebers Papyrus (link to Wikipedia article on Ebers Papyrus), the oldest medical document.
 * Ancient Greece – Similar to ancient Egyptians, the ancient Greeks saw hysteria being related to the uterus of a female. “Hippocrates (5th century BC) is the first to use the term hysteria. Hippocrates believed hysteria was a disease that lies in the movement of uterus (“hysteron”).” Hippocrates’s theory was that since a woman’s body is cold and wet compared to a man’s body whose body is warm and dry, the uterus is prone to illness, especially is deprived from sex. He saw sex as the cleansing of the body so the causes of being overly emotional were due to sex deprivation.

Middle Ages

 * Works from Trotula de Ruggiero (11th century) display women’s diseases and disorders during this time period. Disorders including hysteria. Her teachings resonated of Hippocrates and she is considered the first female doctor in Christian Europe.

Renaissance

 * The uterus was still the explanation of hysteria, the concept of women being inferior to men was still present (despite the Renaissance era being a rebirth to the sciences and arts), and hysteria was still the symbol for femininity.

Modern Age

 * Thomas Willis (17th century) introduces a new concept of hysteria. Thomas Willis believed that the causes of hysteria was not linked to the uterus of the female, but to the brain and nervous system.
 * Hysteria was consequence of social conflicts during the Salem witch trials.
 * Witchcraft and sorcery was later considered absurd during the Enlightenment in the late 17th century and 18th century. Hysteria starts to form in a more scientific way, especially neurologically. New ideas formed during this time and one of them was that if hysteria is connected to the brain, men could possess it too, not just women.
 * Franz Mesmer (18th century) treated patients suffering from hysteria in his method called mesmerism.
 * Jean Charcot (19th century) studied effects of hypnosis in hysteria. Charcot states that hysteria is a neurological disorder and that it is actually very common in men.

Contemporary Age

 * Sigmund Freud’s work, Studies on Hysteria, with Josef Breuer contributes to a psychoanalytic theoryof hysteria. Freud believed that hysteria was caused by a lack of libidinal evolution.

Causes
There is little research done to find evidence as to what causes histrionic personality disorder and where it stems from, however there are a few theories that relate to the lineage of its diagnosis. Traits such as extravagance, vanity, and seductiveness of hysteria have similar qualities to women diagnosed with HPD. An example of over-zealousness could be compared to the famous grande hystérie, a well-known demonstration of hypnotism by Jean-Martin Charcot by using his most well-known subject, Blanche Wittmann. Wittmann was known for her attractiveness and ability to make herself the center of attention from her hysteria and lavish performance.

Psychoanalytic Theory
According to Freud using his psychoanalytic theory, he believed the lustfulness was a projection of the patient's lack of ability to love unconditionally, maturely develop cognitively, and were overall emotionally shallow. He believed the reason of not being able to love could have been from a traumatic death experience from a close relative during childhood or divorce between parents, which gave the wrong impression of committed relationships. Exposure to one traumatic or multiple occurrences of a close friend or family member leaving (abandonment or fate of mortality) would make the person unable to form true and affectionate attachments towards people.

HPD & Antisocial Personality Disorder
Another theory suggests that histrionic personality disorder and antisocial personality disorder could have a possible relationship to one another. Research has found two-thirds of patients diagnosed with histrionic personality disorder also meet similar criteria with antisocial personality disorder. This suggests that both disorders based towards sex-type expressions may have the same underlying problem. Women are hyper-sexualized in the media consistently, engraining thoughts that the only way women are to gain attention is by exploiting themselves, and when seductiveness isn't enough, theatricals are the next step in achieving attention. Men can just as well be flirtatious towards multiple women yet feel no empathy or sense of compassion towards them. They may also be the center of attention from by exhibiting the "Don Juan" macho figure as a role-play. Both examples suggest that predisposition could be a factor as to why certain people are diagnosed with histrionic personality disorder, however little is known whether or not the disorder is influenced by any biological compound or genetically inheritable.

Interviews and Self Report Methods
In general clinical practice with assessment of personality disorders, one form of interview is the most popular; an unstructured interview. The actual preferred method is a semi-structured interview but there is reluctance to use this type of interview because they can seem impractical or superficial. The reason that a semi-structured interview are preferred over an unstructured interview is that semi-structured interviews tend to be more objective, systematic, replicable, and comprehensive. Unstructured interviews, despite their popularity, tend to have problems with unreliability and are susceptible to errors leading to false assumptions of the client. One of the single most successful method for accessing personality disorders by researchers of normal personality functioning is the self-report inventory following up with a semi-structured interview. There some disadvantages with the self-report inventory method that with histrionic personality disorderthere is a distortion in character, self-presentation, and self image .This cannot be assessed simply by asking most clients if they match the criteria for the disorder. Most projective testing depend less on the ability or willingness of the person to provide an accurate description of the self, but there is currently limited empirical evidence on projective testing to assess histrionic personality disorder.

Functional Analytic Psychotherapy
Another way to treat histrionic personality disorder after identification is through functional analytic psychotherapy. The job of a Functional Analytic Psychotherapist is to identify the interpersonal problems with the patient as they happen in session or out of session. Initial goals of functional analytic psychotherapy are set by the therapist and include behaviors that fit the client's needs for improvement. Functional analytic psychotherapy differs from the traditional psychotherapy due to the fact that the therapist directly address and the patterns of behavior as they occur in-session. The in-session behaviors of the patient or client are considered to be examples of their patterns of poor interpersonal communication and to adjust their neurotic defenses. To do this, the therapist must act on the client's behavior as it happens in real time and give feedback on how the client's behavior is affecting their relationship during therapy. The therapist also helps the client with histrionic personality disorder by denoting behaviors that happen outside of treatment; these behaviors are coined with the terms "Outside Problems" and "Outside Improvements". This allows the therapist to assist in problems and improvements outside of session and to verbally support the client and condition optimal patterns of behavior" . This then can reflect on how they are advancing in-session and outside of session by generalizing their behaviors over time for changes or improvement".

Coding Client and Therapist Behaviors
This is called Coding Client and Therapist behavior. In these sessions there is a certain set of dialogue or script that can be forced by the therapist for the client to give insight on their behaviors and reasoning" . Here is an example from" the conversation is hypothetical. T = therapist C = Client This coded dialogue can be transcribed as:
 * ECRB - Evoking clinically relevant behavior
 * CRB1 - In-session problems
 * CRB2 - In-session improvements
 * TCRB1 - Clinically relevant response to client problems
 * TCRB2 - Responses to client improvement

“(ECRB) T:Tell me how you feel coming in here today (CRB2) C: Well, to be honest, I was nervous. Sometimes I feel worried about how things will go, but I am really glad I am here. (TCRB2) T: That’s great. I am glad you’re here, too. I look forward to talking to you. (CRB1) C: Whatever, you always say that. (becomes quiet). I don’t know what I am doing talking so much. (TCRB1) T: Now you seem to be withdrawing from me. That makes it hard for me to give you what you might need from me right now. What do you think you want from me as we are talking right now?”.

Functional Ideographic Assessment Template
Another example of treatment besides coding is Functional Ideographic Assessment Template. The functional ideographic assessment template, also known as FIAT, was used as a way to generalize the clinical processes of functional analytic psychotherapy. The template was made by a combined effort of therapists and can be used to represent the behaviors that are a focus for this treatment. Using the FIAT therapists can create a common language to get stable and accurate communication results through functional analytic psychotherapy at the ease of the client; as well as the therapist.

Epidemiology
Approximately 1-3% of the population has Histrionic Personality Disorder. 10-15% of patients in clinical settings have HPD.

Gender Differences
HPD is diagnosed more frequently in females than males, but it is unclear whether such diagnoses actually reflect a higher prevalence rate of the disorder among females. It is often argued that the medical diagnosis or criterion for HPD is sexually biased, since many of its traits are strongly correlated with what are often thought to be feminine behaviors. Moreover, there is a strong sexual bias for men to be diagnosed with antisocial Personality Disorder, which shares many similar traits with HPD. Some personality researchers have argued that HPD and Antisocial Personality Disorder are separate gender manifestations of the same underlying condition, and that HPD simply represents an exaggerated stereotypical version of female traits, and ASPD represents an exaggerated stereotypical version of male traits.

Cultural Differences
Variation in the prevalence of HPD also exists among different cultures. The disorder is less prevalent in Asian cultures, where overt sexual seductiveness is less frequent; and more prevalent in Hispanic and Latino cultures where overt sexual seductiveness is more frequent. Some researchers argue that such culture differences do not reflect differential prevalence rates among cultures. They believe it signifies a sexual bias in diagnostic criterion, since diagnoses are more prevalent among cultures where sexual seductiveness, a stereotypically feminine behavior, is more common. It is unclear whether criterion should be changed under such cultural contexts, because the DSM-IV criteria may also reflect biases regarding seductiveness that are not shared by other societies.

Life-span
Due to this sexual seductiveness trait, the validity of HPD diagnostic criteria may also vary across lifespan. Sexual seductiveness may become a less effective means to manipulate others or garnishing the attention of others as one gets older. On the other hand, previous research also suggests that histrionic traits may become more overt as a person ages, because histrionic persons continue to rely on ineffective means of getting attention despite being unsuccessful.

Validity and Reliability
Despite the controversies surrounding the diagnostic criteria of HPD, a meta-analysis of HPD diagnoses by Nestadt et al found that HPD is a valid constuct, and can be diagnosed reliably. Moreover, it found that HPD affects men and women equally among young adults, and that a differential sex prevalence rate did not emerge until the age of 45. It also found that women were diagnosed more frequently with HPD due to sampling bias found in hospital-based studies. Women were sampled more often than men in hospital-based facilities, thus making it appear as though the illness is more prevalent in women when in fact the study-samples were disproportionate.