Histrionic Personality Disorder Conversion or Somatic Symptoms

Patients with histrionic personality disorder have an emotionally expressive style, seek excessive attention, are often dramatic, and may present with a conversion disorder. Physicians may feel flattered, captivated, seduced, or sexually aroused by these patients. Alternatively, the physician may feel overwhelmed by the patient's exaggerated or excessive emotions, embarrassed by the sexual overtures, depleted, or confounded by unexplained physical symptoms, such as pseudoseizures, paralysis, and mutism. These patients may unconsciously use their symptoms to elicit attention or support from the physician (Bornstein and Gold, 2008). They may also use their sexuality to recruit others to satisfy their needs to be taken care of or romantically pursued. They fear that they are not desired and will lose the care or admiration of others.

There are two different levels of functioning with the histrionic personality disorder. Kernberg (1984, 1992) describes a neurotically functioning "hysteric" who shows intact reality testing, defenses centered on repression, and stable and mature relations with others. The female hysteric has a flirtatious, clinging, childlike dependence in intimate relationships but can function at mature levels in social and work situations. Male hysterics have similar psychological conflicts, but may appear as "macho" or "effeminate" (Kernberg, 1992). The hysteric of either sex often reacts to medical care with regression to a childlike, sexualized, dependent, and clinging position. They seek to gratify their wishes for dependent care by seducing or flattering others. Outside the office, they usually function well.

By contrast, the "histrionic patient" (Kernberg, 1984, 1992) can display transient losses of reality testing, defenses centered on splitting, and chaotic sexualized relations with others and a range of unexplained physical or somatic complaints. The histrionic patient is self-centered and self-indulgent, with a pervasive childlike dependence that extends from intimate relationships into all aspects of social and occupational functioning. Female histrionics typically act flirtatiously but may become indignant when a man shows sexual interest. Male histrionics also show the self-centered and dependent pattern, but may also have hypochondri-cal and antisocial features. Histrionics of both genders may seek medical care because of unexplained medical symptoms. They may react to medical care with regression but, unlike the hysteric, use defenses centered on "splitting"; they may see the physician as "all good or all bad" and can be extremely devaluing. They may appear severely self-centered, attention seeking, diffusely sexual, hypochondrical, somatic, and exploitative. All this may be coupled with an exhausting dependency on the physician.

In working with hysterics and histrionic patients, a physician needs to be friendly, not overly warm or reserved. Hysterics and histrionics often are helped when the physician uses parallel inquiry when they present with somatic complaints. Hysterics also may benefit from some gratification of their dependent wishes and a free discussion of their fears and emotions. They can often be reassured by an educational and informational approach to their medical illness and are capable of expressing gratitude to the physician. In contrast, the intense dependency of histrionics is often made worse by gratifying the patient's needs. Offering excessive emotional care may make them greedy or demanding for satisfaction of their needs. Histrionics benefit from firm, kind limit setting (especially to their sexual overtures), with neutral acknowledgment and gratification of their reasonable needs. They may be further helped by focusing on their distortions in reality perception and through interpretation of their splitting mechanisms.

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