1. Introduction

Recently, data analysis done by the organization Psychology Today proposed that cluster B personality disorders are in the spotlight of many social media because they are more dramatic and often attract others' attention in public circumstances [1]. Among the four cluster B personality disorders (antisocial personality disorder, narcissistic personality disorder, borderline personality disorder, and histrionic personality disorder) [2], histrionic personality disorder (HPD has an outweigh diagnosis on a particular gender. This has raised psychologists’ curiosity about defining factors affecting this result.

Generally, despite the variability of individuals, patients with HPD tend to have a pattern of intensive attention-seeking emotions, behaviors, and excessive need for being approved. They appear to the public by making loud and inappropriate actions, pretending to be sexually seductive types, and expressing strong emotions to attract others’ attention. To be diagnosed, a person needs to have at least 5 symptoms of HPD plus the general symptoms of personality disorder as written in DSM-5. However, gender differences heavily lie in the process of being diagnosed and identifying a patient’s symptoms from both the clinician and the patient’s views. Whether sex biases exist in DSM was investigated by researchers from the various cultural background. But still, the phenomenon of more diagnosis of women than men with HPD appear in almost every country.

Since the effectiveness of HPD treatment relies heavily on the comorbidity of illnesses and individual differences, sexuality for both the therapist and the patient may be more important than imagination. They need to make a judgment after understanding gender roles and possible biases in facing different patients. Thus, this paper is reviewed based on articles and research in the field of histrionic personality disorder. To be specific, it will discuss gender differences of HPD relating to perspectives of the etiology, impacts, and treatment and give potential suggestions for eliminating prejudice determination.

2. Literature Review

2.1. Status Description

2.1.1. Concepts

As updated in The Diagnostic and Statistical Manual of Mental Disorders-V (DSM-5) [2], personality disorders are identified when a person displays a personality style that is pervasive and enduring, deviated from his or her cultural and societal norms, causing oneself distress and harm, and cannot be categorized to other mental illness. HPD is being categorized in cluster B of personality disorders along with three more personality disorders since they all have similarities that people who have at least one of them act dramatically, and erratically, and is easier to shift their emotions and harm their interpersonal relationships. Histrionic people cause extreme distress to both their own life and their life with others because they feel difficult to manage their emotions and speech to maintain relationships with others. Their behavior may be most difficult to comply with social norms and expectations and generated by a lack of empathy and understanding of others.

2.1.2. Diagnosing Criteria

HPD can be diagnosed when no less than 5 symptoms described below are identified, companied by general symptoms of personality disorders. One of the symptoms of HPD is that it is uncomfortable for the subjects to perceive themselves as not being in the center of attention. They may interpret normal relationships as more intimate than they think and engage in sexually seductive behaviors. To drive other’s attention, they may express strong opinions with impressive standpoint, and are often influenced easily by others. Also, they use more time and efforts to decorate their appearance. In addition to excessive emotional expression and they shifts rapidly about their emotions.

2.1.3. Distribution of Patients

In the year 2002, National Epidemiologic Survey on Alcohol and Related Conditions found that there were approximately 1.8% of personality disorders patients diagnosed with histrionic personality disorder [3]. This data represents the rareness of being diagnosed with HPD twenty years ago. However, in 2022, the statistics for HPD diagnosis in the world increased to 2.1% of the overall personality disorders patients reported by Megan Hull [4].

Since personality disorder focuses on a person’s development of self-consciousness and relationship with society, it is usually diagnosed after 18 years old to prevent frequent growing and changing of personality [5]. According to the gender distribution of HPD, four times more than a woman is likely to be diagnosed than a man as proposed by Jennifer et al in 2021 [6]. To investigate the underlying differences between the two genders, this paper aimed to analyze potential different etiology, impact as well as treatment of HPD patients.

2.2. Etiology

2.2.1. Genetics

Findings in terms of genetics suggested the predisposition of genes affects gender differences in HPD to some extent. Torgersen and Psychol studied this disorder by using twins’ studies [7]. They found out that hysterical dimensions have genetic and familial links to women, but not in men. This result may suggest a vulnerability of gender in response to inheritable genes, or predisposition. There was a similar finding from Cloninger et al in 1986 [8] who studied somatization in terms of family study, in which somatization was a possible history of HPD as mentioned above and described by Bruce [9]. However, no specific genes or mutations can be traced to determine the possibility of genetic impact, which requires researchers in the future to use more standardized and high-tech facilities in doing research.

A family study proposed by Arkonac in 1963 gave evidence showing HPD (or hysterical personality in the previous DSM) patients have more chance to inherit hysterical behaviors in females’ relatives but instead exhibit more sociopathy and alcohol abuse disorder in males [10]. In contrast, Cantwell et al in 1972 [11] build the reliability of the result that HPD patients, regardless of sex, were strongly associated with children developing HPD. This indicates that different gender does not have the same pathogenetic factors of HPD, but still have different clinical pictures as expressing sociopathy or hysterical personality.

In addition to Warner’s review [12] of the link between sociopathy and hysterical personality, an immense amount of previous data indicated an existing familial link and some common characteristics shared in these two personality disorders. However, this study failed to address the causes of gender differences in HPD, rather than only focusing on this phenomenon. Their findings illustrate a strong correlation between HPD, and personality dispositions that happened every day, which indicates that a person’s natural personality, such as introvert or extrovert, also influences the rate of getting HPD to a large extent. HPD may be prototypically appeared as amplifying the previous traits of patients themselves.

2.2.2. Sexual Characteristics and the DSM Criteria

Except for genetic factors of inheritance, individual traits also affect influence the diagnosis of HPD in both genders. One argument is that females and males have different manifestations of possible HPD characteristics. This is verified by Hamburger et al in 1996 [13] and Bornstein et al in 1999 [14], in which Hamburger suggested that men are more likely to express the symptoms of antisocial behaviors and Bornstein found that these behaviors are more indirect than women. Thus, this sexual characteristic affects the determination of clinicians as more aggressive and indirect seductive behaviors of men would be diagnosed with antisocial personality disorder in replacing histrionic personality disorder.

On the contrary, women who present identical behaviors were classified more frequently in HPD because their behaviors are more relevant to prototype symptoms in DSM. This is further supported by Sprock in 2000 [15] describing that masculine HPD behavior compared to feminine and non-sex-typed ones were less likely to be viewed as consistent with HPD behaviors. She showed examples of HPD behaviors by letting participants rate on a scale of 7 to determine the property of the behavior (masculine or feminine or neutral). These behaviors represent women as tendencies to get upset due to others’ comments and physically approach others (both rated 6.14), whereas, men, have an increased likelihood of starting quarrels to get attention (6.00 point). Similarly, all genders have non-gender-typed behavior such as being self-centered in getting things to happen in their ways, with an average rate of 6.33. However, there was also no statistical significance in the study to show relationships between sex roles and the DSM criteria of HPD. Typically, women manifest their theatrical actions by taking dramatic and flirting with others to attract others’ attention, with 6.57 and 6.45 respectively. This may be proposed as a premise about different representations of symptoms on a natural basis. Therefore, to eliminate gender overgeneralization, DSM needs to consider the fundamental differences in different genders’ behavioral choices. In addition, the diagnosis can be sex-typed based (sex-related symptoms of diagnosing HPD should be measured and set). Still, not all criteria are tested to have a gender bias in the results done by Maureen and Thomas in the year 1989 [16].

Women were assumed to seek more help than men in Phillips and Segal’s research in 1969 [17]. However, Clancey and Gove in 1974 showed an opposite point of view, that they found that guys tend to seek more help [18]. It suggested that multiple variables may play parts in diagnosing HPD, such as social norms, gender roles, etc so that these self-reported diagnostic procedures have low reliability as well as validity. Moreover, 90% of HPD female patients met the criteria of hysterical neurosis. This means that the diagnosis of HPD is unspecific and unclear which may be ambiguous with other mental illnesses. Thus, DSM should give specific or exampled HPD behaviors that set a scope for the illness.

2.2.3. Culture and Society

According to cultural and societal influences, the general data of the diagnosis of HPD using DSM has shown that women have HPD over men. This fact does not indicate directly that women are more vulnerable to getting HPD, rather than considering the cultural expectations that lie in diagnosis. It is still not clear whether women are at high risk of getting HPD or being diagnosed by having HPD. Supporting there were few biases in the manual, on one hand, Reich in 1997 [19] as well as Zimmerman and Coryell in 1989 [20] reviewed and assessed DSM-III. They showed similar results that there was no significant sex bias in the DSM in the diagnosis of HPD, even though there were indeed more female HPD patients. This suggests that PD criteria were unrelated to the patient’s sex, but more research should be done to eliminate the doubtful question that the clinician's preference for this diagnosis in women may be due to underlying sex-related psychopathological differences.

On the other hand, as Hamilton hypothesized in 1991 [21], clinicians tend to think people are male (people=male theory) in several criteria manual, this was resulted by the consequence of employing male-based pronouns in general. Culture indeed influenced the history of HPD identifying and diagnosing. There are a large number of differences produced by women and men, but only the defense style of both genders was similar to each other, as proposed by Bornstein in 1998 [14].

Referring to the clinician’s sex, a majority of studies suggested that it would influence the diagnosis of HPD patients. However, this is more corresponding to all the disadvantages of therapy and diagnosis, since even professionals have their personal preferences and school to use a method to identify and ask leading questions. Therefore, different-sex of them may allow gender discrimination or expand the closeness of therapy and the patient, affecting the efficiency and validity of diagnosing. As for the patient’s sex, from Maureen and Thomas [16], the clinician would not be affected by gender when they tried to determine the existence of HPD-liked behaviors, such as exaggerated reaction to a minor significant event, but they would be affected by the sex when came to a determine whether it is antisocial personality disorder or histrionic personality disorder.

2.2.4. Impacts of HPD Patients on Different Genders

Histrionic individuals are greatly affected by their deep-inside cognition of the self and the world, regardless of gender. They generally have low self-esteem and low self-consciousness, but they react hyper confidently in public places. So, they may give others wrong identity interpretations which results in fewer interpersonal relationships. According to Mustafa et al in 2019 [22], the results illustrated that the belief of HPD is correlated with the need for both being approved and liked by the society, especially on social media. The patients usually show their theatrical expression of emotions and stereotypical behavioral patterns on public platforms. By gaining effective attention through these platforms, they are more likely to develop social media addition, which influences their daily life and relationship with family members because they may outlook the performance in the real world.

Moreover, females with HPD have a higher rate of doing beauty surgery as suggested by a study of couples. This means that they may have lower self-esteem so they engaged in this method to meet their gratification.

2.2.5. Impacts on Others

There is a book called Journal of Sex and Marital Therapy [23] which includes an article targeted women who were diagnosed with HPD. Through interviews and therapies, histrionic women reported more sexual boredom, and greater orgasmic dysfunction and were more likely to enter into an extramarital affair than control conditioned women. Specifically, these women caused their husband's or loved ones' troubles because they engaged in obsessive attention-seeking but low-durable behaviors to meet their ego gratification, which harms their intimate relationships, especially through a sexual affair. To maintain a positive relationship with others, people need to have empathetic feelings and understanding of others. However, HPD women tend to ignore this aspect in interpersonal relationships and are often unaware of this failure. Therefore, there is a greater chance for them to develop a so-called “sexual narcissism” since they have their definition of being given a sexual encounter, regardless of their partner’s feelings. In addition, their spouse has more chance to feel a permanent sense of insecurity, frustration, and dissatisfaction.

On the other hand, not only did women encounter interpersonal difficulties, but families and couples with one of the members having HPD also suffered intensively. A qualitative study of couples showed that some HPD patients even became aggressive if they did not receive attention, approval, and admiration from their partners. Sometimes, this aggression even led to more chances of violence [24]. In addition, insufficient gratitude is often thought in HPD patients when they engaged in sexual affair, and they are prone to tiredness.

Moreover, Disney studied that HPD is correlated to the divorce rate in 2012 [25]. This means that interpersonal relationships are to some extent distorted through interactions between HPD patients and others, including spouses, children, and family. Also, relationships with colleagues, neighbors, classmates, and societal friends are greatly influenced by the disorder. This suggests the relationship vulnerability of HPD patients.

Overall, we can say that HPD patients do betray more, but people other than the patients should pay more attention to responding to them, minimizing further harm to their mental health. There are no significant gender differences in the vulnerability of HPD patients in various conditions, according to Minassadat [26], such as their functional vulnerability, and emotional vulnerability. There are a lot more impacts that the disorder brings to different individuals and the society, and people need to show an open-minded view toward them as much as possible.

2.3. Treatment

No medical prescription has been found effective to treat HPD patients unless there is a comorbidity of illnesses. For instance, patients can take antidepressants if they also suffer from a major depressive disorder. dialectical behavior therapy, functional analytic psychotherapy, cognitive behavioral therapy, and cognitive analytic therapy are used to treat personality disorders, and the latter two methods focus on treating HPD.

It is argued that people of a different sex may have a different purpose in seeking help and that men are more likely to find a short-term method rather than talking about emotional changes in the long term like women. In the overall mental health field, genders react distinctively toward psychotherapy, but a few tried to identify the difference between patients receiving treatment for HPD. This might be due to rare samples and unique manifestations of personality disorders in each patient so that they react in their way. Although quite a few researches focus on exploring sex-based therapy, a study done by Louise et al in 2016 [27] demonstrated statistical significance related to types of therapy, dealing preferences, and ways to seek help. Here are two therapy specified to treat HPD patients, Cognitive analytic therapy and functional analytic psychotherapy.

2.3.1. CAT: Cognitive Analytic Therapy

Cognitive Analytic Therapy (CAT) is a method used to treat HPD. It is unique apart from other treatments because it concentrates on leading patients to reform their personalities through different intensity practices. Three stages of the approach of CAT are integrated into treating HPD, of which the first stage is called state stabilization, then modifying communication style and interpersonal reactions, and lastly change patterns and schemas.

The majority of research used qualitative methods to test the treatment of HPD but fail to use quantitative data to generate the strength and limitations of each treatment. However, CAT is a time-series approach that can detect the statistical significance of a patient. So, researchers and therapists can compare and contrast data from the patient to analyze for trends, and efficiency of the therapy and find possible turning points across chapters of therapy [28].

A case describes how therapists treated a female patient: firstly, by letting the patient tend less self and other criticism, then, teaching her to interact with people in other relationships which intended to not use make-up or any decoration on the patient’s clothes. The third and fourth steps tend to reduce seeking attention from others, and then develop an ability to tolerate the fact that they cannot be the center of attention as often as before. There were 4 more phases of the procedure, and all 8 of them tried to deal with each symptom of the participant.

CAT has proven to be effective in this case, that there was a clinically significant improvement in participant’s mental health and personality integration after the treatment, with no deterioration in the follow-up. However, although three out of the five experimental variables (physical appearance, emptiness, and child inside) illustrated a significant effect, increasing anxiety was observed and recorded in the patient because she was going to the termination of the therapy. She is also afraid that her HPD will inherit from her child. Pros and Cons of the CAT method rely on individual differences, for example, whether there is a comorbidity of the disorders. Some patients have depression along with HPD, so they are less likely to turn to a healthy and positive mental status even after the CAT. They were also less likely to receive medicine for depression when more disorders were overlapping each other.

2.3.2. Functional Analytic Psychotherapy (FAP)

An investigation of the effectiveness of FAP on HPD was done by Glenn et al in 2003 [29], which used functional analytic psychotherapy (FAP). It is based on an assumption that problems a client has with the therapist also happen in their daily life with other relationships, so it is vital for the therapist in detecting behaviors of HPD because all the phases of therapy are based on the discovery of clinically relevant behaviors (CRBs). CRBs are classified into three conditions throughout this psychotherapy, in which CRB1s represent problematic behaviors of HPD patients that they want to change, CRB2s represent in-session clients’ behavioral improvements, and CRB3s indicate variables that are responsible for the client’s problem and improved behaviors. The therapists need to actively discover and check these CRBs while they are interacting with HPD patients. Therefore, they can summarize a set of effective behaviors used to improve HPD patients’ positivity toward other interpersonal relationships.

The case proved that FAP is effective for the participant, which is a male.

This therapy allowed him to better determine what kind of relationships he prefered to have with others and what he can bring to those relationships. The findings showed that the patient was able to show less dramatic behavior during treatment and with other people outside of treatment, as well as paid little attention to his own appearance. The therapy was even descriptively helpful for the patient as he engaged in interpersonally close interactions with others more and behave more enjoyable when he was with the therapist after several chapters of treatment. On contrary, FAP has two major problems. The first one is that each participant is different in symptoms and interpersonal ability, so therapists need to sense CRB1 and CRB2 uniquely. Plus, the other issue is that therapists need to notice every CRBs while patients interact with them, which may involve humanistic errors.

Overall, this approach allows patients to reduce their targeted problems and increase prosocial behaviors, but it is still unclear about how to treat individuals who has distinctive HPD-like behaviors.

3. Conclusions

After research and gathering, it is found that genders are abundant differences in the presence of HPD. For example, the likeliness of diagnosing HPD for males is only quartered compared with females. The differences lie within the range of genetics, sexual biases and roles, and culture and society. For inheritance factors, women have a predisposition to familial factors and tend to have a vulnerability to HPD, whereas men do not have such discoveries. Although no specific gene and pathogenetic factor are responsible for developing HPD, different-sex truly has different clinical pictures to express themselves. This is due to gender roles in most societies, people hope that females can act more seductive and less aggressive than males to seek social gratification. This lead to different strategies to attract others and manifest HPD, which makes it clinicians difficult to identify symptoms and diagnosis.

Meanwhile, men and women have distinctions in finding treatment. Although no specific psychotherapy is designed only for one particular gender patient, men and women have different preferences in choosing to take psychotherapy.

The DSM or any classification system has several ways to improve. For instance, HPD symptoms description can focus on the difference with hysterical neurosis so that the criteria will be not as vague as now to fit 90% of women in both disorders. Also, classification systems can emphasize more sex-based symptom descriptions and provide sex-typed treatment specifically.