What is the recommended treatment for a patient with histrionic personality disorder?

Treatment of Histrionic Personality Disorder

Psychotherapy, specifically psychodynamic or cognitive-behavioral approaches, is the recommended treatment for histrionic personality disorder, as there is no established pharmacologic intervention for personality disorders themselves. 1, 2

Primary Treatment Approach

Psychotherapy as First-Line Treatment

• Individual psychotherapy using psychodynamic or cognitive-behavioral frameworks should be the cornerstone of treatment for histrionic personality disorder (HPD). 1, 2

• Cognitive Analytic Therapy (CAT) has demonstrated effectiveness in treating HPD, with statistically significant improvements in core HPD features including focus on physical appearance, feelings of emptiness, and personality integration. 3

• Psychodynamically oriented individual outpatient psychotherapy has proven efficacious for reducing symptomatology and personality pathology across various personality disorders, though specific evidence for HPD remains limited. 2

Treatment Structure and Duration

• A structured approach with 24 sessions plus follow-up sessions over 6 months has shown clinical benefit in HPD presentations. 3

• Long-term psychodynamic group psychotherapy may also be considered as an alternative format, though individual therapy is generally prioritized based on available evidence. 2

Critical Clinical Considerations

Termination Planning

• Special attention must be paid to termination planning in HPD patients, as sudden deterioration can occur at the point of therapy termination, though patients typically recover and maintain progress with appropriate follow-up. 3

• Four additional follow-up sessions spread over a 6-month post-therapy period can help maintain therapeutic gains and manage termination-related regression. 3

Diagnostic Accuracy

• Clinicians must carefully verify the diagnosis and rule out pseudo-presentations, as some individuals may adopt a histrionic persona as a psychological defense mechanism rather than meeting true diagnostic criteria. 4

• A thorough assessment should confirm that presenting symptoms represent genuine personality pathology rather than learned behavior or institutionalization effects. 4

Pharmacotherapy Role

Limited Evidence for Medication

• There is no specific pharmacologic treatment recommended for histrionic personality disorder itself. The available guidelines focus on personality disorders with more robust evidence (borderline, avoidant, dependent) rather than HPD specifically. 2

• If comorbid conditions are present (depression, anxiety disorders), treat these according to standard guidelines:

  • For comorbid depression: Consider SSRIs or cognitive-behavioral therapy per established depression treatment protocols. 5
  • For comorbid anxiety: SSRIs or SNRIs may be appropriate based on the specific anxiety disorder present. 5

Treatment Formulation Strategy

Individualized Case Formulation

• Use configurational analysis methods to establish links between individualized formulation and treatment techniques, examining:

  • States of mind characteristic of the patient
  • Defensive control processes employed
  • Person schemas and relational patterns 1

• A phase-oriented treatment plan should be developed based on these formulation levels, progressing from symptom stabilization through personality integration. 1

Common Pitfalls to Avoid

• Do not accept self-reported diagnoses without independent verification, as HPD presentations can sometimes represent psychological defenses or learned behaviors rather than true personality disorders. 4

• Avoid abrupt termination without adequate preparation, as HPD patients are particularly vulnerable to deterioration during the termination phase. 3

• Do not prescribe medications targeting personality traits themselves in the absence of specific comorbid Axis I disorders that warrant pharmacologic intervention. 2