Treatment of Histrionic Personality Disorder
Psychodynamic psychotherapy or cognitive-behavioral therapy should be the primary treatment for histrionic personality disorder, with psychodynamic approaches showing particularly strong evidence (effect size 1.79 on observer-rated measures) for long-term personality change. 1
Primary Treatment Approach: Psychotherapy
First-Line Psychotherapy Options
Psychodynamic psychotherapy is strongly supported for histrionic personality disorder, demonstrating a large overall effect size of 1.46, with particularly robust results on observer-rated measures (effect size 1.79) and specific personality disorder pathology measures (effect size 1.56). 1
Cognitive-behavioral therapy (CBT) represents an equally valid first-line option, showing an overall effect size of 1.00, with effect sizes of 1.20 on self-report measures and 0.87 on observer-rated measures. 1
Both treatment modalities have demonstrated effectiveness across personality disorder clusters, though the evidence base specifically for histrionic personality disorder remains limited compared to borderline, avoidant, and dependent personality disorders. 2
Specific Psychotherapy Techniques
Cognitive analytic therapy (CAT) has shown effectiveness in a time-series study, with statistically significant improvements in three core histrionic features: focus on physical appearance, feelings of emptiness, and "child inside" experiences, though deterioration may occur at termination requiring careful management. 3
Configurational analysis methods can be used for individualized case formulation, addressing states of mind, defensive control processes, and person schemas specific to histrionic presentations. 4
Treatment Duration and Format
Long-term treatment is indicated, as psychodynamic therapy effect sizes reflect long-term rather than short-term personality change. 1
Out-patient individual psychotherapy (either cognitive-behavioral or psychodynamic) has the strongest evidence base compared to group, day hospital, or inpatient formats. 2
Alliance-Building Considerations
Critical Therapeutic Relationship Issues
Patients with histrionic personality disorder (Cluster B) characteristically push interpersonal limits and boundaries, requiring clinicians to exercise great care to avoid crossing inappropriate lines while attempting to build rapport. 5
The therapeutic alliance must be established early in treatment, as a strong positive alliance predicts successful outcomes while ruptures lead to premature termination. 5
Histrionic patients' troubled interpersonal attitudes will complicate engagement, necessitating careful selection of interventions to retain and involve the patient effectively. 5
Pharmacotherapy Role
When to Consider Medication
Pharmacotherapy is not a primary treatment for histrionic personality disorder itself, but should be considered only for comorbid conditions. 6
For comorbid depression, SSRIs or cognitive-behavioral therapy should be initiated following established depression treatment protocols (moderate strength of evidence). 6
For comorbid anxiety disorders, SSRIs or SNRIs may be appropriate based on the specific anxiety disorder present (moderate strength of evidence). 6
Medications to Avoid
Do not use antidepressants or benzodiazepines for initial treatment of depressive symptoms in the absence of a current or prior depressive episode. 7
Benzodiazepines should be avoided for impulsivity in Cluster B personality disorders as they may increase disinhibition. 8
Common Pitfalls
Avoid premature medication use: Medication should never substitute for psychotherapy, which remains the cornerstone of treatment. 8
Manage termination carefully: Evidence shows sudden deterioration can occur at therapy termination in histrionic patients, requiring extended follow-up sessions over 6 months post-therapy. 3
Don't assume evidence from other personality disorders applies: The available evidence for histrionic personality disorder specifically is limited, with most research focusing on borderline, avoidant, and dependent presentations. 2