What is the treatment for histrionic personality disorder?

Treatment of Histrionic Personality Disorder

Psychotherapy is the cornerstone and primary treatment for histrionic personality disorder, with pharmacotherapy reserved exclusively for comorbid conditions such as depression or anxiety disorders. 1

Primary Treatment Approach: Psychotherapy

The first-line treatment for histrionic personality disorder is structured psychotherapy, not medication. 1 The evidence supports several specific psychotherapeutic modalities:

Clarification-Oriented Psychotherapy

• Clarification-oriented psychotherapy has demonstrated systematic improvements in relationship processes between patients and therapists, which correlates with positive outcomes in 159 patients with HPD. 2
• This approach showed measurable improvements in symptom measures from intake to discharge, representing the first systematic evidence of core therapeutic changes in HPD patients. 2

Cognitive Analytic Therapy (CAT)

• CAT delivered over 24 sessions with 4 follow-up sessions has shown statistically significant improvements in three out of five HPD-specific variables: focus on physical appearance, emptiness, and "child inside" feelings. 3
• This therapy demonstrated clinically significant changes in personality integration and reductions in depression, though termination requires careful management as sudden deterioration can occur at therapy end with eventual recovery. 3

Phase-Oriented Psychotherapy

• A configurational analysis method using theories about states of mind, defensive control processes, and person schemas provides a structured framework for individualized formulation and treatment planning. 4
• This phase-oriented approach links specific formulation levels to treatment techniques, offering a practical guideline for clinicians. 4

Pharmacotherapy: Limited Role Only

Medication should never substitute for psychotherapy and is indicated only for specific comorbid psychiatric conditions. 1

When to Consider Medication

For comorbid major depression:

• SSRIs or cognitive-behavioral therapy should be initiated following established depression treatment protocols (moderate strength of evidence). 5, 1
• The American Psychiatric Association specifically recommends avoiding antidepressants for depressive symptoms in the absence of a current or prior depressive episode. 1

For comorbid anxiety disorders:

• SSRIs or SNRIs may be appropriate based on the specific anxiety disorder present (moderate strength of evidence). 5, 1

Critical Medication Pitfalls to Avoid

• Never prescribe benzodiazepines for impulsivity in histrionic personality disorder, as they may increase disinhibition in Cluster B personality disorders per the American Medical Association. 1
• Avoid premature medication use, as the National Institute of Mental Health advises that medication should never replace psychotherapy as the primary treatment modality. 1

Treatment Process Considerations

Relationship processes between patient and therapist are the most critical therapeutic factor:

• Improvements in the therapeutic relationship systematically correlate with positive outcomes, while process and content changes show only partial relationships to improvement. 2
• The therapeutic alliance and relationship quality should be prioritized and monitored throughout treatment. 2

Termination planning is essential:

• Patients with HPD may experience sudden deterioration at therapy termination, requiring careful planning and extended follow-up sessions to maintain therapeutic gains. 3
• Consider 4-6 follow-up sessions spread over 6 months post-treatment to prevent relapse. 3