The DSM-IV (American Psychiatric Association 1994) diagnostic criteria for histrionic personality disorder are shown in

Table 84-1. These descriptive characteristics do not fit all persons with these disorders and do not comprise all the signs and symptoms of the disorder. They do, however, serve as a means for assembling a series of patients in research and actuarial settings. In treatment, it is helpful to go beyond this menu and to list all the presenting and emerging signs and symptoms. These include not only pathological features but also individually variable inabilities in selective areas of life activities in the realms of work, self-care or creativity, caretaking, and relating well socially.

Differentiation of Level of Self and Other Conceptualization

Earlier, I used the phrase “these disorders” to refer to the typology of histrionic personality disorder. A spectrum of presentations has been reported by many, as reviewed elsewhere. In the past, subcategories were called oral versus phallic, good versus bad, and high-level versus low-level. Although these terms are no longer advisable, in an integrated approach the degree of self-coherency and the maturity of capacity for close relationships with others should be formulated for each patient. The reason is that treatment techniques and course of change will vary depending on such aspects of meaning structure and schematization of self and others. One aspect of such formulations in terms of levels of self and other schematization concerns the degree of dissociative potential of patients, in terms of segregations of different self-concepts without linking and supraordinate identity structures.

Some patients with histrionic personality configurations have neurotic-level conflicts between different goals and ways of reaching these goals but do not have severe vulnerability to sudden and disorganizing deflations in self-esteem. Others have, in addition to conflict, a vulnerability to a chaotic sense of identity. These patients are more likely to either present with or develop in treatment symptoms of depersonalization, derealization, hypochondriacal severe anxiety, and even terror at a sense of personal fragmentation. They will tend to have more symptoms and more explosive shifts in state.

The latter patients are more difficult to treat and could be seen diagnostically as presenting a combination of the style of relating described as histrionic personality disorder and the self pathology described as narcissistic personality disorder or, even more severe, as borderline personality disorder. It is here, however, that descriptive diagnostic systems break down in terms of clinical utility and must give way to individual formulations until an etiological diagnostic system can be developed.

When these individual formulations include inference of a lack of supraordinate self schematic capacities, then the treatment technique should be more supportive: it can still have the exploratory and self-developmental components to be described below, but it must proceed more slowly. That pacing includes tact in giving self-challenging information in small, dose-by-dose components, as well as many repetitions and reviews to determine how the patient is taking this information. In addition, such vulnerable patients need many more rehearsals of new ways of appraising others, verbalizing their feelings, and asserting their needs for the dignity and activity of the self.