Re: CT for Histrionic Personality Disorder

This is not a topic which is easy for me to address briefly, therefore I’m posting an article which Barbara Fleming wrote for the International Cognitive Therapy Newsletter in 1988. She has authored more recent discussions of this topic which appear in Clinical Applications of Cognitive Therapy (Plenum, 1990), Cognitive Therapy of Personality Disorders (Guilford, 1990), and Persönlichkeitsstörungen: Diagnostic und Psychotherapie. (Psychologie Verlags Union, 1996).

Cognitive Therapy with Histrionic Personality Disorder: Resolving a Conflict in Styles

Barbara Fleming, Ph.D.

Case Western Reserve University and Cleveland Center for Cognitive Therapy

Histrionic Personality Disorder is characterized by a "pattern of excessive emotionally and attention seeking, beginning by early childhood and present in a variety of contexts."(DSM-III-R , Pg. 348). These clients are lively, dramatic and, as the title implies, histrionic in style. They are constantly drawing attention to themselves and prone to exaggeration. Their behavior is overly reactive and intense. They are emotionally excitable and crave stimulation, often responding to minor stimuli with irrational, angry outbursts or tantrums. Their interpersonal relationships are impaired and they are perceived by others as shallow, lacking in genuineness, demanding, and overly dependent.

As noted in DSM-III, the client with a Histrionic Personality Disorder has been conceptualized as a caricature of what is defined as femininity in our culture - vain, shallow, self-dramatizing, immature, overly dependent, and selfish. This disorder is most frequently diagnosed in women, and when it is diagnosed in men it has been associated with a homosexual arousal pattern. This gender differential, however, may be more a product of our societal expectations than a true difference in occurrence. It has been suggested that Histrionic Personality Disorder is more appropriately seen as a caricature of sex roles in general, including extreme masculinity as well as extreme femininity (Kolb, 1968; MacKinnon & Michaels, 1971; Malmquist, 1971). The caricature of femininity is fairly commonly diagnosed as histrionic, yet a caricature of masculinity (an overly "macho" male who is dramatic, sensation-seeking, shallow, vain and egocentric) is rarely diagnosed as Histrionic Personality Disorder and even less likely to seek treatment.

Most of the conceptualizations of Histrionic Personality Disorder have been psychodynamic in nature. Early dynamic descriptions emphasized unresolved Oedipal conflicts as the primary determinant of this disorder, while later dynamic theorists focus on the presence of a more pervasive and primitive disturbance arising during the oral stage of development (Halleck, 1967). Shapiro, although primarily psychodynamic in orientation, discusses many of the cognitive aspects of the "neurotic style" of the hysteric (1975). More recently, Millon (1981) has presented what he refers to as a bio-social learning theory view of personality disorders, including the Histrionic Personality Disorder. When the thoughts and beliefs of histrionic clients are examined, however, it seems that a cognitive conceptualization which combines some of the ideas of Millon and Shapiro with Beck's cognitive theory could clarify many of the aspects of the behavior of histrionic clients and suggest areas for useful clinical intervention.

One of the basic beliefs of the person with a Histrionic Personality Disorder seems to be "I am inadequate and unable to handle life on my own." Depressives with this underlying assumption might dwell on the negative aspects of themselves, feeling worthless and hopeless. Histrionic persons, however, seems more likely to draw the conclusion, "Well, then, I'll need to rely on others to take care of me," and then actively sets about finding ways to insure that their needs are sufficiently met by others. As Millon (1981, pg. 131) explains, both the dependent personality and the histrionic personality are dependent upon others for attention and affection, but the dependent personality gets taken care of by emphasizing his or her helplessness and taking a passive role while the histrionic person takes the initiative in actively seeking attention and approval.

Since attention and approval are seen as the only way to survive in the world, histrionic clients tend to hold the underlying assumption that it is necessary to be loved by everyone for everything one does. Any rejection at all is seen as devastating, even when the person doing the rejecting was not actually that important to the client previously. Just the idea that one can be rejected at all reminds the client of his or her tenuous position in the world and is extremely threatening. Feeling basically inadequate yet desperate for approval as their only salvation, people with a Histrionic Personality Disorder are not willing to relax and leave the acquisition of approval to chance. Instead, they work diligently to seek this attention in the ways they have best learned to achieve them--often by fulfilling an extreme of their sex-role stereotype. Female histrionics (as well as some of the males) seem to have learned from an early age that they are rewarded for cuteness, attractiveness, and charm rather than for competence or for any endeavor requiring careful thought and planning. The more "macho" male histrionics learn to play an extreme masculine role, being rewarded for the appearance of virility, toughness, and power rather than actual competence or problem-solving. Understandably, then, both male and female histrionics learn to focus attention on the playing of roles and "performing" for others. Although winning approval from others is the primary goal, they have not learned to carefully observe and analyze the reactions of other people and systematically plan ways to please or impress them. Instead, the histrionic person has been more frequently rewarded for the global enactment of certain roles, so it is in the enactment of these roles that he or she learns to excel. This striving to please others is not necessarily dysfunctional in and of itself. Histrionic people, however, get so involved in this strategy that they take it beyond what is actually effective. They can get carried away with dramatics and attracting attention, losing sight of their actual goal and seeking stimulation and drama for its own sake.

This focus on the external and the dramatic could lead to the characteristic thought style which has been described by Shapiro (1965). The thinking of the histrionic client is seen as impressionistic, vivid, and interesting but lacking detail and focus. This seems to result not only from the histrionic's lack of introspection but also from the fact that he or she simply does not attend to details and specifics in the first place. What is not clearly perceived cannot be recalled in a specific manner, so histrionics' memories of events must necessarily remain global and diffuse. Their resulting objective deficiency in knowledge of specific details and facts, along with a lack of experience in systematic problem-solving, can lead to serious difficulty in coping constructively with conflicts. This serves to further reinforce their sense that they are inadequate to cope with life alone and need to rely on the help of others.

Since the days of Freud's work with Dora, psychoanalytic treatment has generally been seen as the treatment of choice for the various classes of hysteria. Little has been written about the treatment of hysteria from a behavioral point of view (summarized by Bird, 1979), and even less has been presented about behavioral treatment specifically for the client with a Histrionic Personality Disorder. Given the problems that global, diffuse thinking causes for the histrionic client, it seems that a specific, focussed approach to treatment might be particularly useful.

Although admittedly an oversimplification, there is some truth to the statement that we need to "teach the hysteric to think and the obsessive to feel" (Allen, 1977, p. 317). Since the characteristic thought style of clients with Histrionic Personality Disorders is dysfunctional to them in many ways, Cognitive Therapy could be seen as a particularly appropriate treatment. Cognitive Therapy is designed to help clients learn "to identify, reality-test and correct distorted conceptualizations and the dysfunctional beliefs (schemas) underlying these cognitions" (Beck, Rush, Shaw, & Emery, 1979, p.4.). It is a systematic and structured treatment, focusing on specific target problems and goals. The cognitive therapist tries to be well-organized and comes to the session prepared to help the client work systematically towards the achievement of specific goals. The histrionic client, although perhaps cooperative and eager to work, comes to the session with an approach to life which is diametrically opposed to the systematic, structured nature of Cognitive Therapy. With such different basic styles, both the therapist and the client can find Cognitive Therapy quite difficult and frustrating; but, if this conflict in styles can be gradually resolved, the cognitive changes facilitated by therapy can be particularly useful to the client. The therapist needs to maintain steady, consistent effort and flexibility if clients are to accept an approach which is originally so unnatural to them.

Teaching the histrionic client to use the techniques of Cognitive Therapy involves teaching an entirely new approach to the perception and processing of experience. Even before the client can begin to address the issue of monitoring thoughts and feelings, he or she needs to learn to focus attention on one issue at a time. Only then can details of events, thoughts, and feelings be identified. In treating many other disorders, cognitive techniques are basically tools used to help the client to change feelings and behavior. With Histrionic Personality Disorders, however, learning the process of Cognitive Therapy is more than just a means to an end; in fact, the skills acquired just by learning the process of Cognitive Therapy can constitute the most significant part of the treatment.

Since the histrionic client is generally dependent in relationships, the use of collaboration and guided discovery is particularly important. The client is likely to view the therapist as the all-powerful rescuer who will make everything better, so the more active a role he or she is required to play in the treatment the less this image will be maintained. When he or she brings a series of problems to the therapist and asks for quick solutions, the therapist needs to be careful not to be seduced into the role of savior but rather to use questioning to help the client arrive at his or her own solutions.

As one aspect of teaching these clients to focus their attention and to identify thoughts and feelings, it is important to reinforce them for competence and attention to specifics rather than for their more commonly reinforced emotionality and manipulation. If they can learn ways that attention to details and assertion can pay off in the sessions, they may also be able to learn that being assertive and doing active problem-solving can pay off more than manipulation and emotional upheaval in the real world. Thus, it is important for the therapist to be aware of attempts at manipulation within the therapy, so that they are not rewarded. Histrionic clients often maneuver to earn "special status" as clients, having unusual fee arrangements or scheduling considerations. Their demands may seem insatiable and any refusal to comply can be seen as rejection. These clients, therefore, need to learn that there are limits to the demands they can successfully make and that limits are not necessarily a sign of rejection. The therapist needs to set clear limits in the therapy and be firm about enforcing them, while rewarding assertive requests within these limits and demonstrating caring in other ways.

The initial step in Cognitive Therapy with any client involves learning to set an agenda for the session. This generally straightforward and brief method of jointly making a plan for the session helps to enhance the collaborative relationship between the client and the therapist and structures the session to allow for focusing on goals. Since the inability to focus attention is one of the major problem areas for the client with a Histrionic Personality Disorder, the process of learning to set an agenda takes on additional significance. Before any real problem-solving can take place, the client needs to learn to focus attention on specific topics within the therapy session, and the setting of an agenda is an excellent place to begin working on this. Since setting a clear, specific agenda is likely to be a foreign concept to the histrionic client, it is necessary to use a graded task approach along with a great deal of patience. Getting the client to agree on even very broad, vague agenda items without going into extensive elaboration on each area can be quite an accomplishment. If the therapist remains flexible, however, and gradually works to impose more structure, even the most histrionic client can learn to cooperate with the setting of an adequate agenda.
Since focusing attention on specific goals is difficult for histrionic clients, and their natural tendency is to want to come into the session and dramatically fill the therapist in on all the traumatic events of the week, it may be important to schedule a part of each session for that purpose. Thus, one agenda item could be to review how things went during the week (with a clear time limit) so the therapist can be empathic and the client can feel understood; then the rest of the session can be concentrated on working towards goals.

After setting the agenda, the next step in any Cognitive Therapy is the setting of specific goals for the treatment. This is a challenging but crucial stage in the treatment of the histrionic client. One of the largest problems in the treatment of these clients is that they often do not stay in therapy long enough to make significant changes since, as with other activities and relationships, they tend to lose interest and move on to something more exciting. One key to keeping histrionic clients in treatment is to set goals which are genuinely meaningful and perceived as urgent to them, and which present the possibility of deriving some short-term benefit as well as longer term accomplishments. They may have a tendency to set broad, vague goals which sound "noble" and impressive and fit their image of what is expected from a therapy client. They may talk about "feeling better," "living a happier life," "being a better wife and mother," or "being more of a success." It is crucial, however, that the goals be specific and concrete, and that they genuinely feel important to the clients (and not just an image of what they think they "should" want). The therapist can help them to operationalize their goals by asking questions like, "How would you be able to tell if you had achieved your goal?", "What exactly would look and feel different, in what ways?" and "Why exactly would you want to accomplish that?" It may be useful to have clients fantasize in the session about how it would feel to have changed their lives, in order to help them begin to fit their ideas together into a tentative model of who they would like to become. Since one of the main ways the therapist will be able to keep the client in treatment is by demonstrating actual changes towards the goals, the importance of goal-setting cannot be overemphasized.

Once the goals have been set, they can be enlisted as an aid to help teach the client to focus attention. When an agenda has been set, but the client continually wanders off the subject (as he or she invariably will), the therapist can gently but persistently ask questions such as, "Now, that's very interesting, but how is that related to the goal we agreed to discuss?" If he or she continues to oppose efforts to focus on the agreed upon topic (despite having had time scheduled for ventilation), the therapist can introduce one of the primary cognitive techniques in the treatment of histrionic clients: the listing of advantages and disadvantages.

Helping the client to make conscious choices within the therapy session by examining the "pros and cons" of various courses of action is a useful antecedent to learning to make such choices in daily life. The histrionic client tends to react emotionally and dramatically to situations, rarely stopping to think or paying attention to the possible consequences. As a result, he or she tends to feel helpless and out of control over what happens. Exploration of the advantages and disadvantages of changing and working towards goals early in the treatment can help to minimize resistance and make it especially obvious to both the client and the therapist when it occurs. Often, when asked about the disadvantages of changing in the desired ways, the client will adamantly exclaim that it would be wonderful to change and there could not possibly be any disadvantages. With careful examination, it will become clear that changing does have its costs, including that of having to acknowledge some responsibility for actions rather than blaming external forces. If the therapist simply insists that the client focus attention on goals, the client can fight this and a power struggle may ensue with the client arguing that the therapist is "mean" and "doesn't understand." On the other hand, if the therapist consistently points out that it is the client's choice how to spend the therapy time but that achieving the desired goals will require some focus of attention, the client is left to make the decision and whatever is chosen feels more like it came from the client than from the therapist.

After the initial stages of the treatment, the actual therapy will depend to some extent on the client's particular presenting problem and goals. In general, the same Cognitive Therapy techniques would be used with histrionic clients as would be used to treat similar problems in other clients (such as depression, anxiety, etc.) The therapist, however, would need to be prepared to spend additional time in the initial stages of each technique, helping the client to adapt to the structure and to the focus of attention required. Given the hypothesis that the histrionic client's problems are exacerbated by their global, impressionistic thought style, and their inability to focus on specifics, it seems that regardless of the presenting problem teaching the client to monitor and pinpoint specific thoughts will be the crux of the treatment.

For example, in helping histrionic clients reduce depression, the therapist would use the well-established procedures for the Cognitive Therapy of depression (Beck et al., 1979). In teaching them to monitor thoughts using dysfunctional thought sheets, it is likely that a great deal of time will have to be spent on the first three columns, specifying events, thoughts, and feelings. It is unrealistic to expect histrionic clients to be able to go home and monitor thoughts accurately after a simple explanation and demonstration in the session, although this may be possible for many other types of clients. More commonly, histrionic clients will forget the point of monitoring thoughts and will instead bring unstructured pages of prose describing their stream of consciousness throughout the week. They should be reinforced for trying to do the homework, but the procedure will need to be explained again with a focus on the idea that the goal is not just to communicate with the therapist but to learn the skill of identifying and challenging thoughts in order to change emotions If they strongly feel the need to communicate all their thoughts and feelings to the therapist so that the therapist can understand them well enough to help them, they can be encouraged to write unstructured prose in addition to the thought sheets (but not as a substitute).

Once clients have learned to identify their cognitions to some extent, they can begin to make gradual changes in their problematic thought style. The dysfunctional thought records, most widely known for their use in treating depression, can also be used to help clients challenge any thoughts which prove to be dysfunctional for them. Cognitive distortions can be pinpointed and modified, and care can be taken to help them to distinguish reality from their extreme fantasies. Thought sheets can be especially useful in the process of reattribution: helping clients to begin to make more accurate causal attributions. Fred (discussed above) would attribute any slight change in his physical condition to a terrible disease and immediately conclude that he was going to have a heart attack and die. To him, it made no difference whether he became slightly lightheaded due to inhaling gasoline fumes from pumping his own gas, smelling ammonia in a restroom that had just been cleaned, or having a panic attack. Whatever the actual cause of his slight lightheadedness, he immediately concluded he was dying. Teaching him to stop and explore the possible alternative causes for his physical symptoms helped him to make more appropriate causal attributions and interrupt his cycle of panic.

Since histrionic clients have vivid imaginations, their cognitions often take the form of vivid imagery of disaster rather than verbal thoughts. Challenging cognitions is not restricted to verbal thoughts; in fact, imagery modification is an important part of Cognitive Therapy with the histrionic client. The therapist needs to specifically ask them what images go through their minds at upsetting times, since otherwise clients may not realize that imagery is important. Since images can serve as powerful emotional stimuli, neglecting them in the treatment by focusing only on verbal thoughts can greatly decrease the effectiveness of treatment (Beck, 1970).

Once clients have learned to identify their cognitions to some extent, the self-monitoring procedures can be used to help them begin to control their impulsivity. As long as situations occur and they automatically react emotionally and in a manipulative manner, it is very difficult to make any change in their behavior. If they can learn to stop before they react (or, using a graded task approach, stop in the early stages of their reactions) long enough to note their thoughts, they have already taken an major step towards self-control. Thus, even before they learn to effectively challenge their cognitions, the simple pinpointing of cognitions can serve to reduce impulsivity. As histrionic clients begin to learn to pause before reacting, they can also benefit from specific problem-solving training. Since they are rarely aware of the consequences before they act it is helpful for them to learn to do what has been called "means-ends thinking" (Spivack & Shure, 1974). This problem-solving procedure involves teaching the client to generate a variety of suggested solutions (means) to a problem and then accurately evaluate the probable consequences (ends) of the various options.

The treatment goals of histrionic clients often involve improving their interpersonal relationships. They are so concerned about maintaining attention and affection from others that they dominate relationships in indirect ways which seem to carry less risk of rejection. The methods that they most generally use to manipulate relationships include inducing emotional crises, provoking jealously, using their charm and seductiveness, withholding sex, nagging, scolding, and complaining. Although these behaviors seem sufficiently successful for the clients to maintain them, they have long-term costs which are often not apparent to clients due to their focus on the short-term gains. Once clients are able to pause and examine their thoughts when they begin to have a strong emotional reaction, they can learn to challenge them.
Challenging their immediate thoughts may not be sufficient, however, since histrionic individuals so often use emotional outbursts to as a way to manipulate situations.

Martha was a 42 year old woman who was married to a man who worked long hours and did not pay as much attention to her as she wanted. Often when her husband came home late from work, Martha would have a temper tantrum, with automatic thoughts such as "How can he do this to me? He doesn't love me any more! I'll die if he leaves me!" As a result of her tantrum, however, she got a great deal of attention from her husband and he would make clear statements of his love for her, which she found to be very reassuring. Thus, in addition to directly challenging her thoughts when she got emotionally upset, Mary also needed to learn to ask herself, "What do I really want now?." Only when she realized that what she really wanted at that point in time was reassurance from her husband could she begin to explore alternative ways of achieving this.

Once clients can begin to stop and determine what they want out of the situation, they can be taught to explore the various methods for achieving that goal and look at the advantages and disadvantages of each. Thus, they are presented with a choice between having a temper tantrum and trying other alternatives. Instead of asking them to make permanent changes in their behavior, the therapist can suggest that they set up brief behavioral experiments to test out which methods are the most effective with the least long-term cost. Setting up brief behavioral experiments can be much less threatening to clients than the idea of making long-term behavior changes and may help them to try out some behaviors that they would be unwilling initially to make a commitment to.

Once clients are able to explore various means of attempting to get what they want, the therapist can help them to consider the advantages of a method which may be quite new to them: assertiveness. The process of assertiveness training with histrionic clients involves more than just helping them learn to more directly communicate their wishes to others. Before they can communicate their wishes to others, they need to learn to identify those wishes and attend to them. Having spent so much time focusing on how to get attention and affection from others, these clients have lost sight of what it actually is that they want. Thus, effective assertiveness training with histrionic clients will involve using cognitive methods to help them pay attention to what they want in addition to the behavioral methods of teaching them how to communicate assertively.

Of course, the experience of the client in the session needs to reinforce the idea that assertion and competence can be just as rewarding as manipulation and dramatics, if not more so. Thus, the therapist must be careful to reward attempts at clear communication and assertion, without falling into the patterns of so many of the client's previous relationships. This can be quite a challenge even to the experienced therapist, since the style of the histrionic client can be very appealing and attractive and dramatic renditions of experience can be quite absorbing, entertaining, and amusing. The unwary therapist can easily be maneuvered into taking on the role of "rescuer," taking on too much of the blame if the client does not work towards change and giving in to too many demands. This may lead to the therapist feeling manipulated, angered, and deceived by the histrionic client. A therapist who strongly wants to be helpful to others may inadvertently reinforce the client's feelings of helplessness and end up embroiled in a reenactment of the client's usual type of relationship. The methods of Cognitive Therapy can be useful for therapists as well as clients. When the therapist finds himself or herself having strong emotional reactions to the histrionic client and being less than consistent in reinforcing only assertive and competent responses, it may be time for the therapist to monitor his or her own cognitions and feelings. Adapting these same procedures for the use of the therapist can be helpful in recognizing inconsistencies in his or her own behavior which could be interfering with the process of the treatment.

At the same time that clients work to improve their relationships, it is important that they also challenge their beliefs that the loss of the relationship would be disastrous. Even though their relationships may improve, as long as they still believe that they could not survive if the relationship ended, they will have difficulty continuing to take the risks of being assertive. Fantasizing about the reality of what would happen if their relationship should end and recalling how they survived before this relationship began are two ways to begin helping the client to "decatastrophize" the idea of rejection. Another useful method is to set up behavioral experiments which deliberately set up small "rejections" so the client can actually practice being rejected without being devastated.

Ultimately, clients need to learn to challenge their most basic assumption: the belief that "I am inadequate and have to rely on others to survive." Many of the procedures discussed above (including assertion, problem-solving, and behavioral experiments) can increase self-efficacy and help the client to feel some sense of competence. Given the difficulty these clients have in drawing connections, however, it is important to systematically point out to them how each task they accomplish challenges the idea that they cannot be competent. It can also be useful to set up small, specific behavioral experiments designed to test the idea that they cannot do things by themselves.

Even clients who are able to see the advantages of thinking clearly and using assertion may become frightened by the idea that if they learn more "reasonable" ways of approaching life they will lose all the excitement in their lives and become drab, dull people. Histrionic people can be lively, energetic, and fun to be with and they stand to lose a lot if they give up their emotionality completely. It is therefore important to clarify throughout the treatment that the goal is not to eliminate emotions, but to use them more constructively. For example, clients can be encouraged to be dramatic when writing their rational responses, making the rational responses more powerful. Thus, when Suzy was challenging the automatic thought "I'm too busy" while she was procrastinating about doing her homework, her most influential rational response was, "That's a pimply white lie and you know it!"

For clients who feel reluctant to give up the emotional trauma in their lives and insist that they have no choice but to get terribly depressed and upset, it can be useful to help them gain at least some control by learning to "schedule a trauma." Clients can pick a specific time each day (or week) during which they will give in to their strong feelings (of depression, anger, temper tantrum, etc.) but rather than being overwhelmed whenever such feelings occur, they learn to postpone the feelings to a convenient time and keep them within an agreed upon time frame. This often has a paradoxical effect. When clients learn that they can indeed "schedule depression" and stick to the time limits without letting it interfere with their lives, they rarely feel the need to schedule such time on a regular basis. It always remains as an option for them, however, so that long after therapy has been terminated if they convince themselves that they simply have to "get it out of their system," they have learned a less destructive way to accomplish this.

Since the histrionic client is so heavily invested in receiving approval and attention from others, a structured cognitive group therapy can be a particularly effective mode of treatment. Kass, Silvers, and Abrams (1972) demonstrated that group members could be enlisted to assist in the reinforcing of assertion and the extinction of dysfunctional, overly emotional responses. One histrionic client of mine continually focused on her physical symptoms of anxiety, complaining loudly, dramatically, and in graphic detail. When she was placed in a Cognitive Therapy group, the feedback from the other group members, their consistent lack of reinforcement for physical complaints and their positive reinforcement when she discussed other issues was much more successful at reducing her focus on her symptoms than her individual therapy had been. When Suzy entered a Cognitive Therapy group, her manipulative patterns of interacting with men became much more obvious than they had been while she was in therapy with a female therapist. If the client is currently involved in a significant relationship, couple therapy can also be especially useful. In couple treatment, both spouses can be helped to recognize the patterns in the relationship and the ways in which they each facilitate the maintenance of those patterns.

Most of the behavioral research which has been conducted in the area of hysteria has been confined to the treatment of conversion hysteria and somatization disorders (Bird, 1979). Woolson and Swanson (1972) present an approach to the treatment of four "hysterical women" which included some behavioral components, and they report that all four clients made substantial gains towards all of their stated goals within four months of initiating therapy. Kass, et al. (1972) describe an inpatient behavioral group treatment of five women who had been admitted for suicidal intent and diagnosed as having a hysterical personality. Clients were required to adhere to a tight daily schedule including therapeutic exercises to teach appropriate self-assertion. The clients were taught to identify their dysfunctional reactions to stress and systematically modify them. The group members were responsible for specifying each other's hysterical behaviors (which had been operationally defined) and providing the rewards and penalties which had been agreed upon. There was no control group, but multiple and concrete measures of progress were kept. Four of the five clients showed symptomatic improvement and more adaptive behavioral responses at the end of treatment and after an 18 month follow-up. Thus, fairly positive results were obtained in two studies of largely behavioral treatments with a population which is generally acknowledged to be very difficult to treat.

The efficacy of Cognitive Therapy for the treatment of Histrionic Personality Disorders has not yet been tested empirically. It does show clinical promise in that several therapists have used these strategies with a variety of histrionic clients and report it to be an effective treatment which results in less frustration on the part of both therapist and client than the more traditional approaches to treatment.

References

Allen, D.W. (1977). Basic treatment issues. In M.J. Horowitz (Ed.) Hysterical personality. New York: Jason Aronson.
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders, Third Edition - Revised. The American Psychiatric Association.
Beck, A.T. (1970). The role of fantasies in psychotherapy and psychopathology. Journal of Nervous and Mental Disease, 150, 3-17.
Bird, J. (1979). The behavioural treatment of hysteria. British Journal of Psychiatry, 134, 129-137.
Kass, D.J., Silvers, F.M. & Abrams, G.M. (1972). Behavioral group treatment of hysteria. Archives of General Psychiatry, 26, 42-50.
Kolb, L.C. (1968). Noyes' clinical psychiatry (7th ed.) Philadelphia: W.B. Sanders, p. 86.
MacKinnon, R.A. & Michaels, R. (1971). The psychiatric interview in clinical practice. Philadelphia: W.B. Sanders pp. 110-146.
Malmquist, C.P. (1971). Hysteria in childhood. Postgraduate Medicine, 50, 112-117.
Millon, T. (1981). Disorders of personality DSM-III-R: Axis II. New York: Wiley.
Shapiro, D. (1965). Neurotic styles. New York: Basic Books.
Woolson, A.M. & Swanson, M.G. (1972). The second time around: Psychotherapy with the "hysterical woman." Psychotherapy: Theory, Research & Practice, 9, 168-175.

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Re: CT for Histrionic Personality Disorder, by C.Chrysler, 03/24/01

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