The History of Histrionic Personality Disorder and its Biased Development
Histrionic Personality Disorder… Is it formed from drama or attention seeking or just a disorder created by men afraid of women?
HPD first appeared in the Diagnostic and Statistical Manual of Mental Disorders, 2nd edition (DSM) and since the DSM-III it is the only modern disorder in diagnostic classifications that has kept a word in its title that is derived from the old concept of hysteria.
Hysteria originated from the Greek word “hystera” which meant womb or uterus. Plato was the first to describe how the womb affected women’s behaviors and said that “the animal within them is desirous of procreating children, and when remaining unfruitful…gets discontented and angry… causing all varieties of disease.” He believed that many conditions that affected women were caused by the “wicked or wandering womb” and could cause paralysis, mutism, and choking.
Hippocrates, however, was the one who initially began to use the word hysteria and depicted it as “the consequence of a dry womb rising toward the throat searching for humidity, thereby impeding breathing.” He thought that the effects of a “frustrated uterus” would affect widows and virgins.
Galen had a different view of how the womb affected women and believed that these behaviors were caused by a blocked menstrual flow and sexual abstinence. Surprisingly, he also believed that men could exhibit hysterical symptoms due to retained sperm and this belief started the centuries long debate of whether or not men could suffer from hysteria.
Shifting of Views
Although hysteria had been historically viewed as a physical illness that originated from a woman’s body, this view began to shift and during the late 1800s hysteria became the main subject of interest in medical schools as researchers began to look at how personality and unconscious processes played a role in the development and course of hysterical symptoms.
Sigmund Freud published multiple papers about hysteria in the late 19th and early 20th centuries including “Studies of Hysteria,” which labelled hysteria as a disorder that was due to unconscious conflict and explained that in order to alleviate symptoms one must bring the unconscious experiences into conscious awareness. Freud’s work on hysteria created the foundation which helped to establish a conceptual framework and vocabulary “for viewing the symptoms of hysteria as relating to personality, developmental history, and the internal world and fantasies of individuals with hysterical symptoms.” This in turn led to the development of the modern formulations of HPD.
The research Freud conducted with hysterical patients played an important role in the clinical understanding of hysterical symptoms as well as the early development of psychoanalytic theory. However, the patients Freud used to develop this understanding and conceptualization of hysteria were all women which raises the concern that the information derived from Freud’s work could contain gender bias.
Freud’s “Studies of Hysteria” contained only female case studies which Freud used to explain and justify his theories and treatment of hysteria. Their names were Anna O., Emmy von N., Lucy R., Katharina, and Elisabeth von R. The lack of male case studies on hysteria provides further evidence that HPD was born from a biased understanding of who hysterical symptoms are likely to affect and how one with hysteria is expected to behave.
Freud’s work with hysterical patients led to the development of the framework and vocabulary that was later used to create the modern foundations of HPD. However, since the patients he used to study hysteria were all women, this indicates that there is a very good chance that HPD developed from biased data which in turn has resulted in it continuously being perceived and treated as a feminine disorder.
HPD is currently defined in the DSM-5 as a “pervasive pattern of excessive emotionality and attention seeking” and to be diagnosed a person must meet five or more of the following criteria: uncomfortable in situations where they are not the center of attention, inappropriate sexual or provocative behavior when interacting with others, rapidly changing and shallow expression of emotions, using one’s physical appearance to draw attention to oneself, speaking in a way that lacks detail and is overly impressionistic, self-dramatization or exaggerated expression of emotion, is suggestible or easily influenced, and believes that relationships are more intimate then they truly are.
An official diagnostic category for hysteria did not exist until the DSM-II which included a hysterical personality disorder. In the DSM-III the word hysterical was changed to histrionic as many women working in the field of psychology believed that hysterical was too closely related to the perception that hysteria was a condition that only affected women.
Hysteria began as an ailment that could only be suffered by a person with a uterus and while the conceptualization of HPD has changed over the centuries, there still seems to exist a gender bias in the development of this disorder which in turn may have created a bias in how HPD is diagnosed.