#case conceptualisation

Clinical formulations and case conceptualisations are introduced in this post.

These are all generalisations and theories of how HPD develops, not something that is supposed to be true for everyone with HPD.

Psychodynamic model

Histrionics lack relationships with maternal caregivers so turn to paternal caregivers for love and attention

Learn that they can get attention through sexualised behaviours

Men with HPD may be hypomasculine (effeminate) or hypermasculine if their paternal caregiver is emotionally unavailable

Biosocial model

Mood swings, very emotional

Biggest influences are environmental: caregivers’ reinforcement of attention-seeking & manipulative behaviours and histrionic role models

Children learn they can use cuteness, charm, attractiveness & seductive behaviours to get what they want/need (attention from caregivers)

Histrionics are externally focused and largely ignore their internal worlds

Histrionic behaviours are self-perpetuating

Cognitive-Behavioural model

Two main underlying assumptions: “I am inadequate and unable to handle life by myself” and “I must be loved by everyone to be worthwhile.” 

Need attention and approval from others, and in a similar way to DPD feel they are inadequate to look after themselves and need others

Hypersensitive to rejection & criticism (similar to DPD, NPD and AvPD)

Feel they must perform for others to gain approval and self-esteem

Thinking is “impressionistic, global, and unfocused” and leads to over-generalisation, emotional dysregulation, and splitting

Two subtypes:

The controlling type, who tries to gain control through dramatics and manipulation; they struggle with reading others’ emotions and are shallow, self-centred, and uncomfortable without immediate assurance; lack empathy.

The reactive type tries to gain approval and reassurance.

Interpersonal model

People with HPD learnt that their entertainment value and appearance was more important to others than their worth as a person

Learnt that physical appearance and charm can be used to manipulate others

Their childhood homes were unpredictable and probably involved substance abuse

The unpredictability was dramatic and interesting (unlike the “primitive” and life-threatening chaos associated with BPD)

Histrionics were likely rewarded (i.e. had their physical and emotional needs met) for their disabilities, illnesses and complaints

Histrionics “exhibit a strange fear of being ignored, together with a wish to be loved and taken care of by important others, who can be controlled through charm or guile.”

Integrative model

Histrionics experience reactive mood swings and have high levels of energy

They are hyper-responsive and externally oriented

“The self-view of the histrionic will be some variant of the theme “I am sensitive and everyone should admire and approve of me.” The world-view will be some variant of “Life makes me nervous so I am entitled to special care and consideration.” Life goal is some variant of the theme “Therefore, play to the audience, and live in the moment.””

Cargivers’ style based in reciprocity, i.e. “I’ll give you attention if you do what I want”, with minimal or inconsistent discipline and probable neglect

Internal experiences of HPD are “denial of one’s real or inner self; a preoccupation with externals; the need for excitement and attention-seeking, which leads to a superficial charm and interpersonal presence; and the need for external approval. This, in turn, further reinforces the dissociation and denial of the real or inner self from the public self, and the cycle continues.”