Is Drama Queen (or King) a Real Diagnosis?
Life of the party or impulsive attention seeker? Vivacious co-worker or workplace nightmare? Charming friend or emotional drain? Theatrical flair can be attractive -- but constant bouts of drama combined with risky behavior could be a sign of a mental health condition. Here's a look at histrionic personality disorder, estimated to affect about 2 percent of the population.
Degrees of Drama
Those who fit the criteria for histrionic personality disorder are dramatic, theatrical and excessively emotional, according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders -- the psychiatric "Bible." The disorder tends to appear in adolescence or young adulthood.
People with the disorder always seek to be the center of attention in social situations, and often come across as inappropriately seductive, flirtatious and provocative, according to the DSM-5. They're also overly influenced and suggestible, and can be prone to anger. Events that would irritate others instead provoke rages and temper tantrums.
Having a vivid, theatrical personality in itself doesn't mean you have a problem, says Robert M. Fraum, a clinical psychologist in New York City. Actors, for example, use drama with purpose and control. For others, Fraum says, the trait might be a cultural norm.
"These people are emotional and interesting -- expressive people," he says. "So being a drama queen, so to speak, isn't necessarily a personality disorder."
Crossing the Line
In histrionic personality disorder, people tend to be dramatic "quite often," Fraum says. They "don't have a strong center to their personality." Instead, they're ruled by their emotions, which are subject to extreme changes in short periods of time. And, he says, they're also extremely vain and narcissistic.
The disorder is more frequently diagnosed in women, but men have it too. "A woman may be angry that you're not paying enough attention to her," Fraum says. "The man would be angry that you're not respecting him." In certain men, he says, the disorder shows up as jealousy, which is based on "the fundamental insecurity and dependency and weakness in terms of a center."
He describes a scenario of a man who imagines his girlfriend or wife is cheating on him. He might break things, grab his partner, accuse her and demand that she confess -- then break down and cry. "From a woman's point of view," Fraum says, "it's a nightmare."
Functioning in the World
Personality disorders "create problems across the range of human functioning," Fraum says. On the job, employers, associates or clients of those affected "may not want to deal with them," he says. "Their family may not want to deal with them after a while."
A mother may love holding and cuddling her baby, but find her own impulsiveness is a problem when dealing with an older child's social issues or interacting with teachers at school.
In romantic relationships, a person's manner can be really attractive, at first. But after that, things get "complicated," Fraum says, as partners become "extraordinarily demanding."
Attachment to other people can become dysfunctional as "you start getting rejected, let down and abandoned," Fraum says. Substance abuse and other self-destructive behaviors can result, such as multiple affairs, gambling and compulsive shopping.
Roots of the Disorder
Tali Shokek, a psychologist in Towson, Maryland, dislikes the "personality disorder" terminology. "I feel like it's just a shaming label," she says.
If somebody came to her with that diagnosis, she says, her thought process would be, "This person was probably invalidated throughout their childhood, or probably hasn't been heard or cared for or had a support system." That's a more useful approach, she says, than concluding patients are "seductive" or "indecisive," and frustrating to treat.
It's essential to explore root causes with patients, Shokek says. A woman may have been molested and disbelieved as a child. She may have received inconsistent, negligent parenting that did damage, even if it didn't meet the definition of abuse. It could be that dressing seductively and other hallmark behaviors are how she understands love.
"People could say, 'She has a histrionic personality; she's borderline,' whatever," Shokek says. "The fact of the matter is, the underlying thing is probably post-traumatic stress disorder, and possibly depression and anxiety."
A 2012 study in Pediatrics found a connection between harsh physical punishments in childhood and an increased risk of future personality disorders.
What Works
Fraum says patients come to him because their behavior is damaging multiple areas of their lives. A spouse threatening to leave, for example, might be the motivation for treatment.
Therapy is about helping people change their behavior, he says. "You really need specific techniques to teach them -- if not to control their emotions, at least controlling the behavior that results from their emotions." Cognitive behavioral therapy is one option. Treatment might be eclectic, Fraum says; for instance, it could incorporate anger management.
First, he says, "You need to help people calm themselves" and deal with their anxiety, depression and other issues. "If they're impulsive and caught up with sensation and pleasure seeking, you've got to teach them how to get away from the sex, drugs and rock and roll, and other excessive behavior."
With coexisting conditions, medication for anxiety or depression may help, along with counseling.
"You've got to teach them to focus on, 'What's really good about you?'" he says. "Not just that lovely thing you just bought yourself at Bloomingdale's -- what is essentially good about you?" The key, he says, is getting patients to focus on their self-worth and real connections to what's good about life.
When someone in your life has signs of histrionic personality disorder, dealing with them is a serious challenge, Fraum says. "You have to set limits in how you're going to be treated," he says. "You can't permit a person to indulge in uncontrolled rage reactions or jealousy. It can't be all about them."
Focus on behavior, not character, he advises. Be concrete. Explain that you can't give your spouse an hour of undivided attention as soon as you walk through the door, but you'll have more time to listen once the kids are in bed.
It's My Style
Patients don't come to Fraum because they want a personality overhaul. "They know they have a certain style, and they like it," he says. "This is who they are, in their opinion, and you can't take that away from them." What therapists can do, he says, "is address those areas in life where that personal style is leading them to mess up, and teach them how to deal with those situations better."
Lisa Esposito is a Patient Advice reporter at U.S. News. You can follow her on Twitter, connect with her on LinkedIn or email her at lesposito@usnews.com.
