Forthcoming: International Journal of Feminist Approaches to Bioethics
(2011)
Why the Histrionic personality disorder should not be in
the DSM:
A new taxonomic and moral analysis
Abstract
I argue for a reconsideration of the taxonomy of the Histrionic Personality
Disorder ('HPD'). First, HPD does not carry the negative ethical
implications of the other Cluster Bs, which are Anti-Social (ASPD),
Borderline (BPD) and Narcissistic (NPD). Using Aristotelian notions of
character as a heuristic device, I argue that ontologically HPD is not a
personality disorder, but instead a cultural disorder, a result of
attitudes towards traditionally feminine styles of interaction. This
explains the confusion in the research between HPD and hysteria and also
the curious paucity of literature on HPD itself in contrast to the other
Cluster Bs.
Why the histrionic personality disorder should not be in the
DSM:
A new taxonomic and moral analysis
"The scene was pleasant on both sides. A cruder lover
would have lost the view of her pretty ways and attitudes, and spoiled
all by stupid attempts at caresses, utterly destructive of the drama.
Grancourt preferred the drama. Gwendolen . . . found her spirits
rising…as she played at reigning. Perhaps if Klesmer had seen more of
her in this unconscious kind of acting, instead of when she was trying
to be theatrical, he might have rated her chances [on stage] higher."
(George Eliot, Daniel Deronda)[i]
Introduction
The histrionic personality disorder (HPD) stands at the intersection
of ethics, ontology, and philosophy of psychiatry. Although HPD is a
rarely probed diagnosis, it brings into relief the problems of gender and
values in diagnosis, as well as nosological issues. The boundary between
the moral and pathological is so precarious that remapping these concepts
is an ongoing process. Without entering the complex debate over what
constitutes a mental disorder or whether mental disorders tout court are
socially constructed, I shall say that some things considered mental
disorders are real. This entails neither that all are real nor that social
practices have no role in shaping them. Some real mental pathologies might
be the result of gender, racial, ethnic, or sexual orientation biases[ii]
that lead to genuine, distinctive, even harmful, forms of suffering, for
example, anxiety or depression. Other real mental pathologies might be the
projection of these biases, for example, anorexia or body dysmorphic
disorder. HPD, as I argue here, is not a real mental pathology; rather,
'histrionic' refers to a trait or cluster of personality traits that might
lead to some other mental disorder. Its taxonomical status in the DSM
creates conceptual confusions reflected in the relatively scant literature
on HPD.
The status of HPD has great importance, especially for women, who
are more likely to be diagnosed with HPD. First of all, as Peele and
Razavi point out, the diagnosis of a personality disorder is both
misleading and harmful. They remind us that "in 2002 the Washington
Psychiatric Society and the Maryland Psychiatric Society voted to ask the
American Psychiatric Association [APA] to remove the word "personality"
from the titles of present disorders (e.g., histrionic disorder rather than
histrionic personality disorder)." Their grounds are both scientific and
humanitarian. They claim that a personality disorder label does not reflect
the totality of someone's personality and moreover the concept can, for
various reasons, lead to misdiagnosis. Clearly, as they also imply, someone
may be hurt or, worse, discouraged, to hear from a medical authority that
she has a disorder of the personality; after all, this sounds like a harsh
judgment on one's character, and a mental health professional may base such
a diagnosis simply on a patient's meeting a few of seven or more criteria
in the DSM (depending on which personality disorder is in question).
Not everyone diagnosed with a personality disorder, Peele and Razavi
contend, has a positive personality, but some do. Presumably, they mean
that most people have some desirable personality traits such as warmth,
charm, or optimism, even if they do meet the criteria for a given
personality disorder. Peele and Razavi suggest the "APA should take steps
to change the diagnostic categories when the change will encourage
appropriate care and treatment." They also make the important point that
two of the ten personality disorders have misleading names that are not
used by the ICD-10. Thus, on both scientific and humanitarian grounds, they
believe that these concepts have to be reassessed. Even if their analysis
of a personality disorder has some flaws, they have a cogent point about
the need to reassess the category in Axis II and to remove especially those
that are not genuine personality disorders. I shall argue that the so-
called histrionic disorder is neither a pathological disorder nor a moral
disorder (as, arguably, are the other cluster Bs). It is rather what we
should think of as a cultural disorder, although by cultural disorder, as I
later explain, I do not mean what Hacking might call an interactive kind or
Foucault a cultural construct. Let us first turn to what a personality
disorder is.
What is a personality Disorder?
A personality disorder is a diagnosis that falls into Axis II in
the DSM IVTR. Like other diagnoses, it is a condition that is personally
and/or socially maladaptive and can cause great suffering. There are ten
personality disorders, and they are classified into three clusters. The
only other diagnosis included in Axis II, in addition to the ten
personality disorders, is mental retardation. Like mental retardation, a
personality disorder is intransigent and so deeply planted in the psyche
that it is difficult, not to say impossible, to uproot. A personality
disorder appears at some point in early adulthood, once a character is more
developed. Children do not have personality disorders, although they can
show a propensity to develop one or another. For example, some young
children foreshadow their developing ASPD by being cruel to other children
and animals.
Speaking philosophically, a personality disorder is like an
Aristotelian disposition (hexis), which Aristotle discusses in chapter
eight of his Categories. In the Categories, he is concerned to show the
many kinds of answer to the question, "What is it?" and in chapter 8, he
says that sometimes the answer is 'a quality' (poiotês). Of qualities,
some things are basic conditions, which can be of two sorts. He contrasts
a habitual disposition (hexis) like virtue or vice with a state (diathesis)
like health or disease (Categories 8b25--9a4). Both are conditions that
causally influence particular episodic events.[iii]
To use two illustrative examples, let us imagine Smith, who has ASPD,
and Green, who is experiencing auditory hallucinations resulting from a bad
reaction to a medication. Smith murders Jones because Jones has something
that Smith wants. Green, in his anomalous state, kills Peters because he
believes that God has commanded him to do so. Smith's action arises from a
hexis, Green's from a diathesis. The difference is that Smith's condition
of ASPD, qua hexis, is enduring and tenacious, whereas Green's condition,
qua diathesis, is not hard to change. Note that many an Axis I disorder
would be classified as a diathesis, but no Axis II would be. An Axis II
can be only a hexis. The condition associated with HPD, when it is
maladaptive, is a diathesis, not a hexis. Therefore, HPD should not be
Axis II.
The literature on personality disorders is vast. One problem,
as already noted and also cited by Zachar and Kendler,[iv] is that a
patient needs to meet only three or four criteria out of more to be
diagnosed with a given personality disorder. Thus, much is lost in the
diagnosis. More fundamentally, Zachar and Kendler further indicate, there
are various models for understanding personality disorders and other mental
disorders, ranging from essentialist ones such as organic, biopsychosocial,
and harmful dysfunction models to more value-laden, or "nominalist," ones
such as practical kinds and dimensional models.[v] Some psychiatrists
prefer to think of personality disorders in terms of traits. As Joel
Paris neatly describes it:
" Trait profiles constitute the vulnerability factors for
personality disorders and determine which types . . . can develop in
any individual. . . . When traits become too intense, [they are] . . .
amplified. [They] . . . become maladaptive when the same behaviors
are applied to every situation. Thus, behaviors that might be adaptive
in one context will be used in a global and rigid fashion . . . and in
inappropriate ways." [vi]
As Paris points out, traits may have a genetic origin, but whether they
become amplified is another matter.
Philosophers and psychiatrists question what kind of kind a
personality disorder is. That is, is it a natural kind or what Ian Hacking
has named an interactive kind? Louis Charland ascribes a different
ontological status to Cluster Bs than to As and Cs.[vii] He maintains that
they are interactive, not natural and moreover, transient. "Transient" is
how Hacking describes mental illnesses that appear in abundance temporarily
at a given place and culture and thus flourish only in certain socio-
cultural environments, or as Hacking calls them, "ecological niches."[viii]
Before turning to the issue of natural kinds, we should note that ASPD,
BPD, and NPD (the three clearly moral disorders) are probably not transient
in the way that, say, the current illness of anorexia is. While this is an
empirical question that goes beyond the scope of this article, I think that
a look at history and literature of both Western and non-Western cultures
would suggest that these types are universal and embody enduring traits
that, when amplified, can cause distress to the possessor and those around
him (e.g., Achilles, Madoff, Medea).
To say that they are transient, Hacking tells us, is not to say
that they are not real or are merely constructions of environment and
culture. Hacking differentiates between natural kinds, the sort of thing
studied in the natural sciences, and interactive kinds, the sort studied in
the human sciences. A natural kind would be something that exists in nature
and corresponds to our concept. For example, bubonic plague is a natural
kind. It is a human disease but is caused by a certain bacterium that
exists in nature independently of how we think about it. Thus he describes
it as "indifferent."
Interactive kinds interact with the subjects who have them, a process
he terms 'the looping effect.'[ix] A diagnosis may influence the way a
person reacts to himself and his symptoms, and it certainly influences the
way others react to him. For example, someone given the diagnosis of ADHD
might become even more accelerated in given circumstances, because he is
reacting both to his own self-description and to the implicit expectations
others have of him. There are forms of behavior towards people that become
embedded in our institutions and cultural practices. The way a doctor,
parent, or spouse acts towards someone cannot help but influence how she
manifests her pathology. This, in turn, can change the manifestations and,
in turn, the concept of a given pathology itself. Hacking describes the
looping effect as follows:
"[People] can make tacit or even explicit choices, adapt or
adopt ways of living so as to fit or get away from the very
classification that may be applied to them . . . What was known about
people of a kind may become false because people of that kind have
changed in virtue of what they believe about themselves . . . . Looping
effects are everywhere. Think about what the category of genius did to
those Romantics who saw themselves as geniuses, and what their behavior
did to the concept of genius itself. Think about the transformations
effected by the notions of fat, overweight, anorexic." (1999, 34)
In Rewriting the Soul, Hacking describes how the looping effect
changed the disorder of multiple personalities (now, Dissociative Identity
Disorder). For a more familiar example, we can consider how the very idea
and the epidemiology of learning disabilities have changed. That is,
perhaps because of the helicopter parent phenomenon, the taboo lifted: so
more parents have taken their children for testing and have advocated for
changes in the schools; the pharmaceutical companies have continued to
develop new medications for these problems and bio-technology companies
have developed new devices for testing for learning disorders. This feeds
back into the culture and educational institutions. Note that looping
effects hold not only of pathologies. Genius, to use Hacking's example, is
a cultural, not pathological, concept.
HPD, I believe, is taxonomically more like 'genius' than it is like
'BPD' or 'Schizoid personality disorder.' It is interactive in that it
influences the people given the label "HPD,' and the people who see them as
'histrionic' or hysterical.' But, unlike anorexia or NPD, it is not a
genuine disorder. In order to see why HPD is not a personality disorder,
let us consider first why it is not a Cluster B personality disorder.
HPD and Cluster B personality disorders
In the DSM IVTR, HPD falls into Axis II as a member of the B Cluster,
along with Anti-Social personality disorder (ASPD), Narcissistic (NPD), and
Borderline (BPD). The other Cluster Bs all carry negative moral
connotations, because the exemplars of each typically violate the rights
and boundaries of other people.[x] HPD is radically unlike the other
Cluster Bs in this regard. In fact, some people with histrionic traits can
be exquisitely sensitive to and empathic with others, which is one source
of its being maladaptive.
HPD is relatively unknown to the general public, unlike its fellow
Cluster B disorders. In psychiatry, law, moral philosophy, and popular
culture, the literature abounds on dangerous pathologies such as
narcissism, anti-social personalities, and borderlines. When news breaks of
a serial killer like Jeffrey Dahmer, a cold-blooded murderer like Scott
Peterson, or a swindler like Bernie Madoff, we start seeing articles on the
internet, in books, and on television about narcissists and sociopaths.
After the Madoff scandal, the public devoured televised interviews with
mental health professionals who discussed the borderline personality, the
narcissist, and the anti-social individual. The histrionic, however, does
not share this celebrity.
Unlike the other three Cluster Bs, HPD is a predominately female
diagnosis, perhaps because the DSM IV criteria are associated with
stereotypes of traditional femininity: susceptibility to accepting the
beliefs of others, a tendency to sexualize even casual interactions, a
disposition to "shifting and shallow" emotional displays, the use of vague,
imprecise language lacking descriptive power, excessive concern with bodily
appearance, an inordinate need for attention, and—true to its name—the
exaggerated expression of emotion, or as one clinician describes it, "an
excess of . . . pseudoaffect [sic]."[xi] George Eliot draws in exquisite
detail the Victorian femme fatale in the character of Gwendolen in Daniel
Deronda. Gwendolen has many problems, but today she likely would be given
the label 'HPD.' In psychoanalytic and psychiatric literature, the term
histrionic is often used interchangeably with hysteric, the name of its
distinctly feminine ancestor. As we investigate this matter, it begins to
appear as if the classification of HPD makes a pathology of traditional
feminine traits. At a time when feminism is trying to be inclusive of all
women and their choices (and of those men who choose more feminine gender
roles and/or modes of self-presentation), changing this status of HPD as a
pathology becomes ever more urgent.
There is not much research on HPD in the philosophical, psychiatric,
or clinical studies. Representative of this trend is a book in a Jossey-
Bass series edited by Irvin Yalom: Michael Rosenbluth's anthology, Treating
Difficult Personality Disorders.[xii] It contains four articles on BPD,
one on NPD, one on ASPD. Aside from some fascinating psychoanalytic work,
there are basically two sorts of work on HPD. First, some researchers,
noting the gender disparity between diagnoses of the predominantly female
HPD and the largely male ASPD or NPD, have questioned whether HPD
exemplifies in a feminine way the same problems as the NPD or ASPD, or
whether HPD is genetically linked to the Cluster Bs. Researchers vary as
to what the defining characteristic is of cluster Bs, with some suggesting
self-dramatization, others impulsivity, and more recently, a lack of moral
sensitivity, as we see below. [xiii]
Secondly, from a philosophical perspective, moral afflictions,
of which ASPD is one, have always interested philosophers concerned with
responsibility and moral development. Louis C. Charland3 has recently
argued that the differentiating characteristic of Cluster B personality
disorders is moral. According to Charland, Cluster B disorders stand apart
from A and C disorders in being moral disorders rather than clinical and
non-moral disorders. What he means by a moral disorder seems to be a lack
of or a discontinuous understanding that other people are also subjects of
consciousness with rights, interests, and feelings of their own. [xiv] A
successful treatment for a moral disorder would require a patient's
acquiring a new moral outlook and, from a phenomenological standpoint, the
feeling of empathy.
At first glance, this appears to be just the sort of change that
would count as a cure. According to the DSM IVTR, the patient with ASPD
is at least eighteen but has had a consistent pattern of deceitful,
reckless, deviant behavior, having no empathy or regard for legal and
social norms. The criteria for NPD include grandiosity with its
expectations of recognition "without commensurate achievements," pervasive
fantasies of "success, power, brilliance, beauty, or ideal love," sense of
entitlement, a haughtiness, envy accompanied by a need to be envied, lack
of empathy, and a tendency to be "interpersonally exploitative." BPD
involves great volatility, "frantic efforts to avoid real or imagined
abandonment," "alternating . . . extremes of idealization and devaluation"
of others," "chronic feelings of emptiness," lack of impulse control in
arenas such as sex, spending, eating, or substance abuse, a tendency
towards "suicidal gestures," and constant and/or intense anger.
Charland prescribes moral therapy for each of these, but he seems not
to realize that this prescription is impossible to apply. The goal, he
tells us, is to give the person a new sense of himself as a moral agent.
But how can someone without empathy and regard for others develop it? The
patient with ASPD, NPD, or BPD would have to be cured before he could take
Charland's cure.
Aristotle again is enlightening here. Aristotle, in book 7 of his
Nicomachean Ethics, contrasts the enkratic, or self-controlled person, with
the sõphrõn or person of virtue. The enkratic has desires to act against
reason, but acts instead according to reason. Consider two smokers. Both
believe it is prudentially and morally better to be non-smokers and quit
cold turkey. Both kick and bray for the first part of the process. After
awhile, one of them no longer desires to smoke. This person (with virtue),
whose desires are in line with her beliefs, is a sõphrõn . The other one,
the enkratic, finally acquires the habit of not smoking, despite sometimes
wanting to smoke. How do we account for the phenomenon of enkrateia? In
some cases, as in that of the first case, enkrateia is a stage on the way
to acquiring the prudentially and morally valuable characteristic of being
a non-smoker. In the second case, the person lives with flare-ups of an
internecine battle between her desires and her belief. What redeems her is
that she has a higher order desire to be a certain kind of person, a person
who takes responsibility for her health insofar as she can and who is well
enough to be available to people about whom she cares.[xv]
In the case of a person with a moral flaw, she has to have moral
motivations or higher-order moral feelings in order to change. Therefore,
no moral therapy could be truly effective unless it is given to someone who
already views herself as a moral agent and who values herself for that.
This lack of moral awareness seems entrenched in NPD, BPD, and ASPD, which
is why therapists find them so difficult to treat. In the language of
psychoanalysis, they are "malignant hysterics."[xvi] Let us grant that
these other Cluster Bs are moral disorders. What about the histrionic?
Tellingly, in discussing the various ways in which each of the
Cluster Bs is a moral disorder, Charland does not specify why HPD would be
a moral disorder. Rather, he says,
"The moral nature of histrionic personality disorder is more
implied than explicit but it is clear nonetheless. Here the 'excessive
attention seeking' and 'inappropriate sexually seductive and
provocative behavior' referred to is [sic] flatly inconsistent with a
pattern of empathy and regard for others." [xvii]
His description of HPD as a moral disorder is highly problematic for a
number of reasons. First, Charland mentions only two of the eight criteria
for HPD. Conceivably, one could evince these characteristics and not
warrant a diagnosis of HPD. Secondly, one could justifiably be diagnosed
as having HPD without exhibiting either of the two criteria Charland
mentions. Thirdly, it is unclear as to how such behavior precludes empathy
for others. One could imagine situations in which both attention seeking
and/or seductiveness are consistent with empathy for others. For example,
someone might try to draw attention away from a close friend who is under
uncomfortable scrutiny, or someone might behave seductively towards a
person for whom she feels sorry. That Charland cannot describe an
explicit moral transgression characteristic of the histrionic speaks worlds
about the moral status of HPD.
Finally, his criteria for judging HPD to be a moral disorder is
determined on the basis of behavior such as seeking attention or acting
provocatively, whereas the criteria he cites for ASPD and NPD are
subjective or internal states such as 'lacking empathy' and 'disregard for
and violation of the rights of others.' That Charland has not proved HPD
to be moral does not entail that it is not a moral disorder. But the
histrionic exhibits no behavioral characteristic that we could deem morally
bad. As for "theatricality," all human beings assume roles of various
sorts in their social interactions.
Nor do case histories or other first person reports suggest any
moral flaw in the subjectivity of the histrionic. If anything, the
histrionic may have an unusual capacity for empathy, as we see in Eliot's
character of Gwendolen. This is part of her subjectivity. Gwendolen's
story, in fact, can be seen as one of moral awakening and maturation of a
person with histrionic traits. She begins as a woman who has great love
for and attachment to her mother, but who grows into someone with broader
moral sympathies and a genuine moral imagination. Deronda is her moral
guide. Interestingly, he is like a psychoanalyst who handles his counter-
transference with the utmost integrity.
Psychoanalyst Christopher Bolas, who construes a histrionic as a
'benign hysteric,' remarks on the histrionic's capacity for empathy, albeit
within the terms of Bolas' psychoanalytic schema of the primal scene:
When the self becomes an event startling the eyes of the other
it
illustrates the self possessed by the primal scene . . . Driven
to
distraction by the imagined scene . . . the hysteric tries to re-
enter
innocence through the shocked gaze of the other, who for a
moment is an innocent in the presence of something happening
beyond the witness's knowledge. In a flash, hysterics
projectively
identify themselves into the other, bathing in innocence."
(2000, 125-126)
Although a detailed account of Bolas's schema goes beyond the topic of this
article, he makes evident that the histrionic can sense the needs of others
and that she cares about those needs. The person with NPD or ASPD may also
be aware of the needs of others—indeed that is required for them to achieve
some of their mischief--but they differ from the histrionic in that the
narcissist or anti-social person does not care about the needs of others
and feels no empathy for others. Thus, they feel no remorse when they
knowingly make choices that have bad consequences for others.
David W. Allen, M.D. (1991), discussing several cases, depicts the
behavior, subjective experience, and treatment of the histrionic:
" . . . she has by quick . . . expression of feeling aborted the
intensity of its full development . . . . The problem with this patient
is to help her learn how to think better about certain situations . . .
. the therapist might first point out that . . . is one of the
reasons[she] is called histrionic or theatrical—because she is acting
and not fully feeling what seems to be felt. In the acting . . . is a
defense against the very feeling that is portrayed, and that defense is
what the therapist must first point out. " (181)
Allen has had success with his histrionic patients. He emphasizes the care
the therapist must take to manage the counter-transference and not to
hasten the process. He has not found the histrionic to lack empathy or
genuinely deep feelings. He focuses on helping the histrionic think about
connecting feelings and affect.
Allen illuminates the central problem that can emerge in a
carefully choreographed therapy, namely the histrionic's fear of being
known (189-191). Is it surprising that psychologically astute females in a
patriarchal culture would have a "fear of being known?" Hardly. Where
women had (or have) to compete with others for economic survival, as they
did until quite recently in Western culture, it would be to a woman's
advantage to conceal her feelings and sexuality except in extraordinary
circumstances. Thus, it is easy to see why females would develop or
amplify histrionic traits more than males. This is not to say that
genetic factors do not play a role, but rather that how traits manifest
themselves and become amplified may well be a function of the looping
effect that Hacking describes.
When a histrionic appears with depression, the therapist may
diagnose and treat the depression, but then focus on (and pathologize) the
personality style. Histrionics, being sensitive to the reactions of
others, are likely to internalize a therapist's judgment of them as having
a personality disorder. Furthermore, because of their empathy and personal
attractiveness, histrionics are quite vulnerable to therapists who have
trouble maintaining appropriate boundaries in managing their own counter-
transference. Allen speaks expansively on the problem a (usually) male
therapist has with the transference/counter-transference situation with a
female histrionic patient. The therapist may find these patients
intriguing. As he says in discussing a particular case,
"One can imagine the difficulties in treatment if this man
were the psychiatrist, psychologist, or social worker treating a
histrionic or hysterical woman if he had not been well trained and well
analyzed. Probably the best that could happen would be that out of
ethical considerations he would refer her to another therapist—while he
prepared to marry her." (168)
Allen unconsciously betrays his own, more benign, feelings towards these
patients in the language he uses to depict metaphorically the therapist's
role as heroic figure in the histrionic's mental life:
"Figuratively, the therapist holds the string at the juncture of
the
real world and the labyrinthine world of the patient's
unconscious
and past. [He] allows the patient to unwind that Ariadnean string
regressively
throughout its long length into earliest childhood. And when the
patient
comes forward again the therapist gives back the string and map
of the
patient's personal labyrinth." (189-190)
HPD as a Cultural Disorder
HPD is not a mental disorder in the way that say, a schizoid or a dependent
personality disorder is. Nor is it a moral disorder. It is not a hexis;
it is instead a diathesis. Allen understands this (188). HPD is a
personality strategy that is caused by a cultural disorder.[xviii]
What is a cultural disorder?[xix] The notion is ambiguous. It
can refer to an affliction of someone who cannot adjust to the norms of his
culture. It can also refer to a disorder caused by the power hierarchy of
a culture. Or, as in the sense that I am using it here, it can refer to a
culture that treats certain groups or subcultures, or individual members of
them in ways that make them feel alienated, physically inferior, ashamed,
depressed, anxious or show symptoms of another disorder such as anorexia or
PTSD. Consider the culture that so prized the human voice that it
sanctioned castration of adolescent or pre-pubescent boys with promising
vocal careers. These are radically disordered cultures, in which one who
resists their values is considered deviant or mentally ill. Many victims
of these cultures probably do develop anxiety, depression, or other
pathologies. The beautiful voice or even the physical defect of a
castrato was not a mental disorder; yet a resulting generalized anxiety or
a sexual paraphilia would have been.
Analogously, the histrionic, qua histrionic, is reacting to a
disordered culture. The dynamic is subtler than those in the above cases.
There is nothing pathological about having a dramatic élan or an aesthetic
concern with self-presentation. To consider Freud's hysterics, the
ancestors of today's histrionics, their sexual desires did not constitute a
disorder, but their somatizations and conversion disorders were a response
to a culture that condescended to women with imagination and sexuality.
Historically, Western culture has condescended to both. It has
prized qualities such as rhetorical skill in the use of political or
economic power, rational or obsessive thinking styles applied to scientific
research or business strategies. But it has either devalued or
subordinated in importance the application of drama or polish to personal
presentation.[xx] Until recently, it has considered these feminine. Note
that in English, we find the expression drama queen used even when applied
to men. In a sense, we are all drama queens in our self-presentation,
which is part of the tension between the individual and his culture or
subculture, as William Ian Miller claims in his recent Faking It.[xxi]
Miller cogently and wittily argues that it is part of the human condition
to feel anxiety in proportion to the visibility of our enacted roles. If
Miller is correct (as I think he is), then histrionics, who tend to be
especially imaginative, fastidious, or aesthetic in their personal
presentation, may live with greater anxiety or other problems.
Having histrionic traits could thus give rise to shame, anxiety, body
dysmorphic disorder, or any number of other problems, depending upon the
environment and people by whom one is surrounded. The resulting anxiety
will take forms such as anxiety about becoming invisible, or it can
manifest itself in body disorders. Western culture now encourages women to
develop intellectually, economically, and professionally, yet it has not
stopped infantilizing women who have keen aesthetic concerns about their
bodies. It both rewards and punishes them if they are comfortable modeling
traditional femininity.
The goal for the histrionic should be not to change her fundamental
traits, but rather to attain insight into the ambivalent culture that has
tainted her with a diagnostic label. The role of the therapist in a
histrionic's life should be to encourage her (or him) to appreciate her
traits and to develop her talents in ways that allow her to use them as
strengths. Like Daniel Deronda with Gwendolen, a good therapist can help a
histrionic mature by creating a therapeutic space where she need not fear
gaining insight and agency. That would be a real modality of moral
therapy. A personality style is not a personality disorder, even in a
culture where that style may be treated as a disorder. HPD pathologizes
traditional feminine styles and modes of self-presentation. The APA needs
to unmask the histrionic who, qua histrionic, is not bringing distress to
herself or others. For the histrionic may be a person in the process of
distinctive self-actualization.
For insightful comments and criticisms of this paper, I am deeply grateful
to Naomi Zack, David Levine, Cesar Benarroche, Jason Klein, and an
anonymous referee for this journal. For remarks on earlier versions of this
paper, I thank audiences at the conference on Freedom and Psychiatry:
meeting of the International Network of Philosophy and Psychiatry, Dallas,
6-8 October 1998 and at a colloquium at the FAU Center for Mind, Body, and
Culture, March 2009.
-----------------------
[i] 361.
[ii] While homosexuality is no longer included in the DSM as a disorder,
the profound homophobia and other forms of prejudice in some cultures and
subcultures can lead to such disorders as clinical depression and
generalized anxiety disorder, among others.
[iii] For a fuller discussion of this and its relation to ethics, see
Gould 1994.
[iv] 2007, 561
[v] 559-562.
[vi] 1998, 20.
[vii] Actually, he says that the jury is still out on As and Cs, but he
does say that they are
morally neutral (2004, 73).
[viii] Hacking 1998.
[ix] For an excellent critical discussion of Hacking's notion of
interactive kinds, see Tsou.
[x] Charland 2004, 2006 has argued that Cluster B disorders differ from
other personality disorders in that they are moral disorders and, and as
such, require moral therapy rather than psychotherapy.
[xi] Allen 169.
[xii] Rosenbluth 2001
[xiii] See, for example, PR Slavney and GA Chase, Sprock, and Cale and
Lillienfeld.
[xiv] Cf. Matthews 305-308
[xv] Gould 1994, 181.
[xvi] Bollas, 127.
[xvii] 2004, 71; 2006, 122.
[xviii] Allen 187 acknowledges as much.
[xix] I am grateful to Naomi Zack for discussing this notion with me.
[xx] Bordo. Hanson
[xxi] 2003.
References
2000. American Psychiatric Association: Diagnostic and statistical manual
of mental disorders, fourth edition, text revision. Washington, DC:
American Psychiatric Association.
Aristotle. 1938, 1967. Categories. Trans. H. P. Cooke and Hugh Tredennick.
Cambridge, MA: Harvard University Press (Loeb Classical Library),
---------. 1920.Ethica Nicomachea. Ed. Bywater, I. Oxford and New York:
Oxford University Press.
Blacker, Kay H. and Tupin, Joe P. 1991. Hysteria and hysterical
Structures: Developmental and Social theories. In Horowitz, 1991.
Blagov, Pavel S. MA; Westen, Drew Ph.D. 2008. Questioning the coherence of
histrionic personality disorder: borderline and hysterical personality
subtypes in adults and adolescents. The Journal of Nervous and Mental
Disease 196 (11): 785-797.
Bollas, Christopher. 2000. Hysteria. New York: Routledge.
Cale, Ellison M. and Lilienfeld, Scott O. 2002. Histrionic personality
disorder and antisocial personality disorder: sex-differentiated
manifestations of psychopathy? Journal of personality disorders 16 (1): 52-
72.
Charland, Louis C. 2004. Moral treatment and the personality disorders. In
Jennifer Radden (ed.), The philosophy of psychiatry: a companion. New York:
Oxford University Press, 64-77.
--------. 2006. Moral nature of the DSM IV cluster B personality
disorders. Journal of personality disorders 20 (2): 116-25.
Eliot, George. 1876, 1980. Daniel Deronda. Middlesex, England and New
York: Penguin Books.
Gould, Carol S. 1994. A puzzle about the possibility of Aristotelian
enkrateia. Phronesis 39 (2): 174-86.
Hacking, Ian. 1995. Rewriting the soul. Princeton: Princeton University
Press.
-------. 1998. Mad travelers. Charlottesville: University of Virginia
Press.
-------. 1999. The social construction of what? Cambridge: Harvard
University Press.
Hanson, Karen. 1993. Dressing down, dressing up, the philosophical fear of
fashion. In Aesthetics in a feminist perspective, ed. Hilde Hein and
Carolyn Korsmeyer. Bloomington: Indiana University Press: 229-241.
Horowitz, Mardi J. 1991. Hysterical personality style and the histrionic
personality disorder. Northvale: Jason Aronson, Inc.
Looper, Karl J. and Paris, Joel. 2000. What dimensions underlie cluster B
personality disorders? Comprehensive Psychiatry 41 (6): 432-7.
Miller, William Ian. Faking it. Cambridge, UK: Cambridge University Press.
Paris, Joel. 1998. Working with traits: Psychotherapy of personality
disorders. Northvale: Joel Aronson, Inc.
Peele, Roger, M.D. and Razavi, Maryam, M.D. 2007 "DSM recommendation"
Psychiatric news. 42 (3): 2
Rosenbluth, Michael. 2001. Treating difficult personality disorders. San
Francisco: Jossey-Bass.
Slavney and Chase. 1985. Clinical judgements of self-dramatisation. A test
of the sexist hypothesis. The British journal of psychiatry 146: 614-617
Sprock, June. 2000. Gender-typed behavioral examples of histrionic
personality disorder. Journal of psychopathology and behavioral
assessment. 22 (2): 107-122.
Tsou, Jonathan Y. 2007. "Hacking on the looping effects of psychiatric
classifications: what is an interactive and an indifferent kind?"
International studies in the philosophy of science. 21 (3): 329-344.
Zachar, Peter, Ph.D. and Kendler, Kenneth, M.D. 2007. Psychiatric
disorders: A conceptual taxonomy. American journal of psychiatry 164: 557-
65.
