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Histrionic Personality and Antisocial Personality: Caricatures of stereotypes?
Comprehensive Psychiatry (Official Journal of the American Psychopathological
VOL. 25, NO. 2
Association)
MARCH/APRIL
1984
Histrionic Personality and Antisocial Personality: Caricatures of Stereotypes? Phillip R. Slavney ABSTRACT The proposal that the diagnoses Histrionic Personality and Antisocial Personality represent sexrole caricatures of the concepts “woman” and “man”, respectively, was examined utilizing the semantic differential technique for the assessment of connotative meanings. Twenty-eight psychiatric residents and 21 academic psychiatrists rated the concepts “woman”, “man”, “histrionic personality”, and “antisocial personality” on each of 15 bipolar adjectival scales. No important differences were found between the ratings made by male or female psychiatrists or by resident and faculty psychiatrists. The subjects clearly distinguished between the connotative meanings of “woman” and “histrionic personality” and between “man” and “antisocial personality”, though there was a greater resemblance between the first pair of concepts than between the second. The linkages in meaning between women and the diagnosis Histrionic Personality are discussed, and it is proposed that the concept of sex-role caricatures be abandoned since the politrcal overtones of the term “caricature” tend to undermine the empirical work needed to validate or reject clinical diagnoses.
T
HE CLOSE RELATIONSHIP between the concept “woman” (Woman) and the concept “hysterical personality” (Hysterical Personality) or “histrionic personality” (Histrionic Personality) has intrigued and troubled psychiatry for several decades. In 1958 Chodoff and Lyons suggested that the hysterical personality “is a picture of women in the words of men . a caricature of femininity!“’ In 1967 Halleck proposed that the hysterical patient “exaggerates and repeatedly utilized certain aspects of the female role as adaptational devices” and that “any woman under sufficient stress can be expected to occasionally demonstrate behaviors associated with the hysterical adaptation.“’ In 1974 Lerner wrote that in “many ways the ‘feminine character’ and the ‘hysterical character’ are synonymous.“’ In 1982 Chodoff elaborated on his earlier “caricature” formulation by suggesting that what is exaggerated and distorted in the hysterical personality is a group of normal characteristics that are “among those that make up the traditional picture of femininity or womanliness.“4
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Vol. 25, No. 2, (March/April)
1984
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130
PHILLIP R. SLAVNEY
At the same time these ideas were being expressed there was a similar development regarding the relationship between the concept “man” (Man) and the concept “sociopathic personality” or “antisocial personality” (Antisocial Personality). Halleek, for example, suggested that a man deprived of early nurturant love could “deny his need for others, and perhaps turn upon and attack those he perceives as having rejected him . . . behavior . . usually characterized as a form of sociopathy.“? Blacker and Tupin in 1977 proposed that both men and women could present clinically with caricatures of traditional sex roles, so that the male counterpart of “the overly feminine female hysteric is the hypermasculine, pseudosociopathic Don Juan male.“” Chodoff also addressed this issue in his 1982 paper, in which he proposed that, although an exaggeration and distortion of traditional male qualities might appear in some components of the obsessional personality, the sociopathic personality (especially in a milder form Chodoff called “machoism”) might better represent the psychiatric diagnosis for men that corresponds to the hysterical personality for women4 Although these proposals are derived from extensive clinical experience and are supported by careful theoretical formulations, there has been little empirical study of the issues involved. Data are available on related topics, such as the tendency for clinicians to have different concepts of psychological health for men and women6 and the possibility that clinicians could diagnose men and women with identical clinical features as antisocial and hysterical personalities, respectively,’ but the relationships between the concepts Woman and Histrionic Personality and the concepts Man and Antisocial Personality and Man and Compulsive Personality (“obsessional personality”) remain untested. If an investigator wishes to study in a direct manner psychiatrists’ attitudes about the characteristics of and relationships between these concepts he is faced with two potential problems: (1) the likelihood that some psychiatrists will confine their descriptions of personality types to the attributes listed in official diagnostic manuals, and (2) the possibility that others, familiar with the papers quoted above, will respond so as to reproduce or to repudiate one or another of the viewpoints in the literature. An indirect method of studying the relationships between concepts might thus be preferable, and the semantic differential technique has much to recommend it in these circumstances. This technique, developed by Osgood and his colleagues,* has been widely used to measure the meanings of concepts9-I3 It requests subjects to indicate which of two contrasting adjectives is most closely associated in their minds with a particular concept. The aspect of meaning that the semantic differential seeks to assess is the connotative rather than the denotative, the feelings and implications that the concept provokes rather than its meaning as found in a dictionary. It is for this reason that the technique does not ask subjects to provide a definition of the concept “home”, for example, but instead requires them to rate “home” on a series of 7-point bipolar scales, the ends of which might be adjectives such as “good” and “bad”, “small” and “large” or “tense” and “relaxed”. The attitudes of psychiatrists about normal and abnormal personality development are largely formed during their professional educations. For this reason it was decided to conduct the present study in an academic department of psychiatry, where the effects of length of professional experience could be determined. The aim
HISTRIONIC
AND ANTISOCIAL
of the study,
131
PERSONALITIES
in which the semantic
differential
technique
was used, was to see
whether the relationships in meaning between the concepts Woman and Histrionic Personality. Man and Antisocial Personality and Man and Compulsive Personality support a “caricature” hypothesis. MATERIALS AND METHODS The semantic differential test comprised eight concepts rated on each of I5 bipolar adjectival scale\. Four of the five concepts that were the major focus of the study (Woman, Man. Antisocial PersonalIt), Compulsive Personality) were rated by all subjects. The fifth concept. Histrionic Personality, was rated by half the subjects; the other half rated the concept Hysterical Personality in order to assess whether there were connotative differences between the two terms. The concepts Child. Adult, and Paranoid Personality were added to diminish the possibility that response\ would be influenced by subjects’ Interpretations (and misinterpretations) of the purposes of the study. Each concept was presented on a separate page of the test booklet. Four of the 15 bipolar scales were chosen for their relevance to each of the personality concept\ being assessed: dramatic-unobtrusive for Histriomc Personality. illegal-legal for Antisocial Personality. perfectionistic-slipshod for Compulsive Personality and suspicious-trusting for Paranoid Personality Each of these scales contains a term that is central to the definition (denotative meaning) of itr rrspectlve personality concept. and it was anticipated that subJects would rate each concept near the appropriate pole on its defining scale. It was decided not to list more such scales in the semantic differential because that would only reproduce the official definitions of the personality concepts and could make subject\ wary of the judgemental implications of using adjectives such a< “vam” and “irresponsible” in ratlne the concepts
Woman
and Man.
The 11 remaining bipolar scales were chosen to assess the connotative meanings of the concept\ under study and were selected from among those used by Osgood and hit colleagues.” Each of these 11 scales has a high loading on one of the three factors those investigators found to be important m the ascription of meaning by the semantic differential technique. From the evaluative factor were cho\cn happy-sad. complete-incomplete, sweet-sour. beautiful-ugly and hnght-dark: from the potency fact<>r large-small. heavy-light and hard-soft: and from the activity factor fast-slow. actlvr-paasive and hotcold. Katings for each concept were obtained on a 7-point scale. Subjects were Instructed to thmk about the concept in terms of the adjectives comprising the ends of the scale and to indicate whether the concept had a slight. moderate or extreme connection with either adjective. If the concept had nc connection with the adjectives, or if it was equally strong on each side, subject\ could mark the middle position. labeled “neutral or both”. The 15bipolar scales had a different, random arrangement for each concept. To avoid position effect\ the adjectives comprising the ends of the scale were balanced between right and left for their po\,slhlc positive and negative connotations. All Johns Hopkins general psychiatry residents and full-time faculty psychiatrists with sigmflcant clinical teaching responsibilities were asked to participate as subjects. The response rate was loo”. Of the 28 house officers (21 men, 7 women) 10 were PGY-? resident%, I1 PGY-3 and 7 PGY-4. All 71 faculty members were men. English was the first language for 47 of the 49 subjects; the remainmg two. both faculty members. were fluent in English. Because group rather than individual results were to he studied, subjects did not identify themselves by name. and tests were scored wlthout knowledge of Thor had completed them. In order to determine whether the professional experience or the sex of the subjects influenced their ratings of concepts, t-tests were performed usmg group mean scores on every scale for each concept !u comparison\ of resident versus faculty raters and male versus female raters. In these and the followlnp comparisons. the seven intervals on each bipolar scale were assigned scores of 0 to 6. Only difference\ brtween mean scores of 0.5 (half a scale interval) or greater were taken as potentially important becau~ smaller differences, though sometimes statistically significant at the P < .05 level, were thought more likely to reflect trivial differences in meaning. The differences in meaning between pairs of concepts were analyzed scale by scale. The rating giber1 by a particular subject for scale 1 on concept A (eg. Woman) was subtracted from the subject’\ ratmg of \cale I on concept B (eg. Histrionic Personality), and the resulting “difference score” was noted
132
PHILLIP R. SLAVNEY
Forty-nine difference scores were thus obtained for each scale in the comparison of a pair of concepts, and the significance of the sum of these differences was determined with a one-sample t-test.
RESULTS No important differences were found between the concepts Histrionic Personality and Hysterical Personality on any of the data analyses. The ratings for both concepts were therefore pooled and treated as a single concept, Histrionic Personality, in each of the following comparisons. In rating the personality concepts under study on those scales containing their defining (denotative) terms, subjects tended, as expected, to mark scale positions nearer the extreme pole for that term than for its adjectival opposite. Thus, 94% of subjects rated Histrionic Personality as extremely or moderately dramatic, 88% rated Antisocial Personality as extremely or moderately illegal and 92% rated Compulsive Personality as extremely or moderately perfectionistic. When the concepts Woman and Man were compared on the defining terms for the personality concepts no differences were found between them in subjects’ scale marking tendencies for the adjective pairs illegal-legal (Antisocial Personality) and perfectionistic-slipshod (Compulsive Personality), but there was a trend for subjects to rate Woman as more dramatic (Histrionic Personality) than Man, a trend which characterized female as well as male psychiatrists (Table 1). The responses of faculty versus resident subjects and male versus female subjects were compared on each of the 15 scales for the concepts Woman, Man, Histrionic Personality, Antisocial Personality and Compulsive Personality. In only seven of these 150 comparisons were there differences between group mean scores of greater than half a scale interval, and these were also the only group mean differences with a P value of < .05. Faculty members viewed the concept Compulsive Personality as slower, more unobtrusive and more passive than did residents, and faculty rated Antisocial Personality as more slipshod that did house officers. Male subjects rated the concept Woman as more beautiful than did females. This small number of group differences was regarded as no greater than might be expected by chance, and it was thus concluded that all subjects could be treated as a single group to assess possible difference2 in connotative meanings between pairs of concepts. The issue of differences in the connotative meanings of the concepts under study was approached in three ways. First, for each concept the five mean scale scores that showed the greatest deviation from the “neutral or both” position were ascertained. These scores, which deviated from neutral by 0.67 to 2.63 scale intervals, indicate the adjectives that can be regarded as the most outstanding characteristics for each concept from among the alternatives available on the 15 bipolar scales. As can be seen in Table 2, the rank order of these most deviant scales clearly distinguished the concepts from one another. The second way in which differences in the connotative meanings of concepts was studied dealt with the scale by scale comparisons between pairs of concepts. Here the attempt was to discern, within the limits of the particular bipolar scales used, how the concepts Woman and Man, Woman and Histrionic Personality, Histrionic Personality and Antisocial Personality, Man and Antisocial Personality and Man and Compulsive Personality were seen in relation to one another. It should be remembered that subjects were not asked to provide descriptions of these
(All Subjects) Woman (Female Subjects) Woman (Male Subjects) Man (All Subjects) Woman (All Subjects) Man (All Subjects) Woman (All Subjects) Man (All Subjects)
Table 1. Percentage
48
0 12 23 14 14 8
0 0
a 8 0 0
0 0
2 0 0 0
Unobtrusive
Unobtrusive
Legal
Legal
Slipshod
Slipshod
65
61
70
65
72
43
0
0
47
0
0
0
0
Unobtrusive
Neutral or Both
Slight
Unobtrusive
Moderate
Extreme
SCALE POSITION
27
17
8
2
12
40
43
41
Slight
0
0
0
0
0
0
0
8
0
0
0
0
4
12
14
12
Extreme
and
ADJECTIVE
Woman
Perfection&tic
Perfectionistic
Illegal
Illegal
Dramatic
Dramatic
Dramatic
Dramatic
in Rating the Concepts
Moderate
With Which Scale Positions Were Marked by Subjects (42 Male, 7 Female) Man on Defining Terms for Personality Concepts
ADJECTIVE
Frequencies
z! z
Adjectives (In descending rank order)
Large Hard/Active Heavy Complete
Soft Sweet Beautiful Bright Light (tied)
Mean Scores
Man
Reflecting
Woman
Table 2. Rank Order of Adjectives
Dramatic Hot Incomplete Fast Slipshod
Histrionic Personality Illegal Suspicious Active Hard Incomplete
Antisocial Personality
Most From “Neutral
Concepts
Deviating
Perfectionistic Sad Suspicious Legal Cold
Compulsive Personality
or Both” Scale Interval
HISTRIONIC
AND ANTISOCIAL
PERSONALITIES
135
concepts in words of their own choosing; they could only rate the concepts as, say, more or less beautiful because that adjective was one of those provided on a short, arbitrary list of bipolar scales. Again, only differences of half a scale interval or more were accepted as potentially important, and in the following comparisons all such differences were significant at P = .0007 or less. The concept Man differed from the concept Woman on 10 of the 15 scales. Man was rated as less beautiful, sweet, bright, hot, trusting. and dramatic, and as more large, heavy, hard, and active. Woman was rated as different from Histrionic Personality on 11 scales, being considered less fast, hot, dramatic, and as more sweet, happy. complete, small. passive, trusting, legal, and perfectionistic. Antisocial Personality differed from Histrionic Personality on 11 scales, being rated as less dramatic and as more ugly, sour. dark, large, heavy, hard. active. cold, suspicious, and illegal. Man was seen as different from Antisocial Personality on 11 scales in that it was rated as less sour, hard, active and dramatic, and as more beautiful, happy, complete, bright, trusting, legal, and perfectionistic. Man differed from Compulsive Personality on 12 scales. Man was rated as less legal and perfectionistic, and as more beautiful, happy. complete, bright, large, fast. active, hot, trusting, and dramatic. These clear differentiations of concepts from one another was also generally seen in the third type of comparison. In this analysis the mean scores for all 15 scales were displayed in a profile for each concept, and the resulting profiles compared for their shapes. As can be seen in Fig. lA-ID, Woman and Man, Histrionic Personality and Antisocial Personality, Man and Antisocial Personality and Man and Compulsive Personality had quite different profiles. Fig. 1E demonstrates. however, that even though individual mean scale scores for Woman and Histrionic Personality may have been on opposite sides of the “neutral or both” point (Woman, for example. was on the happy side and Histrionic Personality on the sad), the overall shapes of their profiles were similar. DISCUSSION The results of this study indicate that there is a stronger connection between the connotative meanings of the concepts Woman and Histrionic Personality than there is between the concepts Man and Antisocial Personality or Man and Compulsive Personality. Although subjects clearly distinguished between these five concepts on the basis of their outstanding attributes and on scale by scale comparisons. there was a greater tendency for them to link the concept Woman with the adjective dramatic than there was for them to see a relationship between Man and the terms illegal and perfectionistic, and there was a stronger resemblance between the shapes of the mean semantic differential profiles for Woman and Histrionic Personality than there was for Man and Antisocial Personality or Man and Compulsive Personality. Neither the sex of the subjects nor the length of their professional experience seemed to influence their responses. In interpreting these results, certain features of the study must be taken into account. The semantic differential is a well-established technique in psychiatric research. but the very words used to label concepts and bipolar scales could affect
PHILLIP Ft. SLAVNEY
136
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Fig. 1. Mean semantic differential profiles for concepts on bipolar adjectival scales. Scores 0 and 6 represent a strong association between one of the adjectives and the concept; 1 and 5, a moderate association; 2 and 4, a slight association; 3, no association or one that was equally strong with both adjectives.
the conclusions drawn. If, instead of Woman, for example, Maternal or Feminine had been used, the results might have been different. (It is interesting to note in this regard, however, that Hysterical Personality and Histrionic Personality had very similar connotative meanings.) In addition, the limited number of subjects, the fact that most of them were men and the academic setting of the research do not permit the results to be generalized with confidence to most psychiatrists or to others involved in the diagnosis and treatment of psychiatric patients. It might seem that the greatest drawback of the study is that its abstract nature does not speak directly to clinical issues; that it might accurately reflect attitudes but says nothing about practices. This is an important point because the clinical facts are that the diagnosis of histrionic personality is given primarily to women and the diagnosis of antisocial personality to men. The questions for this study,
HISTRIONIC
however,
AND ANTISOCIAL
PERSONALITIES
137
were not whether
there is a sex bias in the diagnosis of patients who are whether the diagnoses clinically identical except for their sexes,’ nor, alternatively, of histrionic personality and antisocial personality reflect actual differences in the psychological and behavioral characteristics of the patients (regardless of sex) who receive them; the questions for this study were whether the concept Histrionic Personality should be regarded as a caricature of the concept Woman and whether either of the concepts Antisocial Personality and Compulsive Personality should be regarded as caricatures of the concept man. These issues have been approached from historical, cultural and clinical perspectives: they can also be studied empirically as questions of meaning, of significance, of implication. There is no doubt that practice shapes meaning, but, as we have seen in the continuing discussion over DSM-III (a document which changed “hysterical personality” to “histrionic personality” because of particular meanings associated with the former term), decisions about meaning can preceed and determine practice. It is in the area of meaning that concern over the relationship between the concepts Woman and Histrionic Personality and (to a much lesser extent) between Man and Antisocial Personality has chiefly arisen. For these issues psychiatry’s problem has not only been whether such relationships are accurate, but also whether they are fair. The results of this study do not support Chodoff’s proposal that either the concept Antisocial Personality or the concept Compulsive Personality represents a sex role caricature of the concept Man. One possible explanation for this may be that adjectives such as “aggressive” and “logical”, which have been described as typically masculine,h were not included on the list of bipolar scales. One could imagine that “aggressive” would be highly rated for Antisocial Personality and “logical” for Compulsive Personality, but if both adjectives are “masculine” then one might also expect Antisocial Personality to be rated high on “logical” and Compulsive Personality on “aggressive”. This is an empirical matter, but to the extent that the bipolar scale active-passive reflects the connotative meanings of the term “aggressive”, it is interesting to note that Man was seen as more active than Compulsive Personality and as more passive than Antisocial Personality (Fig. 1C. 1D). But what of the relationship between Woman and Histrionic Personality? Even though the most outstanding characteristics of these two concepts were found to be quite different, Woman was rated as fairly dramatic. More striking than this single resemblance, however, was the fact that the shapes of the semantic differential profiles for the concepts were quite similar. If the differences between the profiles were only quantitative for adjectives such as dramatic, hot, and fast, why shouldn’t it be said that Histrionic Personality is a caricature of Woman? The problem with this conclusion may not be in the data, but in the terminology, According to the Oxford English Dictionary, “caricature” is a noun whose first meaning is a “grotesque or ludicrous representation of persons or things by exaggeration of their most characteristic and striking features” and a verb whose first meaning is “to represent or portray in caricature: to make a grotesque likeness of.” To propose that the hysterical personality “is a piciure of women in the words of men a caricature of femininity”’ IS to make possible the implications that the diagnosis is only a caricature and that the diagnosticians (caricaturists) take part.
138
PHILLIP R. SLAVNEY
willy-nilly, in a process of ridicule and subjugation. Chodoff accepts at least part of these implications when he states that “much of the behavior of women who conform to the diagnosis of the hysterical personality is the product of cultural pressures, of which a major component is male domination and expectations.“4 On the other hand, he defends himself against the view that “hysteria (is) a particularly heinous example of psychiatric male chauvinism” by acknowledging that if “the concept of sex role caricature as a determinant of psychopathology has merit, it should apply to men as well as to women.“4 Could we not abandon the term caricature, with all its unpleasant meanings? Could we not agree that men and women differ (both by nature and nurture) and that some of these differences will be expressed and observed in their psychological and behavioral attributes? And could we not do this even as we agree with Chodoff that such differences refer to “tendencies and thresholds rather than absolutes,” that they “will vary within different national, ethnic, and religious groups” and that in “many, probably most, respects the normative personalities of men and women will be similar and will vary through the same wide range of dimensions.“4 It is one the professional responsibilities of psychiatrists, however, to recognize the extremes in dimensions of human variation-too little intelligence or independence, too much self-doubting or suspiciousness-for it is at the extremes of such characteristics that vulnerability to emotional distress can lie. We might refer to statistics about those who injure others and those who injure themselves to support the notion that men have a greater tendency to aggressive, illegal acts and women to self-dramatizing and attention-seeking ones. To say that, however, is not to say that the diagnosis antisocial personality represents a caricature of men and histrionic personality a caricature of women; it is only to recognize that traits are dimensions and that the distribution of individuals along those dimensions may be determined in part by their sex. And even if we agree with Chodoff that the Western concept of “femininity” is more likely to represent a cultural stereotype than a biologically-based cluster of traits,4 it does not follow of necessity that the diagnosis histrionic personality is a chauvinistically-motivated caricature of that stereotype. To approach the relationship between women and the diagnosis of histrionic personality from a psychiatric rather than a political viewpoint, we might first examine the evidence that the diagnosis itself is a valid concept. Despite the fact that the histrionic personality has been a topic in the psychiatric literature for 50 years, there have been few attempts to document its existence as a clinical entity. In part this may be due to the difficulty inherent in validiting any category that rests on the demarcation of abnormal from normal along dimensions of variation like personality traits. I4 (When, for example, does normally extraverted become histrionically self-dramatizing?) As well, though, the psychoanalytic and cultural perspectives that have characterized much psychiatric writing on the histrionic personality have focused more on theoretical and therapeutic implications of the diagnosis than on its reliable recognition or empirical validation. Psychoanalytic observations and statistical techniques were combined by Lazare and his colleagues, however, who demonstrated that a principal components analysis of patients’ responses to a self-rating questionnaire could extract factors that were consistent with the traditionally described hysterical trait cluster,15.i6 results that have been replicated by other investigators. I7 In a clinical study, Slavney and McHugh found
HISTRIONIC
AND ANTISOCIAL
PERSONALITIES
139
that patients who received a diagnosis of hysterical personality disorder could be distinguished from control patients by their vulnerability to depression and selfinjury, even though such phenomena were not among the criteria used for the diagnosis of hysterical personality disorder. Ix Although more work is needed, evidence of this type gives support to the validity of the concept histrionic personalit!. Rut what of the traits said to comprise that concept: can they be demonstrated 11) exist? Although psychiatrists agree that self-dramatization is the keystone of what had been called the hysterical personality and is now called the histrionic personality.,‘, the direct measurement of self-dramatization has been difficult. Such is not the ca>t for emotional lability, another trait thought to form part of the histrionic clusterI II a series of studies,?” I2 Slavney and his colleagues demonstrated that variability of mood was positively correlated with self-ratings on hysterical traits in normal men and women, and that patients who received the diagnosis of hysterical personality disorder had greater variability of mood than did control patient%. It \bas of interest that, in the studies of normal subjects, men and women apparently had the same subjective experience of variation in mood. This was at odds with the traditional ascription of greater emotionality to women, but it was proposed that the ascription might still be apt if women were more communicative of thnr emotions than men.?’ It is this last possibility that could serve as one empirIcal link between women and the concept of the histrionic personality. Ejriscoe has demonstrated that, in general. women report both more symptoms and more feelings than men, and she has concluded that consideration of affective responsiveness is important to an understanding of the well-documented sex dlfferences in morbidity and in the utilization of health care services.” Briscoe favors a sociological explanation for the difference in communication of distress: girls ;ire socialized to express their feelings verbally to a greater extent than boys. which results in a greater awareness of feeling states and hence need for emotional support both when an increase in unpleasant feelings manifests itself and when there ih a drop in positive feelings of well-being. ’ These tendencies for women to express feelings more freely and to seek rhe support of others more readily, may, if extreme. represent vulnerabilities to distrea\ in interpersonal relationships. Indeed. it is during the vicissitudes of close relationships that the self-dramatization, emotional lability and dependence of hictricjnic personalities become most evident. To the extent that emotional distress rests on thehe trait\. to the extent that biology. individual life experience and culture make the distress possible and manifest, psychiatrists may see women as their patient\ more often than men and, for reasons clinical rather than political, recognilc :I pattern of complaints and vulnerabilitie\ that is mart: characteristic of one sex than the other. It may be that this type of explanation better accounts for the results of the present study, at least for the relationship observed hetween the connotative meanings of Woman and Histrionic Personality. The lack of a stronger resemblance between Man and Antisocial Personality may have been due to the scales used: with other adjectives there might be stronger support for Chodoff‘s contention that antisocial personality and histrionic personality are cognate diagnoses. .4nd yet one can still disagree that lhese concepts should be regarded ah car!-
140
PHILLIP R. SLAVNEY
catures. Even if social forces are primarily responsible for the development of traits designated by the terms “histrionic” and “antisocial”, those characteristics are no less real, no less a potential source of distress, than if they were primarily determined by genetic factors. As psychiatrists, our effort should be to insure that the diagnoses meant to represent those vulnerabilities are valid concepts that can be reliably recognized, not terms of opprobrium. To call such diagnoses caricatures is to risk placing them in a context of meaning that could undermine those efforts, a context of meaning in which the discourse is political rather than medical and in which motivations are always suspect. ACKNOWLEDGMENT The author wishes to thank the members of the Department of Psychiatry and Behavioral Sciences at Johns Hopkins for their participation in the study, Paul McHugh and Neil Pauker for their comments on the manuscript, and David Edwin and David Zucker for their assistance with the data analysis.
REFERENCES 1. Chodoff P, Lyons H: Hysteria, the hysterical personality, and “hysterical” conversion. Am J Psych 114~734-740, 1958 2. Halleck SL: Hysterical personality traits. Arch Gen Psych 16:750-757, 1967 3. Lerner HE: The hysterical personality: A “woman’s disease.” Comp Psych 15: 157-163, 1974 4. Chodoff P: Hysteria and women. Am J Psych 139:545-55 1, 1982 5. Blacker KH, Tupin JP: Hysteria and hysterical structures: Developmental and social theories, in Horowitz MJ (ed): Hysterical Personality. New York, Jason Aronson, 1977, p 122 6. Broverman IK, Broverman DM, Clarkson FE: Sex-role stereotypes and clinical judgements of mental health. J Consult Clin Psycho1 34:1-7, 1970 7. Warner R: The diagnosis of antisocial and hysterical personality disorders. J Nerv Ment Dis 166:839-845, 1978 8. Osgood CE, Suci GJ, Tannenbaum PH: The Measurement of Meaning. Urbana, University of Illinois Press, 1957 9. Talbot E, Miller SC, White RB: Some aspects of self-conceptions and role demands in a therapeutic community. J Abnorm Sot Psycho1 63:338-345, 1961 10. Eisdorfer C, Altrocchi J: A comparison of attitudes toward old age and mental illness. J Gerontol 16:34&343, 1961 11. Marks IM: Patterns of Meaning in Psychiatric Patients. London, Oxford University ‘Press, 1965 12. Leff JP: Psychiatrists’ versus patients’ concepts of unpleasant emotions. Br J Psych 133:306-313, 1978 13. Felix Gentil MF, Lader M: Effects of anxiety on attitudes-A semantic differential study. Br J Med Psycho1 52:133-139, 1979 14. McHugh PR, Slavney PR: The Perspectives of Psychiatry. Baltimore, Johns Hopkins University Press, 1983, pp 77-91 15. Lazare A, Klerman GL, Armor DJ: Oral, obsessive and hysterical personality patterns. Arch Gen Psych 14:624-630, 1966 16. Lazare A, Klerman GL, Armor DJ: Oral, obsessive and hysterical personality patterns: Replication of factor analysis in an independent sample. J Psychiatr Res 7:275-290, 1970 17. van den Berg PJ, Helstone FS: Oral, obsessive and hysterical personality patterns: A Dutch replication. J Psychiatr Res 12:319-327, 1975 18. Slavney PR, McHugh PR: The hysterical personality. Arch Gen Psych 30:325-329, 1974 19. Slavney PR: The diagnosis of hysterical personality disorder: A study of attitudes. Compr Psych 19:501-507, 1978
HISTRIONIC AND ANTISOCIAL PERSONALITIES 20. Slavney PR, Breitner JCS, Rabins PV: Variability normal women. J Psychiatr Res 13:155-160, 1977
141
of mood and hysterical traits in
21. Rabins PV, Slavney PR: Hysterical traits and variability of mood in normal men. Psycho1 Med 9:301-304, 1979 22. Slavney P, Rich G: Variability of mood and the diagnosis of hysterical personality disorder. Br J Psych 136:402-W, 1980 23. Briscoe M: Sex differences in psychological well-being. Psycho1 Med Monograph Supplement 1. 1982
VOL. 25, NO. 2
Association)
MARCH/APRIL
1984
Histrionic Personality and Antisocial Personality: Caricatures of Stereotypes? Phillip R. Slavney ABSTRACT The proposal that the diagnoses Histrionic Personality and Antisocial Personality represent sexrole caricatures of the concepts “woman” and “man”, respectively, was examined utilizing the semantic differential technique for the assessment of connotative meanings. Twenty-eight psychiatric residents and 21 academic psychiatrists rated the concepts “woman”, “man”, “histrionic personality”, and “antisocial personality” on each of 15 bipolar adjectival scales. No important differences were found between the ratings made by male or female psychiatrists or by resident and faculty psychiatrists. The subjects clearly distinguished between the connotative meanings of “woman” and “histrionic personality” and between “man” and “antisocial personality”, though there was a greater resemblance between the first pair of concepts than between the second. The linkages in meaning between women and the diagnosis Histrionic Personality are discussed, and it is proposed that the concept of sex-role caricatures be abandoned since the politrcal overtones of the term “caricature” tend to undermine the empirical work needed to validate or reject clinical diagnoses.
T
HE CLOSE RELATIONSHIP between the concept “woman” (Woman) and the concept “hysterical personality” (Hysterical Personality) or “histrionic personality” (Histrionic Personality) has intrigued and troubled psychiatry for several decades. In 1958 Chodoff and Lyons suggested that the hysterical personality “is a picture of women in the words of men . a caricature of femininity!“’ In 1967 Halleck proposed that the hysterical patient “exaggerates and repeatedly utilized certain aspects of the female role as adaptational devices” and that “any woman under sufficient stress can be expected to occasionally demonstrate behaviors associated with the hysterical adaptation.“’ In 1974 Lerner wrote that in “many ways the ‘feminine character’ and the ‘hysterical character’ are synonymous.“’ In 1982 Chodoff elaborated on his earlier “caricature” formulation by suggesting that what is exaggerated and distorted in the hysterical personality is a group of normal characteristics that are “among those that make up the traditional picture of femininity or womanliness.“4
From the Department
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and Behavioral
Sciences Johns Hopkins
University
School oj’ .Med-
icrne. Addres.7 reprint
requests to P. Slavney,
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130
PHILLIP R. SLAVNEY
At the same time these ideas were being expressed there was a similar development regarding the relationship between the concept “man” (Man) and the concept “sociopathic personality” or “antisocial personality” (Antisocial Personality). Halleek, for example, suggested that a man deprived of early nurturant love could “deny his need for others, and perhaps turn upon and attack those he perceives as having rejected him . . . behavior . . usually characterized as a form of sociopathy.“? Blacker and Tupin in 1977 proposed that both men and women could present clinically with caricatures of traditional sex roles, so that the male counterpart of “the overly feminine female hysteric is the hypermasculine, pseudosociopathic Don Juan male.“” Chodoff also addressed this issue in his 1982 paper, in which he proposed that, although an exaggeration and distortion of traditional male qualities might appear in some components of the obsessional personality, the sociopathic personality (especially in a milder form Chodoff called “machoism”) might better represent the psychiatric diagnosis for men that corresponds to the hysterical personality for women4 Although these proposals are derived from extensive clinical experience and are supported by careful theoretical formulations, there has been little empirical study of the issues involved. Data are available on related topics, such as the tendency for clinicians to have different concepts of psychological health for men and women6 and the possibility that clinicians could diagnose men and women with identical clinical features as antisocial and hysterical personalities, respectively,’ but the relationships between the concepts Woman and Histrionic Personality and the concepts Man and Antisocial Personality and Man and Compulsive Personality (“obsessional personality”) remain untested. If an investigator wishes to study in a direct manner psychiatrists’ attitudes about the characteristics of and relationships between these concepts he is faced with two potential problems: (1) the likelihood that some psychiatrists will confine their descriptions of personality types to the attributes listed in official diagnostic manuals, and (2) the possibility that others, familiar with the papers quoted above, will respond so as to reproduce or to repudiate one or another of the viewpoints in the literature. An indirect method of studying the relationships between concepts might thus be preferable, and the semantic differential technique has much to recommend it in these circumstances. This technique, developed by Osgood and his colleagues,* has been widely used to measure the meanings of concepts9-I3 It requests subjects to indicate which of two contrasting adjectives is most closely associated in their minds with a particular concept. The aspect of meaning that the semantic differential seeks to assess is the connotative rather than the denotative, the feelings and implications that the concept provokes rather than its meaning as found in a dictionary. It is for this reason that the technique does not ask subjects to provide a definition of the concept “home”, for example, but instead requires them to rate “home” on a series of 7-point bipolar scales, the ends of which might be adjectives such as “good” and “bad”, “small” and “large” or “tense” and “relaxed”. The attitudes of psychiatrists about normal and abnormal personality development are largely formed during their professional educations. For this reason it was decided to conduct the present study in an academic department of psychiatry, where the effects of length of professional experience could be determined. The aim
HISTRIONIC
AND ANTISOCIAL
of the study,
131
PERSONALITIES
in which the semantic
differential
technique
was used, was to see
whether the relationships in meaning between the concepts Woman and Histrionic Personality. Man and Antisocial Personality and Man and Compulsive Personality support a “caricature” hypothesis. MATERIALS AND METHODS The semantic differential test comprised eight concepts rated on each of I5 bipolar adjectival scale\. Four of the five concepts that were the major focus of the study (Woman, Man. Antisocial PersonalIt), Compulsive Personality) were rated by all subjects. The fifth concept. Histrionic Personality, was rated by half the subjects; the other half rated the concept Hysterical Personality in order to assess whether there were connotative differences between the two terms. The concepts Child. Adult, and Paranoid Personality were added to diminish the possibility that response\ would be influenced by subjects’ Interpretations (and misinterpretations) of the purposes of the study. Each concept was presented on a separate page of the test booklet. Four of the 15 bipolar scales were chosen for their relevance to each of the personality concept\ being assessed: dramatic-unobtrusive for Histriomc Personality. illegal-legal for Antisocial Personality. perfectionistic-slipshod for Compulsive Personality and suspicious-trusting for Paranoid Personality Each of these scales contains a term that is central to the definition (denotative meaning) of itr rrspectlve personality concept. and it was anticipated that subJects would rate each concept near the appropriate pole on its defining scale. It was decided not to list more such scales in the semantic differential because that would only reproduce the official definitions of the personality concepts and could make subject\ wary of the judgemental implications of using adjectives such a< “vam” and “irresponsible” in ratlne the concepts
Woman
and Man.
The 11 remaining bipolar scales were chosen to assess the connotative meanings of the concept\ under study and were selected from among those used by Osgood and hit colleagues.” Each of these 11 scales has a high loading on one of the three factors those investigators found to be important m the ascription of meaning by the semantic differential technique. From the evaluative factor were cho\cn happy-sad. complete-incomplete, sweet-sour. beautiful-ugly and hnght-dark: from the potency fact<>r large-small. heavy-light and hard-soft: and from the activity factor fast-slow. actlvr-paasive and hotcold. Katings for each concept were obtained on a 7-point scale. Subjects were Instructed to thmk about the concept in terms of the adjectives comprising the ends of the scale and to indicate whether the concept had a slight. moderate or extreme connection with either adjective. If the concept had nc connection with the adjectives, or if it was equally strong on each side, subject\ could mark the middle position. labeled “neutral or both”. The 15bipolar scales had a different, random arrangement for each concept. To avoid position effect\ the adjectives comprising the ends of the scale were balanced between right and left for their po\,slhlc positive and negative connotations. All Johns Hopkins general psychiatry residents and full-time faculty psychiatrists with sigmflcant clinical teaching responsibilities were asked to participate as subjects. The response rate was loo”. Of the 28 house officers (21 men, 7 women) 10 were PGY-? resident%, I1 PGY-3 and 7 PGY-4. All 71 faculty members were men. English was the first language for 47 of the 49 subjects; the remainmg two. both faculty members. were fluent in English. Because group rather than individual results were to he studied, subjects did not identify themselves by name. and tests were scored wlthout knowledge of Thor had completed them. In order to determine whether the professional experience or the sex of the subjects influenced their ratings of concepts, t-tests were performed usmg group mean scores on every scale for each concept !u comparison\ of resident versus faculty raters and male versus female raters. In these and the followlnp comparisons. the seven intervals on each bipolar scale were assigned scores of 0 to 6. Only difference\ brtween mean scores of 0.5 (half a scale interval) or greater were taken as potentially important becau~ smaller differences, though sometimes statistically significant at the P < .05 level, were thought more likely to reflect trivial differences in meaning. The differences in meaning between pairs of concepts were analyzed scale by scale. The rating giber1 by a particular subject for scale 1 on concept A (eg. Woman) was subtracted from the subject’\ ratmg of \cale I on concept B (eg. Histrionic Personality), and the resulting “difference score” was noted
132
PHILLIP R. SLAVNEY
Forty-nine difference scores were thus obtained for each scale in the comparison of a pair of concepts, and the significance of the sum of these differences was determined with a one-sample t-test.
RESULTS No important differences were found between the concepts Histrionic Personality and Hysterical Personality on any of the data analyses. The ratings for both concepts were therefore pooled and treated as a single concept, Histrionic Personality, in each of the following comparisons. In rating the personality concepts under study on those scales containing their defining (denotative) terms, subjects tended, as expected, to mark scale positions nearer the extreme pole for that term than for its adjectival opposite. Thus, 94% of subjects rated Histrionic Personality as extremely or moderately dramatic, 88% rated Antisocial Personality as extremely or moderately illegal and 92% rated Compulsive Personality as extremely or moderately perfectionistic. When the concepts Woman and Man were compared on the defining terms for the personality concepts no differences were found between them in subjects’ scale marking tendencies for the adjective pairs illegal-legal (Antisocial Personality) and perfectionistic-slipshod (Compulsive Personality), but there was a trend for subjects to rate Woman as more dramatic (Histrionic Personality) than Man, a trend which characterized female as well as male psychiatrists (Table 1). The responses of faculty versus resident subjects and male versus female subjects were compared on each of the 15 scales for the concepts Woman, Man, Histrionic Personality, Antisocial Personality and Compulsive Personality. In only seven of these 150 comparisons were there differences between group mean scores of greater than half a scale interval, and these were also the only group mean differences with a P value of < .05. Faculty members viewed the concept Compulsive Personality as slower, more unobtrusive and more passive than did residents, and faculty rated Antisocial Personality as more slipshod that did house officers. Male subjects rated the concept Woman as more beautiful than did females. This small number of group differences was regarded as no greater than might be expected by chance, and it was thus concluded that all subjects could be treated as a single group to assess possible difference2 in connotative meanings between pairs of concepts. The issue of differences in the connotative meanings of the concepts under study was approached in three ways. First, for each concept the five mean scale scores that showed the greatest deviation from the “neutral or both” position were ascertained. These scores, which deviated from neutral by 0.67 to 2.63 scale intervals, indicate the adjectives that can be regarded as the most outstanding characteristics for each concept from among the alternatives available on the 15 bipolar scales. As can be seen in Table 2, the rank order of these most deviant scales clearly distinguished the concepts from one another. The second way in which differences in the connotative meanings of concepts was studied dealt with the scale by scale comparisons between pairs of concepts. Here the attempt was to discern, within the limits of the particular bipolar scales used, how the concepts Woman and Man, Woman and Histrionic Personality, Histrionic Personality and Antisocial Personality, Man and Antisocial Personality and Man and Compulsive Personality were seen in relation to one another. It should be remembered that subjects were not asked to provide descriptions of these
(All Subjects) Woman (Female Subjects) Woman (Male Subjects) Man (All Subjects) Woman (All Subjects) Man (All Subjects) Woman (All Subjects) Man (All Subjects)
Table 1. Percentage
48
0 12 23 14 14 8
0 0
a 8 0 0
0 0
2 0 0 0
Unobtrusive
Unobtrusive
Legal
Legal
Slipshod
Slipshod
65
61
70
65
72
43
0
0
47
0
0
0
0
Unobtrusive
Neutral or Both
Slight
Unobtrusive
Moderate
Extreme
SCALE POSITION
27
17
8
2
12
40
43
41
Slight
0
0
0
0
0
0
0
8
0
0
0
0
4
12
14
12
Extreme
and
ADJECTIVE
Woman
Perfection&tic
Perfectionistic
Illegal
Illegal
Dramatic
Dramatic
Dramatic
Dramatic
in Rating the Concepts
Moderate
With Which Scale Positions Were Marked by Subjects (42 Male, 7 Female) Man on Defining Terms for Personality Concepts
ADJECTIVE
Frequencies
z! z
Adjectives (In descending rank order)
Large Hard/Active Heavy Complete
Soft Sweet Beautiful Bright Light (tied)
Mean Scores
Man
Reflecting
Woman
Table 2. Rank Order of Adjectives
Dramatic Hot Incomplete Fast Slipshod
Histrionic Personality Illegal Suspicious Active Hard Incomplete
Antisocial Personality
Most From “Neutral
Concepts
Deviating
Perfectionistic Sad Suspicious Legal Cold
Compulsive Personality
or Both” Scale Interval
HISTRIONIC
AND ANTISOCIAL
PERSONALITIES
135
concepts in words of their own choosing; they could only rate the concepts as, say, more or less beautiful because that adjective was one of those provided on a short, arbitrary list of bipolar scales. Again, only differences of half a scale interval or more were accepted as potentially important, and in the following comparisons all such differences were significant at P = .0007 or less. The concept Man differed from the concept Woman on 10 of the 15 scales. Man was rated as less beautiful, sweet, bright, hot, trusting. and dramatic, and as more large, heavy, hard, and active. Woman was rated as different from Histrionic Personality on 11 scales, being considered less fast, hot, dramatic, and as more sweet, happy. complete, small. passive, trusting, legal, and perfectionistic. Antisocial Personality differed from Histrionic Personality on 11 scales, being rated as less dramatic and as more ugly, sour. dark, large, heavy, hard. active. cold, suspicious, and illegal. Man was seen as different from Antisocial Personality on 11 scales in that it was rated as less sour, hard, active and dramatic, and as more beautiful, happy, complete, bright, trusting, legal, and perfectionistic. Man differed from Compulsive Personality on 12 scales. Man was rated as less legal and perfectionistic, and as more beautiful, happy. complete, bright, large, fast. active, hot, trusting, and dramatic. These clear differentiations of concepts from one another was also generally seen in the third type of comparison. In this analysis the mean scores for all 15 scales were displayed in a profile for each concept, and the resulting profiles compared for their shapes. As can be seen in Fig. lA-ID, Woman and Man, Histrionic Personality and Antisocial Personality, Man and Antisocial Personality and Man and Compulsive Personality had quite different profiles. Fig. 1E demonstrates. however, that even though individual mean scale scores for Woman and Histrionic Personality may have been on opposite sides of the “neutral or both” point (Woman, for example. was on the happy side and Histrionic Personality on the sad), the overall shapes of their profiles were similar. DISCUSSION The results of this study indicate that there is a stronger connection between the connotative meanings of the concepts Woman and Histrionic Personality than there is between the concepts Man and Antisocial Personality or Man and Compulsive Personality. Although subjects clearly distinguished between these five concepts on the basis of their outstanding attributes and on scale by scale comparisons. there was a greater tendency for them to link the concept Woman with the adjective dramatic than there was for them to see a relationship between Man and the terms illegal and perfectionistic, and there was a stronger resemblance between the shapes of the mean semantic differential profiles for Woman and Histrionic Personality than there was for Man and Antisocial Personality or Man and Compulsive Personality. Neither the sex of the subjects nor the length of their professional experience seemed to influence their responses. In interpreting these results, certain features of the study must be taken into account. The semantic differential is a well-established technique in psychiatric research. but the very words used to label concepts and bipolar scales could affect
PHILLIP Ft. SLAVNEY
136
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Dramat,c S”*plclo”r Hot Anlre Fast Hard “Pl.”
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,’
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Fig. 1. Mean semantic differential profiles for concepts on bipolar adjectival scales. Scores 0 and 6 represent a strong association between one of the adjectives and the concept; 1 and 5, a moderate association; 2 and 4, a slight association; 3, no association or one that was equally strong with both adjectives.
the conclusions drawn. If, instead of Woman, for example, Maternal or Feminine had been used, the results might have been different. (It is interesting to note in this regard, however, that Hysterical Personality and Histrionic Personality had very similar connotative meanings.) In addition, the limited number of subjects, the fact that most of them were men and the academic setting of the research do not permit the results to be generalized with confidence to most psychiatrists or to others involved in the diagnosis and treatment of psychiatric patients. It might seem that the greatest drawback of the study is that its abstract nature does not speak directly to clinical issues; that it might accurately reflect attitudes but says nothing about practices. This is an important point because the clinical facts are that the diagnosis of histrionic personality is given primarily to women and the diagnosis of antisocial personality to men. The questions for this study,
HISTRIONIC
however,
AND ANTISOCIAL
PERSONALITIES
137
were not whether
there is a sex bias in the diagnosis of patients who are whether the diagnoses clinically identical except for their sexes,’ nor, alternatively, of histrionic personality and antisocial personality reflect actual differences in the psychological and behavioral characteristics of the patients (regardless of sex) who receive them; the questions for this study were whether the concept Histrionic Personality should be regarded as a caricature of the concept Woman and whether either of the concepts Antisocial Personality and Compulsive Personality should be regarded as caricatures of the concept man. These issues have been approached from historical, cultural and clinical perspectives: they can also be studied empirically as questions of meaning, of significance, of implication. There is no doubt that practice shapes meaning, but, as we have seen in the continuing discussion over DSM-III (a document which changed “hysterical personality” to “histrionic personality” because of particular meanings associated with the former term), decisions about meaning can preceed and determine practice. It is in the area of meaning that concern over the relationship between the concepts Woman and Histrionic Personality and (to a much lesser extent) between Man and Antisocial Personality has chiefly arisen. For these issues psychiatry’s problem has not only been whether such relationships are accurate, but also whether they are fair. The results of this study do not support Chodoff’s proposal that either the concept Antisocial Personality or the concept Compulsive Personality represents a sex role caricature of the concept Man. One possible explanation for this may be that adjectives such as “aggressive” and “logical”, which have been described as typically masculine,h were not included on the list of bipolar scales. One could imagine that “aggressive” would be highly rated for Antisocial Personality and “logical” for Compulsive Personality, but if both adjectives are “masculine” then one might also expect Antisocial Personality to be rated high on “logical” and Compulsive Personality on “aggressive”. This is an empirical matter, but to the extent that the bipolar scale active-passive reflects the connotative meanings of the term “aggressive”, it is interesting to note that Man was seen as more active than Compulsive Personality and as more passive than Antisocial Personality (Fig. 1C. 1D). But what of the relationship between Woman and Histrionic Personality? Even though the most outstanding characteristics of these two concepts were found to be quite different, Woman was rated as fairly dramatic. More striking than this single resemblance, however, was the fact that the shapes of the semantic differential profiles for the concepts were quite similar. If the differences between the profiles were only quantitative for adjectives such as dramatic, hot, and fast, why shouldn’t it be said that Histrionic Personality is a caricature of Woman? The problem with this conclusion may not be in the data, but in the terminology, According to the Oxford English Dictionary, “caricature” is a noun whose first meaning is a “grotesque or ludicrous representation of persons or things by exaggeration of their most characteristic and striking features” and a verb whose first meaning is “to represent or portray in caricature: to make a grotesque likeness of.” To propose that the hysterical personality “is a piciure of women in the words of men a caricature of femininity”’ IS to make possible the implications that the diagnosis is only a caricature and that the diagnosticians (caricaturists) take part.
138
PHILLIP R. SLAVNEY
willy-nilly, in a process of ridicule and subjugation. Chodoff accepts at least part of these implications when he states that “much of the behavior of women who conform to the diagnosis of the hysterical personality is the product of cultural pressures, of which a major component is male domination and expectations.“4 On the other hand, he defends himself against the view that “hysteria (is) a particularly heinous example of psychiatric male chauvinism” by acknowledging that if “the concept of sex role caricature as a determinant of psychopathology has merit, it should apply to men as well as to women.“4 Could we not abandon the term caricature, with all its unpleasant meanings? Could we not agree that men and women differ (both by nature and nurture) and that some of these differences will be expressed and observed in their psychological and behavioral attributes? And could we not do this even as we agree with Chodoff that such differences refer to “tendencies and thresholds rather than absolutes,” that they “will vary within different national, ethnic, and religious groups” and that in “many, probably most, respects the normative personalities of men and women will be similar and will vary through the same wide range of dimensions.“4 It is one the professional responsibilities of psychiatrists, however, to recognize the extremes in dimensions of human variation-too little intelligence or independence, too much self-doubting or suspiciousness-for it is at the extremes of such characteristics that vulnerability to emotional distress can lie. We might refer to statistics about those who injure others and those who injure themselves to support the notion that men have a greater tendency to aggressive, illegal acts and women to self-dramatizing and attention-seeking ones. To say that, however, is not to say that the diagnosis antisocial personality represents a caricature of men and histrionic personality a caricature of women; it is only to recognize that traits are dimensions and that the distribution of individuals along those dimensions may be determined in part by their sex. And even if we agree with Chodoff that the Western concept of “femininity” is more likely to represent a cultural stereotype than a biologically-based cluster of traits,4 it does not follow of necessity that the diagnosis histrionic personality is a chauvinistically-motivated caricature of that stereotype. To approach the relationship between women and the diagnosis of histrionic personality from a psychiatric rather than a political viewpoint, we might first examine the evidence that the diagnosis itself is a valid concept. Despite the fact that the histrionic personality has been a topic in the psychiatric literature for 50 years, there have been few attempts to document its existence as a clinical entity. In part this may be due to the difficulty inherent in validiting any category that rests on the demarcation of abnormal from normal along dimensions of variation like personality traits. I4 (When, for example, does normally extraverted become histrionically self-dramatizing?) As well, though, the psychoanalytic and cultural perspectives that have characterized much psychiatric writing on the histrionic personality have focused more on theoretical and therapeutic implications of the diagnosis than on its reliable recognition or empirical validation. Psychoanalytic observations and statistical techniques were combined by Lazare and his colleagues, however, who demonstrated that a principal components analysis of patients’ responses to a self-rating questionnaire could extract factors that were consistent with the traditionally described hysterical trait cluster,15.i6 results that have been replicated by other investigators. I7 In a clinical study, Slavney and McHugh found
HISTRIONIC
AND ANTISOCIAL
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that patients who received a diagnosis of hysterical personality disorder could be distinguished from control patients by their vulnerability to depression and selfinjury, even though such phenomena were not among the criteria used for the diagnosis of hysterical personality disorder. Ix Although more work is needed, evidence of this type gives support to the validity of the concept histrionic personalit!. Rut what of the traits said to comprise that concept: can they be demonstrated 11) exist? Although psychiatrists agree that self-dramatization is the keystone of what had been called the hysterical personality and is now called the histrionic personality.,‘, the direct measurement of self-dramatization has been difficult. Such is not the ca>t for emotional lability, another trait thought to form part of the histrionic clusterI II a series of studies,?” I2 Slavney and his colleagues demonstrated that variability of mood was positively correlated with self-ratings on hysterical traits in normal men and women, and that patients who received the diagnosis of hysterical personality disorder had greater variability of mood than did control patient%. It \bas of interest that, in the studies of normal subjects, men and women apparently had the same subjective experience of variation in mood. This was at odds with the traditional ascription of greater emotionality to women, but it was proposed that the ascription might still be apt if women were more communicative of thnr emotions than men.?’ It is this last possibility that could serve as one empirIcal link between women and the concept of the histrionic personality. Ejriscoe has demonstrated that, in general. women report both more symptoms and more feelings than men, and she has concluded that consideration of affective responsiveness is important to an understanding of the well-documented sex dlfferences in morbidity and in the utilization of health care services.” Briscoe favors a sociological explanation for the difference in communication of distress: girls ;ire socialized to express their feelings verbally to a greater extent than boys. which results in a greater awareness of feeling states and hence need for emotional support both when an increase in unpleasant feelings manifests itself and when there ih a drop in positive feelings of well-being. ’ These tendencies for women to express feelings more freely and to seek rhe support of others more readily, may, if extreme. represent vulnerabilities to distrea\ in interpersonal relationships. Indeed. it is during the vicissitudes of close relationships that the self-dramatization, emotional lability and dependence of hictricjnic personalities become most evident. To the extent that emotional distress rests on thehe trait\. to the extent that biology. individual life experience and culture make the distress possible and manifest, psychiatrists may see women as their patient\ more often than men and, for reasons clinical rather than political, recognilc :I pattern of complaints and vulnerabilitie\ that is mart: characteristic of one sex than the other. It may be that this type of explanation better accounts for the results of the present study, at least for the relationship observed hetween the connotative meanings of Woman and Histrionic Personality. The lack of a stronger resemblance between Man and Antisocial Personality may have been due to the scales used: with other adjectives there might be stronger support for Chodoff‘s contention that antisocial personality and histrionic personality are cognate diagnoses. .4nd yet one can still disagree that lhese concepts should be regarded ah car!-
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catures. Even if social forces are primarily responsible for the development of traits designated by the terms “histrionic” and “antisocial”, those characteristics are no less real, no less a potential source of distress, than if they were primarily determined by genetic factors. As psychiatrists, our effort should be to insure that the diagnoses meant to represent those vulnerabilities are valid concepts that can be reliably recognized, not terms of opprobrium. To call such diagnoses caricatures is to risk placing them in a context of meaning that could undermine those efforts, a context of meaning in which the discourse is political rather than medical and in which motivations are always suspect. ACKNOWLEDGMENT The author wishes to thank the members of the Department of Psychiatry and Behavioral Sciences at Johns Hopkins for their participation in the study, Paul McHugh and Neil Pauker for their comments on the manuscript, and David Edwin and David Zucker for their assistance with the data analysis.
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