Is the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, histrionic personality disorder category a valid construct?

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Comprehensive Psychiatry 51 (2010) 462 – 470 www.elsevier.com/locate/comppsych

Is the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, histrionic personality disorder category a valid construct? Jonas F. Bakkeviga,b,⁎, Sigmund Karteruda,c a

Department of Personality Psychiatry, Ulleval University Hospital, 0407 Oslo, Norway b Division Mental Health Services, Akershus University Hospital c Faculty of Psychiatry, University of Oslo, Oslo, Norway

Abstract Purpose: The study investigated crucial aspects of the construct validity of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) histrionic personality disorder (HPD) category. Material and methods: The study included 2289 patients from the Norwegian Network of Psychotherapeutic Day Hospitals. Construct validity was assessed by means of prevalence, comorbidity with other personality disorders, internal consistency among HPD criteria, severity indices, as well as factor analyses. Results: The prevalence of HPD was very low (0.4 %). The comorbidity was high, especially with borderline, narcissistic, and dependent personality disorders. The internal consistency was low. The criteria seemed to form 2 separate clusters: the first contained exhibitionistic and attention-seeking traits and the other contained impressionistic traits. Conclusion: The results indicated poor construct validity of the HPD category. Different options for the future of the category are discussed. The authors suggest the HPD category to be deleted from the DSM system. However, the clinical phenomena of exhibitionism and attention-seeking, which are the dominant personality features of HPD, should be preserved in an exhibitionistic subtype of narcissism. © 2010 Elsevier Inc. All rights reserved.

1. Introduction Histrionic personality disorder (HPD) made its first official appearance in Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM-II) [1] under the label hysterical personality disorder. Excitability, emotional instability, overreactivity, attention-seeking, self-dramatization, immaturity, self-centeredness, vanity, and dependence described the prototype. The term hysterical was renamed to “histrionic” in DSM-III [2], probably due to a desire to remove the construct from its roots in hysteria [3] and to soften its connotations as to sex. DSM-III [2] introduced criteria of manipulative use of suicide (attempts or gestures) and irrational, angry outbursts, but these criteria were later

⁎ Corresponding author. Department of Personality Psychiatry, Ulleval University Hospital, 0407 Oslo, Norway. Tel.: +47 40218580. E-mail address: [email protected] (J.F. Bakkevig). 0010-440X/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2009.11.009

removed in DSM-III–R [4], mainly due to an overlap with borderline personality disorder (BPD) [3]. Two more criteria were added: “is inappropriately sexually seductive in appearance and behavior” and “has a style of speech that is excessively impressionistic and lacking in detail.” When preparing for DSM-IV [5], low specificity was the reason for removing the criterion “is self-centered, actions being directed toward obtaining immediate satisfaction; has no tolerance for frustration of delayed gratification.” To keep the number of criteria at 8, a new criterion was introduced: “considers relationships to be more intimate than they actually are.” The DSM-III–R [4] criterion “constantly seeks or demands reassurance, approval, or praise” was also considered too unspecific, as it tended to overlap with other personality disorders. It was therefore substituted with “is suggestible, that is, easily influenced by others or circumstances” in DSM-IV [5]. Furthermore, 5 criteria were now the threshold for obtaining the diagnosis, as compared to 4 criteria in DSM-III–R [4]. Not surprisingly, this led to a

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decline in the number of patients diagnosed with HPD [6]. Histrionic personality disorder is now defined as depicted in Box 1. Box 1. Diagnostic criteria for HPD (DSM-IV, 1994) (1) is uncomfortable in situations in which he or she is not the center of attention, (2) interaction with others is often characterized by inappropriate sexually seductive or provocative behavior, (3) displays rapidly shifting and shallow expression of emotions, (4) consistently uses physical appearance to draw attention to self, (5) has a style of speech that is excessively impressionistic and lacking in detail, (6) shows self-dramatization, theatricality, and exaggerated expression of emotion, (7) is suggestible, that is, easily influenced by others or circumstances, and (8) considers relationships to be more intimate than they actually are.

DSM-III DSM-IV DSM-IV DSM-III–R DSM-III–R

USA UK USA USA USA

247 626 644 229 258

3.2 0.0 0.9 1.7 1.9

DSM-IV DSM-III–R DSM-III–R DSM-IV DSM-III–R DSM-III

USA 214 Germany 452 USA 302 USA 742 Norway 2053 USA 797

0.0 1.3 0.3 0.2 2.0 3.0

ICD-10

United Kingdom USA

166

6.0

The material for this study was 2289 patients treated by units connected to The Norwegian Network of Psychotherapeutic Day Hospitals in the time span 1996 to 2006. The assessment battery included Symptom Checklist-90–R as a measure of symptom distress [27], Circumplex of Interpersonal Problems (CIP) as a measure of interpersonal problems [28,29], and Global Assessment of Functioning (GAF) as a measure of psychosocial functioning [5]. The psychometrics of Symptom Checklist-90–R is well established [30]. The CIP mean sum score correlates .99 with IIP [29]. The procedure for assessment of GAF in this study has been found satisfactory (ICC = .96) [31]. The personality disorder diagnoses were assessed by Structured Clinical Interview for the DSM-IV Axis II personality disorders [32] and symptom disorders were assessed by Mini International Neuropsychiatric Interview [33], both procedures according to the LEAD (Longitudinal, Expert, All Data) principle [34]. In addition to the structured interviews, all data (referral letters, patients written narratives, records from other hospitals, and others) were taken into account, and provisional diagnoses were decided on admission case conferences. Formal diagnoses were decided at case conferences after discharge, taking into account observations from a diversity of psychotherapeutic groups during the 18 weeks of treatment. There was no reliability check of the diagnoses. A more detailed description of assessment battery and procedures is provided by [35]. All participants gave their informed consent to sending their assessment data, in anonymous form, to a central database for research purposes. The Regional Ethics Committee and the State Data Inspectorate approved this procedure.

530

1.1

2.1. Statistics

UK USA

73 859

3.0 1.0

χ2 statistics and ϕ coefficients were calculated to assess the relationship between (a) sex and HPD criteria, (b)

Table 1 Prevalence rates across studies

Community samples Black et al (1993) Coid et al (2006) Crawford (2005) Klein et al (1995) Lenzenweger et al (1997) Lenzenweger (2007) Maier et al (1992) Moldin et al (1994) Samuels et al (2002) Torgersen et al (2001) Zimmermann and Coryell (1989) Psychiatric samples Keown et al (2002)

dependent personality disorder (DPD) [3,13-20]; and (d) different levels of psychopathology for those diagnosed with HPD [21-25]. Consequently, one is easily confused as to exactly what kind of patients this diagnosis has been aimed at identifying. As HPD is a construct, in the sense that its criteria are operationalizations of domains of behavior specific to those who are meant to be described by this diagnosis [26], the diverse prevalence rates, extensive comorbidity, and extensive differences among patients within the same category indicate that the construct validity of HPD is questionable. The paucity of research on this diagnosis is also alarming. This is the background for the present study of crucial validity aspects of the HPD pathologic indicators, reliability, and factor loadings in a large sample of personality disordered patients. 2. Material and methods

Such is the naked history of the attempts to operationalize the HPD construct. The terms hysteria, hysterical personality, and histrionic personality disorder mark the development of unrelenting attempts to identify a distinct pattern of psychopathology. However, as of the last 50 years, there has been a sustaining disagreement and uncertainty as to (a) the true nature of the construct [3,7-12]; (b) conflicting prevalence rates (Table 1); (c) significant co-occurrences with BPD, narcissistic personality disorder (NPD), and

Author

463

Diagnostic Country

Posternak and DSM-IV Zimmermann (2002) Ranger et al (2004) ICD-10 Zimmermann et al (2005) DSM-IV

Sample size HPD (%)

464

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and Kaiser Normalization as the rotation method. The selection of factors was based on eigenvalues higher than 1.0, the place of the elbow in the scree-plot and clinical coherence.

Table 2 Prevalence (percentages) for personality disorders and comorbidity with HPD Personality disorder Cluster A Paranoid Schizoid Schizotypal

n

% total

n (HPD)

ϕ coefficients

Level of significance

236 17 30

10.4 0.7 1.3

1 0 0

−.006 −.008 .000

.970 .783 .714

3. Results 3.1. Prevalence and sex distribution

Cluster B Antisocial Borderline Histrionic Narcissistic

38 536 10 18

1.7 23.5 0.4 0.8

1 6 – 2

.043 .057 – .144

.039 .006 – .000

Cluster C Avoidant Dependent Obsessivecompulsive

884 240 204

38.8 10.5 9.0

4 1 1

−.039 .064 .002

.061 .002 .908

PDNOS

414

18.1

–

–

Of all 2289 patients, 71 % were women (n = 1629), and the mean age was 35 years (SE, 0.19). By admission, the mean score on GAF was 45 (SE, 0.11), GSI (Global Severity Index) was 1.5 (SE, 0.01), and CIP was 1.7 (SE, 0.01). The most common Axis I disorders were major depression (n = 1274), social phobia (n = 687), panic disorder (n = 622), and agoraphobia (n = 504). Only 10 (0.4%) of 2289 patients fulfilled the requirements for an HPD diagnosis (Table 2). Among these, the mean age was 33 (SE, 1.41). Of the 10 patients with HPD diagnosis, 8 were female. The sex difference among HPD patients was not significantly different from the sex difference in the sample as a whole (2-tailed Fisher exact, P = .733). However, as compared to that of men, criterion 3 (emotional display) (χ2 = 6.867; df = 2; P = .032) and criterion 7 (suggestible) (χ2 = 9.188; df = 2; P = .010) were significantly more often obtained by women.

–

PDNOS indicates personality disorder not otherwise specified. The table should be read as follows: 10.4% of all patients in the sample had paranoid personality disorder. One of these also had HPD. Paranoid personality disorder correlated negatively with HPD (ϕ coefficient = −.006), although not significant (P = .970). As comorbidity occurs, the percentage will not sum to 100.

diagnostic co-occurrence between HPD and other PDs, and (c) relationship between HPD diagnosis and Axis I disorders. Because of the low prevalence of subjects with HPD diagnosis, Fisher exact t test was used to compare the sex differences in the entire sample with the sex differences among subjects with HPD. Partial correlations were computed to check for relationship between number of HPD criteria and indicators of dysfunction, controlling for number of total personality disorder criteria obtained. Cronbach α [36] was used to assess internal consistency of criteria. The factor structure of HPD was investigated by an exploratory factor analysis, performed with Principal Component Analysis as the extraction method

3.2. Diagnostic co-occurrence Among the HPD patients, the average number of HPD criteria was 5.3 (SE, 0.15), whereas average number of BPD criteria was also 5.3 (SE, 0.63). Average number of total personality disorder criteria among patients with HPD was 22.6, which means that the major part of the personality pathology (17,3 criteria) was due to other criteria. One patient with HPD had 5 other Axis II diagnoses, whereas 2 patients had only the HPD diagnosis. The HPD category correlated significantly (P b .01) with BPD, NPD, and DPD (Table 2). Altogether 454 patients displayed one or more HPD traits.

Table 3 Correlations between the 8 HPD criteria and personality disorder diagnoses HPD criteria

SH

SC

PA

AS

NA

BO

AV

OCPD

DEP

HPD

(1) uncomfortable when not the center of attention (2) sexually seductive or provocative behavior (3) rapidly shifting and shallow expression of emotions (4) use of physical appearance to draw attention (5) excessively impressionistic speech (6) self-dramatization and exaggerated expression (7) suggestible (8) considers relationships more intimate than they are

.004 −.002 −.020 −.029 −.015 −.021 −.005 −.015

−.033 −.022 −.002 −.021 .031 −.022 .012 .026

.067⁎⁎ .039 −.003 .055⁎⁎ −.022 .034 −.015 −.007

.045⁎⁎ .070⁎⁎ .016 .048⁎⁎ .041 −.012 −.006 −.016

.076⁎⁎ .078⁎⁎ .060⁎⁎ .037 .0.28 .071⁎⁎ −.022 −.063⁎⁎

.147⁎⁎ .182⁎⁎ .147⁎⁎ .183⁎⁎ .097⁎⁎ .159⁎⁎ .070⁎⁎ .119⁎⁎

−.169⁎⁎ −.149⁎⁎ −.088⁎⁎ −.068⁎⁎ −.065⁎⁎ −.141⁎⁎ .132⁎⁎ −.110⁎⁎

.089⁎⁎ .021 −.012 .002 .013 .050⁎ .013 .060⁎⁎

.024 .001 −.007 .060⁎⁎ .011 .028 .183⁎⁎ .094⁎⁎

.171⁎⁎ .237⁎⁎ .222⁎⁎ .199⁎⁎ .197⁎⁎ .225⁎⁎ .076⁎⁎ .221⁎⁎

SH indicates schizoid personality disorder; SC, schizotypal personality disorder; PA, paranoid personality disorder; NA, narcissistic personality disorder, BO, borderline personality disorder; AV, avoidant personality disorder; OCPD, obsessive-compulsive personality disorder; DEP, dependent personality disorder. ⁎ P b .05. ⁎⁎ P b .01.

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465

Table 4 Reliability statistics of the HPD criteria HPD criteria

1a

2a

3a

4a

5a

6a

7a

8a

CITC

α

(1) uncomfortable when not the center of attention (2) sexually seductive or provocative behavior (3) rapidly shifting and shallow expression of emotions (4) use of physical appearance to draw attention (5) excessively impressionistic speech (6) self-dramatization and exaggerated expression (7) suggestible (8) considers relationships more intimate than they are

1.00

.392 1.00

.248 .341 1.00

.368 .375 .222 1.00

.153 .206 .378 .108 1.00

.378 .382 .310 .354 .175 1.00

.051 .067 .073 .045 .073 .0.53 1.00

.238 .256 .267 .223 .149 .328 .140 1.00

.447 .489 .410 .417 .279 .484 .107 .385

.589 .582 .617 .603 .642 .583 .724 .611

CITC indicates Corrected Item-Total Correlation, which is the correlation of the criterion with the sum of the other criteria. α is Cronbach α if item deleted. Cronbach α = .651. a HPD criteria 1 to 8.

Among all the symptom disorders, the ones significantly associated with HPD were somatoform disorders (χ2 = 9.190; df = 1; P = .002) and substance use disorders (χ2 = 9.989; df = 1; P = .002). On a trait level, criterion 7 correlated higher with dependent personality disorder and avoidant personality disorder than with HPD. Several HPD criteria correlated significantly with other PDs, especially BPD and NPD (Table 3). The correlations with the category as a whole ranged from .08 to .24.

all personality disorder criteria obtained, the correlations with scores on GAF, CIP, and GSI were lowered and no longer statistically significant. 3.4. Reliabilities Generally, the intercorrelations between the HPD criteria were rather low, indicating that none were redundant (Table 4). Cronbach α was somewhat low (0.65). By removing criteria 7, “is suggestible,” Cronbach α increased to 0.72. 3.5. Factor structure

3.3. Contribution to pathology When correlating the number of HPD criteria fulfilled with scores on distress and dysfunction, GAF scores were not significantly lower (r = −0.40; P = .054), whereas both CIP (r = .079; P = .000) and GSI (r = .094; P = .000) were significantly higher the more HPD criteria fulfilled. When computing partial correlations and controlling for number of

A full Principal Component Analysis on all the Structured Clinical Interview for the DSM-IV Axis II personality disorders criteria revealed a 26-factor solution, with eigenvalues higher than 1, explaining 51.6% of all variance. The HPD criteria 1, 2, 4, 6, and 8 loaded on component 3 (Table 5), explaining 4.2% of all variance, also including criteria 4 for NPD (“requires excessive admiration”). The

Table 5 Principal Component Analysis: factor loadings of the HPD criteria Loadings including all personality disorder criteria

HPD (1) uncomfortable when not the center of attention HPD (2) sexually seductive or provocative behavior HPD (3) rapidly shifting and shallow expression of emotions HPD (4) use of physical appearance to draw attention HPD (5) excessively impressionistic speech HPD (6) self-dramatization and exaggerated expression HPD (7) suggestible HPD (8) considers relationships more intimate than they are NAPD (3) requires excessive admiration a

Loadings including HPD criteria only

Factor 3

Factor 19

Factor 22

Factor 1a

Factor 2a

Factor 3a

.64

–

–

.72 (.73)

–

–

.63

–

–

.67 (.69)

–

–

–

.66

–

–

.73 (.66)

–

.70

–

–

.73 (.73)

–

–

–

.73

–

–

.87 (.77)

–

.63

–

–

.69 (.70)

–

–

– .46

– –

.70 –

– .44 (.44)

– (.48) –

.94 –

.60

–

–

Factor loadings for a 2-factor solution in parenthesis.

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HPD criteria 3 and 5 loaded on component 19, explaining 1.2 % of all variance. The HPD criterion 7 loaded, as the only, on component 20, explaining 1.2% of all variance. This 3-factor solution was confirmed by means of confirmatory factor analysis (not included here). 4. Discussion The main findings in this study were the following: (1) The prevalence rate of HPD was very low (0.4 %). (2) There was no sex difference on a diagnostic level. However, on a trait level, 2 items occurred more frequently among women. (3) Among the HPD patients, the major part of their personality pathology was derived from other personality disorder criteria. (4) Histrionic personality disorder was positively correlated with BPD, NPD, and DPD. (5) Concerning Axis I diagnoses, HPD was significantly associated with somatoform disorder and substance abuse. (6) Number of HPD criteria, when controlled for other cooccurring criteria, was not associated with more symptoms, interpersonal problems or social functioning. (7) The internal consistency was modest to low (Cronbach α = 0.65) but increased to a more satisfactory level when the least reliable criterion (no. 7) was removed. (8) The HPD construct seemed to consist of 2 components: Describable as “attention-seeking” and “impressionistic style.” 4.1. Prevalence rate Table 1 displays the highly divergent previous findings on prevalence rates, ranging from 0% to 3.2% in the general population and from 1% to 6% in patient samples. Major sources of variance will be true sample variance and error variance. The major source of error variance will be measurement errors. The present sample is the largest patient sample ever being investigated for HPD and it was collected from 12 different sites in southern Norway. The sample should be representative for treatment-seeking patients with moderate to severe PDs. Our results therefore support previous findings that indicate a very low prevalence of HPD in patient samples. If the true prevalence of HPD in the general population is around 1%, the small differences compared to patient samples prevalence need some explanations. Most probably, HPD as described in DSM-IV [5] is a less severe personality disorder. Patients with only HPD (no Axis II comorbidity) might seldom reach the level of severity that calls for more extensive treatment such as day hospital treatment. Actually, histrionic behavior has been normalized within the Western societies and may not be as maladaptive as in other cultures. For example, histrionic displays are more risky and maladaptive for women in fundamentalist Muslim societies. Another explanation could be error variance due to the methods in this study, for example, that the clinicians in this study overlooked a substantial number of HPD patients. However, although there was no formal reliability test on the diagnoses, the low prevalence fits with

the clinical experiences of the second author who did supervise the diagnostic procedures of all the involved units. 4.2. Sex differences There is good evidence for HPD being more frequent among females than males [37,38]. The negative result in this study is most probably a type II error due to the low frequency of HPD. The individual criteria occurred more often, and here, we found that females were overrepresented on the criteria emotional display and suggestibility (criteria 2 and 7). 4.3. Diagnostic co-occurrence To suggest that HPD should be completely independent of other personality disorders would be somewhat naïve. Comorbidity is normal and not a threat to the validity of prototype categories. For individual patients, it is a guide into the patient's idiographic clinical picture. For the construct as a whole, it reveals connections to conceptually and empirically similar conditions. If this connection is too intimate, it will threaten the construct validity by way of poor discriminative power. In this study, we observed comorbidity on a diagnostic as well as on a trait level. The comorbidity with BPD was most apparent as there were more patients with HPD and BPD than patients with only HPD. This co-occurrence points to the more dysfunctional aspects of the HPD construct—those patients who display histrionic behavior in combination with more regressive and ego-weak tendencies. The HPD prototype can thus be argued to encompass 2 different levels of severity. The ϕ coefficients (Table 2) suggest that HPD criteria attach themselves to personality disorders of different severity and regressive tendencies. The BPD-HPD connection has been observed and commented by several contemporary authors [39,40] as well as more classical studies. On the basis of a review of 100 different psychoanalyses, Knapp and colleagues [24] stated that “our reports tend to indicate that hysterical patients are, to put it simply, very good or very bad patients” (p. 460). Easser and Lesser [21], following this line of thought, differentiated those they called hysterical and those they called hysteroid, where the levels of severity and dysfunction were the main differences. Equally impressed by the apparent differences among those unitarily diagnosed as hysterics, Zetzel [25] wrote the intriguing article “The socalled good hysterics” where she questioned whether hysterics could be subsumed under the same diagnosis. She introduced the term good and bad hysteric, where she delineated the bad hysteric as something close to what is now known as BPD. Kernberg [22,23], Lazare et al [41], and Marmor [42] suggested distinguishing between different levels of severity and pathology among hysterical personalities by means of identifying their fixations as either oedipal or oral. Simply put, a patient with mild/neurotic/ oedipal hysterical personality and a patient with severe/

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borderline/oral histrionic personality may fulfill the same diagnostic criteria, but their level of severity and intensity will be qualitatively different. Unfortunately, the number of HPD patients in this study was too small to test the difference in severity between HPD/BPD patients and “pure” HPD patients. Another perspective on this co-occurrence might be that both HPD and BPD, as cluster B disorders, share a common genetic disposition [43], which probably involves affect regulation, impulsivity, and self-cohesion. Several data converge as to a close relation between NPD and HPD: (1) The diagnostic co-occurrence, (2) the NPD criterion “demanding excessive admiration” loading on the main HPD factor, and (3) the face validity of the criteria in the main HPD factor. We will later in this article return to the notion of HPD representing a predominantly “warmer” type of narcissism. The comorbidity with DPD needs special considerations. It might both represent a misunderstanding among the diagnosticians as well as a reflection of a true common substance. The suggestibility criterion (no. 7) is quite possibly misconcepted as a sign of dependency akin to the dependency of patients with DPD. The correlation between this criterion and DPD, in addition to this criterion loading on a separate component on the factor analysis and its lowering effect on the Cronbach α, adds weight to this argument. Some find this criterion to identify an overt dependency on others, whereas the original purpose of this criterion was to address the superficial cognitive appraisal of situations and opinions, leading to easily changeable opinions, emotions, and perceptions. This criterion stems from the classical writings of David Shapiro on hysterical neurotic style [44], which gave penetrating insights into how hysterical behavior came to be as a result of diffuse, impressionistic cognitive functioning. On the basis of clinical experience and patients' responses to Rorschach testing, he developed an integrated explanation of the functioning of those with what he called a neurotic hysterical style. He described their cognitive style as overarchingly impressionistic, focusing on impressions rather than details, being led by sudden emotional resonance and forfeiting the use of the mind as the machinery it was meant to be. Their opinions were thus suggestible, formed by impressions and not reflected upon, making them more susceptible to suggestions from others or the impact of new impressions. A lack of commitment is a weak foundation for holding on to one's opinion. Their emotionality is equally superficial, as they are “struck” by familiarity, vividness, colors, or something fascinating upon inspecting facets of the world, which triggers their enthusiasm, rage, sadness, or similarly evoked emotions. As new experiences emerge, their emotions vanish, and in retrospect, they rarely acknowledge those emotions as “theirs.” Criteria 3, 5, and 7 are directly taken from the writings of Shapiro, but in real life, they are possibly more likely to be subject to different interpretations among diagnosticians. The HPD criteria 3, 5, and 7 are thus remnants of theoretical and clinical insight that

467

we suspect is largely unknown to most diagnosticians, making assessment of these criteria difficult and in danger of rather idiosyncratic interpretations. 4.4. Contribution to pathology Most other personality disorders are characterized by a positive correlation between the number of specific personality disorder criteria and pathologic indicators (eg, quality of life, social dysfunction, symptom distress) [45,46]. As for HPD, we could not detect any such correlation. This finding may reflect that the HPD criteria in themselves do not necessarily imply any gross personality pathology, that is, that the level of pathology is mostly due to additional criteria from other (comorbid) personality disorder. 4.5. Reliabilities The reliability statistics resonate with the findings from the factor analyses. The intercorrelations between the criteria are low, indicating that none of the criteria are redundant. However, the intercorrelations between criterion 7 (suggestibility) and the rest, are too low, indicating that this criterion represents something else than “histrionicity” (or, as we have argued above, is misunderstood). When this item is deleted, Cronbach α increases to an acceptable level (α = .72). 4.6. Factor structure The factor analysis displayed that the major part of the construct (the criteria 1, 2, 4, 6, and 8) loaded on the same component (Table 5), which can be labeled “attentionseeking.” The “Shapiro criteria” (3 and 5, “emotional display” and “impressionistic speech”) loaded on a separate component, which can be labeled “impressionistic style.” The criterion 7 (suggestibility) loaded on another separate component. Inspecting the contents of the criteria that represent the main factor (attention-seeking), they all seem to cover aspects of drawing attention to oneself, for example, through sexual behavior, physical appearance, self-dramatization, intimating relations, and demanding admiration. Moreover, this attention-seeking behavior seems qualified by exhibitionism (sexual display, physical appearance, exaggerating expressions) and control strategies (demanding admiration). Exhibitionism has since long been considered a part of the grandiose self [47]. Kohut [47] did also portray the “mirror-hungry” personality, for example, displaying mirror-seeking (attention-seeking) behavior as a means of restoring self-cohesion. Thus, there is a long tradition in regarding attention-seeking and exhibitionism as indicators of narcissistic vulnerability. However, this view has not been adopted by the DSM system that has defined narcissism in a male-biased way, that is, as manifestations of the cold, arrogant, and unempathic part of the grandiose self. Recently, Russ et al [48] have provided evidence for 3 subtypes of narcissism: (1) a grandiose/malignant

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subtype, (2) a covert subtype, and (3) a higher functioning exhibitionistic subtype. Our data support this view, that is, that the major part of the HPD construct consists of a (female dominated) “warmer” type of narcissism, characterized by exhibitionistic colored attention-seeking behavior. One might speculate that criteria 3 and 5 serve the same purpose of attaining self-cohesion through immediate self-affirmation. For example, that the “shallowness” of emotions and speech is a kind of openness as to finding a foothold in the mind of the other, that is, an extreme interpersonal flexibility as also indicated by the tendency to consider relations as more intimate than they are. If this is the case, criteria 3 and 5 might strengthen their relation to the main factor by being better defined. Criterion 7 can be interpreted in the same way, for example, as a strategy for befriending others. However, this criterion seems to need a gross reformulation if it is to serve its intention. Several research options might be fruitful for investigating the connection suggested above, that is, that criteria 3, 5, and 7 might be part of an exhibitionistic attentionseeking strategy. The criteria might be connected to a type of “hyperempathy.” Women are known to be better empathizers than men [49,50], and extreme emphatic capabilities may involve an other-directedness that implies that one easily looses one's own perspective and that the inferences about the other's mind become rather speculative and represent rather a kind of pseudomentalizing than “true” empathy. Furthermore, this exaggerated empathy might be linked to an overinvolved attachment patterns [51-53]. However, much work has to be done to construct a broader and valid category of dysfunctional narcissism. In principle, the challenges are the same as for the other personality disorders [54-58]. Any personality disorder should be defined by its specific maladaptive interplay between temperament, self-cohesion, attachment and social behavior, and the neurobiologic mechanisms that underpin these processes [59-61]. As for the concept of narcissism, in particular we need more studies based upon evolutionary reasoning, for example, what are the precursors of narcissism among other primates? Which neuroaffective systems are involved? How are these engaged by social dominance, rivalry, power struggle and social submission [62-64]? Possibly, narcissism should be regarded more as a clinically significant dimension that pertains to all personality disorders, more than being a discrete disorder in itself. 4.7. Limitations of the study In the paragraph on prevalence rate, we discussed the representativeness of the sample and some possible limitations due to the lack of reliability checks of the diagnoses. Even if the data contain several false-negatives, the

prevalence would still be very low. In the paragraph on diagnostic co-occurrence, we discussed the possibility of a misinterpretation of the essence of criterion no. 7. This is of course somewhat speculative. A reliability check might have clarified this issue. 5. Concluding remarks In light of the foregoing discussion, we see several options for DSM-V: (1) to keep the HPD category as it is; (2) a light modification: to substitute the seventh criterion (suggestibility) with another criterion and refine the definitions of criteria 3 and 5; (3) to delete the entire category from the DSM system; and (4) to delete the HPD category but redefine the essence of the disorder and “move” it to a dimension of narcissism or to NPD, as an exhibitionistic attention-seeking subtype. We support the last option. The grandiose maledominated NPD should be supplemented by a “warmer” female-dominated attention-seeking subtype, described by a behavior pattern of (a) explicit attention-seeking; (b) outerdirectedness, attentiveness, and directedness towards others; (c) self-dramatization; (d) dependency on others' attention, approval, and affiliation; (e) presentation of self through sexualized means; and (f) easily emotional triggered. Possibly these themes could be covered by a dimensional supplement to categorical personality disorder prototypes. References [1] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-II). Washington, DC: American Psychiatric Association; 1968. [2] American Psychiatric Association. Diagnostic and Statistical Manual Of Mental Disorders (DSM-III). Washington, DC: American Psychiatric Association; 1980. [3] Pfohl B. Histrionic personality disorder. In: Livesley WJ, editor. The DSM-IV personality disorders. New York: The Guilford Press; 1995:173. [4] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-III–R). Washington, DC: American Psychiatric Association; 1980. [5] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Washington, DC: American Psychiatric Association; 1994. [6] Blais MA, Baity MR. Rorschach assessment of histrionic personality disorder. In: Huprich SK, editor. Rorschach assessment of personality disorders. London: Lawrence Erlbaum Associates, Publishers; 2006:206. [7] Chodoff P. The diagnosis of hysteria: an overview. Am J Psychiatry 1974;131(10):1073-8. [8] Chodoff P. Psychotherapy of the hysterical personality disorder. J Am Acad Psychoanal Dyn Psychiatry 1978;6(4):497-510. [9] Chodoff P. Hysteria and women. Am J Psychiatry 1982;139 (5):545-51. [10] Chodoff P, Lyons H. Hysteria, the hysterical personality and “hysterical” conversion. Am J Psychiatry 1958;114:734-40. [11] McWilliams N. Psychoanalytic diagnosis: understanding personality structure in the clinical process. New York: Guilford Press; 1994.

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