This programme is a treatment manual for mental health professionals. It assumes clinical training, experience with personality disorders, and a supervision framework. It replaces neither your clinical judgement nor your professional responsibility. Diagnostic criteria are reworded here in our own words, never reproduced. Two warnings specific to this indication. This diagnosis carries a history marked by sexism and gender and cultural biases: it should be made with caution and not confused with an expressive temperament, section 5. And the level of evidence is very thin: no trial addresses this disorder alone, which section 11 sets out plainly.
1. The programme at a glance
Indication. Histrionic personality in adults, as outpatients, with distress or impairment, after ruling out a predominant borderline personality and an untreated mood disorder.
Reference model. Cognitive therapy for personality disorders, centred on the dependence of self-worth on the gaze of others, on impressionistic thinking and on the relational consequences of attention-seeking, enriched with work on recognising emotions, problem-solving and assertiveness, and, in the final phase, on the schemas that lie beneath attention-seeking.
Format. Treatment lasting about a year, that is, some thirty to forty sessions; this manual describes sixteen key sessions, organised in five phases, with extension points indicated. 50-minute sessions, weekly and then fortnightly. A written agenda at every session. Booster sessions.
Targeted mechanism. Slowing the attention cycle by making its costs visible, replacing global impressions with precise descriptions that make it possible to understand and act, differentiating emotions, solving problems instead of amplifying them, tolerating not being at the centre, asking directly for what one needs, protecting decisions from suggestibility, and building a self-worth that rests on something other than the gaze of others.
| Phase |
Session |
Topic |
Session output |
| I. Alliance |
1 |
Welcoming the intensity |
Reason for coming stated, session structured |
|
2 |
Precise goals |
Three concrete goals, written framework |
|
3 |
Assessment |
Risks assessed, associated disorders identified |
| II. Understanding |
4 |
The attention cycle |
Cycle drawn with a real episode |
|
5 |
What attention brings and costs |
Written balance sheet |
|
6 |
From vague to precise |
Two situations described in facts |
| III. Change |
7 |
Naming emotions accurately |
Log of differentiated emotions |
|
8 |
Solving rather than dramatising |
One problem solved step by step |
|
9 |
Existing without being looked at |
Two situations lived without seeking attention |
|
10 |
Mid-point review |
Measures repeated, plan revised |
| IV. Relationships |
11 |
Seduction and its costs |
Situations of seduction examined |
|
12 |
Influence and vulnerability |
A written decision rule |
|
13 |
Asking directly |
Two direct requests made |
| V. Consolidation |
14 |
What lies beneath |
Beliefs and history linked |
|
15 |
Self-worth beyond the gaze of others |
Values and skills written down |
|
16 |
Review, relapse, next steps |
Written plan, measures repeated |
What sets this programme apart from the other manuals on this site. Three things. A patient whose intensity is both the symptom and the way of entering into relationship. A therapist whose steady attention is itself an intervention. And a diagnosis that the manual acknowledges carries a history and biases.
2. Before you begin
Who this programme is for
Psychologists, psychiatrists and psychotherapists trained in cognitive behavioural therapy, with experience of personality disorders and access to supervision. This work tests the therapist's ability to stay warm without being seduced, and attentive without being irritated.
The four preliminary decisions
1. Is this a borderline personality? Self-harm, chronic emptiness, intense fear of abandonment, anger and an unstable identity point towards that diagnosis and its manual. Section 7.
2. Is there a mood disorder? Depression, a hypomanic episode. Section 7.
3. Is the diagnosis being made with caution? Have the expressiveness of a temperament or a culture, and gender stereotypes, been ruled out? Section 5.
4. Is there danger? Suicidal acts, a controlling or violent relationship, financial or sexual exploitation. Section 9.
What this programme does not treat
Predominant borderline personality, which has its own manual.
Somatic symptom disorders and functional neurological disorders, which call for specific care, even though they often coexist.
Hypomanic or manic episodes.
What this programme is not
It is not a therapy that seeks to make the patient less expressive, less warm or less alive. Expressiveness is a quality. What we work on is dependence on the gaze of others, and what it costs.
How to use it
Read sections 3 to 14 first: they ground the choices made in the sessions. Read section 31 before the first session: the relationship is at stake from the outset. The sessions described are key sessions; each may take two or three. Section 39 says what must not be dropped.
3. The clinical picture
What defines the disorder
A lasting and pervasive pattern of excessive emotionality and attention-seeking, present since early adulthood and across a range of contexts.
The forms it takes
Discomfort when not at the centre of attention.
Seductive or provocative behaviour that is inappropriate to the context.
Emotions that shift quickly and seem shallow to others.
Use of physical appearance to draw attention.
Impressionistic speech, rich in impressions and poor in detail.
Dramatisation, theatricality, exaggerated expression of emotion.
Suggestibility: marked sensitivity to the influence of others and of circumstances.
Perceiving relationships as more intimate than they are.
What patients describe
An intense life, full of people and emotions, and at the same time a sense of not really being seen. Boredom as soon as nothing is happening. Relationships that begin in enthusiasm and end in disappointment. The feeling that others find them excessive, shallow, tiring. And, often, a deep fear of not mattering to anyone.
What you see in the consultation
A well-groomed or striking presentation. A colourful, moving account that leaves the therapist touched or captivated, but with few precise facts. Intense, shifting emotions that may seem disconnected from the content. Immediate warmth, quick familiarity, sometimes compliments, sometimes seductiveness. Marked sensitivity to the therapist's attention: a glance at the clock can trigger a sudden shift.
What is not part of it
Repeated self-harm, chronic emptiness, intense anger and a fear of abandonment in the foreground point towards borderline personality. Grandiosity and the need to be admired for one's superiority point towards narcissistic personality.
Epidemiology
Estimates in the general population vary and are uncertain. The diagnosis is made more often in women in clinical settings, whereas population studies do not always show a clear difference, which suggests a diagnostic bias. The disorder is often associated with depressive disorders, somatic symptoms and relationship difficulties.
4. The attention cycle
The model that guides this programme is cognitive and interpersonal. It is presented to the patient simply.
The central piece
A self-worth that depends on the gaze of others: if I'm not noticed, I don't exist; to be loved, I have to be captivating; without others, I'm worthless and I can't cope. It often forms in a history where attention was scarce, unpredictable, or conditional on appearance, charm or intensity — but this is not always the case, and we do not impose it.
The links
1. The perceived lack. An evening when one goes unnoticed, a distracted partner, a meeting where someone else shines, a moment alone.
2. The emotion. Unease, emptiness, a dread of insignificance.
3. The bid for attention. Dramatising, telling a story in a striking way, expressing a strong emotion, seducing, complaining of a symptom, provoking.
4. The immediate benefit. Attention returns, the unease subsides. The behaviour is reinforced.
5. Other people's reaction, in the longer term. Weariness, an impression of shallowness, doubts about sincerity, withdrawal, or, conversely, exploitation by people who take advantage of the seductiveness and suggestibility.
6. The confirmation. Nobody really loves me; I have to do more. The next perceived lack is more intense, and so is the bid for attention.
The loop of impressionistic thinking
Situations are experienced and recounted as global impressions — "it was horrible", "he's wonderful" — rather than as facts. This way of thinking gives the account intensity, but it prevents understanding what happened, distinguishing one's emotions, and solving problems. The problems remain intact, and come back.
What the treatment does
It makes the costs of the cycle visible, slows the bid for attention to leave room for other responses to the lack, replaces impressions with facts, differentiates emotions, teaches how to solve problems, how to ask directly and how to tolerate not being at the centre, and builds a self-worth that rests on values and skills.
What the model explains to the patient
That their need to be noticed is a human need, not a flaw. That their way of meeting it works in the moment and costs a great deal afterwards. And that it is possible to learn to exist in the eyes of others — and in one's own — in another way.
5. Expressiveness, gender and culture: a diagnosis to be made with caution
Why this section exists
Because histrionic personality is the direct heir of hysteria, a notion that for centuries served to discredit women's speech and emotions. The word has been abandoned, but biases persist: the diagnosis is made more often in women, and it can turn into pathology what belongs to a temperament, a culture or a gender norm.
What needs to be distinguished
An expressive temperament, warm and lively, without distress or impairment.
Cultural norms in which emotional expression, physical contact and theatrical storytelling are ordinary.
Gender norms that value appearance, seductiveness and emotion in women, and then penalise them for the same behaviours.
Behaviour suited to a context: a stage career, sales, commercial persuasion.
A reaction to a situation: a crisis, a break-up, a period of loneliness.
What points towards the disorder
Generalisation to all contexts, rigidity, distress or impairment — relationships that collapse, exploitation, depression — and a dependence of self-worth on the gaze of others.
The disorder in men
It is probably underdiagnosed. It may be expressed through attention-seeking centred on exploits, strength, conquests and hypermasculinity, or through dramatised somatic symptoms. It is often classified elsewhere.
What you do
You check the cultural context and gender norms before making the diagnosis. You describe the patient by their difficulties rather than by the label. And you watch in yourself for dismissive reactions — "it's all an act", "she's laying it on thick" — which are precisely what this diagnosis was long used to justify.