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 (Beck et al., 2015), centred on the dependence of self-worth on the gaze of others, on impressionistic thinking, that is, a way of grasping and recounting situations through global impressions rather than facts (sections 4 and 32), and on the relational consequences of attention-seeking. It is enriched with work on recognising emotions, problem-solving and assertiveness, and, in the final phase, on the schemas that lie beneath attention-seeking, that is, deep-seated beliefs about oneself (session 14).
Format. Treatment lasting about a year, that is, some thirty to forty sessions; this manual describes sixteen key sessions, organised in five phases; each key session may take two or three. Sessions last 50 minutes; they are weekly, then fortnightly, and each one follows a written agenda (section 14). Three booster sessions, one, three and six months after the last session, follow the end of treatment (session 16).
Targeted mechanism. Slowing the attention cycle (section 4) 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 watched |
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
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 towards the manual devoted to it, Borderline personality: a therapist's manual. Section 7.
2. Is there a mood disorder? Depression is treated as a priority (section 36). A hypomanic episode differs from histrionic traits in that it is an episode (section 7), and it calls for referral to psychiatry (section 37).
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? Look for suicidal acts, a controlling or violent relationship, financial or sexual exploitation (section 9): from session 1, then in detail in session 3.
What this programme does not treat
Predominant borderline personality, which has its own manual, Borderline personality: a therapist's manual.
Somatic symptom disorders and functional neurological disorders (formerly called conversion disorders), which call for specific care, even though they often coexist.
Hypomanic or manic episodes, which fall within the remit of psychiatry (section 37).
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 summarises the eight points to hold on to in order to remain faithful to the protocol. The folder given to the patient contains seven worksheets: 1 "How we work together" (session 2), 2 "My circle" (sessions 4 and 5), 3 "From vague to precise" (sessions 6, 7 and 13), 4 "Existing without being watched" (session 9), 5 "Charming, and deciding" (sessions 11 and 12), 6 "For those close to you" (section 35), 7 "My plan for what comes next" (sessions 15 and 16); sessions 8 and 14 have no worksheet of their own.
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 be enough to make their mood swing.
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. This is what the person does to bring attention back to themselves: 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 (Novais et al., 2015), 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 then often filed under another diagnosis: narcissistic or antisocial personality when exploits and conquests predominate, somatic symptom disorder when the symptoms predominate.
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.
Frequently asked questions
Should the diagnosis be disclosed?
With caution. The term is often experienced as an insult. We talk about a need to be noticed, intense emotions, relationships that flare up. If the patient asks, we answer honestly, saying that the category is disputed.
The patient pays me compliments at every session.
Accept them without feeding on them, name this tactfully, and explore what it gives them. Section 31.
They cry a lot, then move on to something else very quickly.
This is common. Welcome the emotion, then look for the facts and the precise emotions. Section 21 (session 7).
Are their physical symptoms real?
The symptoms are real. A medical assessment is necessary, and their relational function can be worked on without ever calling them imaginary. Section 36.
They make very theatrical suicidal threats.
Assess the risk every time, directly. The way it is expressed says nothing about its severity. Section 9.
They don't do the tasks between sessions.
Make them short, concrete, personalised, and linked to what matters to them. Section 14.
They are in a relationship that seems to be exploiting them.
Look for the facts, without blaming, and refer to protection services if needed. Section 34.
Is it borderline or histrionic personality?
Look for self-harm, emptiness, anger, fear of abandonment and identity instability. The two often coexist. Section 7.
I find them irritating.
This is a common reaction, and it is information. Work on it in supervision, and watch for the temptation to dismiss. Section 31.
How long?
About a year, then three booster sessions over six months (section 1).