We believe you have “histrionic personality disorder” — say what now!?

After a more than two-year process to find a psychiatrist (again, Canadian system, I waited for a public practitioner to be available) and a roughly six month process of seeing them (on and off, in two sets of sessions), we’ve ended our time together, and formalized my final, final diagnosis.

As a reminder, I’ve been considered for bipolar type II (and cyclothymia, too), borderline personality disorder, variants of anxiety, some consideration went into ADHD, and I initially presented to my doctor and first therapist with major depression (and they suspected I’d been manic).

The entire process, as I chronicled before, revolved around the manifestation of bipolar tendencies, where I’d simultaneously be depressed then manic in very short intervals, sometimes within the same day. These weren’t “normal” mood swings, nor were they properly clinical phases of mania or depression.

We’d settled, in our penultimate meeting, to take me off all medications: I’d tried anti-psychotics (and was on yet another one) but my symptoms weren’t severe enough to warrant them. As my psychiatrist said, my suffering is real, but there’s no biological basis for medicating me.

And so, I’d thought that was it. I’m kinda bipolar — what might be called a dysthymic and hyperthymic personality or tendency — but not enough to diagnose or treat as one would a type I or type II. In other words, I’m always going to have bigger, faster and more intense moods than a “normal” person.

But — and all of my therapists kept saying it — I’m a high-functioning, introspective and intelligent person. I’m sleeping regularly, eating better, exercising at least three times a week, meditating regularly. These are things my clinicians try until they pull out their hair to convince other patients to do.

Then, we had the wrap up session, and my psychiatrist took the time to review the entire patient history, and made the decision to formalize a diagnosis based on that. They said:

In the DSM-5, there’s criteria for histrionic personality disorder, and while it’s mostly women who fall into these criteria, I feel it applies to your case.

I’d never heard of this particular personality issue, but it’s categorized in the “dynamic” types, along with borderline (which was suspected, before).

From the Wikipedia article on the subject:

Histrionic personality disorder (HPD) is defined by the American Psychiatric Association as a personality disorder characterized by a pattern of excessive attention-seeking behaviors, usually beginning in early adulthood, including inappropriate seduction and an excessive need for approval. People diagnosed with the disorder are said to be lively, dramatic, vivacious, enthusiastic, and flirtatious. HPD is diagnosed four times as frequently in women as men. It affects 2–3% of the general population and 10–15% in inpatient and outpatient mental health institutions. / HPD lies in the dramatic cluster of personality disorders. People with HPD have a high need for attention, make loud and inappropriate appearances, exaggerate their behaviors and emotions, and crave stimulation. They may exhibit sexually provocative behavior, express strong emotions with an impressionistic style, and can be easily influenced by others. Associated features include egocentrism, self-indulgence, continuous longing for appreciation, and persistent manipulative behavior to achieve their own needs.

Oh, by the way, this is the modern diagnosis for what Freud’s generation called hysteria. Things have evolved quite a lot, since then.

But how does this apply to my case?

1. Well, I do genuinely seek and crave excessive amounts of attention. I NEED validation. In the Wikipedia article there’s also a mnemonic which spells out “PRAISE ME!” to recall the details of the personality — yeah, that’s me.
2. I don’t like being a room with others where all eyes aren’t on me. As much as I am social anxious, I do get upset in group conversations where I’m within proximity of others, but not being engaged.
3. The more I want someone’s attention, the louder I’d start speaking. Sometimes the speed at which I’ll speak will resemble a symptom of mania, but it’s mostly trying to draw people in.
4. I speak in near constant metaphor — “express strong emotions with an impressionistic style” — and this gets in the way of being understood by others. I’ll also get really pissed off when people are confused by this.
5. And a final example, I can be very easily manipulated and I’m good at manipulating others. I work hard not to do the latter, and it’ll sometimes happen, despite myself. As for the former, well…yikes.
6. While everyone “fakes” a part of themselves while in public, I maintain this even in private, intimate situations. I’ll act to be the person I’m expected to be to the point of self-harm — sometimes even to the detriment of others.

The best part about this profile, in my case, lies in it’s freedom from my prior obsessions in getting a label like “bipolar” or “borderline” — something about those label felt wrong to me, but I played up to the part. With histrionic, it felt right: it felt like a description of my tendencies to be very needy, dramatic.

At the end of the session, once my psychiatrist and I had settled on the details and we both felt comfortable with the conclusions we’d drawn about my personality, it was frankly a relief. We agreed I’ve done all the work to support my health in the long-term, and should I slip again, we have a plan.

Because of the bipolar risk, we’ve stayed away from using SSRIs before, which can aggravate problems by tricking a manic phase while trying to treat depression. Since I’m not likely bipolar in a diagnostic sense, should I because depressed in the future, it’s likely save for me to take an SSRI.

My family doctor, who has a complete history from the psychiatrist, has a note on file that should I come in with depressive symptoms, we’ll make sure they’ve been there long enough to qualify it as a depression. If I start a medication and it goes poorly, we’ll react accordingly.

But, yeah, that’s it. I have a psychological profile of my health issues such that I’m at peace with them, and I have all the resources I need to fight back, should I relapse. So, now, the only left to do is live my best life for as long as the path allows.