Histrionic personality disorder — criteria, differentials and frame-based care (MEQ)

(i) Working diagnosis. Histrionic personality disorder (DSM-5-TR): general PD criteria plus ≥5 of 8 features — discomfort when not centre of attention, inappropriate seductive/provocative interaction, rapidly shifting shallow emotions, use of appearance to draw attention, impressionistic speech, theatricality, suggestibility, relationships experienced as more intimate than they are — present from late adolescence, pervasive, impairing. State that HPD is a pointer diagnosis with contested construct validity; screen carefully for concurrent BPD (abandonment, emptiness, self-harm as regulation) and for major depression post-rupture. Dual diagnosis when both operational thresholds are met is better than forced purity.^[1][2]

(ii) Differentials with discriminators. BPD (abandonment fear, identity diffusion, self-harm regulation — may overlap). NPD (admiration/status and envy more than attention-for-its-own-sake). Mania/hypomania (episodic energy, reduced sleep need — denied here but always reassess). Substance-induced disinhibition. Somatic symptom or factitious pathways if medicalisation dominates. Dependent PD (care-seeking submissiveness). Organic late-onset change (not fitting age of onset). ASPD if rights-violation and conduct history present (not described).^[1][2]

(iii) Risk after overdose. Medical clearance and paracetamol toxicity pathway; intent at the time vs current intent; plan and means; lethality and medical seriousness of 16 tablets; trigger (partner distance); protective factors; hopelessness; depression symptoms; alcohol/substances; access to further means; boundary-related ward risk (sexualised interactions, staff splitting); capacity for discharge decisions; collaborative safety plan; least-restrictive disposition with rapid follow-up — do not dismiss as mere attention-seeking.^[1]

(iv) Psychological plan. Firm unified team frame (consistent limits, no secret special exceptions). Structured psychotherapy targeting externalised self-worth, provisional intimacy, and crisis-as-communication; build affect differentiation and realistic relationship goals. Cite change-process work in psychotherapy for HPD presentations and schema therapy multicentre RCT support for PD more broadly (Bamelis) when global patterns dominate. Plan supervision for countertransference (eroticised rescue or punitive hostility). Measurement of mood, crises, and engagement.^[3][4][5]

(v) Pharmacotherapy principles. No drug treats HPD as a whole. For comorbid major depression, first-line SSRI is appropriate alongside therapy. Example: sertraline 50 mg orally once daily, early review (1–2 weeks) for activation and suicidality, titrate toward 50–150 mg daily as tolerated with response review at 6–12 weeks; counsel sexual side effects and discontinuation; limited dispensing post-overdose. Avoid chronic benzodiazepines as personality treatment. Stop/review dates and measurement-based care.^[1][3]