For whom seek reasoning for new DSM 5 change

Why the Histrionic personality disorder should not be in the DSM: A new taxonomic and moral analysis more
by caroline gould


I argue for a reconsideration of the taxonomy of the Histrionic Personality Disorder (‘HPD’). First, HPD does not carry the negative ethical implications of the other Cluster Bs, which are Anti-Social (ASPD), Borderline (BPD) and... more
I argue for a reconsideration of the taxonomy of the Histrionic Personality Disorder (‘HPD’). First, HPD does not carry the negative ethical implications of the other Cluster Bs, which are Anti-Social (ASPD), Borderline (BPD) and Narcissistic (NPD). Using Aristotelian notions of character as a heuristic device, I argue that ontologically HPD is not a personality disorder, but instead a cultural disorder, a result of attitudes towards traditionally feminine styles of interaction. This explains the confusion in the research between HPD and hysteria and also the curious paucity of literature on HPD itself in contrast to the other Cluster Bs.
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1 Forthcoming: International Journal of Feminist Approaches to Bioethics (2011) Why the Histrionic personality disorder should not be in the DSM: A new taxonomic and moral analysis 2 Abstract I argue for a reconsideration of the taxonomy of the Histrionic Personality Disorder (µHPD¶). First, HPD does not carry the negative ethical implications of the other Cluster Bs, which are Anti-Social (ASPD), Borderline (BPD) and Narcissistic (NPD). Using Aristotelian notions of character as a heuristic device, I argue that ontologically HPD is not a personality disorder, but instead a cultural disorder, a result of attitudes towards traditionally feminine styles of interaction. This explains the confusion in the research between HPD and hysteria and also the curious paucity of literature on HPD itself in contrast to the other Cluster Bs. Why the histrionic personality disorder should not be in the DSM: A new taxonomic and moral analysis The scene was pleasant on both sides. A cruder lover would have lost the view of her pretty ways and attitudes, and spoiled all by 3 stupid attempts at caresses, utterly destructive of the drama. Grancourt preferred the drama. Gwendolen . . . found her spirits rising as she played at reigning. Perhaps if Klesmer had seen more of her in this unconscious kind of acting, instead of when she was trying to be theatrical, he might have rated her chances [on stage] higher. (George Eliot, Daniel Deronda)i Introduction The histrionic personality disorder (HPD) stands at the intersection of ethics, ontology, and philosophy of psychiatry. Although HPD is a rarely probed diagnosis, it brings into relief the problems of gender and values in diagnosis, as well as nosological issues. The boundary between the moral and pathological is so precarious that remapping these concepts is an ongoing process. Without entering the complex debate over what constitutes a mental disorder or whether mental disorders tout court are socially constructed, I shall say that some things considered mental disorders are real. This entails neither that all are real nor that social practices have no role in shaping them. Some real mental pathologies might be the result of gender, racial, ethnic, or sexual orientation biasesii that lead to genuine, distinctive, even harmful, forms of suffering, for example, anxiety or depression. Other real mental pathologies might be the projection of these biases, for example, 4 anorexia or body dysmorphic disorder. HPD, as I argue here, is not a real mental pathology; rather, histrionic refers to a trait or cluster of personality traits that might lead to some other mental disorder. Its taxonomical status in the DSM creates conceptual confusions reflected in the relatively scant literature on HPD. The status of HPD has great importance, especially for women, who are more likely to be diagnosed with HPD. First of all, as Peele and Razavi point out, the diagnosis of a personality disorder is both misleading and harmful. They remind us that ³in 2002 the Washington Psychiatric Society and the Maryland Psychiatric Society voted to ask the American Psychiatric Association [APA] to remove the word ³personality´ from the titles of present disorders (e.g., histrionic disorder rather than histrionic personality disorder).´ Their grounds are both scientific and humanitarian. They claim that a personality disorder label does not reflect the totality of someone¶s personality and moreover the concept can, for various reasons, lead to misdiagnosis. Clearly, as they also imply, someone may be hurt or, worse, discouraged, to hear from a medical authority that she has a disorder of the personality; after all, this sounds like a harsh judgment on one¶s character, and a mental health professional may base such a diagnosis simply on a patient¶s meeting a few of seven or more criteria in the DSM (depending on which personality disorder is in question). Not everyone diagnosed with a personality disorder, Peele and Razavi contend, has a positive personality, but some do. Presumably, they mean that most people have some desirable personality traits such as warmth, charm, or optimism, even if they do meet the criteria for a given personality disorder. Peele and Razavi suggest the ³APA should take steps to change the diagnostic categories when the change will encourage appropriate 5 care and treatment.´ They also make the important point that two of the ten personality disorders have misleading names that are not used by the ICD-10. Thus, on both scientific and humanitarian grounds, they believe that these concepts have to be reassessed. Even if their analysis of a personality disorder has some flaws, they have a cogent point about the need to reassess the category in Axis II and to remove especially those that are not genuine personality disorders. I shall argue that the so-called histrionic disorder is neither a pathological disorder nor a moral disorder (as, arguably, are the other cluster Bs). It is rather what we should think of as a cultural disorder, although by cultural disorder, as I later explain, I do not mean what Hacking might call an interactive kind or Foucault a cultural construct. Let us first turn to what a personality disorder is. What is a personality Disorder? A personality disorder is a diagnosis that falls into Axis II in the DSM IVTR. Like other diagnoses, it is a condition that is personally and/or socially maladaptive and can cause great suffering. There are ten personality disorders, and they are classified into three clusters. The only other diagnosis included in Axis II, in addition to the ten personality disorders, is mental retardation. Like mental retardation, a personality disorder is intransigent and so deeply planted in the psyche that it is difficult, not to say impossible, to uproot. A personality disorder appears at some point in early adulthood, once a character is more developed. Children do not have personality disorders, although 6 they can show a propensity to develop one or another. For example, some young children foreshadow their developing ASPD by being cruel to other children and animals. Speaking philosophically, a personality disorder is like an Aristotelian disposition (hexis), which Aristotle discusses in chapter eight of his Categories. In the Categories, he is concerned to show the many kinds of answer to the question, ³What is it?´ and in chapter 8, he says that sometimes the answer is µa quality¶ (poiotês). Of qualities, some things are basic conditions, which can be of two sorts. He contrasts a habitual disposition (hexis) like virtue or vice with a state (diathesis) like health or disease (Categories 8b25-9a4). Both are conditions that causally influence particular episodic events.iii To use two illustrative examples, let us imagine Smith, who has ASPD, and Green, who is experiencing auditory hallucinations resulting from a bad reaction to a medication. Smith murders Jones because Jones has something that Smith wants. Green, in his anomalous state, kills Peters because he believes that God has commanded him to do so. Smith¶s action arises from a hexis, Green¶s from a diathesis. The difference is that Smith¶s condition of ASPD, qua hexis, is enduring and tenacious, whereas Green¶s condition, qua diathesis, is not hard to change. Note that many an Axis I disorder would be classified as a diathesis, but no Axis II would be. An Axis II can be only a hexis. The condition associated with HPD, when it is maladaptive, is a diathesis, not a hexis. Therefore, HPD should not be Axis II. The literature on personality disorders is vast. One problem, as already noted and also cited by Zachar and Kendler,iv is that a patient needs to meet only three or four criteria out of more to be diagnosed with a given personality disorder. Thus, much is lost 7 in the diagnosis. More fundamentally, Zachar and Kendler further indicate, there are various models for understanding personality disorders and other mental disorders, ranging from essentialist ones such as organic, biopsychosocial, and harmful dysfunction models to more value-laden, or ³nominalist,´ ones such as practical kinds and dimensional models.v Some psychiatrists prefer to think of personality disorders in terms of traits. As Joel Paris neatly describes it: ³ Trait profiles constitute the vulnerability factors for personality disorders and determine which types . . . can develop in any individual. . . . When traits become too intense, [they are] . . . amplified. [They] . . . become maladaptive when the same behaviors are applied to every situation. Thus, behaviors that might be adaptive in one context will be used in a global and rigid fashion . . . and in inappropriate ways.´ vi As Paris points out, traits may have a genetic origin, but whether they become amplified is another matter. Philosophers and psychiatrists question what kind of kind a personality disorder is. That is, is it a natural kind or what Ian Hacking has named an interactive kind? Louis Charland ascribes a different ontological status to Cluster Bs than to As and Cs.vii He maintains that they are interactive, not natural and moreover, transient. ³Transient´ is how Hacking describes mental illnesses that appear in abundance temporarily at a given place and culture and thus flourish only in certain socio-cultural environments, or as Hacking calls them, ³ecological niches.´viii Before turning to the issue of natural kinds, we should note that ASPD, BPD, and NPD (the three clearly moral disorders) are 8 probably not transient in the way that, say, the current illness of anorexia is. While this is an empirical question that goes beyond the scope of this article, I think that a look at history and literature of both Western and non-Western cultures would suggest that these types are universal and embody enduring traits that, when amplified, can cause distress to the possessor and those around him (e.g., Achilles, Madoff, Medea). To say that they are transient, Hacking tells us, is not to say that they are not real or are merely constructions of environment and culture. Hacking differentiates between natural kinds, the sort of thing studied in the natural sciences, and interactive kinds, the sort studied in the human sciences. A natural kind would be something that exists in nature and corresponds to our concept. For example, bubonic plague is a natural kind. It is a human disease but is caused by a certain bacterium that exists in nature independently of how we think about it. Thus he describes it as ³indifferent.´ Interactive kinds interact with the subjects who have them, a process he terms µthe looping effect.¶ix A diagnosis may influence the way a person reacts to himself and his symptoms, and it certainly influences the way others react to him. For example, someone given the diagnosis of ADHD might become even more accelerated in given circumstances, because he is reacting both to his own self-description and to the implicit expectations others have of him. There are forms of behavior towards people that become embedded in our institutions and cultural practices. The way a doctor, parent, or spouse acts towards someone cannot help but influence how she manifests her pathology. This, in turn, can change the manifestations and, in turn, the concept of a given pathology itself. Hacking describes the looping effect as follows: 9 ³[People] can make tacit or even explicit choices, adapt or adopt ways of living so as to fit or get away from the very classification that may be applied to them . . . What was known about people of a kind may become false because people of that kind have changed in virtue of what they believe about themselves . . . . Looping effects are everywhere. Think about what the category of genius did to those Romantics who saw themselves as geniuses, and what their behavior did to the concept of genius itself. Think about the transformations effected by the notions of fat, overweight, anorexic.´ (1999, 34) In Rewriting the Soul, Hacking describes how the looping effect changed the disorder of multiple personalities (now, Dissociative Identity Disorder). For a more familiar example, we can consider how the very idea and the epidemiology of learning disabilities have changed. That is, perhaps because of the helicopter parent phenomenon, the taboo lifted: so more parents have taken their children for testing and have advocated for changes in the schools; the pharmaceutical companies have continued to develop new medications for these problems and bio-technology companies have developed new devices for testing for learning disorders. This feeds back into the culture and educational institutions. Note that looping effects hold not only of pathologies. Genius, to use Hacking¶s example, is a cultural, not pathological, concept. HPD, I believe, is taxonomically more like µgenius¶ than it is like µBPD¶ or µSchizoid personality disorder.¶ It is interactive in that it influences the people given the label ³HPD,¶ and the people who see them as µhistrionic¶ or hysterical.¶ But, unlike anorexia 10 or NPD, it is not a genuine disorder. In order to see why HPD is not a personality disorder, let us consider first why it is not a Cluster B personality disorder. HPD and Cluster B personality disorders In the DSM IVTR, HPD falls into Axis II as a member of the B Cluster, along with Anti-Social personality disorder (ASPD), Narcissistic (NPD), and Borderline (BPD). The other Cluster Bs all carry negative moral connotations, because the exemplars of each typically violate the rights and boundaries of other people.x HPD is radically unlike the other Cluster Bs in this regard. In fact, some people with histrionic traits can be exquisitely sensitive to and empathic with others, which is one source of its being maladaptive. HPD is relatively unknown to the general public, unlike its fellow Cluster B disorders. In psychiatry, law, moral philosophy, and popular culture, the literature abounds on dangerous pathologies such as narcissism, anti-social personalities, and borderlines. When news breaks of a serial killer like Jeffrey Dahmer, a cold-blooded murderer like Scott Peterson, or a swindler like Bernie Madoff, we start seeing articles on the internet, in books, and on television about narcissists and sociopaths. After the Madoff scandal, the public devoured televised interviews with mental health professionals who discussed the borderline personality, the narcissist, and the anti-social individual. The histrionic, however, does not share this celebrity. Unlike the other three Cluster Bs, HPD is a predominately female diagnosis, perhaps because the DSM IV criteria are associated with stereotypes of traditional 11 femininity: susceptibility to accepting the beliefs of others, a tendency to sexualize even casual interactions, a disposition to ´shifting and shallow´ emotional displays, the use of vague, imprecise language lacking descriptive power, excessive concern with bodily appearance, an inordinate need for attention, and²true to its name²the exaggerated expression of emotion, or as one clinician describes it, ³an excess of . . . pseudoaffect [sic].´xi George Eliot draws in exquisite detail the Victorian femme fatale in the character of Gwendolen in Daniel Deronda. Gwendolen has many problems, but today she likely would be given the label µHPD.¶ In psychoanalytic and psychiatric literature, the term histrionic is often used interchangeably with hysteric, the name of its distinctly feminine ancestor. As we investigate this matter, it begins to appear as if the classification of HPD makes a pathology of traditional feminine traits. At a time when feminism is trying to be inclusive of all women and their choices (and of those men who choose more feminine gender roles and/or modes of self-presentation), changing this status of HPD as a pathology becomes ever more urgent. There is not much research on HPD in the philosophical, psychiatric, or clinical studies. Representative of this trend is a book in a Jossey-Bass series edited by Irvin Yalom: Michael Rosenbluth¶s anthology, Treating Difficult Personality Disorders.xii It contains four articles on BPD, one on NPD, one on ASPD. Aside from some fascinating psychoanalytic work, there are basically two sorts of work on HPD. First, some researchers, noting the gender disparity between diagnoses of the predominantly female HPD and the largely male ASPD or NPD, have questioned whether HPD exemplifies in a feminine way the same problems as the NPD or ASPD, or whether HPD is genetically linked to the Cluster Bs. Researchers vary as to what the defining 12 characteristic is of cluster Bs, with some suggesting self-dramatization, others impulsivity, and more recently, a lack of moral sensitivity, as we see below. xiii Secondly, from a philosophical perspective, moral afflictions, of which ASPD is one, have always interested philosophers concerned with responsibility and moral development. Louis C. Charland3 has recently argued that the differentiating characteristic of Cluster B personality disorders is moral. According to Charland, Cluster B disorders stand apart from A and C disorders in being moral disorders rather than clinical and non-moral disorders. What he means by a moral disorder seems to be a lack of or a discontinuous understanding that other people are also subjects of consciousness with rights, interests, and feelings of their own. xiv A successful treatment for a moral disorder would require a patient s acquiring a new moral outlook and, from a phenomenological standpoint, the feeling of empathy. At first glance, this appears to be just the sort of change that would count as a cure. According to the DSM IVTR, the patient with ASPD is at least eighteen but has had a consistent pattern of deceitful, reckless, deviant behavior, having no empathy or regard for legal and social norms. The criteria for NPD include grandiosity with its expectations of recognition ³without commensurate achievements,´ pervasive fantasies of ³success, power, brilliance, beauty, or ideal love,´ sense of entitlement, a haughtiness, envy accompanied by a need to be envied, lack of empathy, and a tendency to be ³interpersonally exploitative.´ BPD involves great volatility, ³frantic efforts to avoid real or imagined abandonment,´ ³alternating . . . extremes of idealization and devaluation´ of others,´ ³chronic feelings of emptiness,´ lack of impulse control in arenas such as sex, 13 spending, eating, or substance abuse, a tendency towards ³suicidal gestures,´ and constant and/or intense anger. Charland prescribes moral therapy for each of these, but he seems not to realize that this prescription is impossible to apply. The goal, he tells us, is to give the person a new sense of himself as a moral agent. But how can someone without empathy and regard for others develop it? The patient with ASPD, NPD, or BPD would have to be cured before he could take Charland¶s cure. Aristotle again is enlightening here. Aristotle, in book 7 of his Nicomachean Ethics, contrasts the enkratic, or self-controlled person, with the sõphrõn or person of virtue. The enkratic has desires to act against reason, but acts instead according to reason. Consider two smokers. Both believe it is prudentially and morally better to be nonsmokers and quit cold turkey. Both kick and bray for the first part of the process. After awhile, one of them no longer desires to smoke. This person (with virtue), whose desires are in line with her beliefs, is a sõphrõn . The other one, the enkratic, finally acquires the habit of not smoking, despite sometimes wanting to smoke. How do we account for the phenomenon of enkrateia? In some cases, as in that of the first case, enkrateia is a stage on the way to acquiring the prudentially and morally valuable characteristic of being a non-smoker. In the second case, the person lives with flare-ups of an internecine battle between her desires and her belief. What redeems her is that she has a higher order desire to be a certain kind of person, a person who takes responsibility for her health insofar as she can and who is well enough to be available to people about whom she cares.xv 14 In the case of a person with a moral flaw, she has to have moral motivations or higher-order moral feelings in order to change. Therefore, no moral therapy could be truly effective unless it is given to someone who already views herself as a moral agent and who values herself for that. This lack of moral awareness seems entrenched in NPD, BPD, and ASPD, which is why therapists find them so difficult to treat. In the language of psychoanalysis, they are ³malignant hysterics.´xvi Let us grant that these other Cluster Bs are moral disorders. What about the histrionic? Tellingly, in discussing the various ways in which each of the Cluster Bs is a moral disorder, Charland does not specify why HPD would be a moral disorder. Rather, he says, The moral nature of histrionic personality disorder is more implied than explicit but it is clear nonetheless. Here the excessive attention seeking and inappropriate sexually seductive and provocative behavior referred to is [sic] flatly inconsistent with a pattern of empathy and regard for others. xvii His description of HPD as a moral disorder is highly problematic for a number of reasons. First, Charland mentions only two of the eight criteria for HPD. Conceivably, one could evince these characteristics and not warrant a diagnosis of HPD. Secondly, one could justifiably be diagnosed as having HPD without exhibiting either of the two criteria Charland mentions. Thirdly, it is unclear as to how such behavior precludes empathy for others. One could imagine situations in which both attention seeking and/or seductiveness are consistent with empathy for others. For 15 example, someone might try to draw attention away from a close friend who is under uncomfortable scrutiny, or someone might behave seductively towards a person for whom she feels sorry. That Charland cannot describe an explicit moral transgression characteristic of the histrionic speaks worlds about the moral status of HPD. Finally, his criteria for judging HPD to be a moral disorder is determined on the basis of behavior such as seeking attention or acting provocatively, whereas the criteria he cites for ASPD and NPD are subjective or internal states such as lacking empathy and disregard for and violation of the rights of others. That Charland has not proved HPD to be moral does not entail that it is not a moral disorder. But the histrionic exhibits no behavioral characteristic that we could deem morally bad. As for theatricality, all human beings assume roles of various sorts in their social interactions. Nor do case histories or other first person reports suggest any moral flaw in the subjectivity of the histrionic. If anything, the histrionic may have an unusual capacity for empathy, as we see in Eliot s character of Gwendolen. This is part of her subjectivity. Gwendolen s story, in fact, can be seen as one of moral awakening and maturation of a person with histrionic traits. She begins as a woman who has great love for and attachment to her mother, but who grows into someone with broader moral sympathies and a genuine moral imagination. Deronda is her moral guide. Interestingly, he is like a psychoanalyst who handles his counter-transference with the utmost integrity. 16 Psychoanalyst Christopher Bolas, who construes a histrionic as a benign hysteric, remarks on the histrionic s capacity for empathy, albeit within the terms of Bolas psychoanalytic schema of the primal scene: When the self becomes an event startling the eyes of the other it illustrates the self possessed by the primal scene . . . Driven to distraction by the imagined scene . . . the hysteric tries to re-enter innocence through the shocked gaze of the other, who for a moment is an innocent in the presence of something happening beyond the witness s knowledge. In a flash, hysterics projectively identify themselves into the other, bathing in innocence. (2000, 125-126) Although a detailed account of Bolas s schema goes beyond the topic of this article, he makes evident that the histrionic can sense the needs of others and that she cares about those needs. The person with NPD or ASPD may also be aware of the needs of others indeed that is required for them to achieve some of their mischief--but they differ from the histrionic in that the narcissist or anti-social person does not care about the needs of others and feels no empathy for others. Thus, they feel no remorse when they knowingly make choices that have bad consequences for others. David W. Allen, M.D. (1991), discussing several cases, depicts the behavior, subjective experience, and treatment of the histrionic: 17 . . . she has by quick . . . expression of feeling aborted the intensity of its full development . . . . The problem with this patient is to help her learn how to think better about certain situations . . . . the therapist might first point out that . . . is one of the reasons[she] is called histrionic or theatrical because she is acting and not fully feeling what seems to be felt. In the acting . . . is a defense against the very feeling that is portrayed, and that defense is what the therapist must first point out. (181) Allen has had success with his histrionic patients. He emphasizes the care the therapist must take to manage the counter-transference and not to hasten the process. He has not found the histrionic to lack empathy or genuinely deep feelings. He focuses on helping the histrionic think about connecting feelings and affect. Allen illuminates the central problem that can emerge in a carefully choreographed therapy, namely the histrionic s fear of being known (189-191). Is it surprising that psychologically astute females in a patriarchal culture would have a fear of being known? Hardly. Where women had (or have) to compete with others for economic survival, as they did until quite recently in Western culture, it would be to a woman s advantage to conceal her feelings and sexuality except in extraordinary circumstances. Thus, it is easy to see why females would develop or amplify histrionic traits more than males. This is not to say that genetic factors do not play a role, but rather that how traits manifest themselves and become amplified may well be a function of the looping effect that Hacking describes. 18 When a histrionic appears with depression, the therapist may diagnose and treat the depression, but then focus on (and pathologize) the personality style. Histrionics, being sensitive to the reactions of others, are likely to internalize a therapist s judgment of them as having a personality disorder. Furthermore, because of their empathy and personal attractiveness, histrionics are quite vulnerable to therapists who have trouble maintaining appropriate boundaries in managing their own counter-transference. Allen speaks expansively on the problem a (usually) male therapist has with the transference/counter-transference situation with a female histrionic patient. The therapist may find these patients intriguing. As he says in discussing a particular case, One can imagine the difficulties in treatment if this man were the psychiatrist, psychologist, or social worker treating a histrionic or hysterical woman if he had not been well trained and well analyzed. Probably the best that could happen would be that out of ethical considerations he would refer her to another therapist prepared to marry her. (168) Allen unconsciously betrays his own, more benign, feelings towards these patients in the language he uses to depict metaphorically the therapist s role as heroic figure in the histrionic s mental life: Figuratively, the therapist holds the string at the juncture of the real world and the labyrinthine world of the patient s unconscious while he 19 and past. [He] allows the patient to unwind that Ariadnean string regressively throughout its long length into earliest childhood. And when the patient comes forward again the therapist gives back the string and map of the patient s personal labyrinth. (189-190) HPD as a Cultural Disorder HPD is not a mental disorder in the way that say, a schizoid or a dependent personality disorder is. Nor is it a moral disorder. It is not a hexis; it is instead a diathesis. Allen understands this (188). HPD is a personality strategy that is caused by a cultural disorder.xviii What is a cultural disorder?xix The notion is ambiguous. It can refer to an affliction of someone who cannot adjust to the norms of his culture. It can also refer to a disorder caused by the power hierarchy of a culture. Or, as in the sense that I am using it here, it can refer to a culture that treats certain groups or subcultures, or individual members of them in ways that make them feel alienated, physically inferior, ashamed, depressed, anxious or show symptoms of another disorder such as anorexia or PTSD. Consider the culture that so prized the human voice that it sanctioned castration of adolescent or pre-pubescent boys with promising vocal careers. These are radically disordered cultures, in which one who resists their values is considered deviant or mentally ill. Many victims of these cultures probably do develop anxiety, depression, or other pathologies. The beautiful voice or even 20 the physical defect of a castrato was not a mental disorder; yet a resulting generalized anxiety or a sexual paraphilia would have been. Analogously, the histrionic, qua histrionic, is reacting to a disordered culture. The dynamic is subtler than those in the above cases. There is nothing pathological about having a dramatic élan or an aesthetic concern with self-presentation. To consider Freud s hysterics, the ancestors of today s histrionics, their sexual desires did not constitute a disorder, but their somatizations and conversion disorders were a response to a culture that condescended to women with imagination and sexuality. Historically, Western culture has condescended to both. It has prized qualities such as rhetorical skill in the use of political or economic power, rational or obsessive thinking styles applied to scientific research or business strategies. But it has either devalued or subordinated in importance the application of drama or polish to personal presentation.xx Until recently, it has considered these feminine. Note that in English, we find the expression drama queen used even when applied to men. In a sense, we are all drama queens in our self-presentation, which is part of the tension between the individual and his culture or subculture, as William Ian Miller claims in his recent Faking It.xxi Miller cogently and wittily argues that it is part of the human condition to feel anxiety in proportion to the visibility of our enacted roles. If Miller is correct (as I think he is), then histrionics, who tend to be especially imaginative, fastidious, or aesthetic in their personal presentation, may live with greater anxiety or other problems. 21 Having histrionic traits could thus give rise to shame, anxiety, body dysmorphic disorder, or any number of other problems, depending upon the environment and people by whom one is surrounded. The resulting anxiety will take forms such as anxiety about becoming invisible, or it can manifest itself in body disorders. Western culture now encourages women to develop intellectually, economically, and professionally, yet it has not stopped infantilizing women who have keen aesthetic concerns about their bodies. It both rewards and punishes them if they are comfortable modeling traditional femininity. The goal for the histrionic should be not to change her fundamental traits, but rather to attain insight into the ambivalent culture that has tainted her with a diagnostic label. The role of the therapist in a histrionic s life should be to encourage her (or him) to appreciate her traits and to develop her talents in ways that allow her to use them as strengths. Like Daniel Deronda with Gwendolen, a good therapist can help a histrionic mature by creating a therapeutic space where she need not fear gaining insight and agency. That would be a real modality of moral therapy. A personality style is not a personality disorder, even in a culture where that style may be treated as a disorder. HPD pathologizes traditional feminine styles and modes of self-presentation. The APA needs to unmask the histrionic who, qua histrionic, is not bringing distress to herself or others. For the histrionic may be a person in the process of distinctive self-actualization. 22 For insightful comments and criticisms of this paper, I am deeply grateful to Naomi Zack, David Levine, Cesar Benarroche, Jason Klein, and an anonymous referee for this journal. For remarks on earlier versions of this paper, I thank audiences at the conference on Freedom and Psychiatry: meeting of the International Network of Philosophy and Psychiatry, Dallas, 6-8 October 1998 and at a colloquium at the FAU Center for Mind, Body, and Culture, March 2009. i 361. While homosexuality is no longer included in the DSM as a disorder, the profound ii homophobia and other forms of prejudice in some cultures and subcultures can lead to such disorders as clinical depression and generalized anxiety disorder, among others. iii For a fuller discussion of this and its relation to ethics, see Gould 1994. 2007, 561 559-562. 1998, 20. iv v vi vii Actually, he says that the jury is still out on As and Cs, but he does say that they are morally neutral (2004, 73). viii Hacking 1998. ix For an excellent critical discussion of Hacking s notion of interactive kinds, see Tsou. 23 x Charland 2004, 2006 has argued that Cluster B disorders differ from other personality disorders in that they are moral disorders and, and as such, require moral therapy rather than psychotherapy. xi Allen 169. Rosenbluth 2001 See, for example, PR Slavney and GA Chase, Sprock, and Cale and Lillienfeld. Cf. Matthews 305-308 Gould 1994, 181. Bollas, 127. 2004, 71; 2006, 122. 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DSM-IV wrote:A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) frantic efforts to avoid real or imagined abandonment.
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

(3) identity disturbance: markedly and persistently unstable self-image or sense of self

(4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, Substance Abuse, reckless driving, binge eating).
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

(7) chronic feelings of emptiness

(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

(9) transient, stress-related paranoid ideation or severe dissociative symptoms

Wouldn't you agree Beatle?