Differentiating Borderline and Histrionic Personalities

So in an effort to understand the differences between BPD and HPD, I have been doing an obsessive online research (this is what I do when I need to understand a topic) to figure out the subtle nuances that characterize a diagnosis from one vs. the other. And in my travels came across some pearls of wisdom disseminated by professionals for professionals for this express purpose, and consequently thought to pass it along here.


http://practicewisdom.blogspot.ca/2012/06/differentiating-borderline-and.html

Differentiating Borderline and Histrionic Personalities

Both may include a similar intensity of affect, and similarly provocative behavior (of all shapes and sizes). However, the driving force behind these symptoms seems to be the key distinction between the two diagnoses.

Here is what the DSM says about this differential diagnosis: although both can "be characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, BPD is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness anad loneliness" (p. 709). Looking further at the diagnostic criteria, HPD is based on a need to be the center of attention, while BPD is based on dysregulation stemming from an unstable sense of self, both independently and in relationship to others.

My supervisor suggests that these different driving forces manifest in the intent behind the client's "dramatic, emotional, or erratic" behavior. Specifically, it is more characteristically erratic in BPD - the emotionality is not typically planned or intended, but the result of the client feeling like s/he is out of control, or even dissolving. In contrast, the behavior seems more instrumental (i.e., goal directed) in HPD - it is in service of gratifying the need for attention, with more calculation as to the effect the behavior will have on others.

Thus, clients with BPD may be much more likely to experience unintended effects of their behavior, but still be unable to choose more adaptive behavior. My supervisors suspected that our client had HPD because she seemed more in control and calculating in her behavior than one would expect from BPD.

The professional in responding to comments goes on to further clarify the differences in behaviour...

I think the key is what specific behavior is in control or out of control. While individuals with BPD are in control much of the time, and often choose maladaptive behaviors to achieve a specific outcome, due to the lack of more adaptive skills, there are times when they experience themselves as out of control, "disintegrating," and feel and display a high intensity of distress in a quite chaotic way. In contrast, individuals with HPD seem much more in control DURING an episode of distress, and may rapidly shift what emotion they are expressing (from crying to smiling, for example) based on factors in the environment. - Natalie L. Hill

I found this helpful and further to this, there was a suggestion from one of the responders to the blog that HPD is kind of a BPD-lite or NPD-lite :

"HPD seems to be characterized by what is -lacking- from it in comparison to BPD and NPD."

Of course given that I have a BPD diagnosis, but recognize that I also display several HPD traits, it begs the question then that the separation between these are not perhaps so distinct and that they are more like ASD in that they exist on a spectrum from normal to maladaptive with normal on one end, BPD on the other and HPD perhaps somewhere in between, closer to the BPD end. I am just speculating of course, but I find thinking in the visual is helpful in understanding, at least for me.

I also found a few other med student sites where a few physicians weigh in and can pass those links along in additional posts to this topic as I my research and reading continues. And here in is a prime example of how my BPD manifests in my brain by becoming an obsessive bug that "NEEDS TO KNOW" and won't allow me to stop until I have satisfied it's thirst for knowledge and understanding.... Perhaps a little OCD thrown into the mix with the BPD and HPD traits?

this discussion amongst physicians and med students about differentiating BPD from HPD was also enlightening....

https://forums.studentdoctor.net/threads/bpd-hpd-overlap.739156/

One physician wrote:

Both disorders can elicit strong feelings of countertransference in therapists. My wife, who understands borderline much better than I do, and has more training in DBT mentioned that DBT is not geared towards the treatment of histrionic personality disorder, and the theory as to how DBT works is based on several theories on borderline PD that do not apply well to histrionic PD. She said the more she learned about DBT, the more she was able to distinguish between BPD and HPD.

Histrionic PD appears to be more focused on a person's need for attention based on their own insecurities such as feelings of inadequacy. BPD is more about a person's own internal conflict, based on conflicting emotional drives that were not resolved as they were growing up. E.g. someone molested by her father may feel a conflicting combination of hate against her father but also love because she is still in the emotional developmental phase where she needs her father's approval. These two drives are in direct opposition to each other, creating confusion and an inability of the woman to emotionally mature until these two conflicting areas can be resolved. It's actually much more complicated than that because in borderlines, there's usually several areas, not just two that are in direct conflict.

Haven'y yet read but a bit, but it is very interesting. Thank you for posting.

From the reading I have done, my understanding is that there is in many cases co-morbidity between Cluster B affected people (for an example please see here https://www.ncbi.nlm.nih.gov/pubmed/18275631 . It has also been proposed that HPD is actually a cluster of BPD https://www.ncbi.nlm.nih.gov/pubmed/28680639.

My ex was affected by PD. When we originally meet she told me that she had been previously diagnosed with BPD, however, during our relationship and especially towards the end, I finally started realizing that the most pervasive pattern in her behavior was the sexual attention seeking component and validation from other men. In addition, she was extremely suggestible. As long as you would pay her a compliment especially about her physical appearance you could easily convince her about your 'good' intentions and be instantly her friend.
She did however, also exhibit classic core symptoms of BPD such as persistent emotional pain and fear of abandonment.

I guess it depends the reason for wanting to establish a firm diagnosis of BPD vs. HPD or vice versa.
Will treatment be different? I know that currently it is claimed that there is a good chance of keeping the disorder's symptoms under control with DBT for BPD but I am not sure what is the case for HPD.