Histrionic Personality Disorder
Histrionic Personality Disorder: Symptoms, Diagnosis and the End of a Category
Histrionic Personality Disorder: Symptoms, Diagnosis and the End of a Category
DESCRIPTION: The ICD-11 has removed histrionic personality disorder, whilst the DSM-5 lists it only in the main text—symptoms, history and what remains of the concept of histrionic personality disorder.
Histrionic Personality Disorder: Removal from the ICD-11, History and What Remains of the Diagnosis
The ICD-11 has removed histrionic personality disorder. There is no successor code. The DSM-5 continues to list it in the current main section, having already omitted it from the alternative model for personality disorders in 2013. This marked the disappearance of a category whose history stretches back to hysteria and whose criteria described a specific pattern of behaviour: demanding attention, displaying emotions, quickly forming close relationships, using one’s appearance as a means of bonding, and reacting to situations as if an audience were present.
The usual narrative cites objective reasons: blurred boundaries, limited research into treatment, and a loaded term. This post puts forward a different thesis. Hysteria, and with it histrionics, were not abolished because their explanation had been refuted. They were removed because, around 1980, American psychiatry wanted to rid itself of a way of thinking in which symptoms have meaning. This was an ideologically motivated purge, and the evidence is clear.
Patterns of behaviour and experience do not disappear simply because a manual removes their name. They are described differently, coded differently, or no longer recorded at all.
Histrionic personality disorder in the ICD-11
The ICD-10 listed eight types of personality disorder: paranoid, schizoid, antisocial, emotionally unstable, histrionic, anankastic, anxious and dependent personality disorder. The histrionic type was designated F60.4.
The ICD-11 has replaced this typological system. It recognises the category 6D10 ‘personality disorder’ and classifies it according to severity: mild, moderate or severe. Five feature domains describe the severity: negative affect, detachment, antisocial behaviour, disinhibition and compulsivity. The borderline pattern has been retained as a qualifier. Its special status stems from an extensive research history and from treatment approaches that explicitly refer to this pattern.
Histrionic personality disorder was not assigned a corresponding qualifier. Those previously coded under F60.4 are described in the ICD-11 in terms of severity and feature domains, often in terms of negative affectivity and disinhibition. This may suffice for statistical and administrative purposes. However, the old category included a type of relationship rarely found within these domains: establishing closeness and self-esteem through visibility, impact, and the demonstrative display of emotions.
The WHO classification came into force in principle on 1 January 2022. Member states are responsible for implementation in their respective areas of application. Germany continues to use the ICD-10-GM for coding. The BfArM expects the transition to ICD-11 to take several more years. F60.4 may therefore continue to appear in German doctors’ letters, documentation and claims.
The DSM-5: current and outdated
The DSM-5 presents two models side by side. In Section II, the authoritative diagnostic section, histrionic personality disorder is still listed under 301.50. The familiar eight criteria apply there. In Section III, the alternative model for personality disorders, it is absent.
The alternative model retains six types: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive and schizotypal. Paranoid, schizoid, histrionic and dependent personality disorders do not appear there as types. Corresponding patterns are described through the diagnosis of a personality disorder, with feature specification and appropriate facets.
The widespread claim that the DSM-5 has abolished histrionic personality disorder is therefore only half true. It remains in the current section of the manual. The model, which the professional debate regards as an improvement on the old types, has dropped it.
Symptoms of histrionic personality disorder
The eight DSM criteria reveal a recognisable pattern:
· Discomfort in situations where one is not the centre of attention
· Interaction that comes across as inappropriately seductive or provocative
· Rapidly shifting and superficial emotional expression
· Constant use of one’s appearance to attract attention
· Impressive language, yet lacking in detail
· Theatrical self-presentation and exaggerated emotional expression
· easily influenced by others or by situations
· a tendency to regard relationships as closer than they actually are
The name itself already determines the interpretation. ‘Histrio’ means ‘actor’ in Latin, and the word is probably of Etruscan origin. Anyone labelled ‘histrionic’ is, by the very name of the diagnosis, portrayed as someone who is putting on a show. This describes their behaviour whilst simultaneously casting doubt on its authenticity. This preconceived notion is one reason the category has been criticised within the profession.
Emotions can be intense whilst simultaneously coming across as a performance. Closeness can be established quickly and dissipate just as rapidly. Someone can dominate a room without feeling secure on the inside. The criteria identify this manifestation but do little to explain how it arises. The DSM provided a list of behavioural patterns. The person’s relationship history remained outside the scope of the diagnosis.
From Hysteria to Histrionics
The 1968 DSM-II introduced ‘hysterical personality disorder’ and already placed ‘histrionic personality’ in brackets alongside it. Both terms were available side by side. Paul Chodoff and Henry Lyons had described the characteristics of the hysterical character in 1958; Chodoff later explicitly proposed the renaming because the image of the hysterical woman had become pejorative.
The 1980 DSM-III then removed the word ‘hysterical’ without replacement. Robert Spitzer and the working group cited two reasons: concerns about gender bias and the intention to separate the personality diagnosis from conversion and somatisation. Neither of these reasons is valid. The first concerns the public perception of a word; the second relates to a decision regarding the manual’s organisational structure.
At the same time, the overarching category disappeared. The ‘hysterical neurosis’ of the DSM-II had encompassed two subtypes – the dissociative and the conversion types – and was classified within the category of neuroses. The name openly reflected its psychodynamic premise: a conflict could manifest itself as amnesia, trance, paralysis, blindness, seizures or pain.
Hysteria was thus subdivided. Parts of it were incorporated into histrionic personality disorder, somatisation and conversion disorders, hypochondria and dissociative disorders. The histrionic category took on the aspect linked to behaviour: theatricality, emotional expression, a need for attention, and the effect on others.
Freud and Breuer had adopted a different approach in their 1895 studies on hysteria. They regarded symptoms as communications about experiences, conflicts and emotions that had found no verbal expression. In cases of histrionics, what remained was a visible pattern of relationships and expression, without a language to explain its origins.
The abolition of the concept
The category of hysteria did not disappear because psychoanalysis had refuted its explanation. Along with the outdated theories about the uterus, femininity, degeneration and suggestibility, the name for the connection between conflict, the body, affect, defence mechanisms and relationships also vanished.
The 1980 DSM-III dismantled this connection. It gave conversion symptoms their own chapter. Amnesia, fugue, trance and similar states became dissociative disorders. Persistent physical complaints were reclassified into somatoform categories. The hysterical character was continued as histrionic personality disorder. Later, the borderline diagnosis incorporated a further set of severe, trauma-related and self-dramatising manifestations. This division produced categories that were easier to count, compare and categorise. It did not provide a new theory for why these symptoms, affects, and relational scenarios so frequently occur together.
Freud and Breuer had interpreted the hysterical symptom as a message. It expressed a conflict that ordinary language could not work through. Paralysis, seizures, blindness, pain, amnesia or dramatic relational scenes were regarded neither as mere delusion nor as meaningless lapses. They had a psychological meaning. Psychoanalysis began with precisely this question: How can someone know something and yet not know it at the same time? How does the body become the site of what must not be said?
The DSM-III reform no longer posed this question. Its aim was diagnostic consistency: two examiners should, where possible, assign the same code to the same set of details. This aim is useful for research, drug approval, statistics, billing and administration. It does not explain symptoms. It replaces reconstructing a conflict with counting manifestations.
The process had a name. Gerald Klerman called the programme ‘neo-Kraepelinian’: a return to Emil Kraepelin’s descriptive pathology, moving away from interpreting individual cases toward categories that can be tested in studies and counted in statistics. With the DSM-III, therefore, it was not just hysteria that fell by the wayside. The term ‘neurosis fell by the wayside, and with it the entire vocabulary in which a symptom could be interpreted as an expression of an inner conflict.
Hysteria was the easiest target for this programme because it offered four points of attack at once.
· A heterogeneous subject. Paralysis, seizures, blindness, pain, amnesia, trance, physical complaints and a personality style were all grouped under a single name.
· A psychoanalytic theory. The term referred to repression, conflict, conversion and unconscious meaning – in other words, precisely those assumptions that were to be eliminated from official diagnostics.
· A stigma attached to femininity. ‘Hysterical’ had become a term of abuse for women in everyday language.
· Poor consistency. Researchers often disagreed on who should be considered hysterical.
The first two points support a revision. The last two are reasons for a different way of speaking—neither calls for abolishing the concept itself.
In antiquity, the term ‘hysteria’ was associated with the pathologisation of women. Psychoanalytic theory, however, had long since dissociated hysteria from the uterus and from the female condition. Freud wrote about male hysteria, and his first publication in this field dealt with a man. Nancy McWilliams clearly describes the hysterical character organisation as a gender-neutral form of personality. It is found in both women and men, at neurotic, borderline and psychotic levels of functioning. In this tradition, ‘hysteria’ does not refer to feminine theatrics. Rather, it refers to conflicts concerning desire, rivalry, self-worth, identification, dependence and affective intensity.
The renaming to ‘histrionics’ avoided the word ‘hysteria’ whilst, ironically, retaining its most superficial connotation. ‘Histrio’ means ‘actor’. The new diagnosis focused on behaviour, seduction, emotional expression, suggestibility and the quest for attention. It obscured the context from which these forms arise and, by its very name, cast doubt on the authenticity of the expression.
Feminist criticism could therefore be directed against a real injustice while also being used for an entirely different professional endeavour. The problem lay in the misogynistic history of medical attribution. A psychoanalytic concept that had explicitly transcended this attribution was eliminated. What remained were isolated symptoms, a label of theatricality, and a vocabulary that removed conflict, bodily expression and relationships from official psychiatry.
Cholera remained cholera
The comparison with cholera illustrates the asymmetry precisely. In both cases, an explanation was discarded. But only once was the subject itself discarded.
· The miasmatic theory incorrectly explained the cause of cholera. Koch’s discovery replaced it with a verifiable cause. The diagnosis remained; the treatment improved.
· Various psychodynamic theories explained conflict, defence mechanisms and bodily expression in different ways. The DSM-III did not replace them with any new, common explanation. It simply broke the subject down into chapters and increased consistency in labelling.
One could have dealt with hysteria in the same way as with cholera. The assumptions about the uterus, the female nature, degeneration and suggestibility could have been discarded. The clinical subject would have remained, its boundaries would have been clarified, and its explanation further developed. This possibility existed. It was not chosen.
The ICD-10 decided otherwise.
Anyone wishing to examine the objection that the breakdown was technically necessary need only look at the ICD-10: the same phenomena, the same era, a different committee, a different decision.
To this day, the ICD-10 lists hysteria, hysterical psychosis and conversion hysteria under F44 as included terms within dissociative disorders [conversion disorders]. The DSM categorisation was therefore not a methodological necessity. The DSM-III committee made this decision, removing the psychoanalytic connection between conflict, bodily expression, dissociation, and relationships from the official diagnostic terminology.
Subsequent revisions of the DSM were developed amidst demonstrably close links to the pharmaceutical industry. In the DSM-5 Task Force, almost 70 per cent of members declared financial ties to pharmaceutical companies. Among the 137 members of the DSM-5 working groups, the figure was 56 per cent. The disclosed links included consultancy work, research funding, speaking fees, seats on company boards and shareholdings.
This fact illustrates the institutional context in which diagnoses were altered: a manual that divides symptoms into distinct groups simultaneously creates separate indications, study populations, areas of clinical practice and markets for medicines. The pharmaceutical industry does not need to prove a cure. It must demonstrate a statistical advantage over a placebo for a defined diagnosis or symptom group.
Jago: Hysteria was never a ‘female’ condition
The argument regarding gender bias lacks a fundamental premise. It assumes that the psychoanalytic concept of hysteria referred to femininity. This applies to antiquity, to the theories of the uterus and to the subsequent public stereotype. It does not apply to the theory itself.
Freud’s first publication in this field appeared in 1886 and dealt with a man. He understood hysteria as a form of conflict resolution, involving repression, conversion, dissociation and bodily expression, and he considered himself, with good reason, to be somewhat hysterical.
Nancy McWilliams, Professor Emerita and Visiting Professor at the Graduate School of Applied & Professional Psychology at Rutgers University, and in private practice in Lambertville, New Jersey, specialises in psychoanalytic psychotherapy and supervision, the diagnostic-therapeutic relationship, alternatives to the DSM and ICD, the integration of feminist theory, diverse population groups, altruism, narcissism, as well as trauma and dissociative disorders. She describes the hysterical character organisation as a gender-neutral personality type that occurs at neurotic, borderline and psychotic levels of functioning. Whilst it is more frequently described in women, men with a hysterical character organisation are by no means rare.
McWilliams cites a literary example that illustrates the point strikingly: Iago from Shakespeare’s *Othello*. He displays no outbursts, no theatricality in the conventional sense, and nothing that would be considered feminine. He is self-controlled, intelligent and an effective schemer. What is hysterical is his inner order:
· extreme sensitivity to status, desire and insult
· a sense of self that depends on power over the desires of others
· an erotically competitive organisation of closeness and enmity
· the ability to shift one’s own conflict into a social setting
Iago does not display his hurt. He creates a situation in which Othello must act it out. This is precisely what psychoanalytic character theory means by a ‘hysterical organisation’, and this is precisely what is no longer present in histrionic personality disorder.
The deletion thus drew on the misogyny of a history and targeted a concept that had long since left that misogyny behind. In its place came a term that, of all things, preserves the most superficial aspect of the old cliché: theatricality.
Who benefited from the removal?
A decision of this magnitude has its winners.
The pharmaceutical industry loves clearly defined lists of symptoms for which approvals can be granted, studies funded and guidelines written. A concept that can only be understood through conflict, defence mechanisms and relationships is not suitable for this purpose.
Insurance companies and administrative bodies prefer stable billing and documentation units. A diagnosis whose determination requires reconstructing a person’s life story cannot be assessed in a matter of minutes.
Research funding rewarded quantifiable criteria and consensus amongst researchers. Those who interpret conflicts do not produce figures that fit grant applications.
And American psychiatry itself distanced itself from psychoanalysis, which had dominated the discipline for decades. Hysteria had been its founding subject. With it, the most visible sign of this dominance disappeared from the official register.
The authority to interpret thus shifted completely. Previously, one would have asked about conflict, defence mechanisms, relationship history and symbolic form. Afterwards, the manual focused on number, duration, onset and exclusion criteria.
Gender and diagnostic practice in histrionic personality disorder
The most serious criticism levelled at the category was that it measured femininity. Its criteria drew on behaviours that Western gender stereotypes label as feminine: emotional expression, physical theatrics, seeking attention, seduction and dependence on approval. In clinical contexts, clinicians frequently attributed the diagnosis to women.
Population data paint a less straightforward picture. The first analysis of the American NESARC survey, involving more than 43,000 respondents, reported a lifetime prevalence of 1.8 per cent for histrionic personality disorder and no difference between men and women. A subsequent revision of the diagnostic algorithms required distress or impairment for each criterion counted. As a result, the prevalence fell to 0.27 per cent. Ironically, in this revised analysis, the diagnosis was more common among women than men: 0.29 per cent compared with 0.24 per cent.
The figures show how strongly prevalence and gender distribution depend on how criteria are operationalised and impairment assessed. Clinical samples are also influenced by referral, self-selection, the type of institution, and investigators' expectations. A diagnosis may stick to women because the vocabulary used evokes cultural images of femininity and because the same behaviours are interpreted differently in men: as charisma, competitiveness, courtship, extraversion or narcissism.
This is the height of the absurdity of the approach: the entire catalogue has nothing to do with femininity, but at best with social role scripts that are not in the least affected by the abolition of diagnoses.
The official reasons
Three reasons were given for the removal of histrionic personality disorder. Each of them describes a real problem. None of them necessitates what has happened.
Overlap. The criteria overlapped with those for narcissistic, borderline and dependent personality patterns. Seeking attention can occur in the context of narcissistic self-esteem regulation, fear of abandonment, dependent attachment or a general disinhibited personality trait. Purely histrionic cases are said to be rare. A category that usually occurs alongside other types struggles to establish itself as a distinct clinical entity.
Nevertheless, this is the most curious reason: otherwise, overlaps and co-occurrence would have to lead to the abolition of most diagnoses. Around half of people with a mental disorder receive at least one further diagnosis in the course of their lives. In pooled studies, the figure is 69 per cent for obsessive-compulsive disorder and over 80 per cent for gambling disorder. The figures rise the longer and more thoroughly the investigations are carried out.
This does not prove that diagnoses are arbitrary. It shows that mental disorders rarely occur as distinct, separate illnesses. Depression, anxiety, trauma, addiction, obsessive-compulsive disorder, dissociation and personality disorder share symptoms, risk factors and developmental trajectories. The ICD-11 responded to this by replacing the old personality disorder types with severity levels and feature clusters. As a result, multiple diagnoses disappear from the statistics. The overlap in the lives of those affected does not disappear.pmc.ncbi.nlm.nih
Limited specific treatment research. For histrionic personality disorder, there is no branch of research with its own well-tested procedures. In contrast, for borderline personality disorder, there are treatment studies on dialectical behaviour therapy, mentalisation-based therapy, transference-focused psychotherapy and schema therapy. The diagnosis remained overshadowed by neighbouring categories, for which research and care provision were more extensively developed.
But this reason is also absurd. The claim that a diagnosis leads directly to a specific therapeutic approach has hardly any empirical basis. There are clear treatment-specific indications for only a few clinical conditions: exposure therapy for specific phobias and obsessive-compulsive disorder, trauma-focused approaches for PTSD, and structured treatments for borderline personality disorder. For the vast majority of diagnoses – and above all the most common ones – there is no established evidence as to which therapeutic approach is superior for which patient, without anyone even considering abolishing them.
Particularly in the case of the common mixed presentations involving depression, anxiety, trauma, addiction, physical symptoms and personality issues, the diagnosis only partially informs the therapeutic decision. Treatment is then guided by considerations of avoidance, self-harm, affect regulation, relationship dynamics, dissociation, self-esteem and the ability to cooperate. The diagnosis identifies the administrative case. Psychotherapeutic work begins where the diagnosis becomes too broad for the individual in question.
Gender-related political implications. The category of histrionics originates in the history of psychiatry and uses gendered criteria.
A diagnosis that treats emotional visibility and physical self-expression as signs of pathology requires a careful distinction to be made between cultural norms, profession, style, sexuality, extraversion and psychological impairment. In practice, this distinction is often not made convincingly.
This reason, too, is peculiar: diagnostic systems are not a catalogue of newly discovered illnesses. Around four-fifths to nine-tenths of its diagnoses are linked to categories that already existed in the earlier history of psychiatry. Accordingly, the terms also convey notions of aetiology and gender roles.
What is usually new are the boundaries within which symptoms are grouped, separated from one another or given a different name. A diagnostic manual therefore rarely discovers a new entity. It decides which phenomena may be regarded as the same entity.
So, all in all: overlap is a possible argument for stricter criteria or for merging with neighbouring categories, not for outright deletion. The borderline pattern overlaps just as strongly with narcissistic and dependent patterns and has survived because treatment research and scientific-policy interest were attached to it. A lack of treatment research is not a characteristic of a subject, but a consequence of where funding flows. A category that nobody researches does not stop being real. And a loaded term can be changed, as Chodoff suggested and as the DSM-II had already paved the way for with brackets. These three reasons explain why the category was open to criticism. They do not explain why nothing replaced it. This gap is not due to a lack of methods, but to intention.
What remains
People who were previously described as histrionic have not disappeared from clinical practice. The ICD-11 distributes their difficulties across severity levels and symptom domains. In many cases, clinicians record negative affectivity and disinhibition. In others, narcissistic, borderline or dependent traits come to the fore.
In the process, something is lost. The old category captured a particular way of structuring relationships. Attention was not merely a reward there. It underpinned one’s sense of self. Without a glance, a reaction, desire or a visible effect, a person might feel empty, insecure or unreal. Emotions were displayed to force a connection. The connection broke down as soon as attention turned away.
Such a structure need not persist as a separate diagnosis. It requires discussing concepts and precisely reconstructing the relational context. How is closeness established? What happens when the other person does not respond? On what does self-esteem depend? What role do clothing, language, erotic tension, drama, crises and the audience play? Merely classifying this as negative affectivity or disinhibition does not answer these questions.
Refraining from a diagnosis does not dissolve the structure. It merely deprives it of a label. Anyone who describes hysterical dynamics solely in terms of negative affectivity, disinhibition, narcissistic sensitivity or borderline symptoms may grasp the individual features yet still lose sight of the bigger picture. Affect, the scene and behaviour remain visible. What becomes invisible is the form of interaction in which desire, fear of dependence, rivalry, the body and the search for recognition converge.
Attention as a market
Whilst diagnostic practice has done away with the term, some of the behaviour described has become a marketable skill. In 1998, Georg Franck described attention as a form of value that can be converted into income. Platforms organise visibility, response, reach and engagement. Those who work there must hold people’s attention.
Constant self-promotion, the use of one’s appearance, the expression of emotions in brief bursts, rapid shifts between arousal and relaxation, and relationships with one’s own following that appear closer than they actually are: the old criteria can be read as a job description for the attention economy.
This does not, however, amount to a remote diagnosis of influencers. Anyone working on platforms where remuneration depends on reach behaves in line with market forces when they generate attention. Adapting to a market is not a disorder. The difference lies in suffering, impairment and a lack of freedom to act differently. It is precisely this aspect that disappears as soon as the criteria are interpreted as a guide to success.
This shift demonstrates how much diagnoses depend on their time. What appeared theatrical and attention-seeking in a manual may be regarded as professional visibility in a platform economy. The yardstick must therefore be neither behaviour alone nor its moral judgement. What remains decisive is whether someone can now regulate relationships and self-worth only through performance, reaction, and varying intensity.
The open question
A category may disappear if it does not delineate an independent subject. However, removing it does not resolve what becomes of the concept itself.
In the case of hysteria, this question was posed for over a century: by Charcot, Freud, Breuer and Janet; in research into conversion disorders; in trauma research; and in the revisions of diagnostic manuals. Histrionics disappeared far more quietly. Its behavioural patterns were distributed amongst traits, related diagnoses and culturally accepted forms of self-expression.
This has far-reaching consequences for clinical care. Diagnoses open up access to treatment, funding and research. When a clinical pattern is dropped from a manual, alternative descriptions must capture the impairment it represents. Otherwise, the individual remains caught between categories: too dramatic for one, not ill enough for the other, visible enough to attract prejudice yet invisible to treatment.
Symptom lists break mental suffering into units that can be counted and compared across study groups. Sleep disturbance, lack of motivation, concentration problems, feelings of guilt, anxiety and suicidal thoughts become points on a scale. An antidepressant does not have to demonstrate that it cures depression, resolves its underlying conflict or changes the person’s life circumstances. For approval, it is sufficient that the score falls more sharply on average with the active ingredient than with a placebo. Guidelines for clinical trials usually regard a 50 per cent reduction as a success.
The procedure measures something real. It measures the change in predefined symptoms over a short period of time. It cannot show why someone became depressed, whether they can love or work again, whether social humiliation, an inescapable dependency or a loss continues to have an effect, or whether the improvement is lasting. The score replaces the story.
Pharmaceutical research breaks down suffering into symptoms, because only symptoms can count as endpoints in a regulatory trial. The drug does not have to demonstrate a cure. It must, on average, produce a better score on the scale.
‘Purge’ sounds harsh for a process involving committees, conferences and votes. It is not, of course, meant to imply a conspiracy. It refers to a result: an entire way of thinking was removed from the official register without its claims having been examined and refuted. The explanation was not replaced; it was deleted. Cholera kept its name, even after its incorrect explanation was rejected. In the case of hysteria, along with the incorrect explanations, the correct question also disappeared: what does the body say when a conflict finds no voice?
Key points in brief
• The ICD-11 replaced the old personality disorder types with a severity classification comprising five feature domains. Histrionic personality disorder was not replaced.
• The borderline pattern was retained as a qualifying criterion. This reflects extensive research and a range of proven treatment methods.
• The DSM-5 continues to list histrionic personality disorder in Section II. Its alternative model in Section III does not include it.
• Germany continues to use the ICD-10-GM. F60.4 therefore remains in use until the German transition.
• The category emerged in 1980 from the hysterical personality disorder in the DSM-II. Hysteria was distributed across several disorder categories.
• Its criteria describe attention-seeking behaviour, theatrical emotional expression, the use of one’s appearance, suggestibility and relationships that are quickly perceived as intimate.
• The name refers to the actor and implies a judgement on the authenticity of the behaviour.
• The reasons cited for its removal include overlap with related diagnoses, a lack of specific research into treatment, and criteria that are gender-biased. None of these reasons necessitates its removal without replacement.
• In 1980, the DSM-III removed not only ‘hysteria’ but also the word ‘neurosis’, thereby eliminating the vocabulary in which a symptom could be interpreted as an expression of conflict. Gerald Klerman described this approach as ‘neo-Kraepelinian’.
• To this day, the ICD-10 lists hysteria, hysterical psychosis and conversion hysteria under F44. The breakdown in the DSM was therefore not a methodological necessity, but a decision by a panel of experts that holds shares in the pharmaceutical industry.
• The psychoanalytic concept of hysteria was gender-neutral. Freud’s first work on the subject, in 1886, dealt with a man.
• The winners were the pharmaceutical industry, the funding bodies, research funding organisations and a psychiatric community that sought to distance itself from psychoanalysis.
• The revised NESARC analysis reduced the prevalence from 1.84 to 0.27 per cent and found a higher rate among women. The result demonstrates how heavily diagnostic figures depend on operationalisation and criteria for impairment.
• Seeking attention can be a professional requirement and a successful strategy in the platform economy. Clinically, what remains decisive is suffering, impairment and the compulsion to regulate self-worth and relationships solely through visibility.
Sources
· American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Publishing.
· Bach, B., & First, M. B. (2018). Application of the ICD-11 classification of personality disorders. BMC Psychiatry, 18.
· Federal Institute for Drugs and Medical Devices. ICD-11: Status of implementation in Germany.
· Franck, G. (1998). The Economics of Attention: A Draft. Munich: Carl Hanser.
· Freud, S., & Breuer, J. (1895). Studies on Hysteria. Leipzig and Vienna: Deuticke.
· Grant, B. F., Stinson, F. S., Dawson, D. A., Chou, S. P., Ruan, W. J., & Pickering, R. P. (2004). Prevalence, correlates, and disability of personality disorders in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 65, 948–958.
· Chodoff, P., & Lyons, H. (1958). Hysteria, the hysterical personality and ‘hysterical’ conversion. American Journal of Psychiatry, 114, 734–740.
· Klerman, G. L. (1978). The evolution of a scientific nosology. In J. C. Shershow (ed.), Schizophrenia: Science and Practice. Cambridge: Harvard University Press.
· Mayes, R., & Horwitz, A. V. (2005). DSM-III and the revolution in the classification of mental illness. Journal of the History of the Behavioural Sciences, 41, 249–267.
· Shakespeare, W. (1604). Othello, the Moor of Venice.
· World Health Organisation. ICD-10, F44 Dissociative disorders (conversion disorders), including: hysteria, hysterical psychosis, conversion hysteria, conversion reaction.
· McWilliams, N. (2011). Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2nd ed.). New York: Guilford Press.
· Freud, S. (1886). Observation of a case of severe hemianesthesia in a hysterical man. Wiener Medizinische Wochenschrift, 36, 1633–1638.
· Chodoff, P. (1982). Hysteria and women. American Journal of Psychiatry, 139, 545–551.
· Skodol, A. E. (2015). The alternative DSM-5 model for personality disorders. Annual Review of Clinical Psychology, 11, 499–524.
· Trull, T. J., Jahng, S., Tomko, R. L., Wood, P. K., & Sher, K. J. (2010). Revised NESARC personality disorder diagnoses: Gender, prevalence, and comorbidity with substance dependence disorders. Journal of Personality Disorders, 24, 412–426.
· World Health Organisation. ICD-11 for Mortality and Morbidity Statistics: Personality Disorders.
Related
DESCRIPTION: The ICD-11 has removed histrionic personality disorder, whilst the DSM-5 lists it only in the main text—symptoms, history and what remains of the concept of histrionic personality disorder.
Histrionic Personality Disorder: Removal from the ICD-11, History and What Remains of the Diagnosis
The ICD-11 has removed histrionic personality disorder. There is no successor code. The DSM-5 continues to list it in the current main section, having already omitted it from the alternative model for personality disorders in 2013. This marked the disappearance of a category whose history stretches back to hysteria and whose criteria described a specific pattern of behaviour: demanding attention, displaying emotions, quickly forming close relationships, using one’s appearance as a means of bonding, and reacting to situations as if an audience were present.
The usual narrative cites objective reasons: blurred boundaries, limited research into treatment, and a loaded term. This post puts forward a different thesis. Hysteria, and with it histrionics, were not abolished because their explanation had been refuted. They were removed because, around 1980, American psychiatry wanted to rid itself of a way of thinking in which symptoms have meaning. This was an ideologically motivated purge, and the evidence is clear.
Patterns of behaviour and experience do not disappear simply because a manual removes their name. They are described differently, coded differently, or no longer recorded at all.
Histrionic personality disorder in the ICD-11
The ICD-10 listed eight types of personality disorder: paranoid, schizoid, antisocial, emotionally unstable, histrionic, anankastic, anxious and dependent personality disorder. The histrionic type was designated F60.4.
The ICD-11 has replaced this typological system. It recognises the category 6D10 ‘personality disorder’ and classifies it according to severity: mild, moderate or severe. Five feature domains describe the severity: negative affect, detachment, antisocial behaviour, disinhibition and compulsivity. The borderline pattern has been retained as a qualifier. Its special status stems from an extensive research history and from treatment approaches that explicitly refer to this pattern.
Histrionic personality disorder was not assigned a corresponding qualifier. Those previously coded under F60.4 are described in the ICD-11 in terms of severity and feature domains, often in terms of negative affectivity and disinhibition. This may suffice for statistical and administrative purposes. However, the old category included a type of relationship rarely found within these domains: establishing closeness and self-esteem through visibility, impact, and the demonstrative display of emotions.
The WHO classification came into force in principle on 1 January 2022. Member states are responsible for implementation in their respective areas of application. Germany continues to use the ICD-10-GM for coding. The BfArM expects the transition to ICD-11 to take several more years. F60.4 may therefore continue to appear in German doctors’ letters, documentation and claims.
The DSM-5: current and outdated
The DSM-5 presents two models side by side. In Section II, the authoritative diagnostic section, histrionic personality disorder is still listed under 301.50. The familiar eight criteria apply there. In Section III, the alternative model for personality disorders, it is absent.
The alternative model retains six types: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive and schizotypal. Paranoid, schizoid, histrionic and dependent personality disorders do not appear there as types. Corresponding patterns are described through the diagnosis of a personality disorder, with feature specification and appropriate facets.
The widespread claim that the DSM-5 has abolished histrionic personality disorder is therefore only half true. It remains in the current section of the manual. The model, which the professional debate regards as an improvement on the old types, has dropped it.
Symptoms of histrionic personality disorder
The eight DSM criteria reveal a recognisable pattern:
· Discomfort in situations where one is not the centre of attention
· Interaction that comes across as inappropriately seductive or provocative
· Rapidly shifting and superficial emotional expression
· Constant use of one’s appearance to attract attention
· Impressive language, yet lacking in detail
· Theatrical self-presentation and exaggerated emotional expression
· easily influenced by others or by situations
· a tendency to regard relationships as closer than they actually are
The name itself already determines the interpretation. ‘Histrio’ means ‘actor’ in Latin, and the word is probably of Etruscan origin. Anyone labelled ‘histrionic’ is, by the very name of the diagnosis, portrayed as someone who is putting on a show. This describes their behaviour whilst simultaneously casting doubt on its authenticity. This preconceived notion is one reason the category has been criticised within the profession.
Emotions can be intense whilst simultaneously coming across as a performance. Closeness can be established quickly and dissipate just as rapidly. Someone can dominate a room without feeling secure on the inside. The criteria identify this manifestation but do little to explain how it arises. The DSM provided a list of behavioural patterns. The person’s relationship history remained outside the scope of the diagnosis.
From Hysteria to Histrionics
The 1968 DSM-II introduced ‘hysterical personality disorder’ and already placed ‘histrionic personality’ in brackets alongside it. Both terms were available side by side. Paul Chodoff and Henry Lyons had described the characteristics of the hysterical character in 1958; Chodoff later explicitly proposed the renaming because the image of the hysterical woman had become pejorative.
The 1980 DSM-III then removed the word ‘hysterical’ without replacement. Robert Spitzer and the working group cited two reasons: concerns about gender bias and the intention to separate the personality diagnosis from conversion and somatisation. Neither of these reasons is valid. The first concerns the public perception of a word; the second relates to a decision regarding the manual’s organisational structure.
At the same time, the overarching category disappeared. The ‘hysterical neurosis’ of the DSM-II had encompassed two subtypes – the dissociative and the conversion types – and was classified within the category of neuroses. The name openly reflected its psychodynamic premise: a conflict could manifest itself as amnesia, trance, paralysis, blindness, seizures or pain.
Hysteria was thus subdivided. Parts of it were incorporated into histrionic personality disorder, somatisation and conversion disorders, hypochondria and dissociative disorders. The histrionic category took on the aspect linked to behaviour: theatricality, emotional expression, a need for attention, and the effect on others.
Freud and Breuer had adopted a different approach in their 1895 studies on hysteria. They regarded symptoms as communications about experiences, conflicts and emotions that had found no verbal expression. In cases of histrionics, what remained was a visible pattern of relationships and expression, without a language to explain its origins.
The abolition of the concept
The category of hysteria did not disappear because psychoanalysis had refuted its explanation. Along with the outdated theories about the uterus, femininity, degeneration and suggestibility, the name for the connection between conflict, the body, affect, defence mechanisms and relationships also vanished.
The 1980 DSM-III dismantled this connection. It gave conversion symptoms their own chapter. Amnesia, fugue, trance and similar states became dissociative disorders. Persistent physical complaints were reclassified into somatoform categories. The hysterical character was continued as histrionic personality disorder. Later, the borderline diagnosis incorporated a further set of severe, trauma-related and self-dramatising manifestations. This division produced categories that were easier to count, compare and categorise. It did not provide a new theory for why these symptoms, affects, and relational scenarios so frequently occur together.
Freud and Breuer had interpreted the hysterical symptom as a message. It expressed a conflict that ordinary language could not work through. Paralysis, seizures, blindness, pain, amnesia or dramatic relational scenes were regarded neither as mere delusion nor as meaningless lapses. They had a psychological meaning. Psychoanalysis began with precisely this question: How can someone know something and yet not know it at the same time? How does the body become the site of what must not be said?
The DSM-III reform no longer posed this question. Its aim was diagnostic consistency: two examiners should, where possible, assign the same code to the same set of details. This aim is useful for research, drug approval, statistics, billing and administration. It does not explain symptoms. It replaces reconstructing a conflict with counting manifestations.
The process had a name. Gerald Klerman called the programme ‘neo-Kraepelinian’: a return to Emil Kraepelin’s descriptive pathology, moving away from interpreting individual cases toward categories that can be tested in studies and counted in statistics. With the DSM-III, therefore, it was not just hysteria that fell by the wayside. The term ‘neurosis fell by the wayside, and with it the entire vocabulary in which a symptom could be interpreted as an expression of an inner conflict.
Hysteria was the easiest target for this programme because it offered four points of attack at once.
· A heterogeneous subject. Paralysis, seizures, blindness, pain, amnesia, trance, physical complaints and a personality style were all grouped under a single name.
· A psychoanalytic theory. The term referred to repression, conflict, conversion and unconscious meaning – in other words, precisely those assumptions that were to be eliminated from official diagnostics.
· A stigma attached to femininity. ‘Hysterical’ had become a term of abuse for women in everyday language.
· Poor consistency. Researchers often disagreed on who should be considered hysterical.
The first two points support a revision. The last two are reasons for a different way of speaking—neither calls for abolishing the concept itself.
In antiquity, the term ‘hysteria’ was associated with the pathologisation of women. Psychoanalytic theory, however, had long since dissociated hysteria from the uterus and from the female condition. Freud wrote about male hysteria, and his first publication in this field dealt with a man. Nancy McWilliams clearly describes the hysterical character organisation as a gender-neutral form of personality. It is found in both women and men, at neurotic, borderline and psychotic levels of functioning. In this tradition, ‘hysteria’ does not refer to feminine theatrics. Rather, it refers to conflicts concerning desire, rivalry, self-worth, identification, dependence and affective intensity.
The renaming to ‘histrionics’ avoided the word ‘hysteria’ whilst, ironically, retaining its most superficial connotation. ‘Histrio’ means ‘actor’. The new diagnosis focused on behaviour, seduction, emotional expression, suggestibility and the quest for attention. It obscured the context from which these forms arise and, by its very name, cast doubt on the authenticity of the expression.
Feminist criticism could therefore be directed against a real injustice while also being used for an entirely different professional endeavour. The problem lay in the misogynistic history of medical attribution. A psychoanalytic concept that had explicitly transcended this attribution was eliminated. What remained were isolated symptoms, a label of theatricality, and a vocabulary that removed conflict, bodily expression and relationships from official psychiatry.
Cholera remained cholera
The comparison with cholera illustrates the asymmetry precisely. In both cases, an explanation was discarded. But only once was the subject itself discarded.
· The miasmatic theory incorrectly explained the cause of cholera. Koch’s discovery replaced it with a verifiable cause. The diagnosis remained; the treatment improved.
· Various psychodynamic theories explained conflict, defence mechanisms and bodily expression in different ways. The DSM-III did not replace them with any new, common explanation. It simply broke the subject down into chapters and increased consistency in labelling.
One could have dealt with hysteria in the same way as with cholera. The assumptions about the uterus, the female nature, degeneration and suggestibility could have been discarded. The clinical subject would have remained, its boundaries would have been clarified, and its explanation further developed. This possibility existed. It was not chosen.
The ICD-10 decided otherwise.
Anyone wishing to examine the objection that the breakdown was technically necessary need only look at the ICD-10: the same phenomena, the same era, a different committee, a different decision.
To this day, the ICD-10 lists hysteria, hysterical psychosis and conversion hysteria under F44 as included terms within dissociative disorders [conversion disorders]. The DSM categorisation was therefore not a methodological necessity. The DSM-III committee made this decision, removing the psychoanalytic connection between conflict, bodily expression, dissociation, and relationships from the official diagnostic terminology.
Subsequent revisions of the DSM were developed amidst demonstrably close links to the pharmaceutical industry. In the DSM-5 Task Force, almost 70 per cent of members declared financial ties to pharmaceutical companies. Among the 137 members of the DSM-5 working groups, the figure was 56 per cent. The disclosed links included consultancy work, research funding, speaking fees, seats on company boards and shareholdings.
This fact illustrates the institutional context in which diagnoses were altered: a manual that divides symptoms into distinct groups simultaneously creates separate indications, study populations, areas of clinical practice and markets for medicines. The pharmaceutical industry does not need to prove a cure. It must demonstrate a statistical advantage over a placebo for a defined diagnosis or symptom group.
Jago: Hysteria was never a ‘female’ condition
The argument regarding gender bias lacks a fundamental premise. It assumes that the psychoanalytic concept of hysteria referred to femininity. This applies to antiquity, to the theories of the uterus and to the subsequent public stereotype. It does not apply to the theory itself.
Freud’s first publication in this field appeared in 1886 and dealt with a man. He understood hysteria as a form of conflict resolution, involving repression, conversion, dissociation and bodily expression, and he considered himself, with good reason, to be somewhat hysterical.
Nancy McWilliams, Professor Emerita and Visiting Professor at the Graduate School of Applied & Professional Psychology at Rutgers University, and in private practice in Lambertville, New Jersey, specialises in psychoanalytic psychotherapy and supervision, the diagnostic-therapeutic relationship, alternatives to the DSM and ICD, the integration of feminist theory, diverse population groups, altruism, narcissism, as well as trauma and dissociative disorders. She describes the hysterical character organisation as a gender-neutral personality type that occurs at neurotic, borderline and psychotic levels of functioning. Whilst it is more frequently described in women, men with a hysterical character organisation are by no means rare.
McWilliams cites a literary example that illustrates the point strikingly: Iago from Shakespeare’s *Othello*. He displays no outbursts, no theatricality in the conventional sense, and nothing that would be considered feminine. He is self-controlled, intelligent and an effective schemer. What is hysterical is his inner order:
· extreme sensitivity to status, desire and insult
· a sense of self that depends on power over the desires of others
· an erotically competitive organisation of closeness and enmity
· the ability to shift one’s own conflict into a social setting
Iago does not display his hurt. He creates a situation in which Othello must act it out. This is precisely what psychoanalytic character theory means by a ‘hysterical organisation’, and this is precisely what is no longer present in histrionic personality disorder.
The deletion thus drew on the misogyny of a history and targeted a concept that had long since left that misogyny behind. In its place came a term that, of all things, preserves the most superficial aspect of the old cliché: theatricality.
Who benefited from the removal?
A decision of this magnitude has its winners.
The pharmaceutical industry loves clearly defined lists of symptoms for which approvals can be granted, studies funded and guidelines written. A concept that can only be understood through conflict, defence mechanisms and relationships is not suitable for this purpose.
Insurance companies and administrative bodies prefer stable billing and documentation units. A diagnosis whose determination requires reconstructing a person’s life story cannot be assessed in a matter of minutes.
Research funding rewarded quantifiable criteria and consensus amongst researchers. Those who interpret conflicts do not produce figures that fit grant applications.
And American psychiatry itself distanced itself from psychoanalysis, which had dominated the discipline for decades. Hysteria had been its founding subject. With it, the most visible sign of this dominance disappeared from the official register.
The authority to interpret thus shifted completely. Previously, one would have asked about conflict, defence mechanisms, relationship history and symbolic form. Afterwards, the manual focused on number, duration, onset and exclusion criteria.
Gender and diagnostic practice in histrionic personality disorder
The most serious criticism levelled at the category was that it measured femininity. Its criteria drew on behaviours that Western gender stereotypes label as feminine: emotional expression, physical theatrics, seeking attention, seduction and dependence on approval. In clinical contexts, clinicians frequently attributed the diagnosis to women.
Population data paint a less straightforward picture. The first analysis of the American NESARC survey, involving more than 43,000 respondents, reported a lifetime prevalence of 1.8 per cent for histrionic personality disorder and no difference between men and women. A subsequent revision of the diagnostic algorithms required distress or impairment for each criterion counted. As a result, the prevalence fell to 0.27 per cent. Ironically, in this revised analysis, the diagnosis was more common among women than men: 0.29 per cent compared with 0.24 per cent.
The figures show how strongly prevalence and gender distribution depend on how criteria are operationalised and impairment assessed. Clinical samples are also influenced by referral, self-selection, the type of institution, and investigators' expectations. A diagnosis may stick to women because the vocabulary used evokes cultural images of femininity and because the same behaviours are interpreted differently in men: as charisma, competitiveness, courtship, extraversion or narcissism.
This is the height of the absurdity of the approach: the entire catalogue has nothing to do with femininity, but at best with social role scripts that are not in the least affected by the abolition of diagnoses.
The official reasons
Three reasons were given for the removal of histrionic personality disorder. Each of them describes a real problem. None of them necessitates what has happened.
Overlap. The criteria overlapped with those for narcissistic, borderline and dependent personality patterns. Seeking attention can occur in the context of narcissistic self-esteem regulation, fear of abandonment, dependent attachment or a general disinhibited personality trait. Purely histrionic cases are said to be rare. A category that usually occurs alongside other types struggles to establish itself as a distinct clinical entity.
Nevertheless, this is the most curious reason: otherwise, overlaps and co-occurrence would have to lead to the abolition of most diagnoses. Around half of people with a mental disorder receive at least one further diagnosis in the course of their lives. In pooled studies, the figure is 69 per cent for obsessive-compulsive disorder and over 80 per cent for gambling disorder. The figures rise the longer and more thoroughly the investigations are carried out.
This does not prove that diagnoses are arbitrary. It shows that mental disorders rarely occur as distinct, separate illnesses. Depression, anxiety, trauma, addiction, obsessive-compulsive disorder, dissociation and personality disorder share symptoms, risk factors and developmental trajectories. The ICD-11 responded to this by replacing the old personality disorder types with severity levels and feature clusters. As a result, multiple diagnoses disappear from the statistics. The overlap in the lives of those affected does not disappear.pmc.ncbi.nlm.nih
Limited specific treatment research. For histrionic personality disorder, there is no branch of research with its own well-tested procedures. In contrast, for borderline personality disorder, there are treatment studies on dialectical behaviour therapy, mentalisation-based therapy, transference-focused psychotherapy and schema therapy. The diagnosis remained overshadowed by neighbouring categories, for which research and care provision were more extensively developed.
But this reason is also absurd. The claim that a diagnosis leads directly to a specific therapeutic approach has hardly any empirical basis. There are clear treatment-specific indications for only a few clinical conditions: exposure therapy for specific phobias and obsessive-compulsive disorder, trauma-focused approaches for PTSD, and structured treatments for borderline personality disorder. For the vast majority of diagnoses – and above all the most common ones – there is no established evidence as to which therapeutic approach is superior for which patient, without anyone even considering abolishing them.
Particularly in the case of the common mixed presentations involving depression, anxiety, trauma, addiction, physical symptoms and personality issues, the diagnosis only partially informs the therapeutic decision. Treatment is then guided by considerations of avoidance, self-harm, affect regulation, relationship dynamics, dissociation, self-esteem and the ability to cooperate. The diagnosis identifies the administrative case. Psychotherapeutic work begins where the diagnosis becomes too broad for the individual in question.
Gender-related political implications. The category of histrionics originates in the history of psychiatry and uses gendered criteria.
A diagnosis that treats emotional visibility and physical self-expression as signs of pathology requires a careful distinction to be made between cultural norms, profession, style, sexuality, extraversion and psychological impairment. In practice, this distinction is often not made convincingly.
This reason, too, is peculiar: diagnostic systems are not a catalogue of newly discovered illnesses. Around four-fifths to nine-tenths of its diagnoses are linked to categories that already existed in the earlier history of psychiatry. Accordingly, the terms also convey notions of aetiology and gender roles.
What is usually new are the boundaries within which symptoms are grouped, separated from one another or given a different name. A diagnostic manual therefore rarely discovers a new entity. It decides which phenomena may be regarded as the same entity.
So, all in all: overlap is a possible argument for stricter criteria or for merging with neighbouring categories, not for outright deletion. The borderline pattern overlaps just as strongly with narcissistic and dependent patterns and has survived because treatment research and scientific-policy interest were attached to it. A lack of treatment research is not a characteristic of a subject, but a consequence of where funding flows. A category that nobody researches does not stop being real. And a loaded term can be changed, as Chodoff suggested and as the DSM-II had already paved the way for with brackets. These three reasons explain why the category was open to criticism. They do not explain why nothing replaced it. This gap is not due to a lack of methods, but to intention.
What remains
People who were previously described as histrionic have not disappeared from clinical practice. The ICD-11 distributes their difficulties across severity levels and symptom domains. In many cases, clinicians record negative affectivity and disinhibition. In others, narcissistic, borderline or dependent traits come to the fore.
In the process, something is lost. The old category captured a particular way of structuring relationships. Attention was not merely a reward there. It underpinned one’s sense of self. Without a glance, a reaction, desire or a visible effect, a person might feel empty, insecure or unreal. Emotions were displayed to force a connection. The connection broke down as soon as attention turned away.
Such a structure need not persist as a separate diagnosis. It requires discussing concepts and precisely reconstructing the relational context. How is closeness established? What happens when the other person does not respond? On what does self-esteem depend? What role do clothing, language, erotic tension, drama, crises and the audience play? Merely classifying this as negative affectivity or disinhibition does not answer these questions.
Refraining from a diagnosis does not dissolve the structure. It merely deprives it of a label. Anyone who describes hysterical dynamics solely in terms of negative affectivity, disinhibition, narcissistic sensitivity or borderline symptoms may grasp the individual features yet still lose sight of the bigger picture. Affect, the scene and behaviour remain visible. What becomes invisible is the form of interaction in which desire, fear of dependence, rivalry, the body and the search for recognition converge.
Attention as a market
Whilst diagnostic practice has done away with the term, some of the behaviour described has become a marketable skill. In 1998, Georg Franck described attention as a form of value that can be converted into income. Platforms organise visibility, response, reach and engagement. Those who work there must hold people’s attention.
Constant self-promotion, the use of one’s appearance, the expression of emotions in brief bursts, rapid shifts between arousal and relaxation, and relationships with one’s own following that appear closer than they actually are: the old criteria can be read as a job description for the attention economy.
This does not, however, amount to a remote diagnosis of influencers. Anyone working on platforms where remuneration depends on reach behaves in line with market forces when they generate attention. Adapting to a market is not a disorder. The difference lies in suffering, impairment and a lack of freedom to act differently. It is precisely this aspect that disappears as soon as the criteria are interpreted as a guide to success.
This shift demonstrates how much diagnoses depend on their time. What appeared theatrical and attention-seeking in a manual may be regarded as professional visibility in a platform economy. The yardstick must therefore be neither behaviour alone nor its moral judgement. What remains decisive is whether someone can now regulate relationships and self-worth only through performance, reaction, and varying intensity.
The open question
A category may disappear if it does not delineate an independent subject. However, removing it does not resolve what becomes of the concept itself.
In the case of hysteria, this question was posed for over a century: by Charcot, Freud, Breuer and Janet; in research into conversion disorders; in trauma research; and in the revisions of diagnostic manuals. Histrionics disappeared far more quietly. Its behavioural patterns were distributed amongst traits, related diagnoses and culturally accepted forms of self-expression.
This has far-reaching consequences for clinical care. Diagnoses open up access to treatment, funding and research. When a clinical pattern is dropped from a manual, alternative descriptions must capture the impairment it represents. Otherwise, the individual remains caught between categories: too dramatic for one, not ill enough for the other, visible enough to attract prejudice yet invisible to treatment.
Symptom lists break mental suffering into units that can be counted and compared across study groups. Sleep disturbance, lack of motivation, concentration problems, feelings of guilt, anxiety and suicidal thoughts become points on a scale. An antidepressant does not have to demonstrate that it cures depression, resolves its underlying conflict or changes the person’s life circumstances. For approval, it is sufficient that the score falls more sharply on average with the active ingredient than with a placebo. Guidelines for clinical trials usually regard a 50 per cent reduction as a success.
The procedure measures something real. It measures the change in predefined symptoms over a short period of time. It cannot show why someone became depressed, whether they can love or work again, whether social humiliation, an inescapable dependency or a loss continues to have an effect, or whether the improvement is lasting. The score replaces the story.
Pharmaceutical research breaks down suffering into symptoms, because only symptoms can count as endpoints in a regulatory trial. The drug does not have to demonstrate a cure. It must, on average, produce a better score on the scale.
‘Purge’ sounds harsh for a process involving committees, conferences and votes. It is not, of course, meant to imply a conspiracy. It refers to a result: an entire way of thinking was removed from the official register without its claims having been examined and refuted. The explanation was not replaced; it was deleted. Cholera kept its name, even after its incorrect explanation was rejected. In the case of hysteria, along with the incorrect explanations, the correct question also disappeared: what does the body say when a conflict finds no voice?
Key points in brief
• The ICD-11 replaced the old personality disorder types with a severity classification comprising five feature domains. Histrionic personality disorder was not replaced.
• The borderline pattern was retained as a qualifying criterion. This reflects extensive research and a range of proven treatment methods.
• The DSM-5 continues to list histrionic personality disorder in Section II. Its alternative model in Section III does not include it.
• Germany continues to use the ICD-10-GM. F60.4 therefore remains in use until the German transition.
• The category emerged in 1980 from the hysterical personality disorder in the DSM-II. Hysteria was distributed across several disorder categories.
• Its criteria describe attention-seeking behaviour, theatrical emotional expression, the use of one’s appearance, suggestibility and relationships that are quickly perceived as intimate.
• The name refers to the actor and implies a judgement on the authenticity of the behaviour.
• The reasons cited for its removal include overlap with related diagnoses, a lack of specific research into treatment, and criteria that are gender-biased. None of these reasons necessitates its removal without replacement.
• In 1980, the DSM-III removed not only ‘hysteria’ but also the word ‘neurosis’, thereby eliminating the vocabulary in which a symptom could be interpreted as an expression of conflict. Gerald Klerman described this approach as ‘neo-Kraepelinian’.
• To this day, the ICD-10 lists hysteria, hysterical psychosis and conversion hysteria under F44. The breakdown in the DSM was therefore not a methodological necessity, but a decision by a panel of experts that holds shares in the pharmaceutical industry.
• The psychoanalytic concept of hysteria was gender-neutral. Freud’s first work on the subject, in 1886, dealt with a man.
• The winners were the pharmaceutical industry, the funding bodies, research funding organisations and a psychiatric community that sought to distance itself from psychoanalysis.
• The revised NESARC analysis reduced the prevalence from 1.84 to 0.27 per cent and found a higher rate among women. The result demonstrates how heavily diagnostic figures depend on operationalisation and criteria for impairment.
• Seeking attention can be a professional requirement and a successful strategy in the platform economy. Clinically, what remains decisive is suffering, impairment and the compulsion to regulate self-worth and relationships solely through visibility.
Sources
· American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Publishing.
· Bach, B., & First, M. B. (2018). Application of the ICD-11 classification of personality disorders. BMC Psychiatry, 18.
· Federal Institute for Drugs and Medical Devices. ICD-11: Status of implementation in Germany.
· Franck, G. (1998). The Economics of Attention: A Draft. Munich: Carl Hanser.
· Freud, S., & Breuer, J. (1895). Studies on Hysteria. Leipzig and Vienna: Deuticke.
· Grant, B. F., Stinson, F. S., Dawson, D. A., Chou, S. P., Ruan, W. J., & Pickering, R. P. (2004). Prevalence, correlates, and disability of personality disorders in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 65, 948–958.
· Chodoff, P., & Lyons, H. (1958). Hysteria, the hysterical personality and ‘hysterical’ conversion. American Journal of Psychiatry, 114, 734–740.
· Klerman, G. L. (1978). The evolution of a scientific nosology. In J. C. Shershow (ed.), Schizophrenia: Science and Practice. Cambridge: Harvard University Press.
· Mayes, R., & Horwitz, A. V. (2005). DSM-III and the revolution in the classification of mental illness. Journal of the History of the Behavioural Sciences, 41, 249–267.
· Shakespeare, W. (1604). Othello, the Moor of Venice.
· World Health Organisation. ICD-10, F44 Dissociative disorders (conversion disorders), including: hysteria, hysterical psychosis, conversion hysteria, conversion reaction.
· McWilliams, N. (2011). Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2nd ed.). New York: Guilford Press.
· Freud, S. (1886). Observation of a case of severe hemianesthesia in a hysterical man. Wiener Medizinische Wochenschrift, 36, 1633–1638.
· Chodoff, P. (1982). Hysteria and women. American Journal of Psychiatry, 139, 545–551.
· Skodol, A. E. (2015). The alternative DSM-5 model for personality disorders. Annual Review of Clinical Psychology, 11, 499–524.
· Trull, T. J., Jahng, S., Tomko, R. L., Wood, P. K., & Sher, K. J. (2010). Revised NESARC personality disorder diagnoses: Gender, prevalence, and comorbidity with substance dependence disorders. Journal of Personality Disorders, 24, 412–426.
· World Health Organisation. ICD-11 for Mortality and Morbidity Statistics: Personality Disorders.
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