problems in Family Practice

The Female Hysterical Personality Disorder

David D. S ch m id t, M D Edward Messner, M D Chapel Hill, North Carolina, and Boston, Massachusetts

It is not uncommon in family practice for the family physician to practice. The interview stresses tech­ encounter the female patient with a hysterical personality disorder. nique and the formulation stresses A case presentation and interview are provided to help the family developmental psychology. The sug­ physician recognize the problem. A formulation of this case stresses gestions for management emphasize the role for the general physician psychosexual development, which will provide the reader with in­ rather than for the psychotherapeutic sight that can be generalized to other patients. Major emphasis is behavioralist. given to practical guidelines for the clinician for management of this frequently difficult problem in a medical setting.

The hysterical personality disorder diagnosis of hysterical personality. In Case Presentation is not yet clearly defined by psychia­ this paper, the term female hysterical G.S. is a 20-year-old female who try. The analytic school stresses a personality disorder is used to avoid barged into her family doctor’s office fixation at the Oedipal phase of being sexist and to underscore that we in the midst of a busy afternoon, psychosocial development. Others 1 ’ 2 are discussing one specific aspect of a complaining that she was nervous and base this diagnosis on a constellation more general problem. needed help. Although she had tried to of behavioral traits. Furthermore, the The female patient with a hysterical commit suicide in the past, she denied personality disorder must be differen­ personality disorder can be a problem having any thoughts or plans for doing tiated from the hysterical neurosis or patient in family practice. If the physi­ so now. After a brief encounter, she classical hysterical conversion reaction. cian can recognize such a patient and was given a small amount of diazepam The medical profession is often guilty have some strategy for managing the and arrangements were made for a of using the term “hysterical overlay” intrapersonal problems that frequently “long interview” as part of a teaching as a label for those patients who arise between patient, physician, and seminar in a family medicine precep- appear to be exaggerating symptoms. paramedical staff, he may avoid feel­ torship that has previously been de­ Traditionally, this has been con­ ings of and . Further­ scribed.6 She promised to call the sidered an exclusively female disorder. more, successfully helping such a pa­ family doctor if she became desperate The recent trend to base the diagnosis tient learn to interact with others in a before that scheduled appointment in on observable behavior has led to the more appropriate fashion by engen­ 48 hours. recognition that this constellation of dering a mature and stable doctor- The entire family had been cared traits can be seen in men. Luisada3 has patient relationship can be rewarding for by the family doctor, and the reviewed a series of males with the for the physician. patient had been seen on one occasion This paper employs a format that during the past year for a minor has been used to describe for family problem. The “long interview” re­ physicians other common emotional vealed that the patient had exper­ From the D e p a r tm e n t o f F a m ily M e d ic in e , University of North Carolina School of problems.4,5 The case presented repre­ ienced tremendous emotional turmoil Medicine, Chapel H ill, North Carolina, and the Department of Psychiatry, Harvard Med­ sents an extreme example in order to during recent months, including hos­ ical School, Boston, Massachusetts. Re­ emphasize certain points. The reader is pitalizations for attempted suicides. quests for reprints should be addressed to Dr, David D, Schmidt, Departm ent of Fam­ asked to keep in mind that many less The family had very carefully and ily Medicine, University of North Carolina dramatic variations on this theme are successfully concealed this informa­ at Chapel Hill, Room 711, Clinical Sciences Building 220 H, Chapel H ill, NC 27514. encountered almost daily in a family tion.

THE JOURNAL OF FAM ILY PRACTICE, VOL. 4, NO. 3, 1977 5 7 3 According to the patient, the prob­ that he would save me . . . Patient: I do. I get the urge and I lems all began about a year previously. Now I’ve found someone else, just do it. The patient had a close relationship Michael. I never thought I could find Doctor: It is still puzzling why you with a hoy named Steve. They enjoyed anybody else. Now I find out I’m would go that far. What is it that each otliSf’f company and planned to pregnant, and he wants me to have.an drives you to do something as des­ get married. For no obvious reason, abortion. I don’t want him to have me perate as trying to commit suicide? she tried to jump off a bridge while have an abortion so he can take off Especially when things are going well Steve was watching. Soon after this, he after. I this boy very much and he particularly that first time with Steve' broke off the engagement. At this me. Patient: Well, in my mind I think I point, she became quite despondent Doctor: You believe he does love was testing him. and had a Series of hospitalizations. you?T3 Doctor: That’s an intriguing idea During one df these hospital stays she Patient: I do. It was so sudden . . . what would you be testing?17 became involved with an attendant When I try to kill myself, I ask why? I Patient: To see if he would say who eventually insisted that they stop have someone who loves me. “Don’t kill yourself, I love you too seeing each other. Two months prior Doctor: Even though you’re getting much.” Mike said that when I tried to to the interview she fell in love with along well with your boyfriend, you kill myself, and he meant it. another boy named Mike. A few days still want to kill yourself? Doctor: How did you feel when he before the interview she realized that Patient: Yes, I do. Saturday I tried said it and meant it? she was pregnant with Mike’s child. it. I took 20 pills. I was with him. I Patient: I felt hopeless. Now 1 kept falling asleep. Finally I had to tell couldn’t kill myself because I’d be him. He made me go to the hospital. hurting him ...... and my parents. Doctor: We have at least two sets of Doctor: Your thoughts, then, are problems to work on. First is your that maybe part of wanting to commit Interview concern about the pregnancy and sec­ suicide is getting proof that someone The following edited interview de­ ond your relationship with this man. loves you. tails some of the patient’s recent be­ How do you feel about him?T4 Patient: My mother loves me. havior. In addition, it contains infor­ Patient: I love him very much. Doctor: Is there any about mation on which a formulation was Doctor: But you don’t what her love? developed and the diagnosis of hysteri­ he says about his love for you.TS Patient: Oh no. She has always cal personality disorder was made. The Patient: When I first told him I was helped and supported me. She visited footnotes marked “T” are designed to pregnant he said we’ll have it and work me every day in the hospital. She describe interviewing technique. things out. Then after a while he said understands about the pregnancy. Doctor: Maybe we can try to figure he didn’t want the baby. He wants me Doctor: Do other people love you? out what is causing this trouble. Let’s to go into Boston and have an abor­ Patient: It’S no secret that my go back to your breaking up with the tion. It only takes a few minutes. We father and I don’t get along. My former boyfriend.11 That seems to don’t want to start with a baby. I father’s cold. He would not say hello have set off some of your . Is don’t want him to be trapped into to you if you twisted his arm. He’s out that right? marrying me because of the baby. of it completely. When he learned Patient: That’s when I started to go Doctor: What makes you hesitate about the pregnancy he said, “If I had in and out of the hospitals. to have the abortion? Is it because ruined a girl like that, my father would Doctor: Have you ever had any you’re afraid that you’ll lose him? have whipped me.” He thinks that I’m nervous problems or tension before Patient: I don’t know. I don’t ruined now, a ruined woman. My this last birthday?T2 know. It is kind of confusing. I was mother accepts it, but my father Patient: No. The day I turned 20 confused last Saturday when I took thinks I’m a ruined woman. was the day it all started. I’ll never the pills. Doctor: Tell me some more about forget that birthday as long as I live. Doctor: Do you often go into your father. He seems different than Doctor: Why did you break up with action like that? the rest of the family. your boyfriend? Patient: Oh yes. Last time I really Patient: My father? He works hard, Patient: Because I tried to commit felt angry - I have a brand new car — I that’s about the only thing I can say. suicide in front of him. He couldn’t took a big rock and threw it through He comes home from work and take it any longer. I don’t even know the windshield. I only had the car for watches TV. On weekends, he watches why I did it then. I had no good two days. TV. He never expresses . My reason . . . Then, when I broke up with Doctor: You really do go into mother and father don’t even sleep him I really wanted to do it. I really action.16 together. meant business. Before I was hoping Doctor: Has your mother ever tried An attempt to clarify her conscious to explain why they don’t share the assessment of this relationship. She believes that he ioves her but he will leave her same bed? T 4 . Exploring the onset of symptomatic be­ This patient presents m ultiple problems. Patient: My mother had a nervous havior can help the clinician to understand The clinician tries to sort them out. breakdown while she was carrying me. it. It is analogous to understanding a physi­ T 5 t .: ■ T h is IS an attem pt to underscore cal symptom like chest : When did it start? How? Where? etc. as a basic problem in her relationship with M ic h a e l. T 2 „ Testing seems to be a technique she An attem pt to confirm the date on which T 6 employs to attem pt to cope with her dis­ the symptoms began. This delineates her impulsiveness. tru s t.

5 7 4 THE JOURNAL OF FAM ILY PRACTICE, VOL. 4, NO. 3, 1977 •jhey were going to break up. But she would you feel about that?711 ness and sexual arose she felt jja(j me and they decided to stay Patient: I wouldn’t want to be close guilty. This was not consciously together because of me. That makes to him. recognized by the patient. She then me feel small. All their problems are Doctor: Why? tested the relationship and spoiled it because of me, because I was born.T8 Patient: I don’t know. I can’t make by trying to commit suicide in Doctor: That’s quite a burden.T9 myself. I would feel very uncomfort­ Steven’s presence. Patient: I didn’t ask to be born. able if he were to try to be close to When the patient gets into any type Doctor: Does your father love any­ me. of a therapeutic relationship, whether one else? it be with a psychiatrist or with a Patient: He loves my younger family physician, the doctor must be Formulation brother. He does things with him. aware of these dynamics or he is going They’re pretty close. It appears that the patient had a to fall into the same trap. As the Doctor: How does he feel about reasonably good home environment doctor and patient develop rapport, you? until she entered adolescence. She had she is going to feel a closeness in this Patient: He now thinks that I’m a been “Daddy’s little girl.” As she relationship. This closeness will then ruined woman. matured into a young lady there was become threatening. She will then feel Doctor: Does he think that, or is probably a resurgence of some natural compelled to break it up. The doctor that your interpretation of what he attraction between father and daugh­ must be prepared for this and realize thinks? His reaction to the pregnancy ter. There is a variable amount of that she will try to test him to see sounds to me more like an indictment sexuality involved in the relationship whether he will reject her as her against Mike than against you. Has between parent and child, particularly feelings of closeness develop. your father ever been close to you? between opposite sexes. This often This patient demonstrates the be­ Patient: Oh yes. When I was four or surfaces to a conscious level. There is havioral characteristics of the hys­ five he used to take me to the park all an intensification of these feelings at terical personality disorder: (1) his­ the time. He kept calling me “Daddy’s adolescence. trionic behavior, (2) emotional labil­ little girl.” Most people can handle these un­ ity, (3) dependency, (4) excitability, Doctor: When did that change? comfortable feelings well. In a healthy and (5) seductiveness. Histrionic be­ Patient: When I was about 14 or family these feelings of sexual attrac­ havior is characterized by dramatic, 15. That’s when I started having acci­ tion can be tolerated. An occasional theatrical gestures, with an air of dent after accident. I fell off a horse, I twinge of physical attraction does not artificial superiority aimed at gaining broke my toe, I had several car acci­ cause . However, this patient’s attention. Emotional lability is char­ dents, 1 stepped on a needle . . . one father seems to have a rigid sense of acterized by outbursts of laughter and accident after another, (laughter) right and wrong regarding sex, as crying; the individual may swing from Doctor: This all started when you manifested by his statement that “if I one to the other with minimal stimula­ were 15? ruined a girl my father would have tion. Excitability includes impulsive Patient: Yes. come after me with a whip.” behavior. The external environment Doctor: What brought that on? It appears that these feelings were produces an exaggerated emotional How could you be a careful person not tolerated in this patient’s family. response in these individuals. Seduc­ until age fifteen? One might conjecture that in order to tiveness represents a defense mech­ Patient: I don’t know. I’m still go on living together they reached a anism or means of reacting with those clumsy. parting of the ways. There could be no around her. Doctor: Is that when you and your more hugging and kissing and close­ father stopped being close?710 ness. This would be too threatening. Management of the Hysterical Person­ Patient: Yes, more or less when I This could account for the apparent ality Disorder in the Medical Setting was going into high school. separation that the patient so vividly Roger Peele and Stella Rubin7 offer Doctor: How did this distance de­ described at age 14. four general goals in the management velop? You were Daddy’s little girl for The subsequent series of accidents of hysterical personalities in a medical so many years. possibly represent a form of self- setting: (1) shift the patient’s emphasis Patient: We just came to the point induced punishment for feelings of on control of others to control of self; that he wouldn’t talk to me and I guilt that may have been evoked by (2) help her develop appropriate ways wouldn’t talk to him. I never tell him the unconscious attraction that the of communicating her needs; (3) avoid anything. I don’t talk to him and he patient had for her father. It is a iatrogenic drug abuse; and (4) reduce don’t talk to me. universal reaction that punishment dependency to an acceptable level. We Doctor: What if something were to alleviates guilt. offer some concrete suggestions for happen to make it possible for you to This mixture of attraction and guilt the family physician for achieving be close to your father again? How is then transferred to her relationships these goals. with other men. This could explain 1. Increase Self-Control The story of her origin is strikingly why she seemed compelled to behave similar to th a t o f h e r fe tu s . in a manner that destroyed her rela­ T9 To help this patient learn self- This is an attem pt to show some recogni­ tionship with Steve at a time when control, the physician himself must be tion of her fe e lin g o f g u ilt. things were at their best. When close- T10 the model of self-control. As closeness This was intended to clarify that her develops in the doctor-patient relation­ father had been close to her prior to her T l1 The physician explores the current bar early adolescence. riers to closeness. ship, the patient may feel uncomfort-

THE JOURNAL OF FAM ILY PRACTICE, VOL. 4, NO. 3, 1977 5 7 5 able and try to provoke the doctor tient develop appropriate ways for This must be done in a non threatening into rejecting her. The provocations communicating her needs by first of­ and nonconfronting way, always may well produce intense anger. The fering an example himself of clear and emphasizing and encouraging the ther physician must understand the origins accurate communication. He should be apeutic alliance. The goal is to have of his anger and remain steadfast in his explicit in his relationship and clearly the patient learn how to translate her willingness to maintain a neutral define the rules that he expects her to behavior into more appropriate verbal stance. abide by in dealing with himself and communication with those about her At a time of confrontation, the his office staff. It is sometimes highly productive to doctor might try to interpret this As an expression of her wish for ask the patient how she feels when she process to the patient. When the physi­ intimacy, this patient will usually try talks to the physician. How does she cian recognizes that the patient is to obtain more information about the imagine his reaction? What does she trying to arouse in him, he personal life of the physician than is wish or that his attitude might be’ can invite the patient to examine the appropriate. The physician must set If there is a significant male in the interaction. He can say, for example, limits for the amount of information patient’s life, the doctor might en­ “It might be well for us to look at about his personal life that he can her to try to communicate what is happening here.” Or, “Let’s share comfortably with the patient. At with him in a more meaningful fash­ try to understand what’s going on.” the same time he can invite the patient ion. This intervention should take into Or, “Perhaps we can figure out what to try to understand the attempt to account the anxiety which greater this might lead to.” The main idea is get the information. meaningfulness might evoke. If she can to present an attitude of observation The egocentric nature of the pa­ share her inner feelings with that in which both patient and clinician tient’s personality produces a great person, she may be more successful in cooperate. This sort of cooperative thirst for attention. The physician is controlling her behavior. If the family effort is known in psychiatry as the tempted to give this attention by physician also provides care for this therapeutic alliance. When the pa­ listening to her many unbelievable significant male (boyfriend, husband, tient’s cooperation has been enlisted — stories. This type of attention is coun­ etc), he might spend some time ex­ if only momentarily — the physician terproductive and encourages the pa­ plaining to him why the patient has can try to translate an inappropriate tient to continue inappropriate be­ such an intense thirst for proof that behavior into a verbal communication. havior. She may feel compelled be­ she is loved, why she is uncomfortable The clinician might ask, “What did tween visits to get involved in some with intimacy, and why she appears so you imagine would be my reaction untoward event so that she has some dependent on him. This information when you did what you just did?” material to give the physician. If this may help that person, as the patient “What did you wish I would feel (or pattern develops, the physician might and he try to improve their relation­ do, or say)?” “What did you fear I discourage her descriptions of bizarre ship. The physician must be careful might feel (or do, or say)?” behavior and encourage her to discuss not to breach the patient’s confiden­ The basic strategy is to add some the feelings that preceded this activity. tiality by first obtaining her informed distance, objectivity, and perspective The doctor can help the patient de­ permission to talk with the significant to the patient’s intense emotional ex­ velop ways for communicating ver­ other. perience. As the observational process bally rather than through inappro­ is emphasized, the patient comes to priate behavior or suicidal gestures. 3. Avoid Iatrogenic Drug Abuse recognize that manipulation, threats, The female with a hysterical per­ A very simple but important prin­ and other histrionic behaviors serve as sonality disorder may interact with the ciple is that the physician should a form of communication. The clini­ office staff in a manipulative manner. consistently and affirmatively avoid cian can then encourage the patient to By manipulative, we mean that the iatrogenic drug abuse. The patient may communicate by talking rather than patient attempts to evoke emotions or offer varied and multiple somatic com­ by acting. This change will take time. to provoke responses in a purposeful plaints. These symptoms often are A life-long pattern of adaptation is not way. Usually the patient is not con­ presented in an exaggerated and dra­ relinquished easily. The clinician must scious of that purpose, although it is matic manner. Dismissing the patient help the patient to see that talking is often obvious to the victim of the by writing a prescription can be anoth­ preferable and not unduly painful. At manipulation or to other observers. If er form of rejection. Multiple visits the same time he must demonstrate the physician and his staff understand and multiple prescriptions expose the that impulsive action is often damag­ that this manipulative behavior is part patient to the hazards of adverse drug ing, self-defeating, irreversible, dis­ of the emotional disorder, a successful reactions. honorable, and contrary to the pa­ manipulation might not evoke the Patients with hysterical personality tient’s ideals. The knowledgeable usual degree of anger. It will be pro­ disorders have been shown to be drug physician who is successful in this ductive for the physician to discuss the and alcohol addiction prone. Rather effort may demonstrate for the first patient’s behavior with the staff and to than freely using sedatives and tran­ time to the patient that she can encourage the staff to maintain a quilizers that have the potential for participate in a nonthreatening hetero­ mature, neutral stance in their encoun­ addiction, it is recommended that the sexual relationship. ters with the patient. The physician physician reserve the phenothiazines might, as described above, initiate an for severe anxiety, and the tricyclics open discussion with the patient of for marked . Use of any 2. Improve Communications what the patient was trying to accom­ medication should be made with ex­ The practitioner can help the pa­ plish with this inappropriate behavior. ceptional caution and parsimony.

576 THE JOURNAL OF FAMILY PRACTICE, VOL. 4, NO. 3, 1977 4, Reduce Dependency Conclusion peutic goal is a long-term one, which The physician may help the patient The case history, the “long inter­ the physician can work towards over reduce her dependency on people in view,” and the formulation are pre­ months or years as he provides con­ general by not allowing her to become sented in some detail. It is suggested tinued comprehensive medical care for too dependent on the physician. This that they be studied thoroughly by the the family unit. can be accomplished most effectively reader. When dealing with emotional through interpretation of the process. problems, there is no substitute for “How do you feel when you ask me to obtaining sufficient historical data in decide (do, prevent, advise) something making a reasonably accurate diag­ References for you?” “How do you feel when I nosis. It has been clearly demonstrated 1. Alarcon RD: and hysterical that this investment of time ultimately personality: How come one without the do it?” “How do you feel when I other? Psychiatr Q 47:258-275, 1973 don’t?” The clinician can encourage reduces the total demand on the 2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental the patient to take an active role in her health-care system made by patients Disorders, ed 3. Washington, DC, American own medical care. If the physician with emotional problems.8 Psychiatric Association, 1968 3. Luisada PV, Peele R, Pittard EA: The becomes involved in formal counsel­ The subsequent suggestions for hysterical personality in men. Am J Psychia­ managing the female with a hysterical try 131:518-522, 1974 ing, he must avoid the temptation to 4. Schmidt DD, Messner E: The role of give advice. He must avoid offering personality disorder include no men­ the fam ily physician in the crisis of impend­ tion of time. These are concrete guide­ ing divorce. J Fam Pract 2:99-102, 1975 reassurance about the future. The 5. Schmidt DD, Messner E: The manage­ physician will be more effective if he lines for physician and staff inter­ ment of ordinary . J Fam Pract 2:259-262, 1975 can get the patient to examine her action with such a patient in a tradi­ 6. Messner E, Schmidt DD: Videotape own behavior or to examine alterna­ tional medical setting. The develop­ in the training of medical students in psy­ chiatric aspects of family medicine. Int J tive possibilities and then reach her ment of a therapeutic alliance need Psychiatry Med 5: 269-273, 1974 own conclusion. When dealing with not extend the usual encounter more 7. Peele R, Rubin SI: The hysterical personality: Identifying and managing one issues of dependency, the patient can than a few minutes. The avoidance of of the problem patients of medical practice. anger and the satisfaction of helping South Med J 67:679-682, 1974 assume responsibility and receive some 8. Crawford JW, Crawford S: Psychiatry recognition even for minor changes in the patient grow in her ability to and group medical practice: The diagnostic interact with others compensate for process, referral patterns, and utilization of behavior that might help foster her services. Am J Psychiatry 130:637-642, sense of independence. the additional effort. The latter thera­ 1 9 7 3

THE JOURNAL OF FAM ILY PRACTICE, VOL. 4, NO. 3, 1977 5 7 7