Journal of Psychopathology and Behavioral Assessment, Vol. 22, No.

2, 2000

Gender-Typed Behavioral Examples of Histrionic

Personality Disorder
June Sprock1,2
Accepted: February 2, 2000

Findings that clinicians diagnose Histrionic Personality Disorder more frequently in women may be due to the feminine gender weighting of the criteria
or because the diagnostic label elicits a feminine stereotype. Using a method
derived from the act-frequency approach, undergraduates generated behavioral examples of the DSM-IIIR and DSM-IV Histrionic criteria without
regard to sex or according to sex role instructions that elicited masculine or
feminine sex roles. A national sample of psychologists and psychiatrists rated
the representativeness of the symptoms for the Histrionic criteria or for
Histrionic Personality Disorder. Feminine behaviors were rated more representative of Histrionic Personality Disorder and somewhat more representative of the Histrionic criteria than masculine behaviors suggesting that the
feminine sex role is more strongly associated with the label than the criteria.
Masculine behaviors were also rated less representative than sex-unspecified
examples. Results provide a possible explanation for the higher rates of
diagnosis of Histrionic Personality Disorder in women.
KEY WORDS: histrionic personality disorder; sex bias; personality disorders; diagnostic bias.

INTRODUCTION
Kaplan (1983) asserted there is sex bias in the DSM-III (APA, 1980)
criteria for Histrionic Personality Disorder (HPD) because HPD is diag1

Indiana State University.

To whom correspondence should be addressed at Department of Psychology, Indiana State
University, Terre Haute, Indiana 47809.

107
0882-2689/00/0600-0107$18.00/0 2000 Plenum Publishing Corporation

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nosed more often in women and the criteria are based on a feminine
stereotype. However, differential rate of diagnosis does not necessarily
suggest bias and may reflect actual differences in the prevalence of the
disorder. In addition, even if sex bias does exist, the source of bias may reside
in the clinicians assessment rather than the diagnostic criteria (Widiger &
Spitzer, 1991). It is important to differentiate between potential sources of
bias which can occur independently, be confused with, or interact with each
other (Widiger, 1998).
Several studies have demonstrated clinician sex bias in the diagnosis
of HPD by manipulating the sex of a patient in a case history while holding
the rest of the information constant (e.g., Ford & Widiger, 1989; Hamilton,
Rothbart, & Dawes, 1986; Warner, 1978). For example, Ford and Widiger
(1989) found that clinicians were influenced by patient sex when rating the
applicability of Histrionic personality disorder to a case. However, they
failed to find evidence of sex bias when the clinicians were asked to make
judgments about the presence of individual Histrionic criteria. They concluded that sex bias was associated with the diagnostic label (i.e., clinicians
associate Histrionic Personality Disorder with being female) rather than
the diagnostic criteria. More recently, Funtowicz and Widiger (1995, 1999)
examined evidence for sex bias in the diagnostic criteria for personality
disorders based on the level of dysfunction required for a diagnosis. They
found that the threshold for diagnosing personality disorders more frequently diagnosed in women (including HPD) was no lower than for personality disorders diagnosed more often in men, providing little evidence for
a bias against women in the diagnostic criteria.
However, there is considerable support for the contention that the
construct of Histrionic personality disorder is consistent with a feminine
stereotype. Two studies conducted with undergraduate participants (Landrine, 1989; Rienzi & Scrams, 1991) found that a sex-unspecified case
representing HPD was predicted to be about a woman suggesting that it
elicited a sex-specific stereotype. Sprock, Blashfield and Smith (1990) found
that undergraduates who sorted the DSM-IIIR (APA, 1987) personality
disorder criteria on a continuum from masculine to feminine rated the
HPD criteria as feminine. While they did not conclude that their results
demonstrated sex bias in the criteria, they suggested that the HPD criteria
had a feminine gender weighting.
Further, men and women may manifest symptoms of HPD differently
(e.g., Bornstein, 1999). These differences would affect the likelihood of
HPD being assigned if the symptom presentations differ in representativeness for the diagnostic criteria or for the diagnosis. For example, the expression of Histrionic tendencies in men may be more indirect (Bornstein,
1999), manifested through antisocial behaviors (Hamburger, Lilienfeld, &

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109

Hogben, 1996), and therefore less representative. If so, more women may
be diagnosed with HPD because their symptom presentations are more
prototypic. Also, feminine sex-typed behaviors are more consistent with
the gender weighting of the Histrionic criteria (i.e., Sprock et al., 1990).
Moreover, behaviors consistent with a feminine sex role may be more likely
to invoke the sex-typed stereotype associated with the diagnostic label (i.e.,
Ford & Widiger, 1989).
The purpose of this study was to examine the representativeness of
sex-typed behavioral examples of HPD symptoms at the criterion level and
at the diagnostic level in order to better understand how sex bias associated
with Histrionic Personality Disorder might occur. The methodology was
derived from Buss and Craiks (1983) act-frequency approach in which
specific behavioral descriptions (acts) are used to exemplify personality
traits or dispositions. Personality disorders are viewed as syndromes of
dispositions, which are categories of acts, and are related to everyday dispositions and behaviors (Buss & Craik, 1986, 1987). The act-frequency approach starts with the nomination of acts for a set of dispositions associated
with a construct or set of constructs; typically, undergraduates are asked
to list specific acts (behavioral examples) that exemplify the dispositions.
The resulting lists of acts are then evaluated by panels of experts for their
prototypicality for the dispositions and/or the constructs (Buss & Craik,
1985). Buss and Craik (1987) suggested the act-frequency approach as a
systematic way to investigate the conceptual basis of personality disorders;
acts could be nominated for the traits or the diagnostic criteria associated
with the disorders followed by prototypicality ratings to identify representative acts and the structure of the concepts. For example, Shopshire and
Craik (1996) had undergraduates generate specific behavioral descriptions
for three personality disorders including HPD. Then, clinical psychologists
and nonclinicians rated the prototypicality of the acts for the personality
disorders or for everyday dispositions, respectively.
In the present study, specific behavioral examples were generated for
the criteria for HPD but sex-role instructions were used to elicit sex-typed
behavioral examples of how they might be manifested by men and women
in everyday behaviors. Undergraduates in separate instruction conditions
were asked to list masculine, feminine, or sex-unspecified behavioral examples for the DSM-IIIR (APA, 1987) and DSM-IV (APA, 1994) criteria for
HPD. Then, a national sample of clinical psychologists and psychiatrists
rated the prototypicality of the behaviors; half rated the representativeness
of the behaviors for the specific Histrionic criterion for which they were
listed and half rated the representativeness of the behaviors for the construct
of Histrionic Personality Disorder overall. It was expected that feminine
behaviors would be rated as better examples of the criteria than masculine

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behavioral examples due to the feminine gender weighting of the criteria

(i.e., Sprock et al., 1990), and much better examples of the construct of
HPD since the diagnostic label may more strongly invoke a feminine sex
role stereotype (i.e., Ford & Widiger, 1989).

METHOD
Participants
The behavioral examples were generated by 120 undergraduate students (60 females, 60 males) enrolled in an introductory psychology course
at a medium sized university in the Midwest. Nearly all participants were in
their first or second year of college. For most, this was their first psychology
course. In the course, they were introduced to abnormal psychology but
not the specific diagnostic criteria for personality disorders.
A national sample of 300 psychiatrists and 300 clinical psychologists were
asked to rate the prototypicality of the behaviors. Names were randomly
selected from the directories of the American Psychiatric Association and
the American Psychological Association (Clinical Division). A total of 157
mental health professionals (58 psychiatrists, 97 psychologists, 1 dually credentialed, 1 who failed to identify profession) returned completed protocols
(return rate of 26.2% overall; 19.5% for psychiatrists; 32.5% for psychologists). Most were male (69.4%), Caucasian (88.5%), and they had an average
age of 49.8 years (SD 10.8). Overall, they were quite experienced with an
average of 19.2 years (SD 11.7) post-degree experience and an average of
72.9% (SD 30.6) of their time spent in clinical activities. More than half
(60.3%) were in full-time clinical practice and their most frequent employment setting was private practice (54.0%). Most (83.3%) reported that at least
half of their practice is with adults. There were no statistically significant differences in characteristics between the group assigned to rate the representativeness of the behaviors for the HPD criteria (n 82) and those asked to
rate the prototypicality of the behaviors for HPD (n 75).

Procedure
In part 1, the undergraduate participants were asked to list three
behavioral examples for each of the Histrionic criteria. A total of ten criteria
were used: the eight criteria in the DSM-IIIR plus the two new criteria in
the DSM-IV. Six of the criteria in the DSM-IIIR and DSM-IV were judged
to be the same or similar in content but reworded. One third (20 males,

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111

20 females) were assigned to each of the three instruction conditions: masculine instruction condition (asked to list three behavioral examples of each
HPD criterion that would be typical for males), feminine instruction condition (asked to list three behavioral examples for each criterion that would
be typical for females), or sex-unspecified instruction condition (asked to
list three behaviors per criterion). The instructions and one of the DSMIIIR or DSM-IV criteria for Histrionic Personality Disorder appeared at
the top of each page and the criteria were presented in random order.
Instructions were also presented orally, testing was done in small groups,
and there was no time limit for completion of the task. Participants received
extra credit in their introductory psychology course.
The individual lists were consolidated to yield a list of behaviors for
each HPD criterion by combining identical behaviors and synonyms. In
addition, behaviors were eliminated if they were judged to be irrelevant
or were traits rather than behaviors. Six doctoral students in clinical psychology and the author served as judges and independently edited and collapsed
the lists in order to maximize reliability. Disagreements between the lists
were discussed afterwards and resolved. Generally, a conservative approach
was adopted (i.e., leaving behaviors on the list, not combining behaviors)
when there was disagreement between the judges. All of the behaviors
were worded to be gender neutral (i.e., no pronouns or both masculine and
feminine pronouns) so that the clinicians would not simply be responding to
the sex identified by the pronoun. However, some of the behaviors clearly
represented sex-typed behaviors (e.g., wears excessive makeup). There was
no restriction on behaviors being listed for more than one criterion, and there
was considerable overlap in the behaviors listed for the different HPD criteria. The final lists of behaviors contained between 29 and 66 behaviors for
the Histrionic criteria (mean 41.5, median 40, total 415).
There was also a high degree of overlap between behaviors generated
in the three sex role instruction conditions. Therefore, a decision needed
to be made about how to handle behaviors that were listed in two or more
conditions. Behaviors were considered masculine if they were listed in the
masculine or in both the masculine and the sex-unspecified condition, but
not if they were also listed in the feminine condition. Behaviors were
considered feminine if they were generated in the feminine or in both the
feminine and the sex-unspecified condition, but not if they were also listed
by participants in the masculine condition. All other behaviors were considered not sex-typed including those listed in the sex-unspecified condition,
those listed in both the masculine and the feminine condition, and those
listed by participants in all three conditions.
In part 2, psychologists and psychiatrists received a letter requesting
their participation along with the list of behaviors to be rated and a demo-

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graphic and professional experience questionnaire. A pre-addressed

stamped envelope was included to return the materials. The mailings proceeded in two stages: DSM-IIIR based behaviors and ratings, DSM-IV
based behaviors and ratings. Half of the psychologists (n 150) and half
of the psychiatrists (n 150) were randomly assigned to the group asked
to rate the representativeness of the behaviors for the HPD diagnostic
criteria; the remaining half were asked to rate how well the behaviors
represented the construct of HPD. Participants in both rating conditions
received a subset (approximately one tenth) of the total list of behaviors.
Clinicians assigned to rate the representativeness of the behaviors for the
diagnostic criteria received all behaviors listed for one of the HPD criteria
and were asked to rate how good an example the behaviors were for that
criterion. Clinicians assigned to rate the prototypicality of the behaviors
for HPD received a subset of behaviors from the lists across Histrionic
criteria and were asked to rate how good an example the behaviors were
for Histrionic Personality Disorder. Clinicians were free to use their own
conceptualization of Histrionic Personality Disorder; they were not instructed to use a definition based on either the DSM-IIIR or DSM-IV. For
both groups, the 7-point rating scale (1 not a good example to 7
excellent example) and the instructions appeared at the top of the page.
Behaviors were presented in a pre-determined random order. A reminder
postcard was mailed to them approximately two weeks after the initial
mailing of materials.

RESULTS
Means for the criteria ratings and for the HPD ratings were calculated
for each of the behaviors individually as well as across behaviors. Paired
sample t-tests were used to compare ratings of the behaviors as examples
of the HPD criteria and as examples of the diagnosis of HPD. Univariate
and multivariate analysis of variance was used to compare ratings of the
behaviors based on their categorization according to sex role (i.e., masculine, feminine, not sex-typed).
There was a small but statistically significant difference in the representativeness ratings of the behaviors as examples of the HPD criteria according to their sex role type, F(2,413) 3.116, p .045, .12. Masculine
behaviors were rated as significantly poorer examples of the HPD criteria
than non-sex-typed and feminine (trend) behaviors. Likewise, ratings of
the representativeness of the behaviors for the construct of HPD differed
significantly based on sex role, F(2,413) 4.095, p .017, .14. Feminine
behaviors and non-sex-typed behaviors were rated as better examples of

Histrionic Personality Disorder

113

HPD than masculine behavioral examples. When the analysis was repeated
eliminating behaviors that were poor examples of the HPD criteria (i.e.,
mean rating of less than 3.0 on the 7-point scale), the difference in representativeness ratings for HPD was greater, F(2,361) 8.251, p .001, .21.
Feminine and non-sex-typed behaviors were rated much better examples
of HPD than masculine behaviors. There were no statistically significant
interactions between sex role and criterion (i.e., which HPD criterion the
behaviors were listed for) for either the criteria ratings or the HPD ratings.
Pearson correlation revealed a small but statistically significant relationship between the two types of ratings (i.e., ratings of the behaviors as
examples of the HPD criteria and as examples of HPD), r .294, p
.001. Overall, the behaviors were rated as better examples of their respective
HPD criterion than as examples of HPD, t 2.65, df 415, p .008, r
.13. There was also a significant difference in the criteria ratings, F(9,386)
7.916, p .001, .39, and the HPD ratings, F(9,386) 6.441, p
.001, .36, based on the criterion for which the behaviors were listed.
That is, the behaviors listed for some HPD criteria were rated as better
examples of their respective HPD criterion than were the behaviors listed
for other HPD criteria (i.e., the students listed better examples for some
criteria than for others). Additionally, the behaviors listed for some HPD
criteria were rated more representative of HPD (i.e., the behavioral examples for some criteria were more representative of the overall construct of
HPD). However, there was not a statistically significant interaction between
criterion and type of rating. Also, behaviors that were listed by undergraduates in all three instruction conditions were rated significantly better examples of their respective HPD criterion than those listed by participants in
only one or two instruction conditions, F(2,412) 9.184, p .001,
.21; however, they were not rated as better examples of HPD.
Table I presents the behaviors rated most representative of each of
the HPD criteria (mean of 5.5 or higher on the 7-point scale). In general,
behaviors rated as good examples of the HPD criteria tended to be those
that were feminine (i.e., generated in the feminine or both the feminine
and sex-unspecified instruction condition) or not sex-typed (i.e., generated
in the sex-unspecified, both masculine and feminine, or all three conditions).
Highly prototypic examples (mean of 6.0 or higher) were not found for
four criteria (2, 3, 5, and 6) and one criterion (7) failed to have any behaviors
rated as good examples.
Table II presents the behaviors rated most representative of HPD
(mean of 5.5 or higher on the 7-point scale). The table is divided into three
prototypes based on sex role: feminine, masculine, and non-sex-typed. The
feminine prototype consisted of six highly prototypic examples (mean of
6.0 or higher) plus another 11 behaviors rated as good examples, with many

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Table I. Behavioral Examples Rated Most Representative of Each Histrionic Personality

Disorder Criterion a: Means b, Instruction Condition c and Behavioral Examples
Criterion 1: Is uncomfortable if not the center of attention
6.00
M
Starts fights or arguments to get attention
5.83
F
Uses vulgar language to get attention
5.83
FN
Acts obnoxious to get attention
5.67
MF
Shows off or brags to get attention*
5.67
MFN
Leaves the situation when not the center of attention
5.50
MN
Acts childish or immature to get attention*
Criterion 2: Is inappropriately sexually seductive or provocative
5.83
F
Tries to seduce members of the opposite sex
5.83
MFN
Hangs all over members of the opposite sex
5.67
N
Forward in talking to members of the opposite sex*
5.67
MN
Makes sexual innuendos or suggestive remarks to members of
the opposite sex*
Criterion 3: Displays rapidly shifting and shallow emotions
5.89
MF
Says he/she hates you one minute, is your best friend the next
5.56
MF
Loving one minute, cold the next, e.g., cold after sex
Criterion 4: Consistently uses physical appearance/Overly concerned with physical attractiveness
6.14
F
Gets very upset by comments on his/her appearance
6.14
N
Grooms constantlyalways checks his/her hair or makeup
6.00
MFN
Always looks at him/herself in the mirror
5.86
F
Has plastic surgery
5.86
MN
Always asks if others approve of his/her appearance
5.57
M
Changes outfits many times
5.57
N
Always asks if makeup is okay
Criterion 5: Style of speech that is excessively impressionistic
5.86
MN
Is vague, general, not specific in what he/she says
Criterion 6: Self-dramatization, theatricality, exaggerated expression of emotion/Expresses
emotion with inappropriate exaggeration
5.56
F
Damages someones property when angry or upset
5.56
F
Tells other not to touch him/her when upset
5.56
N
Jumps up and down when excited
5.56
MN
Hits things (inanimate objects) when angry
Criterion 7: Is suggestible
None
Criterion 8: Considers relationships more intimate
6.14
FN
Physically clings or hangs all over others
6.14
MFN
Gets angry or jealous if a person he/she likes interacts with
members of the opposite sex*
6.00
N
Gets angry or jealous if a person he/she likes does not spend
time with him/her*
5.86
M
Does everything he/she can to maintain a relationship including
use of force or coercion
5.86
F
Quickly starts referring to himself/herself and another person
as we
5.86
MFN
Gets angry or upset if a person he/she likes does not call
5.71
F
Asks do you love me? excessively in a relationship
5.71
F
Tries to control a person in a relationship (e.g., insists they do
things together)
5.71
FN
Insists on holding hands with others
5.71
MFN
Starts talking about commitment (e.g., best friends, going steady,
marriage) early in a relationship

Histrionic Personality Disorder

115
Table I. (Continued)

5.71
MFN
Touches and makes physical contact with others excessively*
5.57
F
Asks for a commitment early in a relationship
5.57
F
Insists on sitting overly close to others
5.57
MN
Exaggerates about the level of intimacy in a relationship*
DSM-IIIR Criterion 1: Constantly seeks or demands reassurance, approval, or praise
6.70
MFN
Repeatedly asks if he/she did a good job
6.30
F
Always asks others if they love or care for him/her
6.20
MF
Always asks if others approve of his/her actions
5.90
MFN
Always tries to do things to please others
5.90
MF
Always asks if others approve of his/her appearance
5.70
FN
Always asks if others approve of his/her clothes
DSM-IIIR Criterion 7: Is self-centered
6.33
MFN
Insists on getting his/her way*
6.08
MFN
Is impatient, wont wait
6.00
MFN
Does not show caring, empathy or consideration for others or
their feelings
5.92
N
Is impulsive, does not think of consequences or plan ahead
5.83
MFN
Uses or hurts people to get what he/she wants
5.75
M
Insists that he/she is always right
5.75
F
Uses dirty tricks to get his/her own way
5.67
FN
Only does things for his/her benefit
5.58
M
Takes things that arent his/hers without asking
5.58
M
Expresses insincere feelings in order to get sex
5.50
MF
Lies to get his/her way
a

DSM-IV and DSM-IIIR criteria are paraphrased and combined for criteria 1 through 6.
Behaviors with means of 5.5 or higher on the 7-point scale. Means of 6.0 or higher are in bold.
c
Instruction condition(s) for which the behaviors were listed in part 1: M masculine, F
feminine, N sex-unspecified.
*Also rated as a good example of HPD overall.
b

coming from criterion 6. In contrast, the masculine prototype included only

two highly prototypic examples plus another 10 good examples, mostly
from criterion 1 and criterion 6. The non-sex-typed prototype consisted of
23 behaviors with 8 highly representative examples.
Behaviors rated as prototypic of the HPD criteria were not necessarily
viewed as prototypic of Histrionic Personality Disorder; only nine of the behaviors rated as a good example of an HPD criterion were also rated good
examples of HPD. Also, most of the prototypic behaviors for HPD were
generated as examples of criterion 6 (self-dramatization, theatricality, and
exaggerated expression of emotion), 1 (uncomfortable if not the center of
attention), or 8 (considers relationships more intimate). None came from
criterion 4 (consistently uses physical appearance), and only one each came
from criterion 3 (displays rapidly shifting and shallow emotions) or criterion
7 (is suggestible).
DISCUSSION
Feminine behavioral examples of Histrionic Personality Disorder were
rated as somewhat better examples of the HPD criteria and as more repre-

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Table II. Behavioral Examples Rated Most Representative of Histrionic Personality Disorder:
Feminine, Masculine and Non-Sex-Typed Prototypes
Meana

Instructionb
Condition

Feminine Prototype
6.57
FN
6.45
F
6.13
F
6.11
F
6.00
FN
6.00
F
5.89
F

Criterionc

Behavior

6
1
R7
R7
R1
R7
6

Talks dramatically
Flirts to get attention
Says or does anything to get attention
Pouts to get what he/she wants
Talks a lot to get attention
Flirts with others
Screams to embarrass others when angry or
upset
Gets excited frequently or easily
Rejoices over minor things
Gets upset when he/she does not receive
praise
Acts as if in love with someone he/she
barely knows
Loses control of emotions
Flirts
Shows off or brags
Frequently talks about someone he/she likes
Is overly affectionate toward others
Uses suggestive body movements

5.88
5.71
5.71

FN
F
F

6
6
R1

5.63

FN

5.63
F
5.57
F
5.57
FN
5.56
F
5.50
F
5.50
FN
Masculine Prototype
6.25
M

6
6
6
8
8
2
1

6.17

MN

5.89
5.88

MN
MN

1
2

5.75

5.63
5.60

M
M

6
1

5.57
5.56

M
M

6
6

5.56
M
5.50
M
5.50
M
Non-Sex-Typed Prototype
6.14
N
6.14
MF
6.13
MFN
6.11
N
6.00
N

6
3
8
5
1
6
6
2

6.00

6.00

MFN

Exaggerates emotions in order to get attention

Exaggerates about the level of intimacy in a
relationship*
Acts childish or immature to get attention*
Makes sexual innuendos or suggestive remarks to members of the opposite sex*
Entertains others, tries to be the life of the
party
Over-exaggerates verbs when speaking
Starts talking to others when not the center
of attention
Tries to be best friends with everyone
When upset tells others he/she does not
want to see them
Acts overly nice
Changes friends to get what he/she needs
Shows up unannounced
Exaggerates
Shows off or brags to get attention*
Shows exaggerated facial expressions
Screams when excited
Forward in talking to members of the opposite sex*
Gets angry or jealous if a person he/she
likes does not spend time with him/her*
Embellishes or exaggerates facts

Histrionic Personality Disorder

117

Table II. (Continued)

6.00

MFN

5.89
5.89

N
MF

5
6

5.89
5.89
5.88
5.86
5.80
5.78
5.75
5.64
5.60
5.56
5.56

MFN
MFN
N
MFN
MF
MFN
MFN
N
MFN
N
N

7
R7
1
2
6
6
1
6
2
6
8

5.56

MFN

5.50

Gets angry or jealous if a person he/she likes

interacts with members of the opposite sex*
Is overly emotional in his/her speech
Cries to get attention or to get what he/she
wants
Changes opinions frequently
Insists on getting his/her way*
Laughs excessively to get attention
Dresses suggestively, seductively
Tells stories
Cries frequently or easily
Talks a lot to get attention
Slams doors
Flirts with members of the opposite sex
Gives dirty looks when angry or upset
Frequently says that he/she is in love with
someone
Touches and makes physical contact with others excessively*
Makes plans for himself/herself and another
person without consulting that person

Behaviors with a mean of 5.5 or higher on the 7-point rating scale were included. Means of
6.0 or higher are in bold.
b
Instruction condition(s) for which the behaviors were listed in part 1: M masculine, F
feminine, N gender unspecified
c
The two DSM-IIIR criteria not included in the DSM-IV are as follows: R1 DSM-IIIR
criterion 1; R7 DSM-IIIR criterion 7.
*Also rated as a good example of its respective HPD criterion.

sentative of the construct of HPD overall than masculine behavioral examples. These differences, albeit small, were statistically significant and may
be due to the feminine gender weighting of the HPD criteria (Sprock et al.,
1990). In addition, results support Ford and Widigers (1989) contention
that the feminine sex role stereotype is more strongly associated with the
diagnostic label than the criteria. If feminine behaviors are seen as better
examples of the HPD criteria and the construct of HPD, there is an increased likelihood of the diagnosis being assigned to women. It is important
to point out that behaviors that were not sex-typed (i.e., listed in the sexunspecified, both masculine and feminine, or all three instruction conditions) were rated as highly as feminine behaviors. A more accurate interpretation may be that masculine behaviors are seen as less representative of
the HPD criteria and particularly of the construct of Histrionic Personality
Disorder. Alternatively, undergraduates may have had difficulty generating
as good examples of the criteria that reflected a masculine sex role because
of the feminine gender weighting of the criteria; however, this explanation
still suggests difficulties in applying the HPD criteria to behaviors likely to
be seen more often in men.

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The pattern of ratings also may provide some insight into how clinicians
view Histrionic Personality Disorder. Based on the high frequency of the
behaviors in the prototypes, some of the criteria (i.e., 6: dramatization,
theatricality, exaggerated emotion; 1: is uncomfortable unless the center
of attention; 8: considers relationships more intimate) appear to reflect core
symptoms of the disorder. Interestingly, several behaviors representing the
DSM-IIIR criterion, is self-centered, which is no longer part of the DSM-IV
criteria for HPD were rated as very representative of the diagnosis. The
deletion of this criterion does not mean that self-centered behaviors are
not seen with HPD; its specificity was poor (Pfohl, 1991) and many of
the revisions to the personality disorder criteria were made to maximize
distinctiveness and reduce overlap with other categories. Few behavioral
examples for criterion 3 (rapidly shifting and shallow affect) or criterion 7
(is suggestible), and none for criterion 4 (uses physical appearance), were
rated as prototypic of HPD. Conclusions regarding the prototypicality of
specific criteria should be viewed with caution, however, due to the considerable overlap of behaviors listed for different criteria (e.g., some variant of
flirting was listed for criteria 1, 2, and 6 and DSM-IIIR criterion 7). This
overlap may have occurred because the criteria consist of a combination
of trait and behaviorally based descriptions reflecting features that are not
necessarily independent constructs. Also, the behavioral examples generated for some criteria may have been poor (e.g., the behaviors listed for
criteria 3 and 7 had low mean ratings as examples of the criteria) which
may have affected their ratings for representativeness for the diagnostic
construct overall.
Undergraduates may have had difficulty generating good examples of
some criteria because of lack of familiarity with the features being described.
For example, the failure to find any prototypic behaviors for criterion 7
may have resulted from their failure to understand the meaning of suggestibility. Also, the behaviors listed were less specific than is typical for
research using the act-frequency approach, perhaps due to differences in
the instructions (i.e., they were asked to think of a category of individuals
rather than a particular person). Moreover, the undergraduate participants
were not told that the symptoms represented the criteria for HPD. Everyday
behavioral examples may not adequately reflect how the features would
be manifested in the context of a clinical diagnosis of HPD. For example,
Shopshire and Craik (1996) found that everyday dispositional constructs
could be used to represent personality disorders, but their associated behavioral examples were not necessarily prototypic of the personality disorder.
In the present study, few behaviors rated as good examples of the
HPD criteria were considered prototypic of HPD, suggesting that additional
meaning is conveyed by the diagnostic label beyond the meaning of individ-

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ual criteria. For example, the differences between masculine and feminine
sex-typed behavioral examples were greater for the representativeness ratings of the behaviors for the diagnosis of HPD than for their representativeness for the HPD criteria. Also, behaviors listed in all three instruction
conditions were rated as more prototypic of the HPD criteria than those
listed in one or two conditions (probably because prototypic examples are
more likely to be listed by more participants), but they were not necessarily
rated more representative of HPD. Because information is lost when symptoms are viewed out of the broader context of the diagnosis, the prototypic
behavioral examples of HPD are probably more meaningful than the behaviors rated as good examples of the individual criteria.
Limitations of this study include the sample size and generalizability
of the results. First, although differences in the prototypicality ratings for
masculine, feminine, and non-sex-typed behaviors were statistically significant due to the large number of behaviors that were rated, the size of the
differences was small. In addition, while the overall sample was moderate,
each behavior was rated by only a subset of the participants (approximately
one tenth) to lessen the time demand on the professionals. Therefore,
statistical analyses focused on grouped behavior, and the means for individual behaviors should be viewed with caution. The small number of raters
for each behavior also precluded multivariate analyses (e.g., principal component or cluster analysis) which would have allowed for identification of
the underlying factors or clusters of the prototypic behaviors. However,
certain behaviors (i.e., flirting, exaggerating, showing off) appeared repeatedly on the lists of prototypic behaviors (i.e., there was no restriction on
behaviors being listed for more than one HPD criterion and different
professionals rated each of the lists) suggesting that they may be highly
prototypic behaviors that are representative of some of the core behavioral
features of HPD.
The return rate was higher for psychologists than psychiatrists and the
majority of clinicians who participated were white males. Although some
studies have found sex differences in the diagnosis of personality disorders
(e.g., Loring & Powell, 1988; Morey & Ochoa, 1989), the majority of studies
have failed to show that clinician sex affects the evaluation of personality
disorder diagnoses and symptoms (Funtowicz & Widiger, 1999; Widiger,
1998). However, the ratings and conceptualization of HPD of those who
completed the study may have differed in some systematic way from those
who did not return the materials. Information on clinicians who did not
return the materials was not available for statistical comparison with those
who chose to participate. It is also important to remember that these results
reflect the views of clinicians and may differ from behaviors seen in actual
patients with HPD.

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The decision to combine similar DSM-IIIR and DSM-IV criteria that

had been reworded may be a threat to the internal validity of the study,
particularly for the criteria ratings. Even relatively minor changes can have
a significant effect on prevalence (e.g., Blashfield, Blum, & Pfohl, 1992)
and may subtly influence the definition of the construct. Further, because
the data were collected in two stages, perceptions of the diagnosis may
have shifted with time and the introduction of the DSM-IV criteria.
A final caution concerns the interpretation of the behaviors listed
in the sex-unspecified condition. While the intent of the sex-unspecified
condition was to obtain behaviors that were neutral with regard to sex
roles, it is likely that the undergraduates thought of specific individuals as
they came up with behavioral examples for the criteria. If so, the examples
may not have been sex role neutral; however, if there was an equal probability of recalling male and female examples, neither sex role would be represented by the behaviors. A people male bias has been suggested as a
consequence of the use of masculine pronouns to refer to the generic case
(Hamilton, 1991; Merrit & Kok, 1995). According to this hypothesis, in the
absence of contradictory information (i.e., the sex-unspecified condition),
an image of a male person would be more likely to be invoked. However,
if the Histrionic criteria reflect a feminine stereotype, as has been suggested,
then the undergraduates would have been more likely to think of behavioral
examples from women, and the sex-unspecified behaviors might actually
tend to reflect feminine behaviors. Although the latter may be more likely,
in either case, the behaviors generated in the sex-unspecified condition
cannot be assumed to be entirely free of the influence of sex roles. Thus,
the categorization of the behaviors (e.g., behaviors generated in both the
masculine and the sex-unspecified conditions were considered masculine)
could be called into question, and there is the possibility that some of the
behaviors listed in the non-sex-typed prototype may not be sex role neutral.
Despite some cautions in interpretation, results suggest that Histrionic
Personality Disorder is more consistent with feminine than masculine sex
role behaviors. Thus, feminine sex-typed behaviors are likely to be viewed
as more characteristic of the disorder while masculine sex-typed behaviors
are seen as less typical. As a result, masculine behavioral examples are less
likely to lead to a diagnosis of HPD. These findings raise the possibility
that underdiagnosis in men, instead of or in conjunction with overdiagnosis
in women, may help explain the higher rates of diagnosis of HPD for women.
One way to assist clinicians in identifying HPD in men, as well as
women, might be to include more specific behavioral examples in the criteria, particularly masculine behavioral examples. Although this recommendation has been suggested previously as a way to correct sex bias, it is not
necessarily desirable (Widiger, 1998). Even though the behaviors used could

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be those rated highly prototypic of HPD, inclusion of masculine behaviors

might result in a subtle shift in the meaning of the construct. Another
possibility would be to include behavioral examples which are equally
applicable to men and women. Non-sex-typed behaviors (prototypic behaviors listed in both the masculine and feminine conditions or all three instruction conditions) might provide the most balanced examples of the disorder.
Finally, it is not clear that having a diagnostic system completely free
of gender weighted constructs is the ultimate goal. Traits representative of
HPD and other personality disorders are found in everyday dispositional
constructs which are reflected by everyday behaviors (i.e., Shopshire &
Craik, 1996). It is likely that many of these everyday dispositions and
behaviors also have gender loadings. A classification of personality disorders should describe maladaptive personality constructs as they actually
occur. While the criteria should not contribute to misdiagnosis (overdiagnosis or underdiagnosis) in one sex or the other through the inclusion
of sex role behaviors that are not part of the diagnostic constructs, it
does not seem reasonable to remove the contribution of sex role if that
component reflects core aspects of the constructs and its removal results
in a change in their meanings.

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