Given that other people hold the key to survival in the world, histrionic patients tend to also hold the basic belief that it is necessary to be loved by everyone for everything one does. This leads to a very strong fear of rejection. Even entertaining the notion that rejection is possible is extremely threatening to these individuals, because this reminds the patient of his or her tenuous position in the world. Any indication of reje tion at all is devastating, even when the person doing the rejecting was not actually that important to the patient. Feeling inadequate yet desperate for approval as their only salvation, people with HPD cannot relax and leave the acquisition of approval to chance. Instead, they feel constant pressure to seek this attention in the ways they have learned are ef- fective, often by fulfilling an extreme of their sex-role stereotype. Female histrionics (as well as some of the males) seem to have been rewarded from an early age for cuteness, physical attractiveness, and charm rather than for competence or for any endeavor requiring systematic thought and planning. The more “macho” male histrionics have learned to play an extreme masculine role, being rewarded for virility, toughness, and power rather than interpersonal competence or problem-solving ability. Understandably, then, both male and female histrionics learn to focus attention on the playing of roles and “performing” for others.

People with a HPD view themselves as sociable, friendly, and agreeable, and, in fact, they are often perceived as very charming at the beginning of a relationship. However, as the relationship continues, the charm seems to wear thin and they gradually are seen as overly demanding and in need of constant reassurance. Given that being direct involves the risk of rejection, they often use more indirect approaches such as manipulation to try to gain attention but will resort to threats, coercion, temper tantrums, and suicide threats if more subtle methods seem to be failing.

Histrionic people are so concerned about eliciting external approval that they learn to value external events over their own internal experience. With so little focus on their own internal life, they are left without any clear sense of identity apart from other people and see themselves primarily in relation to others. In fact, their own internal experience can feel quite foreign and uncomfortable to them and at times they actively avoid self-knowledge, not knowing how to deal with it. Having some vague sense of the superficial nature of their feelings may also encourage them to shy away from true intimacy with another person for fear of being “found out.” Because they have paid little attention to their own in- ternal resources, they have no idea how to respond when depth is required in a relationship. Thus, their relationships tend to be very shallow, superficial, and based on role playing.