The Histrionic Patient - A Case Study

Notes of first therapy session with Marsha, female, 56, diagnosed with Histrionic Personality Disorder

Marsha visibly resents the fact that I have had to pay attention to another patient (an emergency) "at her expense" as she puts it. She pouts and bats suspiciously long eyelashes at me: "Has any of your female patients fallen in love with you?" - she suddenly changes tack. I explain to her what is transference and countertransference in therapy. She laughs throatily and shakes loose an acid blond mane: "You may call it what you want, doctor, but the simple truth is that you are irresistibly cute."

I steer away from these treacherous waters by asking her about her marriage. She sighs and her face contort, on the verge of tears: "I hate what's been happening to Doug and me. He has had such a stretch of bad luck - my heart goes out to him. I really love him you know. I miss what we used to be. But his rage attacks and jealousy are driving me away. I feel that I am suffocating."

Is he a possessive paranoid? She shifts uneasily in her seat: "I like to flirt. A little flirting never hurt nobody is what I say." Does Doug share her insouciance? He accuses her of being too provocative and seductive. Well, is she? "A woman can never be too much of either" - she protests mockingly.

Has she ever cheated on her husband? Never. So, why his jealous tantrums? Because she has been pretty direct with men she fancied, told them what she would do with them and to them if circumstances were different. Was this a wise thing to do in public? Maybe not the wisest, but it sure was fun, she laughs.

How did men react to her advances? "Usually, with an enormous erection." - she chuckles - "How did you react, doctor?" I was embarrassed, I admit, even annoyed. She doesn't believe me, she says. No red-blooded male has ever been put off by the lure of an attractive female and "from where I sit, you sure look as red-blooded as they come."

Doug has been her fourth serious relationship this year. How can such a short-lived liaison be meaningful? "Depth and intimacy can be created ove
ight" - she assures me, they are not a function of the length of acquaintance. But surely they depend on the amount of time spent together? "Is this your wife?' - she points at a silver-framed picture on my desk - "I bet you are hitting it off in the sack!" Actually, I tell her, that's my daughter. She shrugs off her faux-pas and sprawls across my duvet, long legs exposed to the hip and crossed at the ankles.

She sighs theatrically and shields her eyes with her hand: "I wish it was all over." Does she mean her relationship with Doug? "No, silly", she was referring to her tumultuous life and its vagaries. Does she really mean it? Of course not. She rolls to one side, leaning on her elbow, face supported by an open palm: "I just wish people were more lighthearted, you know? I wish they knew how to enjoy life to the maximum, give and take with joy. Isn't this what psychotherapy is all about? Aren't these the skills you, as a psychiatrist, are trying to instil in your patients?"