Which of the following is most typical of the interpersonal attitudes and Behaviours of someone with histrionic personality disorder?

Pearls & Considerations

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This disorder is difficult to treat.

Like most personality disorders, patients present for treatment primarily when stress or other situational factors within their lives have made their ability to function and cope effectively impossible.

Suicidality and risk of self-injury should be assessed on a regular basis, and suicidal threats and self-mutilation should not be ignored or dismissed. Patients may present with a higher risk for, or history of, suicidal gestures.

Patients may report high rates of impulsive behavior motivated by sensation- or novelty-seeking.

An alternative model in DSM-5, section III, reconceptualizes histrionic personality disorder as “Personality Disorder, Trait Specified,” which rates (1) impairment in personality functioning (identity, self-direction, empathy, and/or intimacy) and (2) pathologic trait domains such as attention seeking, grandiosity, and manipulativeness.

Histrionic Personality Disorder

The most notable features ofhistrionic personality disorder (HPD) are excessive emotionality and an almost insatiable need for attention. These individuals are overly concerned with their physical appearance, they have poor frustration tolerance (with emotional outbursts), and their speech is impressionistic and vague. They view physical attractiveness as the core of their existence, and as such, are often provocative in dress, flamboyant in mannerisms, and inappropriately seductive in behavior. While they appear superficially charming, others tend to view them as vain and lacking in genuineness. Histrionic and narcissistic personality disorders are closely associated.

The differential diagnosis for HPD includes other cluster B personality disorders and somatization disorder. BPD differs from HPD in that the borderline patient displays more despair and suicidal/parasuicidal behaviors. The narcissistic patient is more preoccupied with grandiosity and envy than is the histrionic individual. The person with dependent personality disorder, while sharing the need for acceptance and reassurance, lacks the degree of emotionality seen in histrionic individuals. Somatization disorder can co-exist with HPD, but it is distinguished by the greater emphasis on physical complaints.

This disorder occurs in 2% to 3% of the general population. While women receive the diagnosis more often than do men, many clinicians believe that men are underdiagnosed. This disorder is more common in first-degree relatives of people with this disorder. Like most personality disorders, the course is variable. Some individuals experience an attenuation or softening of the core symptoms during middle age. Others may experience a complicated course, including co-morbid somatization, conversion, pain, and dissociative, sexual, and mood disorders. Two major caveats pertain to this diagnosis. The first is that emotional displays can vary from culture to culture, and what is histrionic in one culture may be identified as normal emotional expression in another. The other concerns the great co-morbidity this disorder has with BPD. Some believe that while not all borderline patents are histrionic, most HPD patients have sufficient borderline traits to merit a diagnosis of BPD.

Summary

1.

Hysteria was formulated based on anatomical features of women; however, the syndrome quickly moved away from its emphasis on female anatomy to a personality style characterized by emotionally found in both men and women.

Hysteria has been linked to sexual repression (Freud, 1905); however, the symptoms have expanded, and we are focused on the personality symptoms and how it relates to female psychopathy.

Hysteria and trauma have been linked with researchers finding traumatized patients elevate scales measuring hysteria.

More cases of hysteria, hysterical personality, and HPD have been found in women. Clinical bias in applying these diagnoses appears to account for the differences between genders (Pfohl, 1991; see Chapter 2); however, in women, hysteria can be understood as a caricature of femininity (Chodoff, 1982).

The predominant hysterical personality symptoms include: avoid affectively toned situations, more prone toward shallow expression of emotion, display hyper-emotionality, display dependency, suggestibility, have somatic complaints, overly dramatic, present a depression that is not true to self, and an impressionistic cognitive style (Briquet, 1859; Charcot, 1875; Chodoff & Lyons, 1958; Easser & Lesser, 1965; Horowitz, 1991; Janet, 1907; Jung, 1921; Krohn, 1978; Lazare & Klerman, 1968; Reich, 1980; Shapiro, 1965).

The histrionic individual actively manipulates the environment by employing a variety of interpersonal maneuvers and giving nurturance to others in the service of receiving praise or attention from others (Cunliffe & Gacono, 2005; Gacono & Meloy, 1994; Millon & Davis, 1996).

The hysterical personality is a mixture of present-day DSM Histrionic (HPD) and Borderline (BPD) Personality Disorders (APA, 2013; Kernberg, 1986; Zetzel, 1968).

Hysteria and paranoia have been linked perhaps due to the increased rates of trauma and the hysterical personality containing BPD traits.

Hysteria, antisocial personality, and psychopathy have been linked genetically (Millon et al., 2000). Most studies have found antisociality more in males and hysteria more in females, suggesting a gendered style underlying criminality (Cloninger & Guze, 1970a, 1970b; Cunliffe & Gacono, 2005; Forrest, 1967; Gacono & Meloy, 1994; Guze, 1964; Guze et al., 1971; Robins, 1966; Smith, Gacono, & Cunliffe, 2018, 2019, 2020a, 2020b, 2020c).

Histrionic Personality Disorder

Patients with histrionic personality disorder have an emotionally expressive style, seek excessive attention, are often dramatic, and may present with a conversion disorder. Physicians may feel flattered, captivated, seduced, or sexually aroused by these patients. Alternatively, the physician may feel overwhelmed by the patient's exaggerated or excessive emotions, embarrassed by the sexual overtures, depleted, or confounded by unexplained physical symptoms (e.g., pseudoseizures, paralysis, and mutism). These patients may unconsciously use their symptoms to elicit attention or support from the physician (Bornstein and Gold, 2008). They may also use their sexuality to recruit others to satisfy their needs to be taken care of or romantically pursued. They fear that they are not desired and will lose the care or admiration of others.

There are two different levels of functioning with the histrionic personality disorder.Kernberg (1984, 1992) describes a neurotically functioning “hysteric” who shows intact reality testing, defenses centered on repression, and stable and mature relations with others. The female hysteric has a flirtatious, clinging, childlike dependence in intimate relationships but can function at mature levels in social and work situations. Male hysterics have similar psychological conflicts but may appear as “macho” or “effeminate” (Kernberg, 1992). The hysteric of either sex often reacts to medical care with regression to a childlike, sexualized, dependent, and clinging position. They seek to gratify their wishes for dependent care by seducing or flattering others. Outside the office, they usually function well.

By contrast, a “histrionic patient” (Kernberg, 1984, 1992) can display transient losses of reality testing, defenses centered on splitting, chaotic sexualized relations with others, and a range of unexplained physical or somatic complaints. The histrionic patient is self-centered and self-indulgent, with a pervasive childlike dependence that extends from intimate relationships into all aspects of social and occupational functioning. Female histrionics typically act flirtatiously but may become indignant when a man shows sexual interest. Male histrionics also show the self-centered and dependent pattern but may also have hypochondriacal and antisocial features. Histrionics of both genders may seek medical care because of unexplained medical symptoms. They may react to medical care with regression but, unlike the hysteric, use defenses centered on “splitting”; they may see the physician as “all good or all bad” and can be extremely devaluing. They may appear severely self-centered, attention seeking, diffusely sexual, hypochondriacal, somatic, and exploitative. All of this may be coupled with an exhausting dependency on the physician.

In working with hysterics and histrionic patients, a physician needs to be friendly, neither overly warm nor reserved. Hysterics and histrionics often are helped when the physician uses parallel diagnostic inquiry when they present with somatic complaints. Parallel diagnostic inquiry is a technique in which the clinician simultaneously explores potential physical and psychological factors involved in the patient's complaints. Hysterics also may benefit from some gratification of their dependent wishes and a free discussion of their fears and emotions. They can often be reassured by an educational and informational approach to their medical illnesses and are capable of expressing gratitude to the physician. In contrast, the intense dependency of histrionics is often made worse by gratifying the patient's needs. Offering excessive emotional care may make them greedy or demanding for satisfaction of their needs. Histrionics benefit from firm, kind limit setting (especially to their sexual overtures), with neutral acknowledgment and gratification of their reasonable needs. They may be further helped by focusing on their distortions in reality perception and through interpretation of their splitting mechanisms.

8.6 Summary and Conclusions

In this chapter, we have surveyed the topic of personality disorders, beginning with an explanation of the concept of personality disorder itself. According to the DSM-5 (American Psychiatric Association, 2013), an individual may have a personality disorder when he or she exhibits patterns of behavior that deviate from the norms of his or her culture, that are pervasive and inflexible across many aspects of his or her life, and that lead to distress or impairment. To be considered as personality disorders, these patterns of behavior must emerge in adolescence or in adulthood.

The DSM-5 currently lists 10 personality disorders, which are grouped into three “clusters.” Within cluster A (the “odd, eccentric” disorders) are the schizoid, schizotypal, and paranoid personality disorders. Cluster B (the “dramatic, erratic” disorders) contains the borderline, histrionic, narcissistic, and antisocial personality disorders. Within cluster C (the “anxious, fearful” disorders) are the avoidant, dependent, and obsessive-compulsive personality disorders.

Many researchers believe that the DSM-5 system has serious shortcomings. For example, the symptoms of a given disorder often do not appear together, whereas the symptoms of different disorders often do. Moreover, the grouping of personality disorders into clusters does not closely match observed results. Also, although the DSM-5 treats disorders as categories (i.e., a person either is or is not diagnosed as having a given disorder), the evidence indicates that these disorders are dimensions rather than categories.

Some researchers have proposed a new system for classifying and diagnosing personality disorders. This system, which is based on assessment of impaired personality functioning and pathological personality traits, was originally meant to replace the set of 10 personality disorders, but it was ultimately included in the DSM-5 only as an idea for further study. Impaired personality functioning involves problems both with the self (one's identity and self-direction) and with interpersonal interaction (empathy and intimacy). Pathological personality traits are very diverse and can be categorized into domains resembling the major dimensions of normal personality. In using the new system to diagnose a patient, the clinician rates the severity of impairment exhibited by the patient, considering the various forms of self and interpersonal functioning and their impairment. The clinician also diagnoses the patient by assessing the patient's levels of the various pathological personality traits.

To a large extent, questions about the biological bases, the genetic and environmental origins, and the evolutionary adaptive functions of personality disorders will have answers similar to those found for normal variation in personality characteristics. Possible exceptions include some of the features of Borderline and Schizotypal personality disorders.

Treatment of personality disorders is difficult, but several methods of psychological therapy have shown at least some success, including psychodynamic therapy, CBT, and DBT. Some drug-based therapies have also shown modest success.

Research

Studies have investigated the tenets of interpersonal defence theory and used the theory as a basis for investigating issues about therapy. This research has included nomothetic observational investigations of process and outcome in therapy (e.g., Hartmann, 2001; Westerman, Foote, & Winston, 1995; Westerman, Tanaka, Frankel, & Kahn, 1986), experimental studies with non-clinic samples (Dahmen & Westerman, 2007; Westerman & Prieto, 2006; Westerman & Steen, 2009) and theory-building case studies (Westerman, 2018b; Westerman & de Roten, 2017; Westerman & Muran, 2017). Here, I offer a brief summary of those studies that investigated psychotherapy with patients with personality disorders.

One of those studies (Westerman et al., 1995) investigated relationships between outcome and the extent to which patients’ in-session interpersonal behaviour with their therapists was coordinating versus noncoordinating. All patients (N = 16) in this study had diagnoses on Axis II of DSM III of compulsive, avoidant, dependent, passive-aggressive and/or histrionic personality disorder. Assessments of coordination were made at four time points for each case.

The findings indicated that, for the full sample, coordination averaged across the four phases of therapy was significantly positively related to improvement. This relationship was quite large in magnitude. Average coordination accounted for 31% of the variance in outcome.

Results also showed that change in coordination during treatment was differentially related to improvement in the two kinds of brief psychodynamic therapy included in the study. In one treatment condition, which took an insight-oriented approach that focused on identifying patients’ maladaptive interpersonal patterns in their relationships, coordination assessed early in treatment was most strongly associated with outcome and there was no relationship between improvement in coordination over time and outcome. In the other condition, which emphasized confronting patients’ in-session defensive behaviour, coordination assessed later in treatment was most strongly associated with outcome and there was a positive relationship between improvement in coordination over time and outcome.

Overall, the results suggested that for patients with the types of personality disorders included in this study, the degree to which a patient engages in the therapeutic relationship in a coordinating manner plays a very important role. In addition, the findings offered some support for the view that if a patient with one of those personality disorders relates to his or her therapist in a highly noncoordinating manner early in therapy, it may be best to focus on promoting successful outcome by helping the patient change how he or she relates to the therapist.

However, note that therapist interventions in this study were not examined in terms of case formulations based on interpersonal defence theory. Any given insight-oriented intervention may or may not have accurately identified key features of a patient’s problematic behaviour according to an interpersonal defence formulation and, similarly, a confrontation may or may not have had desirable interpersonal significance when considered in terms of the theory.

The theory-building case studies I referred to earlier went beyond quantitatively assessing extent of coordination failures by carefully examining patient and therapist behaviours in terms of case formulations based on interpersonal defence theory. Two of those studies (Westerman, 2018b; Westerman & Muran, 2017) investigated therapy with patients with personality disorders.

Theory-building case study methodology is well suited for investigating theories in which case formulations play a central role because this method involves intensive qualitative analysis of individual cases. As Stiles (2009) explained, it also offers a way to investigate the validity of theories that is in some respects preferable to hypothesis-testing group studies because in a theory-building case study, a researcher examines whether individual observations simultaneously conform to the multiple tenets of a theory. If they do, this provides compelling incremental support for the theory under investigation.

Westerman and Muran (2017) conducted a theory-building case study of the treatment of a 28-year-old female patient included in the same treatment condition of the umbrella study (Muran et al., 2005) that also included Jane’s case. Based on DSM IIIR, she had Axis II diagnoses of avoidant, self-defeating and paranoid personality disorders, and an Axis I diagnosis of anxiety disorder NOS.

The results provided support for the following tenets of interpersonal defence theory: (1) noncoordinating patterns are attempts to pursue wished-for interpersonal outcomes while trying to avoid feared responses, (2) defensive behaviour by patients makes it more likely that therapists will respond countertransferentially (negative responses distinct from the fear and positive response distinct from the wish) and (3) countertransference responses contribute to maintaining patients’ defensive patterns. In addition, the study compared the analyses of therapeutic relationship processes in terms of case formulations based on interpersonal defence theory to alliance assessments on the Working Alliance Inventory (Tracey & Kokotovic, 1989). That comparison suggested that the former may provide a better basis for studying the alliance.

I am currently conducting an intensive theory-building multiple case study project (Westerman, 2018b). This project employs a paired-comparison design. It includes four cases, one good outcome case and one poor outcome case treated by the same therapist and another good outcome-poor outcome pair treated by another therapist. Jane’s case is part of this project; the case studied by Westerman and Muran (2017) is not. The four cases come from the same treatment condition of the nomothetic umbrella project as Jane’s case. The four patients all had diagnoses including one or more Cluster C personality disorder.

Careful analyses of patient and therapist behaviours in terms of case formulations based on interpersonal defence theory provided further support for the tenets of the theory investigated by Westerman and Muran (2017). In addition, the paired-comparison design led to findings about what contributed to positive outcome. In the poor outcome cases, throughout treatment, patient behaviour was noncoordinating and therapist behaviour was characterized by countertransference responses. In the good outcome cases, this was also true for both patient and therapist behaviours up until the middle of treatment. At about that point in both good outcome cases, however, the patients started to behave in a more coordinating manner and therapists’ responses became less countertransferential. Preliminary analyses suggest that two changes by the therapists may have played key roles in promoting the good outcomes – making interventions that accurately identified the patients’ interpersonal wishes and behaving towards the patients in ways that realized the patients’ wishes in the therapeutic exchange.

Social dominance and deception (manipulation, arrogance)

The last major set of antagonism traits include manipulation and arrogance—both representing strategies for deceiving and dominating others. Antagonistic manipulation involves a duplicitous interpersonal style that utilizes flattery or deception to control others. This facet has been linked to Machiavellianism (O'Boyle, Forsyth, Banks, Story, & White, 2015); deceitfulness in antisocial personality disorder; and the interpersonal manipulation seen in psychopathy, narcissism, and borderline personality disorder (Lynam, 2012). Antagonistic arrogance is marked by apparent confidence, boastfulness, and belief of one's own superiority and is observed in grandiose features of psychopathy and grandiose narcissism (Miller et al., 2016), as well as histrionic personality disorder (Samuel & Widiger, 2008). These facets have less biological research, and behavioral manifestations of Machiavellianism and narcissism are also considerably driven by other FFM domains including high extraversion, high neuroticism, and low conscientiousness; therefore biological findings based on these phenotypes may be driven only partly by antagonism (O'Boyle et al., 2015).

The research on the heritability of these traits has suggested a typical combination of genetic and environmental influences. Heritability studies that have utilized the NEO-PI-R (Jang et al., 1996, 1998) have found that manipulation and arrogance are attributed mainly to the nonshared environment (53%–75%). However, whereas manipulation seems to be also driven by additive genetics (25%–47%), arrogance seems to be instead driven in part by shared family environment (26%–33%). These results are consistent with research on the Dark Triad (psychopathy, narcissism, and Machiavellianism), which reflect extremes in both arrogant and manipulative behaviors. Research suggests dark traits are driven mostly by genetic (31%–64%) and nonshared environmental factors (30%–41%), although Machiavellianism was also influenced by the shared environment (39%) (Vernon, Villani, Vickers, & Harris, 2008).

Like other facets of antagonism, arrogant/manipulative traits (at least as manifested in narcissism) have also been linked to hormones such as testosterone and cortisol. One study investigating the Dark Triad (measured using the Short Dark Triad measure; Jones & Paulhus, 2014) found that grandiose narcissism (but not Machiavellianism or psychopathy) was associated with increased basal levels of testosterone and cortisol, suggesting a link between these hormones and propensities toward social domination as well as a sensitivity toward social esteem and status (Pfattheicher, 2016). Grandiose narcissism, in particular, has been associated with increased cortisol reactivity in response to interpersonal stressors and perceived threats to the self (Edelstein, Yim, & Quas, 2010). This is consistent with the idea that social evaluation and status elicits a strong threat response for individuals with narcissism. Finally, testosterone levels have been found to underlie the relationship between grandiose narcissism and aggression (Lobbestael, Baumeister, Fiebig, & Eckel, 2014), suggesting that higher levels of basal testosterone may predispose narcissistic individuals toward aggressive behavior. However, others argue that the testosterone-cortisol ratio is most important, specifically low levels of cortisol combined with high levels of testosterone (Terburg, Morgan, & van Honk, 2009).

In a related vein, narcissism has been associated with heightened activation of the salience network, particularly increased right anterior insula activity, the region implicated in representation of the self (Fan et al., 2011). These data are consistent with theoretical interpretations of the narcissistic interpersonal style in regard to sensitivity to perceived threat to their ego, resulting in a variety of interpersonal strategies such as manipulation and arrogance as a means of self-protection (Baumeister, Smart, & Boden, 1996). Indeed, alterations in neural circuits related to the self are observed in narcissism, with evidence of weakened connectivity between the regions of the brain involved in processing of self-relevant stimuli (medial-prefrontal cortex) and reward (ventral-striatum) (Chester, Lynam, Powell, & DeWall, 2015). This physiological disconnect between representations of the self and reward would be consistent with self-regulatory theories of narcissism (Morf & Rhodewalt, 2001). Specifically, for narcissists, arrogance and external validation seeking serves as a regulatory strategy to compensate for deficits in deriving an intrinsic sense of self-worth.

While the arrogance associated with narcissism involves heightened reactivity and preoccupation with representations of the self, manipulative tendencies may relate to decreased sensitivity to the emotional consequences of deceiving others (e.g., anxiety, guilt, sympathy). For example, the brain has been shown to adapt to dishonesty, such that with continued lying, the amygdala response dampens to the negative feeling associated with preparing to tell a lie (Garrett, Lazzaro, Ariely, & Sharot, 2016). This suggests that habituation to deception may actually cause reduced amygdala activation, although more research is needed to determine the causal nature of the relationship. Further, the interpersonal-affective facet of psychopathy has been associated with lower activation of the amygdala and enhanced activation of the dorsolateral prefrontal cortex during an emotion-recognition task, suggesting that these individuals rely less on emotional centers of the brain for processing emotional information (Gordon, Baird, & End, 2004). Consistent with this, studies consistently find that intentionally deceiving someone in an experimental deception task is associated with increased activity in the prefrontal cortex among a nonclinical sample (Abe, Suzuki, Mori, Itoh, & Fujii, 2007). Studies have associated pathological lying (measured using the PCL-R) with increased prefrontal white matter (Yang et al., 2007) and Machiavellianism with increased prefrontal cortex gray matter volume (Verbeke et al., 2011). Machiavellianism was also found to be associated with increased activation of the dorsolateral prefrontal cortex during a laboratory Trust game but only during conditions that required cooperation (Bereczkei et al., 2015). This suggests that for individuals with Machiavellian traits, cooperative social interactions require more cognitive effort, possibly because these interactions involve weighing the pros and cons of exploiting another person for personal gain. Collectively, these findings suggest that manipulation, in particular, relates to deficits in the emotional processing regions of the brain, in combination with increased prefrontal involvement in processing cues.

In summary, the arrogant and manipulative facets of antagonism have been less researched in the context of biological studies. These traits characterize individuals with an increased propensity toward social dominance and sensitivity toward social esteem/status, coupled with an ease with which to use deception and flattery to achieve one's goals. These tendencies are associated with at least two physiological profiles: the increased vigilance to threats to self (e.g., hyperactive salience network, increased basal testosterone and cortisol) observed in arrogance/narcissism, and the decreased reliance on emotional processing and more effortful control during deception. Whereas arrogance involves a biased preoccupation with the self, manipulation involves more calculated and cold processing of social cues to determine the most advantageous option for the self. The somewhat discordant biological findings across arrogance and manipulation may mirror the distinct social style differences observed between these traits (e.g., boastfulness versus deceit), but which all represent behavioral strategies for achieving/maintaining dominance over others.

Gender Bias

Studies around the world have confirmed the presence of gender bias in the general public (Banks, 1988; Chapman, Tashkin, & Pye, 2001; Heilman, 2012), employment settings, (Bosak & Sczesny, 2011; Hoyt, 2012; Isaac, Lee, & Carnes, 2009), and clinical judgment (Broverman, Broverman, Clarkson, Rosenkrantz, & Vogel, 1970; Chiaramonte & Friend, 2006; Davidson & Abramowitz, 1980; Flanagan & Blashfield, 2003). In the early years of psychology, investigators reported that there was a tendency to diagnosis borderline personality disorder in women but not in men (Pope, Jonas, Hudson, Cohen, & Gunderson, 1983). However, other studies have refuted this finding (Boggs et al., 2009; Ford & Widiger, 1989; Henry & Cohen, 1983).

Despite this, bias has been found in several DSM-5 (APA, 2013) personality disorders including Dependent and Histrionic Personality Disorders (females) and Antisocial, Narcissistic, and Paranoid Personality Disorders (males; Corbitt & Widiger, 1995; Flanagan & Blashfield, 2003; Jane, Oltmanns, South, & Turkheimer, 2007; Skodol & Bender, 2003; Widiger, 1998). However, other studies (Benson, Donnellan, & Morey, 2017; Braamhorst et al., 2015; Morey, 2019; Morey, Bender, & Skodol, 2013; Zimmerman, 2012) have suggested that bias exists not in the criteria themselves but the way in which they were applied. That is, the consensus was that the criteria are not biased and found that when clinicians closely followed the categorical and dimensional criteria listed in the DSM-5, the interrater reliability and validity estimates increased dramatically. These findings support the need for all clinicians and researchers be cognizant of and take steps to eliminate bias in their professional work.

Although the negative effects of gender bias against women is well-established (Antonczyk, Fitzenberger, & Sommerfield, 2010; Blau & Kahn, 1994; Brynin & Perales, 2016; Hellemans, Loeys, Dewaele, & De Smet, 2015; Like-Haislip & Tusinsky-Miofsky, 2011; Matud, 2009), a different trend surfaces when examining gender bias with female offenders. Compared to males, female juvenile offenders have been found to have a lower likelihood of being removed from their home by the court in post-adjudicative dispositions (Espinoza, Belshaw, & Osho, 2008) and more likely to be handled informally at the entry level of the justice system (McDonald & Chesney-Lind, 2001). Additionally, Shatz and Shatz (2012) found that prosecutors were much less likely to seek the death penalty and juries less likely to impose a capital sentence when the offender was female. Interestingly, the authors discovered the opposite trend when the victim was another woman.

Although variations exist across offense category and location (Doerner & Demuth, 2009), female defendants are more likely to be treated more leniently than their male counterparts by the criminal justice system (Bickle & Peterson, 1991; Daly & Bordt, 1995; Spohn, 2000, 2002; Steffensmeier, Kramer, & Streifel, 1993). Spohn (2002) determined that the odds of receiving a prison sentence were roughly 2.5 times greater for male defendants. In their very large and representative, nation-wide federal sample (N = 59,897), Doerner and Demuth (2009) found that young African American males received much longer sentences while Hispanic males were much more likely to receive incarceration than a diversion program. Brown and King (1998) found that female police officers were much more supportive and sympathetic toward female offenders than their male counterparts and held more negative attitudes toward male offenders. Additionally, Smith, Makarios, and Alpert (2006) found that police officers of both genders were much more likely to be suspicious of male but not female drivers at routine traffic stops. Although Bierie (2010) did not find differences across gender for violent assaults in federal prison, women were found to be less likely to receive punishment for non-violent infractions from female officers. Despite this, some researchers have reported that women are treated more harshly than men (Motz, 2020; Specktorov-McClennan, 1994) with very little reliable data to support their assertions.

Consistent with most of the scientific literature on crime and offenders, most research studies on prison adjustment and rule violations have focused on men (Warren, Hurt, Loper, & Chauhan, 2004; Worrall & Morris, 2011). Inmate discipline within correctional facilities also appears to vary as a function of gender. In her study of two correctional facilities in Texas (one male and one female), Specktorov-McClellan (1994) found that although women received more disciplinary violations than men, the infractions they received were “less serious.” Additionally, when they committed more serious infractions, they were more likely to receive harsher punishment.

We conducted an extensive literature review of studies which examined institution misconduct and discipline of inmates as a function of gender. We used a wide range of search terms on PsycINFO, ProQuest Dissertations and Theses, and Google Scholar. These included inmate discipline, gender bias in female offenders detained for misconduct, male and female inmate discipline base rates, prison misconduct, differential treatment of male and female offenders in corrections, women offenders and inmate discipline, and control and management of male and female incarcerated offenders. The literature reviewed yielded eight studies (Celinksa & Sung, 2014; Chen et al., 2014; Craddock, 1996; Harer & Langan, 2001; Jiang & Winfree, 2006; Specktorov-McClennan, 1994; Thompson & Loper, 2005; Warren et al., 2004; see Table 2.3) that investigated the relationship between gender and institutional misconduct.

Table 2.3. Gender differences and institutional conduct.

F, female; M, male; Min, minimum; SR, self-report; UNK, unknown.

Although there were serious methodological problems in most of the studies, the consensus among the studies was that women adjusted more easily to prison than men and engaged in less violence and other serious infractions. Nearly all the investigators reported that they were more likely to receive a reduction in privileges and detainment in confinement units. However, all but one of the studies (Harer & Langan, 2001 was the only exception) contained bias and poor methodology which limited the reliability of the results. Of the eight studies reviewed, six (Celinska & Sung, 2014; Chen et al., 2014; Gover et al., 2008; Jiang & Winfree, 2006; Specktorov-McClellan, 1994; Thompson & Loper, 2005) used self-report measures to assess institutional adjustment, mental health status, and clinical/personal history. Although one of these studies used official prison records to assess the number of infractions (Jiang & Winfree, 2006), the other five relied exclusively on the individuals’ verbal statements and responses to brief self-report measures rather than a measure of psychopathy (PCL-R). This is important as within our sample of incarcerated women (N = 242) psychopathy strongly predicted increased rule breaking behavior across a range of different levels of infraction. For example, psychopathic women (PCL-R ≥ 30) engaged in significantly more high (i.e., assaults; psychopaths; M = 0.39, SD = 0.78; non-psychopaths; M = 0.10, SD = 0.50), medium (i.e., sexual behaviors; psychopaths; M = 1.6, SD = 3.94; non-psychopaths; M = 0.41, SD = 0.68), and low (i.e., insolence; psychopaths; M = 4.44, SD = 11.63; non-psychopaths; M = 1.59, SD = 3.45) risk infractions.

The case of convicted Canadian serial killer and female psychopath Karla Holmolka provides another example of gender bias. Although there was physical evidence presented at her trial that she was beaten by her husband and co-defendant Paul Bernardo on numerous occasions, video evidence of the crimes showed her directing and encouraging Bernardo. She also physically participated in the assaults, and gleefully laughed as they tortured and murdered a number of teenage girls they had abducted (including her 15-year-old sister, Tammy). There is consensus among legal scholars, scientists, and the forensic psychologists who evaluated her, that her history of domestic violence did not tell the complete story and rather than a helpless victim, she was also an active, callous, and remorseless perpetrator (Banwell, 2011).

TBC was struck by a comment made by a senior prison official conducting a tour of a maximum-security facility in Florida when he was informed, “you have to think of these girls as your kid sister or your daughter, they aren’t responsible for the things they do.” It is hard to imagine this type of misattribution being applied to male offenders or this sort of a priori excuse for their behavior being provided. These types of erroneous perceptions highlight the difficult task of assessing female offenders. Examiners must be on guard and adopt an objective, professional, neutral, and factual mindset when interacting with or conducting evaluations with female offenders.

The alternative personality model for DSM-5