Histrionic personality features and high-risk sexual behavior among STD clinic patients

Material Information

Histrionic personality features and high-risk sexual behavior among STD clinic patients
Nettles, Christopher Derrick
Publication Date:
Physical Description:
x, 58 leaves : ; 28 cm


Subjects / Keywords:
Personality disorders ( lcsh )
Sexually transmitted diseases -- Patients -- Sexual behavior ( lcsh )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )


Includes bibliographical references (leaves 46-58).
General Note:
Department of Psychology
Statement of Responsibility:
by Christopher Derrick Nettles.

Record Information

Source Institution:
|University of Colorado Denver
Holding Location:
|Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
166343864 ( OCLC )
LD1193.L645 2007m N47 ( lcc )

Full Text
Christopher Derrick Nettles
B.S., National American University, 1995
B.A., University of Colorado at Denver and Health Sciences Center, 2004
A thesis submitted to the
University of Colorado at Denver and Health Sciences Center
in partial fulfillment
of the requirements for the degree of
Master of Arts
Clinical Psychology

This thesis for the Master of Arts
degree by
Christopher Derrick Nettles
has been approved
Mary Coussons-Read

Nettles, Christopher Derrick (M.A., Clinical Psychology)
Histrionic Personality Features and High-Risk Sexual Behavior Among STD Clinical
Thesis directed by Assistant Professor Eric G. Benotsch
More than 25 infectious organisms are transmitted through sexual activity and many are
responsible for other clinical syndromes. Previous research has examined relationships
between personality disorder features and HIV/STD risk behavior. Three of the four
Cluster B personality disorders in the Diagnostic and Statistical Manual of Mental
Disorders Antisocial, Borderline and Narcissistic have been associated with sexual
risk behaviors. Surprisingly, there is a dearth of published research on the relationship
between the remaining cluster B personality disorder, Histrionic, and high-risk sexual
behavior. In the present study, symptomatic and asymptomatic women (n=199) and
men (n=198) presenting at a sexually transmitted disease (STD) treatment clinic were
surveyed using Audio Computer-Assisted Self Interviewing procedures. Participants
completed measures assessing Histrionic personality features, substance use, and
sexual-risk. This study proposed two main hypotheses: 1) That Histrionic personality
features will predict active, passive, and partner-related high-risk sexual behaviors, and
2) That those with higher Histrionic personality features will have significantly higher
risk (odds) of STD/HIV infection. Support for the first hypothesis was demonstrated.

Scores on the measure of Histrionic personality traits were associated with high-risk
sexual activity. Bivariate correlations showed relationships between Histrionic
personality and the number of unprotected anal, oral, and vaginal partners. There were
also significant relationships between Histrionic personality and the total number of
unprotected sexual acts and unprotected oral sexual acts. Those reporting giving or
receiving money, drugs or shelter for sex reported significantly higher Histrionic scores
than those who had not. Those reporting that they had had sex with someone they knew
had been in jail also reported higher Histrionic personality scores than those who had
not. Sequential logistic regression showed that Histrionic personality significantly
predicted sexual activity with multiple partners when controlling for age, education,
substance use, and MSM status. Results from this study failed to confirm the second
hypothesis. Evidence that Histrionic personality features may play a role in engaging
in behaviors that put one at risk for contracting or transmitting certain infections has
important implications from clinical and theoretical standpoints. The research presented
here may represent an important line of investigation for many future studies.
This abstract accurately represents the content of the candidates thesis. I recommend
its publication.
Eric G. Benotsch

I dedicate this thesis to my parents, who instilled in me a strong thirst for knowledge,
the freedom with which to pursue it, and support that has never faltered.

I would like to express my sincerest gratitude to my advisor and mentor, Dr. Eric
Benotsch for his guidance, support and for providing me with the freedom in which I
could make my own mistakes and then learn from them. My heartfelt thanks also goes
to my committee members, Dr. Kevin Everhart and Dr. Mary Coussons-Read for their
unmitigated support.

LIST OF TABLES...............................................x
1. INTRODUCTION..............................................1
Sexually Transmitted Infections...........................1
Personality Disorders.....................................8
High-Risk Sexual Behavior and Cluster B Personality Disorders... 10
2. METHOD...................................................16
Participants, Setting, and Procedures....................16
Histrionic Personality Features......................19
Sexual Risk Behavior.................................21
Sexually Transmitted Infections......................21
Data Analysis............................................21
3. RESULTS..................................................23
Histrionic Personality Features........................ 23
High-Risk Sexual Behavior................................23

Comparison of sexual behaviors by group............27
Sexually Transmitted Infections.......................29
Histrionic Personality Features and High-Risk Sexual Behavior.30
Prediction of STIs....................................33
4. DISCUSSION............................................34
Future Research.......................................41
A. QUESTIONABLE..........................................45

1. Group Frequencies of High and Low Risk......................................29
2. Group Frequencies Sexually Transmitted Infections..........................30
3. Histrionic Personality and High-Risk Behavior Spearman Correlations........31
4. Sequential Logistic Regression Analysis Predicting Multiple Partner Status.33

One definition of high-risk sexual behavior is sexual activity that increases the
probability of negative outcomes associated with such sexual contact (Cooper, 2002).
Sexual activity considered high-risk may relate to the active behavior itself. This
includes such behaviors as having multiple partners; unprotected vaginal, oral, or anal
intercourse; sex with casual or unknown partners; and sex while under the influence of
substances. Sexual risk may also be passive in nature, for example, failure to discuss
risk topics prior to intercourse. Some high-risk activities may be related to the nature
of the partner, such as sex with an injection drug user or nonexclusive partner
(Washington Department of Health, 2002). While there can be numerous negative
outcomes associated with high-risk sexual behavior, this study will focus on outcomes
that have potential for disease transmission.
Sexually Transmitted Infections
More than 25 infectious organisms are transmitted through sexual activity and
many are responsible for other clinical syndromes. According to Centers for Disease
Control and Prevention (CDC) estimates, 19 million new STIs occur each year in the
United States (CDC, 2005a). Weinstock and colleagues (2004) suggest that as many
as half of these new infections occur in our nations youth.

The most common STIs are bacterial in nature (CDC, 2005a, 2005b). Most
bacterial STIs, such as chlamydia, gonorrhea, trichomoniasis, nongonococcal
urethritis (NGU), and syphilis can be easily diagnosed and usually successfully
treated; yet, they remain important public health problems. Though these infections
are usually curable, they can still result in negative health effects. However, many
new STIs have been discovered or have newly arisen during the last 50 years that are
viral in nature. These viral infections have no known cure and are recognized as
major preventable causes of death and disability. These include HIV infection,
human papillomavirus infection, and hepatitis B virus infection (Institute of
Medicine, 1997).
The three most commonly reported STIs appear to be an increasing public
health concern. Close to one million new chlamydia diagnoses were reported in 2004,
an increase of almost 6% over 2003 rates (CDC, 2005a). Yet the reported cases may
only represent one-third of the actual new chlamydial infections (Weinstock, Berman &
Cates, 2004). New infections of primary and secondary syphilis also appear to be on
the rise over the last 4 years, due mainly to increasing infections among men who have
sex with men (MSM; Bronzan, Echavarria, Hermida, Trepka, Bums & Fox, 2002;
CDC, 1999; CDC 2001; CDC, 2002, CDC 2003; CDC, 2004a; Chen, Gibson, Katz,
Klausner, Dilley, D'Souza, Lee, & Paffel, 2003; Robinson, Chiliade, Lee, Bautista &
Saenz, 2004; Schwarcz, et al., 2002). Although new cases of gonorrheal infections are

decreasing, infections of drug resistant gonorrhea appear to be on the rise (CDC,
Chlamydia is an infection by the bacterium, Chlamydia trachomatis. In 2004,
929,464 chlamydia infections were reported in the Untied States. From 1987 to 2004,
reported chlamydia infections increased over six fold, from 78.5 per 100,000 to 485
per 100,000. This increase is most likely due to better screening, more sensitive tests,
and improved reporting, as well as increases in disease burden (CDC, 2005e).
Infection by C. trachomatis is often asymptomatic and can therefore remain
undiagnosed for long periods of time. The health consequences can be severe for
women with untreated chlamydia (CDC, 2005b; Weinstock, Berman & Cates, 2004).
These health consequences for women include pelvic inflammatory disease (PID),
ectopic pregnancy, and infertility. It is estimated that up to 40 percent of women with
untreated chlamydia infections develop PID, and infertility may result in up to 20
percent of these women (Hillis & Wasserheit, 1996).
Men tend to have relatively few complications from chlamydia, yet these may
include epididymitis and urethritis (CDC, 2005b). Most symptomatic chlamydia
infections in men are classified as nongononcoccal urethritis. Recent data also
suggest that chlamydia can be linked to sterility in men (Idahl, Boman, Kumlin &
Olofsson, 2004).

Gonorrhea is an infection caused by the bacterium Neisseria gonorrhoeae that
tends to infect the mucous membranes of the genital urinary tract. Infections can also
occur in the throat and rectum (Anderson, Keith, Novak, & Elliot, 2002). This
infection is the second most commonly reported STI in the United States; however,
new infections have declined steadily since 1974 (CDC, 2005b). Just as in chlamydial
infections, gonorrhea is thought to be underdiagnosed and underreported. It is
estimated that each year there are up to twice as many infections than are reported
(Weinstock, Berman, & Cates, 2004).
Normally, gonorrhea is easily cured; however, untreated cases can lead to
health problems. Among women, gonorrhea is another major cause of PID. which can
lead to chronic pelvic pain, ectopic pregnancy, and infertility. Untreated gonorrhea in
men can cause epididymitis, a painful condition of the testicles that can result in
infertility (CDC, 2005b). There is also concern over the increasing number of drug
resistant gonorrhea infections (Ratelle, Bertrand, & Dumas, 2004).
Trichomoniasis is a vaginal infection by the protozoan Trichomonas vaginalis.
It is characterized by itching, burning, and frothy, pale yellow to green malodorous
vaginal discharge (Anderson, et al., 2002). Trichomoniais is thought to be the most
common non-reportable STD in women, with an estimated 7.4 million new infections
annually in the United States (Weinstock, et ah, 2004). Prevalence estimates of this
infection range as high as 47% in women and 17% in men (Schwebke, 2004). Though

infection with T. vaginalis is normally cured easily, detection can be difficult as up to
half of infected women and almost all infected men show no symptoms (Wilkerson,
Sinert, Friedman, & Brillman, 2006).
Trichomoniasis has long been considered a relatively minor STI with relatively
few complications (Schwebke, 2004); however, some studies have demonstrated more
serious complications associated with this infection. For example, Moodley and
colleagues (2002) found an association between infection with T. vaglinalis and PID in
a study of 696 African women with HIV. This infection has also been associated with
increased risk of developing certain types of cervical cancer (Viikki, 2000).
Syphilis is an STI caused by the bacterial organism Treponema pallidum.
Untreated, it will progress in distinct stages over a period of years and involve multiple
organ systems (Anderson, et al., 2002). Stage one, occurring between ten and ninety
days after exposure, is characterized by the appearance of a chancre at the site of
infection. This chancre disappears after ten to forty days, often creating an impression
that it was not a serious symptom (McGregor, Richard, & Pulver, 2006) The second
stage develops 4 to 10 weeks after the appearance of the primary lesion. Secondary
syphilis has a wide range of presentations including malaise, fever, bone and joint pain
and a generalized body rash that does not itch (McGregor et al., 2006). It remains
highly infectious during this stage and can be spread by kissing. These symptoms
usually continue from 3 weeks to 3 months (Anderson, et al., 2002). The third stage

may not develop for 3 to 15 or more years (McGregor et al., 2006). Tertiary syphilis
often results in soft rubbery tumors, organ damage, intense pain, and neurological
symptoms. These complications can lead to physical disability or premature death
(Anderson, et al., 2002). About 15% to 20% of tertiary syphilis infections result in
neurosyphilis, which in one of its worst forms, general paresis, results in personality
changes, mental changes similar to schizophrenia or mania, and progressive vegetative
degeneration leading to death (Knudsen, 2005)
The rate of reported primary and secondary syphilis in the United States has
been declining since 1941, reaching a nadir in 2000. That trend has now reversed, with
syphilis infections increasing between 2000 and 2004. Overall increases in rates during
2000-2004 were documented only among men (CDC, 2005c). This increase appears to
be due, in part, to increases in infections among MSM (Bronzan, et al., 2002; CDC,
1999; CDC 2001; CDC, 2002, CDC 2003; CDC, 2004b; Chen, et al., 2002; D'Souza, et
al., 2003; Robinson, et al., 2004; Schwarcz, et al., 2002). In 2004, for the first time in
over ten years, the rate of syphilis among women did not decrease (CDC, 2005c).
The human immunodeficiency virus (HIV) is a retrovirus that causes acquired
immune deficiency syndrome (AIDS; Anderson, et al., 2002). HIV is transmitted
primarily through sexual contact with an infected individuals blood, semen, or cervical
secretions (Goedert, 1987). HIV progresses to AIDS due to the progressive loss of
CD4+ T-lymphocytes through their destruction or decreased production (McCune,

2001; Rowland-Jones, 1999). AIDS represents the end-stage of HIV infection where
the immune system can no longer protect a person from a wide variety of opportunistic
infections and without treatment results in death (Anderson, et al., 2002).
By the end of 2003, it is estimated that between 1,039,000 and 1,185,000
people in the United States were infected by HIV/AIDS, with approximately one
quarter of those people unaware of their infection (Glynn & Rhodes, 2005). In the 35
areas with confidential name-based HIV infection reporting, the estimated number of
HIV/AIDS cases decreased each year from 2001 through 2003 and then increased
approximately 1% from the end of 2003 through the end of 2004 (CDC, 2005d).
Prevention of bacterial STIs has important implications for HIV prevention.
Studies show that ulcerative and non-ulcerative STIs enhance the risk of sexually
transmitted HIV infection (Cameron, et al., 1989; Fleming & Wasserheit, 1999; Laga,
et al., 1993; Plummer, et al., 1991; Wasserheit, 1992). For example, if they are exposed
to HIV, women already infected with chlamydia are up to five times more likely to
become infected with HIV (Royce, Sena, Cates, & Cohen, 1997). Increased risk of
infection with HIV has also been demonstrated in those with bacterial vaginosis
(Schmid, Markowitz, Joesoef, & Koumans, 2000), trichomoniasis (Fleming &
Wasserheit, 1999; Laga, et al., 1993; Sutton, et al., 1999), gonorrhea and syphilis
(Fleming & Wasserheit, 1999).

A number of factors have been shown to influence the risk of STI and HIV
transmission. Some of these factors are biological in nature, such as the presence of
other STIs (Aral, 1993; Aral & Wasserheit, 1995) or lack of male circumcision (Cook,
Koutsky & Holmes, 1994; Lavreys, et al., 1999). Other risk factors are demographic
and psychosocial in nature (for a full review see Kalichman, 1998). Demographic
correlates include, but are not limited to, age, education (e.g., Kelly, Murphy, Roffman,
Soloman & Winett, 1992), and socioeconomic status (e.g., Newbum, Miller,
Schoenbach & Kaufman, 2004). Psychosocial correlates include substance use (e.g.,
Leigh & Stall, 1993; Colfax, et al., 2004), avoidant coping, loneliness, depressive
symptoms, and impulsivity (Semple, Patterson & Grant, 2000). Among the
psychological correlates of high-risk sexual behavior are various personality disorders.
Personality Disorders
The subject of what constitutes a personality is an enormous topic about which
numerous theories have been developed and volumes of material have been written.
According to Gordon Allport, the etymology of the word personality is rooted in the
Latin term persona. This word, persona, was originally employed to mean a mask one
assumes or the way one appears to others and not necessarily that way one really is
(Allport, 1937). Through time, the term later came to refer the observable
characteristics of a person. Another meaning of personality relates to the hidden,

inner psychological qualities of a person (Corsini, 2002). Personality is seen today as
an enduring and complex pattern of psychological characteristics that manifest
automatically in most areas of functioning (Millon, Grossman, Millon, Meagher &
Romnath, 2004).
For some, these enduring psychological characteristics can cause pervasive
difficulties with functioning in one or more major life domains. People who have long-
standing characteristics of personality that cause such difficulty may be considered to
have a personality disorder. The Diagnostic and Statistical Manual of Mental
Disorders, Forth Edition, Text Revision (DSM IV-TR, American Psychiatric
Association, 2000) defines a personality disorder as an enduring pattern of inner
experience and behavior that deviates markedly from the expectations of the
individuals culture..., is inflexible and pervasive, is stable over time, has an onset in
early adolescence or adulthood, and leads to distress or impairment (p.686).
DSM IV-TR (American Psychiatric Association, 2000) includes 10 different
personality disorders which are grouped into three clusters. Cluster A, called the odd-
eccentric cluster, is made up of paranoid, schizoid and schizotypal. Cluster B is
thought of as the dramatic-emotional-erratic cluster and contains antisocial, narcissistic,
histrionic, and borderline. Cluster C, termed the anxious-fearful cluster, consists of
avoidant, dependent, and obsessive-compulsive.

There appears to be little in the way of empirical research that tie the four
disorders in the B cluster together. Some have suggested that the underlying theme in
the B cluster is a general lack of empathy for others (Hamilton, 1988; Ruegg, Haynes &
Frances, 1997; Kraus & Reynolds, 2000); however, it is difficult to see how Histrionic
Personality Disorder (HPD) fits into this conceptualization. Others have suggested that
a theoretical key defining feature of the Cluster B personalities is behavioral and
emotional dysregulation (Skodol, Oldham & Gallaher, 1999; Taylor, 2004); however,
while there is evidence for this in borderline (Conklin, Bradley, & Westen, 2006;
Donegan, et al., 2003) and antisocial (Muller, et al., 2003) personality disorders, there
has been little empirical research to support this view in the other Cluster B disorders.
Yet, emotional and behavioral dysregulation do appear to tie the four disorders in
Cluster B rather well, with impulsivity and risk-taking emerging as a consistent theme.
Hollander and Rosen (2000) have suggested that patients with antisocial, histrionic, and
narcissistic PDs may be likely to engage in unsafe sexual behavior because of the
impulsivity associated with these disorders; although, they do not directly tie these
disorders to sexual risk.
High-Risk Sexual Behavior and Cluster B Personality Disorders
Much of the literature regarding the relationship between personality disorders
and sexual risk taking has focused on Antisocial Personality Disorder (Martinez-
Baptista, 2004). Antisocial Personality Disorder (APD) is defined by a persistent

pattern of disregard for and violation of the rights of others (American Psychiatric
Association, 2000). Impulsive behaviors and reckless disregard for the safety of self
and of others figures prominently in APD (Millon, 1994; Millon, 1981). Persons with
this disorder are uncomfortable with stagnation and routine; hence, they find it difficult
to delay gratification (American Psychiatric Association, 1994). These traits are
believed to contribute to a disposition toward sexual promiscuity, sexual coercion and
sensation-seeking activities that result in inconsistent condom use (Martinez-Baptista,
2004). According to Millon, (1981) those with prominent antisocial personality
features may be resistant to social pressures for attitude and behavior change related to
practicing safer sex. Indeed, researchers have found that APD is among the most
common of personality disorders among HIV-infected individuals (Brooner, Bigelow,
Strain & Schmidt, 1990; Brooner, Greenfield, Schmidt & Bigelow, 1993) and among
STD clinic patients (Erbelding, Hutton, Zenilman, Hunt & Lyketsos, 2004).
Borderline Personality Disorder (BPD) is characterized by a pervasive pattern
of impulsivity, unstable interpersonal relationships and instability in self-image
(American Psychiatric Association, 2000). Millon and Davis (1996) suggest that these
individuals present with a lack of impulse control, lack of anxiety tolerance, and
cognitive flightiness in which there are rapidly changing perceptions about self and
others. They exhibit frustration and intolerance with being alone which leads to
frenzied searches for companionship and equally frantic attempts to avoid being

abandoned (Millon & Davis, 1996). This pattern may lead to unsafe sexual practices as
partners are unrealistically idealized. These individuals may be unable to realistically
evaluate the level of risk associated with certain sexual behaviors or sexual partners.
As part of their desperate attempts to avoid loneliness, they may act in sexually
promiscuous ways (Martinez-Baptista, 2004).
Kelly and colleagues (1992) established associations between BPD and
hypersexuality, indiscriminant sexual behavior and impulsive sexual practices.
Borderline traits have been found more commonly in HIV seropositive individuals than
in their seronegative counterparts (Ferrando, 1997). Similarly, associations between
sexual abuse, borderline personality features, and high-risk sexual behavior have been
demonstrated (Kalichman, Sikkema, Difonzo, Luke & Austin, 2002). Adult patients
with BPD, particularly if they have a co-morbid Axis I disorder, have been found to be
at increased risk for unsafe sex practices (Hull, Clarkin & Yeomans, 1993). In a
longitudinal examination of personality factors and sexual risk behavior among
psychiatric patients, BPD features were significantly associated with number of sex
partners after controlling for demographics and substance use (Martinez-Baptista,
Narcissistic Personality Disorder (NPD) is characterized by a pervasive pattern
of grandiosity, need for admiration, and lack of empathy (American Psychiatric
Association, 2000). Some have suggested that impulsivity is also a major component

of this disorder (Vazire & Funder, 2006; Siever, 2002). In their metanalysis of the
relationship between impulsivity and narcissism, Vazire and Funder (2006) found a
mean correlation of approximately 0.34 (95% Cl of 0.28 0.40) between impulsivity
and narcissism across eight articles containing 17 effect size estimates. Impulsivity has
been linked to sexual risk in numerous studies (Donohew et al., 2000; Lo Conte,
OLeary, & Labouvie, 1997; McCoul & Haslam, 2001; Robbins & Bryan, 2004; Seal
& Agostinelli, 1994).
There is little research directly linking NPD to sexual risk behaviors. Although,
Schneider and Irons (2001) have suggested that NPD may be a primary factor in the
etiology of some sexual disorders, especially those involving certain paraphilias.
Others have found significant associations between the personality trait of narcissism
and infidelity in women during the first year of marriage (Buss & Shackelford, 1997).
Lavan and Johnson (2002) demonstrated significant associations between NPD and
increased number of sexual partners in adolescent women. Sexual narcissism is a
construct conceptualized as a variant of NPD in which there is a preoccupation with
sex, a history of promiscuity, sexual manipulation and sexual exploitation (Apt &
Hurlbert, 1994). Sexual narcissism has been shown to be associated with an increased
number of sexual partners in 49 military men who were in treatment for abusing their
wives (Hurlbert, Apt, Gasar, Wilson, & Murphy, 1994).

Individuals with Histrionic Personality Disorder (HPD) are typically described
as superficial, flirtatious, sexually seductive, emotionally labile, and excessively
attention-seeking (American Psychiatric Association, 2000). In an examination of the
Positive Predictive Value (PPV; a measure of sensitivity and specificity) of the DSM-
IV criteria for HPD, criterion 2, interaction with others is often characterized by
inappropriate sexually seductive or provocative behavior (American Psychological
Association, 1994; 2000) shows the highest PPV (Links, 1996). Another trait identified
with HPD is the belief that other people exist only to serve and admire them
(MacKenzie, 1997), which may lead them to be exploitative of others. This
exploitative tendency may be related to the construct of sexual narcissism described by
Apt and Hulbert (1994). Gunderson (1988) posits that those with HPD are preoccupied
with erotically pleasing others to compensate for feeling unlovable. Although
approximately 85% of individuals diagnosed with HPD have been women (Millon,
1986), other research suggests that the prevalence rates are essentially equivalent in
men and women (Nestadt, Romanoski, Chalel & Merchant, 1990). It should be noted
that the differential sex prevalence of HPD is a controversial issue (Bomstein, 1999;
Sprock, Blashfield, & Smith, 1990; Widiger, 1998).
Sexual risk characterized as increasing the risk of STIs has been examined in
other cluster B personality disorders (e.g., Martinez-Baptista, 2004), but has yet to be
fully explored in those with HPD. However, Apt and Hurlbert (1994) have observed

that women with HPD often tend to have a pattern of sexual behavior that is similar to a
behavior pattern that is associated with sexual narcissism. Specific symptoms of HPD
have also been shown to be significantly associated with multiple sexual partners in
male and female adolescents seeking primary care (Levan & Johnson, 2002). Others
have suggested that impulsivity in the cluster B personality disorders (including HPD)
may contribute to sexual-risk taking (Hollander & Rosen, 2000). Surprisingly, given
the eroticized symptomatology of HPD, there is a dearth of published research on the
relationship between HPD and sexual behavior, especially regarding behavior that
results in an STI. This study seeks to fill this gap in the literature. The present study
will examine the relationship between Histrionic personality features, high-risk sexual
behaviors, and STIs in adults presenting for treatment at a sexually transmitted disease
Histrionic personality features will predict active, passive, and partner-related
high-risk sexual behaviors.
Those with higher Histrionic personality features will have significantly higher
risk (odds) of STDs/HIV infection.

Participants, Setting, and Procedures
To investigate the association between Histrionic personality features and
sexual risk behavior, people seeking services from the Sexually Transmitted Disease
Clinic of Denver Public Health were recruited. Five hundred and eighty eligible clinic
patients were approached by Denver Public Health STD Clinic staff at random, and
invited to participate in the study. Clinic patients were ineligible to participate if any of
the following was true:
1. Under 18 years old
2. Not able to understand and speak English fluently
4. Not willing to provide informed consent for participation or a review of their
medical record at the time of survey completion and at 6-months after initial
survey completion.
5. Present for a follow-up visit.
6. Subjects deemed incompetent or appearing to be under the influence of
alcohol or drugs were not enrolled.
Recruitment continued until the study recruitment goal of 200 men and 200 women was
met. This resulted in a 69% acceptance rate among those approached.

Those agreeing to participate were taken to a nearby private room to review and
sign the consent form and complete the AC AS I-formatted questionnaire. Two
participants removed themselves from the study after consenting, resulting in a total of
398 participants completing the questionnaire. All participants who completed the
questionnaire were compensated fifteen dollars for their participation. Each participant
was also asked to agree to a review of the medical record once they have met with the
doctor and had an examination, as well as an archival review of their medical records.
Specific information gathered from the medical records were results of the examination
conducted on the day of recruitment, and new STD diagnoses.
The consent process was conducted in a private, quiet room by experienced
Denver Public Health STD clinic staff. Potential subjects were encouraged to ask
questions regarding the study. Competency was assessed by asking subjects to
summarize the purpose of the study in their own words. Study staff reviewed the
consent in detail with the patient. A signed copy of the consent was provided to the
participant at the conclusion of the consenting process.
All study procedures and survey methods were approved by the Colorado
Medical Institutional Review Board and by the University of Colorado at Denver and
Health Sciences Center Downtown Denver Campus Human Subjects Research

Of the 400 patients agreeing to participate, two declined participation in the
study after providing consent, resulting in a final study total of 398 participants 199
male and 199 female. Most of the sample identified themselves as heterosexual
(85.7%), with the rest indicating a bisexual (5.8%), gay/lesbian (7.5%) sexual
orientation, or Dont Know (0.8%). One individual refused to answer the sexual
orientation question. Sexual orientation of participants differed by gender; for females,
92.5% identified as heterosexual, 7.0% as bisexual. For males, 78.9% identified as
heterosexual, 4.5% as bisexual, 14.6% as gay, 1.5 as dont know, and 0.5% refused to
answer the question. The mean age was 29.2 (SD=10.0, range 18-62). The sample was
ethnically diverse, with 34.4% identifying as white, 30.9% indicating African-
American decent, 26.9% indicating Hispanic heritage, 1.5% Asian-American, 1.8%
Native American, and the remaining 4.5% indicating other ethnicity. This sample
had a relatively low SES, with 45.2% indicating less than $10,000 in yearly income,
22.4% reporting between $11,000 and $20,000, 15.1% between 21,000 and $30,000,
8.5% between $31,000 and $40,000, and 8.0% over $40,000; 0.8% declined to answer
this question. More than half (58.5%) of the sample had less than 12 years of
education. Most participants (55.8%) indicated that they were employed, with the
remaining indicating either they were unemployed (22.5%), student status (15.2%), or
receiving disability (2.8%) and the remaining 3.3% choosing other employment

This investigation utilized Audio Computer-Assisted Self Interviewing
(ACASI) technology. This is a computer-aided method that allows participants to
listen to questions through earphones and simultaneously read them on a computer
screen. The participant enters responses directly into the computer. Skip patterns can
be programmed into ACASI to ensure that only relevant questions are asked of the
participants, reducing question burden. For sensitive topics, ACASI has been
demonstrated to be an effective method for reducing socially desirable responding as
compared to standard interviewer administered questionnaires (Hewitt, 2002;
Macalino, Celentano, Latkin, Strathdee, & Vlahov, 2002; Turner, Ku, Rogers,
Lindberg, & Pleck, 1998).
Histrionic Personality Features
Symptoms of Histrionic Personality Disorder (HPD) were examined using
items adapted from the Schedule for Nonadaptive and Adaptive Personality (SNAP;
Clark, 1993). The SNAP is a factor analytically derived, self-report measure for the
assessment of Axis II personality disorders (Clark, 1993). The SNAP is composed of
15 scales assessing personality and affective traits. It also contains 13 scales to assess
each of the DSM-III-R (American Psychiatric Association, 1987) Axis II diagnoses.
All SNAP (Clark, 1993) scales have demonstrated internal consistencies and acceptable
test-retest reliabilities (Simms, 2002).

Nine questions used to determine Histrionic Personality Features (HPF) were
taken from the SNAP Histrionic Diagnostic Scale (Clark, 1993) and mapped to the
current (DSM-IV-TR, American Psychiatric Association, 2000) criteria for Histrionic
Personality Disorder. For example, the SNAP (Clark, 1993) item I wear clothes that
draw attention was selected to represent the Histrionic Personality Disorder criterion
consistently uses physical appearance to draw attention to self. Items were selected to
represent each of the 8 diagnostic criteria for Histrionic Personality Disorder except for
the criterion has a style of speech that is excessively impressionistic and lacking in
detail, which requires observation and cannot be adequately assessed using the
methods of this study. Questions from the SNAP were further adapted to a 4-point
Likert scale to provide dimensional rather than categorical scoring of the criteria.
Participants are asked to indicate their agreement with the questions ranging from 1 -
strongly disagree to 4 strongly agree." Similar adaptations of the measure have
shown utility in previous research (Kalichman et al., 2001; Kalichman, Gore-Felton,
Benotsch, Cage & Rompa, 2004). Individuals answers to the nine questions were
averaged and then mean item substitution was employed to account for missing data.
Higher scores are indicative of more Histrionic personality features. Specific questions
are included in Appendix A. In the present sample, this measure showed acceptable
internal consistency as indicated by Cronbachs alpha (0.70).

Sexual Risk Behavior
Questions pertaining to sexual risk were also included. These assessed number
of men and women partners, participation in vaginal, anal and oral sex (with or without
a condom); substance use in conjunction with sexual behavior; and type of partner (e.g.,
commercial sex worker). Many questions were specific to the gender of the
participant. These questions assessed sexual behavior over the past 4 months and are
similar to others shown to be reliable in measuring sexual risk in men who have sex
with men (MSM; Kauth, St Lawrence, & Kelly, 1991; Parsons, Halkitis, Wolitski, &
Gomez, 2003) and heterosexuals (Purcell, et al., 2006).
Sexually Transmitted Infections
Patients were evaluated for symptoms of STIs. If a patient exhibited symptoms
or if the clinician suspected the presence of an STI, the patient was tested for infection.
Depending on symptomatology, patients may have been tested for chlamydia,
gonorrhea, trichomoniasis, nongonococcal urethritis, bacterial vaginosis, syphilis, or
Data Analysis.
Data were collected from the ACASI questionnaire and patient medical records.
Analyses were performed to examine cross-sectional relationships between histrionic
personality features, recent sexual risk behaviors, and STD diagnoses. Missing data
were omitted from analyses resulting in slightly different ns for various statistical tests.

Because distributions of the sexual behavior variables were highly skewed to the right,
nonparametric analyses were used in analyses with these variables as recommended by
Ott and Longnecker (2001). STD diagnosis variables were dichotomous; therefore,
logistic binary regressions were conducted when examining these variables.

Histrionic Personality Features
In the present sample, the mean scaled score for Histrionic Personality Features
(HPF) was 21.50 (SD=3.88, range=10.00-36.00). There were no significant differences
in the Histrionic score between men (M=21.78, SD=3.93) and women [M=21.22,
SD=3.82; t(395)=1.44, ns]; white (n=137, M=21.73, SD=3.54) and non-white
individuals [n=260, M=21.38, SD=4.05, /(395)=0.85, ns], or between various
employment status indicators [F(4, 392)=1.23, ns]. There was no significant
relationship between income and HPF [F(4, 389)=1.11, ns]. Age and years of
education completed were both negatively related to HPF [r(397)=-1.38,/?=0.006;
r(398)=-l .48, p=0.003, respectively]. Sexual orientation was significantly related to
HPF, with MSM showing significantly higher scores (M=23.15, SD=3.93) than women
(M=21.22, SD=3.82) and heterosexual men [M=21.42, SD=3.86; F(2, 394)=4.30,
High-Risk Sexual Behavior
Since different sexual behaviors were reported for women, heterosexual men
and MSM, this section provides separate descriptions of sexual behavior for each

demographic group. All participants were asked to report on specific high-risk sexual
behaviors in which they had engaged in the past four months.
Women participants reported that they had sex after consuming too much
alcohol an average of 2.87 times over the past four months (SD=5.48, range 0-50).
They reported having sex after consuming drugs an average of 1.95 times (SD=9.16,
range 0-100). Women also reported an average of 2.61 (SD=8.50, range 0-100)
partners with whom they had unprotected vaginal intercourse and an average number of
16.78 (SD=29.63, range 0-220) unprotected vaginal acts. Women reported an average
of 0.99 partners (SD=4.59, range 0-55) with whom they had unprotected anal
intercourse and reported a mean of 2.78 (SD=6.72, range 0-40) unprotected anal acts.
Lastly, women reported that they engaged in unprotected oral sex with a mean number
of 1.65 men (SD=4.67, 0-55) and reported an average 8.97 (SD=22.51, 0-250)
unprotected oral acts performed on a partner who was a man and had an average of
8.57 (SD=20.94, range 0-200) unprotected oral acts received from a man.

Heterosexual Men
Men were classified as heterosexual (n=157) if they self-identified as
heterosexual and reported no sexual activity with another man in the past four months.
Heterosexual men participants reported having sex after drinking too much alcohol an
average of 4.41 times (SD=16.02, range 0-160) and reported having sex after
consuming drugs an average of 3.40 times (SD=16.26, range 0-160). These men
reported a mean of 1.63 partners (SD=2.98, range 0-32) with whom they had
unprotected vaginal sex, and an average of 2.44 unprotected women oral sex partners
(SD=12.95, range 0-161). Heterosexual men reported a mean of 12.41 unprotected
vaginal acts (SD=17.03, range 0-100), performed a mean number of 6.26 (SD=12.49,
range 0-100) unprotected oral acts on women, and had an average of 10.12 (SD=22.10,
range 0-161) unprotected oral acts performed on them by women over the four month
period. Thirty-seven of these men (23.6%) reported a mean number of 1.38 women
(SD=0.59, range 0-3) with whom they had unprotected anal sex, and an average
number of 1.78 (SD=3.34, range 0-20) unprotected anal acts.

Men Who Have Sex with Men
Men were classified as MSM (n=41) if they self-identified as gay/bisexual or
reported having a sexual encounter with another man in the previous four months.
These men reported having sex after drinking too much an average of 2.17 times
(SD=6.56, range 0-40) and having sex after consuming drugs an average of 7.83 times
(SD=24.29, range 0-120). MSM reported having unprotected anal intercourse with
2.41 men (SD=5.06, range 0-25), on average. Of the men reporting unprotected anal
intercourse (n=24), there were an average of 7.92 unprotected insertive anal (UIA) acts
(SD=17.13,range 0-80) and an average of 14.04 (SD=24.91, range 0-80) unprotected
receptive anal (URA) acts. These men also reported having unprotected oral sex with a
mean of 3.73 men (SD=4.68, range 0-20). Of the men reporting unprotected oral
intercourse (n=34), there were an average of 12.65 unprotected insertive oral (UIO) acts
(SD=22.76, range 0-100) and an average of 14.24 (SD=22.83, range 0-100) unprotected
receptive oral (URO) acts.
In conducting the above analyses, a very small but interesting subset of MSM
(n=l 1) emerged that reported unprotected sexual activity with both men and women in
the previous 4 months. These men reported having sex after consuming alcohol an
average of 1.36 times (SD=3.23, range 0-10) and after taking drugs an average of 1.82
times (SD=4.62, range 0-15). These men reported an average of 3.45 (SD=3.98, range

0-11) unprotected vaginal and 2.45 (SD=4.46, range 0-15) unprotected oral sex partners
who were women; an average of 0.73 (SD=1.56, range 0-5) unprotected anal and 1.18
(SD=1.78, range 0-5) unprotected oral sex partners who were men.
Comparison of sexual behaviors by group
Women, heterosexual men, and MSM were compared on a number of aggregate
measures of high-risk sexual behaviors. Nonparametric comparisons were made
between groups on number of unprotected sexual acts, number of unprotected anal and
vaginal sexual acts, number of unprotected oral sexual acts, and number of partners
with whom participants have had unprotected anal, oral, or vaginal sex. Between-
group comparisons were also made on the reported number of times the participant has
engaged in sexual activity after consuming drugs or too much alcohol. Lastly, an
analysis was completed on the relationship between membership in these groups and
having two or more sexual partners in the previous four months. Bonferroni
corrections were made for two-way group comparisons.
The three groups did not differ significantly on total number of unprotected acts
[Kruskal-Wallis H(2, 362)=4.23, n.s.]; number of unprotected anal and vaginal acts
[Kruskal-Wallis H(2, 321)=0.702, n.s.] ; and number of unprotected oral acts [Kruskal-
Wallis H(2, 301)=5.16, n.s.]. There were also no significant differences between

women and heterosexual men on the number of vaginal sex partners [z(354)=1.06,
n.s.]. There were significant between-group differences on number of anal sex partners
[Kruskal-Wallis H (2, 393)=30.50, /?<0.0001 ] and number of oral partners [Kruskal-
Wallis H(2, 393)=36.34, pO.OOOl], MSM reported significantly more anal partners
(M=5.42, SD=17.66) than women (M=l .00, SD=4.59, p<0.0001) or heterosexual men
(M=0.33, SD=0.65, p<0.0001). MSM also reported significantly more oral partners
(M=4.39, SD=4.48) than women (M=1.80, SD=5.07, p<0.0001) or heterosexual men
(M=2.44, SD=12.95, p<0.0001). There was a significant relationship between the
sexual risk group and the frequency of participants who reported two or more sexual
partners in the previous four months l/2(2, 398)=19.15, /?<0.0001; see Table 1], MSM
were significantly overrepresented in the group reporting more than one sexual partner
in the previous four months.

Table 1. Group Frequencies of High and Low Risk
Women (n=199) Heterosexual Men (n=158) MSM (n=41)
Number of Low Risk Expected % 53.5% 53.5% 53.5%
partners risk Actual % 59.3% 54.4% 22.0%
High risk Expected % 46.5% 46.5% 46.5%
Actual % 40.7% 45.6% 78.0%
Sexually Transmitted Infections
In the present sample, 26.6% (n=106) tested positive for at least one STI. No
one in the sample received current syphilis, trichomoniasis or genital ulcerative disease
diagnoses. Three percent (n=12) were diagnosed with a first episode of genital warts,
4.0% (n=16) with gonorrhea, 11.1% (n=44) with chlamydia, 1.3% (n=5) with a first
episode of herpes, and 0.8% (n=3) with HIV. In women, 3.5% (n=7) received a
diagnosis of pelvic inflammatory disease, and 5.0% (n=10) mucopurulent cervicitis. In
men, 18.6% (n=37) received a diagnosis of non-gonococcal urethritis. There was a
significant relationship between risk group and STI diagnosis [^(2, 398)=13.40,

/?=0.001; see Table 2]. Heterosexual men and MSM were significantly overrepresented
in the group with an STI diagnosis.
Table 2. Group Frequencies Sexually Transmitted Infections
Women (n=199) Heterosexual Men (n=158) MSM (n=41)
STI diagnosis No Expected % 73.4% 73.4% 73.4%
Actual % 81.4% 64.6% 68.3%
Yes Expected % 26.6% 26.6% 26.6%
Actual % 18.6% 35.4% 31.7%
Histrionic Personality Features and High-Risk Sexual Behavior
Nonparametric bivariate correlations between Histrionic Personality Features
and certain aggregate high-risk sexual behaviors revealed significant relationships in
most cases (see Table 3).

Table 3. Histrionic Personality and High-Risk Behavior Spearman Correlations
1. 2. 3. 4. 5. 6. 7.
1. Histrionic Personality 1.0 . . . . .
2. # Anal partners 0.174| 1.0 - - - - -
3. # Oral partners 0.224f 0.202f 1.0 . .
4. # Vaginal partners 0.110* 0.109* 0.257f 1.0 . .
5. # unprotected oral acts 0.194f 0.159f 0.244f 0.135* 1.0 .
6. # unprotected vaginal and anal acts 0.072 0.064 0.162f 0.116* 0.535| 1.0 -
7. # unprotected acts 0.122* 0.165f 0.33 It 0.206| 0.849| 0.864| 1.0
t /X0.01
Scores on the histrionic measure were also related to the number of times
having sex after having too much to drink (rho=.282,p<.001) and after taking drugs
(rho=.213, /?<.001). Significantly higher histrionic scores were reported by individuals
who indicated that they had (n=27) versus those who had (n=369) not given money,
drugs or shelter for sex [ M=23.48, SD=5.08 Vs. M=21.36, SD=3.75; /(394)=2.76,
/?< 01] and those who have (n=29) versus those who have not (n=367) received money,

drugs or shelter for sex [M=24.41, SD=4.56 Vs. M=21.28, SD=3.74; r(394)=4.28,
/K.001]. Those reporting that they have had sex with someone who has been in jail
(n=152, M=22.43, SD=4.13) also showed significantly higher histrionic personality
scores than those reporting that they have not [n=244, M=20.93, SD=3.61; r(394)=3.79,
A sequential logistic regression analysis was used to examine the independent
association of Histrionic personality features, after controlling for factors that have been
previously shown to be related to sexual risk. Since there were demonstrated
relationships between MSM status and high-risk sexual behaviors in the present sample
and previous research has demonstrated a relationship between characteristics such as
age and education to high-risk sexual behavior, these were entered into the first step as
control variables (see Table 4). The demographic variables, as a group, significantly
predicted multiple partner status [x2(3,395)=21.53,/?<0.0001] at step one; while age
and education were not significant (p=0.21 andp=0.73, respectively), MSM status was
a significant predictor (p<0.001). The second step included a categorical variable
coding for substance use during sex and significantly added to the prediction
[y2(l ,395 )=21.81, pO.OOO 1 ]. The final step included Histrionic personality features
and also significantly added to the prediction of multiple partner status, %2( 1,395)=6.36,
p< 0.012.

Table 4. Sequential Logistic Regression Analysis Predicting Multiple Partner Status
Variable and Step OR Cl E
1. Age 1.00 (0.98, 1.01) 0.754
Education 0.86 (0.90, 1.10) 0.862
MSM status 5.42 (2.40, 12.24) <0.001
2. Sex while using substances 2.49 (1.57,3.95) <0.001
3. Histrionic Personality 1.08 (1.01, 1.43) 0.013
Prediction of STIs
A univariate logistic regression indicated that multiple partner status predicted
diagnosis with an STI (OR=1.74, 95% 0=1.11-2.73, p=0.015). Histrionic scores,
although in the predicted direction, did not predict STI diagnosis at the univariate level
(OR=1.04, 95% 0=0.98-1.10, n.s.)

The first hypothesis that Histrionic personality features will predict active,
passive and partner related high-risk sexual behaviors is largely supported. At the
bivariate level Histrionic personality features were related to the number of unprotected
anal, oral, and vaginal partners. There was also a significant relationship between
Histrionic personality features and the total number of unprotected sexual acts and
unprotected oral sexual acts. Those reporting giving or receiving money, drugs or
shelter for sex reported significantly higher Histrionic scores than those reporting that
have not. Those reporting that they had had sex with someone they knew had been in
jail also reported higher Histrionic personality scores than those who had not. Most
importantly, a sequential logistic regression showed that Histrionic personality scores
significantly predicted sexual activity with multiple partners when controlling for age,
education, substance use, and MSM status.
The second hypothesis for this study was that Histrionic scores would be
positively related to risk of STD infection. While those with multiple partners showed
an almost one and one-third greater risk of infection with an STD, higher scores on the
Histrionic measure did not predict increased odds for infection with an STD. Complex
relationships often exist between psychological variables and disease outcomes that
make prediction difficult without large sample sizes and/or longitudinal designs.

Contrary to some accounts (Millon, 1986) this study did not find significant
differences between women and men on Histrionic scores. This finding supports
research, such as that by Nestadt et al., (1990) which suggests that prevalence rates are
essentially equivalent in men and women. One interesting finding of the present study
was the significantly higher Histrionic scores among MSM. This finding, however,
should be viewed with a great deal of caution, as the numbers of MSM in this study
were quite small. The finding that MSM reported greater Histrionic features may play
into stereotypes which research indicates therapist trainees may hold regarding gay men
(Boysen, Vogel, Madon, & Wester, 2006).
Another small, yet interesting, group that emerged in this study were MSM that
also reported sexual activity with women. While the numbers in this study were too
small to afford detailed analysis, these MSM appeared to have relatively high-risk
sexual behaviors. High-risk MSM who also have sex with women may represent a
potential epidemiological bridge between the sexual networks of homosexuals and
heterosexuals and, therefore, deserve further study (for potential implications see
Laumann & Youm, 1999 and Aral, 1999). An epidemiological bridge serves to
facilitate the transmission of infections from relatively high-risk groups to relatively
low-risk groups.

High-risk sexual behavior has been associated with many of the cluster B
personality disorders, specifically APD and BPD (Hull et al., 1993; Kalichman et al.,
2002; Kelly, et al., 1992; Martinez-Baptista, 2004). Certain patterns of behavior,
particularly increased numbers of sexual partners, have been documented in NPD (Apt
& Hurlbert, 1994; Buss & Shakleford, 1997; Hurlbert et al., 1994; Lavan & Johnson,
2002). Given the sexually charged nature of the symptomatology of HPD (APA, 1994,
2000) it is surprising that there is little research directly examining the role HPD may
play in behaviors that put individuals at increased risk for STIs. The present research
addresses this gap in the literature by showing that psychological characteristics
considered necessary for the diagnosis of HPD (APA, 1994,2000; Clark, 1993) appear
to be associated with an increased tendency to engage in behaviors that may put these
individuals at risk for infection with STIs.
Infection with an STI has the potential for many negative outcomes. While
often curable, bacterial STIs still present many potential problems for those infected,
including pelvic inflammatory disease, infertility and sterility (Hillis & Wasserheit,
1996; Idahl, et al., 2004). Bacterial STIs also enhance the risk of sexually transmitted
HIV infection (Cameron et al., 1989; Fleming & Wasserheit, 1999; Laga et al., 1993;
Plummer et al., 1991; Wasserheit, 1992). Infection with viral STIs, such as human
papillomavirus infection and HIV are often associated with much more severe

outcomes, such as increased risk for certain forms of cancer (Lazo, 1999), and in the
case of HIV, death (Anderson et al., 2002). Hence, STIs are considered major
preventable sources of morbidity and mortality (Institute of Medicine, 1997).
The high prevalence of personality disorders, especially Antisocial Personality
Disorder, among STD clinic patients has been recognized by other researchers
(Erbelding, Hutton, Zenilman, Hunt & Lyketsos, 2004). Erbelding and her colleagues
(2004) have suggested that publicly funded health clinics may need to explore
offering innovative behavioral approaches, beyond those currently offered in order to
improve HIV and STD prevention outcomes. At the very least, public health
clinicians should be trained to recognize potential personality disorders and to refer
these patients for help that goes beyond services that an STD clinic can provide
(Kalichman & Cain, 2004).
Undoubtedly, mental health clinicians should be cognizant of the relationship
between cluster B personality features and sexual-risk behaviors. Mental health
clinicians who may come in contact with those exhibiting the various forms of cluster B
personality pathology will certainly want to assess these patients for high-risk sexual
behaviors regardless of the specific diagnosis. While mental health professional may
be aware of the association of other cluster B personality disorders with sexual risk
behavior, HPD may not immediately come to mind. Those with HPD may initially
present to a mental health professional with some form of Axis I disorder, such as

depression; problems with sexual risk may not be immediately apparent. A detailed
sexual history is often not obtained unless the presenting problem is a sexual disorder.
Mental health practitioners should obtain detailed relationship and sexual histories from
clients who exhibit features associated with HPD. More traditional HIV risk reduction
strategies that rely on education and behavioral-skills building may be insufficient for
these individuals. It may also prove fruitful to integrate mental health services with
sexual risk reduction messages for those exhibiting HPD and other cluster B
Indeed, other research examining sexual compulsivity among patients in
various medical clinics have made similar recommendations (Benotsch, Kalichman, &
Pinkerton, 2001; Kalichman & Cain, 2004). Kalichman & Cain (2004) suggest that
behavioral self-management strategies used in cognitive behavioral therapy for sexual
preoccupations and poor impulse control might be adapted for inclusion in STI
risk-reduction counseling.
Dialectical Behavior Therapy (DBT; Linehan, 1993a, 1993b), which contains
elements of behavioral, cognitive and supportive psychotherapies, may offer some
potential treatment strategies for those exhibiting high-risk sexual behaviors in the
context of cluster B personality disorders. Good evidence exists for the impact of DBT
on the management of behavioral problems of impulsivity and self-harming behavior
for those with Borderline Personality Disorder (Roth & Fonagy, 2005). Patients with

BPD usually have multiple problems and this may be true of other cluster B personality
disorders, including HPD. The course of DBT over time is organized into a number of
stages and structured in terms of hierarchies of targets at each stage. Early stage
treatment focuses on harmful behaviors and behaviors that interfere with the quality of
life, together with developing the necessary skills to resolve these problems (Linehan,
1993a). Quality of- life interfering behaviors include criminal behaviors, interpersonal
dysfunction, high-risk sexual behavior, or homelessness (Salsman, 2006). DBT also
explicitly addresses skill deficits by systematically teaching 4 sets of skills in a group
format: mindfulness, distress tolerance, emotional regulation, and interpersonal
effectiveness. The interpersonal effectiveness skills may be particularly useful for
those with HPD, as these skills focus on effective ways of achieving ones objectives
with other people: to effectively ask for what one wants, to say no and have it taken
seriously, to maintain relationships and to maintain self-esteem in interactions with
others (Linehan, 1993b). Use of treatment strategies that have been shown effective in
other cluster B personality disorders, such as BPD, may prove useful if there are
underlying issues linking this set of disorders.
Evidence is beginning to emerge that may link the cluster B personality
disorders at a neurological level. There is evidence from studies examining the
relationship between cluster B personality disorders and other risky behaviors that
impulsivity may mediate the relationship between these personality disorders and

certain risk behaviors. Steel and Blaszczynski (1998) found that impulsivity mediates
the relationship between personality dysfunction and the severity of pathological
gambling; they posit that impulsivity may be part of the general structure of cluster B
and certain cluster C personality disorders. Other researchers have found a similar
mediating link of impulsivity between cluster B personalities and substance use
disorders and self-harming behaviors (Casillas & Clark, 2002). Similarly, other
researchers have found a general set of disinhibitory traits that may convey risk of
substance use disorders and symptoms of all four cluster B personality disorders in men
(Taylor, Reeves, James & Bobadilla, 2006). Recently, a genetic profile that includes an
allele coding for a low-activity version of MAO A has been shown to be associated with
these personality disorders (Jacob, et al., 2005).
A number of issues may be considered limitations in this study of Histrionic
personality and high-risk sexual behavior. The study examined these traits in a sample
of individuals presenting for treatment at an STD clinic, hence; the participants may
represent a particularly high-risk population. While this may limit generalizability to
lower risk individuals, interventions targeting the highest risk individuals offer the most
hope of curbing the spread of STIs. The fact that the current study examined
participants in a single city may also limit the generalizability.

The current study was also cross-sectional in design; therefore, the ability to
draw causal conclusions is limited. While the definition of a personality disorder
suggests that these patterns of inner experience and behavior have an onset in
adolescence or early adulthood (American Psychiatric Association, 2000), the design of
this study cannot establish the temporal precedence of personality pathology. It is
plausible that certain personality characteristics and high-risk sexual behaviors arise
concurrently in response to some third variable.
Common method variance may be among alternative explanations for the
findings in this study. Common method variance refers to variance that is attributable
to the measurement method rather than the constructs] of interest (Fiske, 1982, p 81).
Several forms of sources of common method variance could account for some of the
covariation among the constructs in this study (Padsakoff, MacKenzie, Lee &
Podsakoff, 2003). Respondents may have reacted to items more as a result of their
social acceptability than their true feelings. Another potential form of common method
variance stems from the fact that all questions used in this study were self-reported,
therefore, may suffer from common rater-effects, which could result in systematic over
or underreporting throughout the survey.
Future Research
The present study raises many potential subjects for further study. A
longitudinal design may help to provide evidence for the causal direction in the

relationship between Histrionic personality and high-risk sexual behavior. A
longitudinal design may also be useful in exploring factors that may mediate the
relationship between Histrionic personality and sexual risk. Good candidates for
mediational variables include impulsivity and sensation-seeking (Donohew et al., 2000;
Lo Conte, et al., 1997; McCoul & Haslarn, 2001; Robbins & Bryan, 2004; Seal &
Agostinelli, 1994).
Another useful exercise would be to examine the relationship of Histrionic
personality to the incidence of STIs over time. This study failed to find a relationship
between Histrionic personality features and STI outcomes. A study using a larger
sample size conducted over a longer period of time may uncover this hypothesized
Personality disorders are thought to be among the most resistant disorders to
treatment (Davison, 2002). Research examining treatment modalities that are effective
in reducing sexual risk behaviors in those with cluster B personality disorders is an
important future endeavor. Such research may want to examine underlying difficulties
those with HPD may have with maintaining relationships. Future research may also
need to examine the antecedents of high-risk sexual encounters among those with HPD
in order to determine appropriate treatment targets.
Research has reported that clinicians are less inclined than researchers to use
direct questions in determining the presence of personality disorders (Zimmerman &

Mattia, 1999); hence, questions have been raised about the validity of research on
personality disorders in which diagnoses are based on self-report measures (Westen,
1997). This study examined self-reported Histrionic personality characteristics rather
than a diagnosis of Histrionic Personality Disorder, per se\ therefore, research using an
actual clinician diagnosis could prove enlightening.
Comparison of STD clinic patients to the general population may help to
determine if STD clinic patients exhibit higher HPD symptoms than the general public.
Further research with STD clinic patients exhibiting Histrionic features, such as
qualitative interviews, may provide additional information regarding why these
individuals tend to engage in higher risk sexual behaviors which could inform treatment
strategies. Further examination of Histrionic personality features in MSM may also
prove interesting.
Overall, this study was methodologically strong. The sample size of 400 is
relatively large for a study of this type. All measures used in the study have been
empirically validated and demonstrated good reliability. The use of ACASI also
represents a methodological strength, as only relevant questions were asked of the
participants and ACASI is an effective method to reduce socially desirable responding

over standard interviewer administered questionnaires (Hewitt, 2002; Macalino, et al.,
2002; Turner, et al., 1998).
This study represents an important addition to research on high-risk sexual
behavior and personality characteristics. Negative consequences from engaging in high-
risk sexual behavior are manifold. Transmission of infections that have serious health
implications are just one of the negative outcomes that can result from engaging in
high-risk sexual behavior. While research has uncovered a relationship between some
of the cluster B personality disorders and sexual risk-taking, Histrionic Personality
Disorder remains one of the least studied disorders falling in this cluster. Evidence that
Histrionic personality features may play a role in engaging in behaviors that put one at
risk for contracting or transmitting certain infections has important implications from
clinical and theoretical standpoints. The research presented here may represent an
important line of investigation for many future studies.

SNAP Histrionic Questions_________________DSM IV Histrionic Criteria
1. I like people to notice how I look when I go out in public Criterion 1
2. I like to show off Criterion 6
3. I frequently check with others to see if Im doing OK Criterion 7
4. I dress to attract sexual attention Criterion 2
5. The way I behave often gets me in trouble on the job, at home or at school. Functioning deficit
6. I wear clothes that draw attention Criterion 4
7. I often feel lively and cheerful for no good reason Criterion 3
8. My mood often goes up and down. Criterion 3
9. I express my feelings much more openly than most people do. Criterion 8

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental
disorders (3rd edition, Revised). Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th edition). Washington, DC: Author.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental
disorders: DSM-IV-TR. Washington, DC: Author.
Anderson, K., Keith, J., Novak, P. D., & Elliot, M. A. (2002). Mosby's medical,
nursing, & allied health dictionary (6th ed.): Mosby St. Louis.
Apt, C., & Hurlbert, D. F. (1994). The sexual attitudes, behavior, and relationships of
women with histrionic personality disorder. Journal of Sex & Marital Therapy,
20(2), 125-133.
Aral, S. O. (1993). Heterosexual transmission of HIV: The role of other sexually
transmitted infections and behavior in its epidemiology prevention and control.
Annual Review of Public Health, 14, 451 -467.
Aral, S. O. (1999). Sexual network patterns as determinants of STD rates: paradigm
shift in the behavioral epidemiology of STDs made visible. Sexually
Transmitted Diseases, 26(5), 250-261.
Aral S.O. & Wasserheit J.N. (1995). Interactions among HIV, other sexually
transmitted diseases, socioeconomic status, and poverty in women. In O'Leary
A. and Jemmott L.S. (Eds.), Women at risk: issues in the primary prevention of
AIDS. New York: Plenum Press, 13-41.
Benotsch, E. G., Kalichman, S. C., & Pinkerton, S. D. (2001). Sexual compulsivity in
HIV-positive men and women: Prevalence, predictors, and consequences of
high-risk behaviors. Sexual Addiction & Compulsivity: The Journal of
Treatment and Prevention, 8(2), 83-99.
Bomstein, B. (1999) Dependent and histrionic personality disorders. In Millon, T.,
Blaney, P.H., and Davis, R.D. (Eds.), Oxford Textbook of Psychopathology,
New York: Oxford University Press, 523-534.

Boysen, G. A., Vogel, D. L., Madon, S., & Wester, S. R. (2006). Mental health
stereotypes about gay men. Sex Roles, 54( 1), 69-82.
Bronzan R., Echavarria L., Hermida J., Trepka M., Bums T., Fox, K. (2002). Syphilis
among men who have sex with men (MSM) in Miami-Dade County, Florida
[Abstract]. In: Program and abstracts of the 2002 National STD Prevention
Conference, San Diego, California, March 4-7.
Brooner, R. K., Bigelow, G. E., Strain, E., & Schmidt, C. W. (1990). Intravenous drug
abusers with antisocial personality disorder: Increased HIV risk behavior. Drug
and Alcohol Dependence, 26(1), 39-44.
Brooner, R. K., Greenfield, L., Schmidt, C. W., & Bigelow, G. E. (1993). Antisocial
personality disorder and HIV infection among intravenous drug abusers.
American Journal of Psychiatry, 150(1), 53-58.
Buss, D. M. & Shackelford, T. K. (1997). Susceptibility to infidelity in the first year of
marriage. Journal of Research in Personality, 31, 193-221.
Cameron, D. W., Simonsen, J. N., D'Costa, L. J., Ronald, A. R., Maitha, G. M.,
Gakinya, M. N., et al. (1989). Female to male transmission of human
immunodeficiency virus type 1: Risk factors for seroconversion in men. Lancet,
2(8660), 403-407.
Casillas, A., & Clark, L. A. (2002). Dependency, impulsivity, and self-harm: Traits
hypothesized to underlie the association between cluster B personality and
substance use disorders. Journal of Personality Disorders, 16(5), 424-436.
Centers for Disease Control and Prevention (1999). Resurgent bacterial sexually
transmitted disease among men who have sex with men-King County,
Washington, 1997-1999. Morbidity and Mortality Weekly Report, 48,113-111.
Centers for Disease Control and Prevention (2001). Outbreak of syphilis among men
who have sex with men Southern California, 2000. Morbidity and Mortality
Weekly Report, 50, 117-20.
Centers for Disease Control and Prevention (2002). Primary and secondary syphilis
among men who have sex with men New York City, 2001. Morbidity and
Mortality Weekly Report, 51, 853-6.

Centers for Disease Control and Prevention (2003). Primary and Secondary Syphilis -
United States, 2002. Morbidity and Mortality Weekly Report, 52, 1117-20.
Centers for Disease Control and Prevention (2004a). Increases in fluoroquinolone-
resistant Neisseria gonorrhoeae among men who have sex with men United
States, 2003, and revised recommendations for gonorrhea treatment, 2004.
Morbidity and Mortality Weekly Report, 53, 335-338.
Centers for Disease Control and Prevention (2004b). Sexually Transmitted Disease
Surveillance 2003 Supplement, Syphilis Surveillance Report. Atlanta, GA:
U.S. Department of Health and Human Services, Centers for Disease Control
and Prevention.
Centers for Disease Control and Prevention (September, 2005a). Sexually
Transmitted Disease Surveillance, 2004. Atlanta, GA: U.S. Department of
Health and Human Services.
Centers for Disease Control and Prevention (November, 2005b). Trends in
Reportable Sexually Transmitted Diseases, 2004: National Surveillance Data
for Chlamydia, Gonorrhea, and Syphilis. Atlanta: GA: U.S. Department of
Health and Human Services.
Centers for Disease Control and Prevention (December, 2005c). Sexually Transmitted
Disease Surveillance 2004 Supplement, Syphilis Surveillance Report. Atlanta,
GA: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention.
Centers for Disease Control and Prevention (2005d). HIV/AIDS Surveillance Report,
2004. Vol. 16. Atlanta: US Department of Health and Human Services, Centers
for Disease Control and Prevention. Retrieved December 28, 2005 from .
Centers for Disease Control and Prevention (2005e). Sexually Transmitted Disease
Surveillance 2004 Supplement, Chlamydia Prevalence Monitoring Project.
Atlanta, GA: U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention. Retrieved January 13,2006 from 2004FINAL.pdf.

Chen S. Y, Gibson S., Katz M.H., Klausner J. D., Dilley J. W., Schwarcz S. K., et al.
(2002). Continuing increases in sexual risk behavior and sexually transmitted
disease among men who have sex with men: San Francisco, Calif. 1999-2001
[Letter], American Journal of Public Health', 92, 1387.
Colfax, G., Vittinghoff, E., Husnik, M. J., McKiman, D., Buchbinder, S., Koblin, B., et
al. (2004). Substance use and sexual risk: A participant-and episode-level
analysis among a cohort of men who have sex with men. American Journal of
Epidemiology, 159, 1002-1012.
Conklin, C. Z., Bradley, R., & Westen, D. (2006). Affect regulation in borderline
personality disorder. The Journal of Nervous and Mental Disease, 194(2), 69-
Cook, L. S., Koutsky, L. A., & Holmes, K. K. (1994). Circumcision and sexually
transmitted diseases. American Journal of Public Health, 84(2), 197-201.
Cooper, M. L. (2002). Alcohol use and risky sexual behavior among college students
and youth: Evaluating the evidence. Journal of Studies on Alcohol, 14,101
Corsini, R. (2002). The dictionary of psychology. London: Brunner-Routledge.
Davison, S. E. (2002). Principles of managing patients with personality disorder.
Advances in Psychiatric Treatment, 5(1), 1-9.
Donegan, N. H., Sanislow, C. A., Blumberg, H. P., Fulbright, R. K., Lacadie, C.,
Skudlarski, P., et al. (2003). Amygdala hyperreactivity in borderline
personality disorder: implications for emotional dysregulation. Biological
Psychiatry, 54(11), 1284-1293.
Donohew, L., Zimmerman, R., Cupp, P. S., Novak, S., Colon, S., & Abell, R. (2000).
Sensation seeking, impulsive decision-making, and risky sex: Implications for
risk-taking and design of interventions. Personality and Individual Differences,
28(6), 1079-1091.
D'Souza G., Lee J. H., Paffel J. M. (2003). Outbreak of syphilis among men who have
sex with men in Houston, Texas. Sexually Transmitted Diseases, 30, 872-873.

Ferrando, S. J. (1997). Substance use disorders and HIV illness. AIDS Reader, 7(2), 57-
Erbelding, E. J., Hutton, H. E., Zenilman, J. M., Hunt, W. P., & Lyketsos, C. G.
(2004). The prevalence of psychiatric disorders in sexually transmitted disease
clinic patients and their association with sexually transmitted disease risk.
Sexually Transmitted Diseases, 57(1), 8-12.
Fiske, D. W. (1982). Convergent-discriminant validation in measurements and research
strategies. In D. Brinbirg & L. H. Kidder (Eds.), Forms of validity in research.
San Francisco: Jossey-Bass.
Fleming, D. T., & Wasserheit, J. N. (1999). From epidemiologic synergy to public
health policy and practice: The contribution of other sexually transmitted
diseases to sexual transmission of HIV infection. Sexually Transmitted
Infections, 75, 3-17.
Glynn, M., & Rhodes, P. (2005). Estimated HIV prevalence in the United States at the
end of 2003 [paper], National HIV Prevention Conference. Atlanta.
Goedert, J. J. (1987). What is safe sex? Suggested standards linked to testing for human
immunodeficiency virus. New England Journal of Medicine, 576(21), 1339-
Gunderson, J. G. (1988). Personality disorders. In: Nicholi Jr., A., (Ed.), The new
Harvard guide to psychiatry. Cambridge, MA: Harvard University Press, pp.
Hamilton, N. G. (1988). Self and others: Object relations theory in practice, Northvale,
NJ: Aronson.
Hewitt, M. (2002). Attitudes toward interview mode and comparability of reporting
sexual behavior by personal interview and audio computer-assisted self-
interviewing: Analyses of the 1995 national survey of family growth.
Sociological Methods & Research, 37(1), 3-26.
Hillis, S.D. & Wasserhei,t J. N. (1996). Screening for Chlamydia A key to the
prevention of pelvic inflammatory disease. New England Journal of Medicine,
334(21), 1399-1401.

Hollander, E., & Rosen, J. (2000). Impulsivity. Journal of Psychopharmacology, 14(2
Suppl 1), S39-44.
Hurlbert, D. F., Apt, C., Gasar, S., Wilson, N. E., & Murphy, Y. (1994). Sexual
narcissism: A validation study. Journal of Sex and Marital Therapy, 20(1), 24-
Hull, J. W., Clarkin, J. F., & Yeomans, F. (1993). Borderline personality disorder and
impulsive sexual behavior. Hospital & Community Psychiatry, 44(10), 1000-
Idahl, A., Boman, J., Kumlin, U. & Olofsson, J. I. (2004) Demonstration of Chlamydia
trachomatis IgG antibodies in the male partner of the infertile couple is
correlated with a reduced likelihood of achieving pregnancy. Human
Reproduction, 19, 5,1121-1126.
Institute of Medicine (1997). The Hidden Epidemic: Confronting Sexually Transmitted
Diseases. Committee on Prevention and Control of Sexually Transmitted
Diseases. Washington, DC: National Academy Press.
Jacob, C. P., Muller, J., Schmidt, M., Hohenberger, K., Gutknecht, L., Reif, A., et al.
(2005). Cluster B personality disorders are associated with allelic variation of
monoamine oxidase A activity. Neuropsychopharmacology, 30, 1711-1718.
Kalichman, S. (1998). Preventing AIDS: A sourcebook for behavioral interventions.
Mahwah, N.J.: Lawrence Erlbaum Associates.
Kalichman, S. C. Benotsch, E. G., Rompa, D, Gore-Felton, C., Austin, J., Luke, W. et
al. (2001) Unwanted sexual experiences and sexual risks in gay and bisexual
men: Associations among revictimization, substance use and psychiatric
symptoms. Journal of Sex Research, 38, 1-9.
Kalichman, S. C., & Cain, D. (2004). The relationship between indicators of sexual
compulsivity and high risk sexual practices among men and women receiving
services from a sexually transmitted infection clinic. The Journal of Sex
Research, 41(3), 235-242.
Kalichman, S. C., Gore-Felton, C., Benotsch, E. G., Cage, M. & Rompa, D. (2004).
Trauma symptoms, sexual behaviors, and substance abuse: Correlates of

childhood sexual abuse and HIV risks among men who have sex with men.
Journal of Child Sexual Abuse, 13, 1-15.
Kalichman, S. C., Sikkema, K. J., DiFonzo, K. G., Luke, W. G., & Austin, J. G. (2002).
Emotional adjustment in survivors of sexual assault living with HIV-AIDS.
Journal of Traumatic Stress, 15(4), 289-296.
Kauth, M. R., St Lawrence, J. S., & Kelly, J. A. (1991). Reliability of retrospective
assessments of sexual HIV risk behavior: A comparison of biweekly, three-
month, and twelve-month self-reports. AIDS Education and Prevention, 5(3),
Kelly, J. A., Murphy, D. A., Bahr, G. R., Brasfield, T. L., Davis, D. R., Hauth, A. C., et
al. (1992). AIDS/HIV risk behavior among the chronic mentally ill. American
Journal of Psychiatry, 149(1), 886-889.
Knudsen, R. P. (January 3,2005) Neurosyphilis. Retrieved March 24, 2007 from
http ://www. emedicine. com/neuro/topic684.htm.
Kraus, G., & Reynolds, D. J. (2001). The" abc's" of the cluster b's: Identifying,
understanding, and treating cluster b personality disorders. Clinical Psychology
Review, 21(3), 345-373.
Laga, M., Manoka, A., Kivuvu, M., Malele, B., Tuliza, M., Nzila, N., et al. (1993).
Non-ulcerative sexually transmitted diseases as risk factors for HIV-1
transmission in women: Results from a cohort study. AIDS, 7(1), 95-102.
Laumann, E. O., & Youm, Y. (1999). Racial/ethnic group differences in the
prevalence of sexually transmitted diseases in the United States: a network
explanation. Sexually Transmitted Diseases, 26(5), 250-261.
Lavan, H., & Johnson, J. G. (2002). The association between axis I and II psychiatric
symptoms and high-risk sexual behavior during adolescence. Journal of
Personality Disorders, 7(5(1), 73-94.
Lavreys, L., Rakwar, J. P., Thompson, M. L., Jackson, D. J., Mandaliya, K, Chohan,
B. H., et al. (1999). Effect of circumcision on incidence of human
immunodeficiency virus type 1 and other sexually transmitted diseases: A

prospective cohort study of trucking company employees in Kenya. The
Journal of Infectious Diseases, 180(2), 330-336.
Lazo, P.A. (1999). The molecular genetics of cervical carcinoma. British Journal of
Cancer, 80, 2008-2018
Linehan, M. M. (1993a). Cognitive-Behavioral treatment of borderline personality
disorder. New York: Guilford Press.
Linehan, M. M. (1993b). Skills Training Manual for Treating Borderline Personality
Disorder. New York: Guilford Press.
Links, P. S. (1996). Clinical assessment and management of severe personality
disorder, Washington, DC.: American Psychiatric Press.
Lo Conte, J. S., OLeary, A., & Labouvie, E. (1997). Psychosocial correlates of HIV-
related sexual behavior in an inner-city STD clinic. Psychology and Health, 12,
Macalino, G. E., Celentano, D. D., Latkin, C., Strathdee, S. A., & Vlahov, D. (2002).
Risk behaviors by audio computer-assisted self-interviews among HIV-
seropositive and HIV-seronegative injection drug users. AIDS Education &
Prevention, 14(5), 367-378.
MacKenzie, K. R. (1997). Time-managed group psychotherapy: Effective clinical
applications, American Psychiatric Press, Washington, DC.
Martinez-Baptista, L. M. (2004). The relationship between personality pathology and
HIV-risk in a sample of mentally ill adults [Dissertation]. Miami: University of
McCoul, M. D., & Haslam, N. (2001). Predicting high risk sexual behaviour in
heterosexual and homosexual men: The roles of impulsivity and sensation
seeking. Personality and Individual Differences, 31(8), 1303-1310.
McCune, J. M. (2001). The dynamics of CD4 T-cell depletion in HIV disease. Nature,
410, 974-979.

McGregor, T. A., Richard, A. J., & Pulver, B. (April 24,2006). Syphilis. Retrieved
May 12, 2006, from
Millon, T. (1981) Disorder of personality: DSM-III: Axis II. New York: Wiley-
Millon, T., 1986. A theoretical derivation of pathological personalities. In: Millon, T.
and Klerman, G., (Eds.) Contemporary directions in psychopathology, New
York: Guilford Press,, pp. 639-669.
Millon, T. (1994) Toward a new personology : An evolutionary model. New York: J.
Wiley & Sons.
Millon, T. & Davis, R.D. (1996) Disorders of personality: DSM-IV and beyond. New
York: Wiley-Interscience.
Millon, T., Grossman, S., Meagher, S., Millon, C., & Everly, G. (2000). Personality
guided therapy. New York: Wiley.
Moodley, P., Wilkinson, D., Connolly, C., Moodley, J., & Sturm, A. W. (2002).
Trichomonas vaginalis is associated with pelvic inflammatory disease in
women infected with human immunodeficiency virus. Clinical Infectious
Diseases, 34(4), 519-522.
Muller, J. L., Sommer, M., Wagner, V., Lange, K., Taschler, H., Roder, C. H., et al.
(2003). Abnormalities in emotion processing within cortical and subcortical
regions in criminal psychopaths evidence from a functional magnetic
resonance imaging study using pictures with emotional content. Biological
Psychiatry, 54(2), 152-162.
Nestadt, G., Romanoski, A. J., Chalel, R. and Merchant, A., (1990). An
epidemiological study of histrionic personality disorder. Psychological
Medicine, 20,413-422.
Newbem, E. C., Miller, W. C., Schoenbach, V. J., & Kaufman, J. S. (2004). Family
socioeconomic status and self-reported sexually transmitted diseases among
black and white American adolescents. Sexually Transmitted Diseases, 31(9),

Ott, R. L., & Longnecker, M. (2001). An Introduction to Statistical Methods and Data
Analysis. Pacific Grove, CA: Wadsworth Group: Inc.
Parsons, J. T., Halkitis, P. N., Wolitski, R. J., & Gomez, C. A. (2003). Correlates of
sexual risk behaviors among HIV-positive men who have sex with men. AIDS
Education and Prevention, 15(5), 383-400.
Plummer, F. A., Simonsen, J. N., Cameron, D. W., Ndinya-Achola, J. O., Kreiss, J. K.,
Gakinya, M. N., et al. (1991). Cofactors in male-female sexual transmission of
human immunodeficiency virus type 1 .Journal of Infectious Diseases, 163(2),
Podsakoff, P. M., MacKenzie, S. B., Lee, J. Y., & Podsakoff, N. P. (2003). Common
method biases in behavioral research: A critical review of the literature and
recommended remedies. Journal of Applied Psychology, 88(5), 879-903.
Purcell, D. W., Mizuno, Y., Metsch, L. R., Garfein, R., Tobin, K., Knight, K., et al.
(2006). Unprotected sexual behavior among heterosexual HIV-positive
injection drug using men: Associations by partner type and partner serostatus.
Journal of Urban Health, 83(4), 656-668.
Ratelle, S., Bertrand, T., & Dumas, W. (2004). Increases in fluoroquinolone-resistant
Neisseria gonorrhoeae among men who have sex with menUnited States,
2003, and revised recommendations for gonorrhea treatment, 2004. MMWR
Morbidly and Mortality Weekly Report, 53, 335-338.
Robbins, R. N., & Bryan, A. (2004). Relationships between future orientation,
impulsive sensation seeking, and risk behavior among adjudicated adolescents.
Journal of Adolescent Research, 19(4), 428-445.
Robinson B .C., Chiliade P. A., Lee C., Bautista. J., & Saenz, G. (2004). Redirecting
elimination efforts in response to the changing epidemiology of syphilis. In:
Programs and abstracts of the 2004 National STD Prevention Conference;
March 8-11, Philadelphia, PA. Abstract 167.
Rowland-Jones, S. (1999). HIV infection: Where have all the T-cells gone? Lancet,
354(9X12), 5-7.

Royce, R. A., Sena, A., Cates, W., & Cohen, M. S. (1997). Sexual transmission of HIV.
New England Journal of Medicine, 336, 1072-1078.
Ruegg, R. G., Haynes, C. and Frances, A., 1997. Assessment and management of
antisocial personality disorder. In Rosenbluth, M. and Yalom, I., (Eds),
Treating difficult personality disorders, San Francisco: Jossey-Bass, 123-172.
Salsman, N. L. (2006) Understanding the usefulness of psychosocial interventions for
personality disorders. Retrieved March 30,2007 from
Schmid, G., Markowitz, L., Joesoef, R., & Koumans, E. (2000). Bacterial vaginosis and
HIV infection. Sexually Transmitted Infections, 76, 3-4.
Schneider, J. P., & Irons, R. R. (2001). Assessment and treatment of addictive sexual
disorders: Relevance for chemical dependency relapse. Substance Use and
Misuse, 36(13), 1795-1820.
Schwarcz, S. K., Kellogg, T. A., McFarland, W., Louie, B., Klausner, J., Withum, D.
G., et al. (2002). Characterization of sexually transmitted disease clinic patients
with recent human immunodeficiency virus infection. The Journal of Infectious
Diseases, 756(7), 1019-1022.
Schwebke, J. R. (2004). Trichomoniasis care today: A clinicians guide to timely
diagnosis and successful treatment. Retrieved May 1, 2006, from Mono
Seal, D. W., & Agostinelli, G. (1994). Individual differences associated with high-risk
sexual behaviour: Implications for intervention programmes. AIDS Care, 6(4),
Semple, S. J., Patterson, T. L., & Grant, I. (2000). Psychosocial predictors of
unprotected anal intercourse in a sample of HIV positive gay men who
volunteer for a sexual risk reduction intervention. AIDS Education and
Behavior, 12, 416-430.

Siever, L. J. (2002) Neurobiology of impulsive-aggressive personality-disordered
patients. Psychiatric Times, 19(8), 1.
Simms, L. J. (2002). Development, reliability, and validity of a computerized adaptive
version of the schedule for nonadaptive and adaptive personality [Thesis],
Retrieved 6/8/2006 from
Skodol, A. E., Oldham, J. M., & Gallaher, P. E. (1999). Axis II comorbidity of
substance use disorders among patients referred for treatment of personality
disorders. American Journal of Psychiatry, 156, 733-738.
Steel, Z., & Blaszczynski, A. (1998). Impulsivity, personality disorders and
pathological gambling severity. Addiction, 93(6), 895-905.
Sutton, M. Y., Sternberg, M., Nsuami, M., Behets, F., Nelson, A. M., & St. Louis, M.
E. (1999). Trichomoniasis in pregnant human immunodeficiency virus-infected
and human immunodeficiency virus-uninfected Congolese women: Prevalence,
risk factors, and association with low birth weight. American Journal Obstetrics
and Gynecology, 181(3), 656-662.
Sprock, J., Blashfield, R. K., & Smith, B. (1990). Gender weighting of DSM-III-R
personality disorder criteria. American Journal of Psychiatry, 147, 586-590.
Taylor, J. (2004). Electrodermal reactivity and its association to substance use
disorders. Psychophysiology, 41(6), 982-989.
Taylor, J., Reeves, M., James, L., & Bobadilla, L. (2006). Disinhibitory trait profile
and its relation to cluster B personality disorder features and substance use
problems. European Journal of Personality, 20(4), 271-284.
Turner, C. F., Ku, L., Rogers, S. M., Lindberg, L. D., & Pleck, J. H. (1998).
Adolescent sexual behavior, drug use, and violence: Increased reporting with
computer survey technology. Science, 280(5365), 867-873.
Vazire, S., & Funder, D. C. (2006). Impulsivity and the self-defeating behavior of
narcissists. Personality and Social Psychology Review, 10(2), 154-165.

Viikki, M. (2000). Gynaecological infections as risk determinants of subsequent
cervical neoplasia. Acta Oncologica, 39{ 1), 71-75.
Washington State Department of Health. (2002). Major risk and protective factors -
Sexual Behavior. Retrieved December 13,2005, 2005, from Sex.doc
Wasserheit, J. N. (1992). Epidemiological synergy. Interrelationships between human
immunodeficiency virus infection and other sexually transmitted diseases.
Sexually Transmitted Diseases, 19(2), 61-77.
Weinstock, H., Berman, S., & Cates Jr., W. (2004). Sexually transmitted diseases
among American youth: Incidence and prevalence estimates, 2000.
Perspectives on Sexual and Reproductive Health, 36(1), 6-10.
Westen, D. (1997). Divergences between clinical and research methods for assessing
personality disorders: implications for research and the evolution of axis II.
American Journal of Psychiatry, 154, 895-903.
Widiger, T. A. (1998) Sex biases in the diagnosis of personality disorders. Journal of
Personality Disorders, 12, 95-118.
Wilkerson, R. G., Sinert, R., Friedman, B. W., & Brillman, J. C. (2006).
Trichomoniasis. Retrieved April 30,2006, from .htm
Zimmerman, M., & Mattia, J. I. (1999). Differences Between Clinical and Research
Practices in Diagnosing Borderline Personality Disorder. American Journal of
Psychiatry, 156, 1570-1574.