By Patricia J. Anderson
Clinical Assessment & Diagnosis, Fall 1997, Denis Ferguson
Self-Defeating Personality Disorder
According to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV) a personality disorders is, “… an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (First, 1994, p. 629). Personality traits are enduring patterns of how we see, relate to, and think about our world and ourselves. Personality disorders are diagnosed only when these traits are inflexible, maladaptive and cause subjective distress or significant functional impairment (First, 1994).
Self-Defeating Personality Disorder (SDPD) (previously called Masochistic Personality Disorder) was included in Appendix A of the DSM-III-R which qualified it as a proposed disorder that needed further research. The word masochism was eliminated to avoid its association with older psychoanalytic views of female sexuality and the implication unconscious pleasure gained from suffering. The most basic aspect of SDPD is it’s pervasive pattern of self-defeating behaviors that start in early adulthood and occur in a variety of situations (Williams, 1987).
“A. A pervasive pattern of self-defeating behavior, beginning by early adulthood and present in a variety of contexts. The person may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which he or she will suffer, and prevent others from helping him or her, as indicated by at l least five of the following” (Williams, 1987, pp. 373-374):
“(1) chooses people and situations that leads to disappointment, failure or mistreatment even when better options are clearly available
(2) rejects or renders ineffective the attempts of others to help him or her
(3) following positive personal events (e.g., new achievement), responds with depression, guilt, or a behavior that produces pain (e.g., an accident)
(4) incites angry or rejecting responses from others and then feels hurt, defeated, or humiliated (e.g., makes fun of spouse in public, provoking an angry retort, then feels devastated)
(5) rejects opportunities for pleasure, or is reluctant to acknowledge enjoying him or herself (despite having adequate social skills and the capacity for pleasure)
(6) fails to accomplish tasks crucial to his or her personal objectives despite demonstrated ability to do so (e.g., helps fellow students write papers but is unable to write own)
(7) is uninterested in or rejects people who consistently treat him or her well (e.g., is unattracted to caring sexual partners)
(8) engages in excessive self-sacrifice that is unsolicited by the intended recipients of the sacrifice” (Williams, 1987, pp. 373-374; & Spitzer et al, 1989, p. 1563 & Skodol et al, 1994, p. 563).
“B. The behaviors in A do not occur exclusively in response to, or in anticipation of, being physically, sexually, or psychologically abused
The behaviors in A do not occur only when the person is depressed Note: For coding purposes, record: 301.90 Personality Disorder NOS (Self-defeating Personality Disorder)” (Williams, 1987, pp. 373-374).
Behavioral & Emotional Manifestations
Despite the availability of better options, clients with SDPD repeatedly get involved in relationships or situations that are self-defeating and painful. The DSM-III-R offers an example a woman who enters relationships with alcoholic men who aren’t available emotionally or a man with excellent qualifications who is continually underemployed, failing to obtain recognition or optimal salary (Williams, 1987). It’s common knowledge that the spouse and family of an alcoholic suffer some type of abuse, but the criteria deny the application of SDPD when the behaviors occur as the result of abuse. The DSM-III-R example of a woman with an alcoholic man is a poor example because it simply adds to confusion, rather than clarifying the diagnostic criteria. Teacher comment: Absolutely.
When these clients need any type of help, they reject reasonable offers, by politely refusing or with behaviors that sabotage efforts of help. They loan money to friends, but won’t accept loans for themselves. Despite not being asked to do so, they’re excessively self-sacrificing toward others. The sacrifice lacks any reward as one might gain from altruism. The sacrifices induce guilt from others which leads others to avoid or reject them. It’s characteristic for SDPD clients to behave in ways that bring anger or rejection from others. After belittling their spouse in public they feel hurt when their spouse retaliates. They might describe numerous situations where they failed to do things they were capable that would have brought them personal success. Accomplishment or praise leads to depression, guilt, or to their doing something that leads to a negative occurrence (Williams, 1987).
These clients may not contact a physician when they’re sick. They may not take vacations. When they do participate in pleasurable activities, they may deny enjoyment. People who treat them well are perceived as boring. Caring relationships, whether personal, professional or with a needed therapist, are rejected. They may describe great sex with volatile or insensitive partners, and not find caring partners attractive. In therapy, they may make requests for special attention and feel rejected when attention is denied; they’re non-compliant with agreed upon treatment plans (Williams, 1987).
Potential Diagnostic Confusion with Other Categories & Differential Diagnosis
Predisposing factors include being physically, sexually or psychologically abused as a child or witnessing a parent being abuse while growing up. Initial clinical studies suggest that SDPD may be one of the more common personality disorders. Sex ratio, according to clinical samples, is 3:2 for females and 2:1 for males. According to familial patterns, SDPD is more common among first-degree biological relatives of others with the disorder than among the general population (Williams, 1987).
A person experiencing abuse may behave in ways that seem to be self-defeating. A woman may stay in an abusive relationship or may avoid the pleasure of seeing her friends. These behaviors might merely be coping strategies to avoid threats to her life if she leaves the relationship or further abuse if she spends time with friends. The diagnosis is not made if “self-defeating” behaviors occur only in response to, or in anticipation of abuse, however there are occasions when the diagnosis is appropriate for a person who has or is being abused. In such a case it needs to be determine that the self-defeating behavior is a persistent pattern, not limited to situations of actual or threatened abuse. An example being a person with a long history of SDPD who has only recently being abused (Williams, 1987).
A person may exhibit self-defeating behavior as a symptom of the Mood Disorder. The diagnosis of SDPD is not made if the self-defeating behavior occurs only when depressed. People with SDPD frequently have superimposed Major Depressive Episodes or Dysthymia (Williams, 1987). Teacher comment: Good clarification.
To make a diagnose of personality disorder, the clinicians need to evaluate the client’s long-term patterns of functioning in which problematic personality features appeared early adulthood. The clinician should establish stability of personality traits over time and in different situations to distinguish between characteristics that came about in response to specific stressors or more transient mental states, such as Mood or Anxiety Disorders, Substance Intoxication. Assessment of personality disorders in general may be complicated because clients sometimes experience them as ego-syntonic. When personality changes emerge and persist after an individual has been exposed to extreme stress, a diagnosis of Posttraumatic Stress Disorder should be considered (First, 1994).
SDPD shares some features with other personality disorders, especially Borderline, Dependent, Passive Aggressive, Obsessive Compulsive, and Avoidant. Complications include Dysthymia and Major Depressive Episodes; suicidal ideation or behavior may also be present (Williams, 1987).
Robert Spitzer, Janet Williams, Frederic Kass and Mark Davies (1989) summarized criticisms in psychological literature about SDPD’s potential inclusion in the DSM-III-R. One is lacking validity. Second, some think it’s sexist and potentially harmful to women. Third, when the criteria were developed transient coping responses to abuse weren’t included. Spitzer et al (1989) did a National Field Trial with the hope of shedding empirical light on the diagnostic viability of SDPD. A questionnaire was sent to two thousand psychiatrists with a special interest in personality disorders. Fifty one percent said they believed there was a need for the diagnosis. Spitzer et al (1898) found no relationship between the respondents sex, despite the fact women were the most vocal opponents. The researchers expected to find that those from psychotherapeutic orientations and those trained many years ago when the concept of “masochistic personality” came out of the psychoanalytic perspective would endorse the diagnosis. None of these hypothesis were validated because they found no relationship between type of practice or years of clinical experience (Spitzer et al, 1989).
Borderline, Dependent and SDPD were diagnosed more commonly among women, forty two percent of female and twenty eight percent of male clients met the criteria. There was a relative lack of independence and overlap among these three personality disorders, ninety percent of the cases of SDPD were associated with Dependent or Borderline Personality Disorder (Spitzer et al, 1989).
Among the large sample of psychiatrists, over half believe that none of the DSM-III personality disorders adequately described the pattern of SDPD. Many psychodynamically oriented practitioners felt that their experience supported the validity of the diagnosis. Others claim that the concept lacked empirical evidence, was sexist, and did pose a serious danger to women. Despite the fact that the diagnostic criteria conform well to the practices of those who find the category useful, SDPD was rarely the only personality disorder diagnosed. The high threshold of five criteria show that the behaviors described in the criteria aren’t unique to SDPD. Despite the fact that SDPD is not now a part of the DSM-IV, psychiatrists in this National Field Trial showed that many of them are using it as a diagnostic category. The responding psychiatrists lacked consensus regarding the need for the category and the analysis provided limited descriptive validity and considerable overlap with Borderline and Dependent personality disorders. Similar to many other established personality disorders, the criteria for SDPD doesn’t have high descriptive validity (Spitzer et al, 1989).
Andrew Skodol, John Oldham, Peggy Gallaher, and Sophia Bezirganian (1994) also conducted a study to assess the validity of SDPD. They used one hundred each of applicants for inpatient treatment for personality disorders or psychoanalysis. Each client was independently evaluated in face to face interviews by experienced clinicians using the Structured Clinical Interview for DSM-III-R and the Personality Disorder Examination (Skodol et al, 1994).
Like Spitzer et al (1989), Skodol et al (1994) found overlap between SDPD and other psychiatric disorders. It’s not a problem within the paradigm of psychoanalysis, but raises questions within other modalities. Some have argued that the diagnosis of SDPD might obscure a coexisting affective disorder; while others think SDPD is sufficiently described within Dependent and Passive-Aggressive personality disorders. SDPD co-occurred significantly with six other personality disorders per the Personality Disorder Exam and with seven according to the Structured Clinical Interview. Both interviews noted significant co-morbidity between Borderline and SDPD. Examination of axis II co-morbidity using the consensus personality disorder diagnosis noted significant co-morbidity of SDPD and Borderline and Dependent personality disorders (Skodol et al, 1994).
The diagnosis of SDPD did not differ significantly as far as sex ratio than that of other personality disorders, seventeen diagnosed with SDPD were female and seven were male. The internal consistency was identical to the 0.61 reported by Spitzer et al (1989) in a National Field Trial. However, Spitzer et al’s (1989) studies relied on unstructured clinical evaluations, not structured assessments. Results regarding the discriminant value of individual criteria confirm those of Spitzer et al, (1989) in that SDPD criterion 1 is the most discriminating (Skodol et al, 1994).
In Spitzer et al’s (1989) study all the participants had personality disorders. Forty two percent of Skodol et al’s (1994) group had no personality disorder. Skodol et al (1994) concluded that item sets for both Borderline and Dependent personality disorders were stronger in every respect than those of SDPD. Because SDPD overlapped substantially with Borderline and Dependent personalities it was redundant to include them in the DSM-II-R. To resolve the problem of multiple overlapping disorders, a hierarchy may be needed to discriminate between personality disorders (Skodol et al, 1994).
The authors found a significant association between SDPD and a current mood disorder despite the exclusion criterion requiring that features of SDPD not be limited to periods of depression. It’s not known whether clients diagnosed with SDPD would continue to meet the criteria after affective treatment of their mood disorder. Clients with SDPD were more likely to be employed than those with other personality disorders which contradicts the self-sabotage aspect of the SDPD construct. Despite rigorous methods, Skodol et al (1994) found only fair internal consistency, difficulty in measurement, overlap on other axis I and axis II disorders, and no relationship to validators for the proposed DSM-III-R SDPD category (Skodol et al, 1994).
Feminist Perspectives to Treatment Approaches
Rhoda Unger and Mary Crawford (1992) claim that the notion of SDPD is merely a label for women’s masochism in staying in abusive situations. Victims of interpersonal violence have high rates of mental illness, yet a study of this diagnosis never asked the three hundred women about abuse (Unger & Crawford 1992, p. 593). When removed from abusive situations for six months, symptoms either disappeared altogether or were diminished. This finding argues against a disorder of personality itself. SDPD is an example of a double bind that blames women if they don’t keep the family together, but labels them crazy if they stay with an abusive partner (Unger & Crawford, 1992).
Psychologist, Paula J. Caplan, (1992) says the sexism of mental health professionals results in oversights, inadequate treatment, mistreatment and harm, disproportionately to women, but sometimes also to men. Caplan (1992) says that other biases also profoundly twist and skew the diagnostic process, such as, racism, homophobia, ageism, and classism. Caplan (1992) was watching while the debate ensued about the misogynistic proposal for including SDPD in the DSM. Despite changing the original title, “masochistic personality disorder,” the criteria and their implications were the same for women. The criteria included putting other people’s needs before your own, not being appreciated even though they really are, and settling for less when they could have more (Caplan, 1992).
Caplan (1992) posits that the diagnosis applies to what she calls the , “good wife syndrome” (Caplan, 1992, p. 74). Women are socialized to place the needs of others before their own (which is referred to as being unselfish) and to settle for less when they could have more. Caplan (1992) argues that a person with low self-esteem doesn’t realize they could do better. It’s well documented that women’s traditional work that revolves around children and housework, isn’t appreciated. After a women conscientiously learns her culturally prescribed role, she’s then subject to being labeled psychiatrically disordered (Caplan, 1992).
The diagnosis is a description of a typical psychologically or physically abused women. These women endure the destruction of their self esteem by the abuse, and then they try even harder to be “good women” by becoming more self-denying, giving and undemanding in the attempt to stop the abuse. Using the label SDPD, “is a pernicious form of victim-blaming” (Caplan, 1992, p. 74). In spite of the DSM’s caution about not applying SDPD when abuse is involved, it’s well documented that therapists rarely ask about abuse and when they do, clients are reluctant to discuss it due to fear and shame (Caplan, 1992).
SDPD is dangerous because it leads therapist and clients to believe that the problem stems from the woman’s pathological need to be abused and unappreciated – the problem comes from within the woman herself. In the process of writing her book, The Myth of Women’s Masochism (1987), Caplan (1992) heard from hundreds of women who had been in years of traditional therapy and were regularly told by their therapists that they brought on their problems. She offers an example dialogue between a typical client and therapist, “But Fred was wonderful … when we were dating. It wasn’t until our wedding night that he started to beat me,” the therapist too often replies, “So consciously you didn’t choose an abusive man. But your self-defeating motives are unconscious!” (Caplan, 1992, p. 75). Caplan (1992) believes that this “treatment”, (p. 75) is a major cause for depression in women because they’re given the unjustified message that they can’t escape the abuse because their sick unconscious motives will inevitably lead them to another abuser. What could be more depressing than this belief!
Proponents of SDPD’s inclusion in the DSM revision have said themselves that clients with a diagnosis of SDPD have “negative therapeutic responses” (Caplan, 1992, p. 75), that therapy makes them worse. Caplan (1992) compares this to treating a broken leg treated by placing a cast on your arm – your leg gets worse. Not only does the belief in SDPD among therapists not help clients, it actually make them worse. Caplan (1992) wonders why insurance companies don’t resist SDPD because most nice women and virtually all battered women could be diagnosed with SDPD.
Caplan (1992) says SDPD shares an amazing aspect with Premenstrual Syndrome (PMS). Neither have corresponding equivocal diagnosis for men. There’s no DSM category for extreme forms of male socialization, such as, “Macho Personality Disorder” or an equivalent to PMS such as, “Testosterone-Based Aggressive Disorder” (Caplan, 1992, p. 76). Unger and Crawford (1992) suggests that if we twist the SDPD to make it fit males, it would be called, “Delusional Dominating Personality Disorder,” describing the pathological social norm of the “real man” (Unger & Crawford 1992, p.569).
Caplan, Paula J. (1992). Gender Issues in the Diagnosis of Mental Disorder. In Women & Therapy. Vol 12, (4).
First, Michael B., (Ed). (1994). Diagnostic and Statistical Manual of Mental Disorders. (Fourth Edition). Washington, DC: American Psychiatric Association, pp. 629-634.
Skodol, Andrew E., Oldham, John M., Gallaher, Peggy E., & Bezirganian, Sophia. (1994). Validity of Self-Defeating Personality Disorder. In American Journal of Psychiatry, 151: pp. 560-567.
Spitzer, Robert L., Williams, Janet B. W., Kass, Frederic., Davies, Mark. (1989). National Field Trial of the DSM-III-R Criteria for Self-Defeating Personality Disorder. In American Journal of Psychiatry. 146:12, December, pp. 1561-1567.
Unger, Rhoda and Crawford, Mary. (1992). Women and Gender: A Feminist Psychology. New York: McGraw-Hill, Inc.
Williams, Janet B. W., (Ed). (1987). Diagnostic and Statistical Manual of Mental Disorders. (Third Edition-Revised). Washington, DC: American Psychiatric Association, pp. 367-374.