Self Defeating Personality Disorder Dsmiiir Appendix A

Clinical Description

The basic pattern of the Self-Defeating Personality Disorder involves behaviors that undermine the person's ability to be successful, happy, and healthy in a wide variety of contexts. Self-defeating people are habitually attracted to people who invariably disappoint them, hurt them, or make them suffer. They typically reject or avoid pleasurable experiences. They typically fail to accomplish tasks that are critical to their own success (despite the ability to be successful at such tasks) such as educational goals and objectives in occupational settings. They also resist and render useless efforts by others to help them be successful, and they tend to invoke angry or rejecting responses from others, yet later report that they feel demoralized, hurt, and disappointed by how others have responded. They usually rationalize their self-defeating behavior, and they may argue vehemently with their therapists about the justification for their actions. One of our patients in her 6th year of a 2-year master's program, argued vociferously that finishing her program symbolically represented death (in part because she was a diabetic). She clung to her rationalization despite pleas from her therapist and family and despite evidence from standardized tests (she scored in the 95th percentile on the Graduate Record Examination) that she had the ability to complete her degree program. Ironically, she also devoted her time to a research professor who was not supervising her thesis and who did not pay her. The latter behavior also met an official criterion of the Self-Defeating Personality Disorder diagnosis: engages in excessive self-sacrifice, not solicited by the recipient of the sacrifice.

One of us also performed an intake on a 58-year-old woman about to undergo gastric surgery. As she recalled her husbands from her first three marriages, all of whom she reported as abusive alcoholics, she blithely exclaimed, "it seems like there's a pattern here." When asked about her current husband, she dismissively said, "Oh, he's an alcoholic." Despite the possibility that her definition of alcoholism may have been overly broad, the possibility that she has been chronically attracted to abusive men or people harmful to her was likely. In therapy, such patients may readily comply with initial requests of the therapists and also may initially make insightful comments about their past behaviors. However, with time, the therapists usually come to realize the difficulties that self-defeating persons make for themselves and the myriad ways they manage to disrupt and prevent real therapeutic success.

After the apparent establishment of solid and trusting rapport with their therapist, self-defeating personality disordered patients may start to make special demands and then react with noticeable anger and disappointment when their unrealistic requests are not met. In therapy, these patients may also engage in a "yes, but" game, as they come up with reasons for maintaining unhealthy behaviors. The therapist's attempt to subtly suggest more assertive and successful modes of behaving are often met with sometimes subtle and sometimes blatant refusal. These interactions often mirror their social and family interactions as well, where offers of assistance are also met with rejection, despite clear needs for the help and assistance. Not surprisingly, people with Self-Defeating Personality Disorder very often do not comply or agree with treatment plans but are adept at sabotaging them to confirm that "nothing helps." Table 5.2 lists the DSM-IV-TR diagnostic criteria for Self-Defeating Personality Disorder.

Potential Age-Bias of Criteria

Some of the possibilities for meeting Self-Defeating Personality Disorder criteria may be curtailed with the aging process, such as there may be fewer opportunities to undermine occupational and educational goals. These situations, where the older person may

Table 5.2 Diagnostic Criteria for Self-Defeating Personality Disorder (DSM-III-R, Appendix A)

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 least five of the following:

(1) chooses people and situations that lead 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, guilty, 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 himself 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 his or her 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

B. The behaviors in A do not occur exclusively in response to, or in anticipation of, being physically, sexually, or psychologically abused.

C. The behaviors in A do not occur only when the person is depressed

Source: From Diagnostic and Statistical Manual of Mental Disorders, third edition, revised, American Psychiatric Association, 1987, Washington, DC: Author. Copyright 1987 by American Psychiatric Association. Reprinted with permission.

have been clever at disrupting or failing when younger, no longer seem as relevant. Although most of the other symptoms of the disorder arguably would not seem to be impacted much by aging, the manifestations of the disorder can be affected by aging.

Theorized Pattern in Later Life and Possible Impact of Aging One pattern we have observed is that older people with Self-Defeating Personality Disorder create inappropriate excuses as they age such as "I'm far too old for that" when they are not, and "I could never do that at my age," while many people are successful at their age in such endeavors. Older persons who have long had Self-Defeating Personality Disorder features have the opportunity to exhibit these traits as they age, especially as their actual needs for physical or instrumental assistance increase. One of our patients, who broke her hip at 85 years old, insisted that she could return to her home without any outside help, yet complained vehemently to her adult children that she was being neglected. Her adult children reported her consistent efforts at thwarting their good intentions: They offered to pay for maid service—her reply, "they'll steal from me"; they wanted to provide food service—"they all have lousy food"; they tried to set up therapy—"they just want your money." Whereas being successful at deflecting help may be a lifelong trait, opportunities to render help ineffective often present with greater frequency in later life, and as such, these traits may become more obvious.

Although opportunities to choose people and situations that may be unhealthy or unsuccessful may diminish somewhat as people age (due to lowered social opportunities), the limited available opportunities are typically met with chronic and well practiced self-defeating behaviors. Whatever successes these patients experience are still met with depression, guilt, or psychosomatic ailments. Whatever pleasures they are offered are met with scorn, rejection, reluctance, and disinterest. Whenever they meet kind and supportive caregivers, doctors, or acquaintances, they are uninterested, instead seeking out people likely to be rejecting. One of our older patients reported in therapy the mantra that he was "born to fail," which he habitually made come true.

Another common pattern is that of the aging martyr who has sacrificed herself throughout her life, often accompanied with bitterness and regret. The consequences of such martyrdom often become more pronounced in later life. One of our patients had a long history of giving large sums of money to a heroin-addicted daughter who chronically refused treatment. During middle age when the patient was working, she could afford these contributions, but in later life she lost her home and could not afford her own basic necessities, yet continued the pattern of giving money to her daughter (despite knowing the daughter would buy drugs with the money). The lifelong martyr knows no role except suffering, so therapy, with its purpose to reduce suffering, can be antithetical to this style and very difficult.

As noted, some of the opportunities for self-defeating individuals to exhibit their behavior in later life may be diminished (especially educational and occupational areas). Thus, clinicians who follow the DSM criteria strictly may find that a patient fails to meet 5 of the 8 Self-Defeating Personality Disorder criteria, despite a high likelihood of the presence of the disorder. At these times, it may be important for clinicians to keep in mind the current DSM's warning that the criteria are only meant to be a general guide to clinical practice. The criteria are not to be used in cookbook fashion. It is, of course, important that clinicians are aware of all the criteria for a particular diagnosis and the threshold for its application (e.g., must meet 5 of 8 criteria) to avoid inappropriate and idiosyncratic diagnoses. However, the DSM notes that limitations of the classification system must be recognized and that all individuals who, for example, meet 5 of the 8 criteria for the Self-Defeating Personality Disorder will not all be alike in the expression of their self-defeating behaviors. The DSM-IV-TR specifically states that "the exercise of clinical judgment may justify giving a certain diagnosis to an individual even though the clinical presentation falls just short of meeting the full criteria for the diagnosis as long as the symptoms that are present are persistent and severe" (p. xxxii). Thus, when an older person persistently engages in unambiguous self-defeating behaviors across diverse situations (e.g., with family, peers, doctors, or caregivers), a diagnosis of Self-Defeating Personality Disorder becomes likely, especially given a prior history for such behavior.

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