Self-defeating Personality Disorder: Recognition and Treatment

July 27, 2012

Patients with masochistic tendencies present with self-defeating patterns and often reject help.

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How does SDPD present, and how does the clinician avoid unwittingly reinforcing a very problematic behavior pattern?

Here with information to help you identify the symptoms and treat the disorder is Dr. Nancy McWilliams, Professor at Rutgers University Graduate School of Applied and Professional Psychology in Piscataway, New Jersey. Dr. McWilliams also offers brief commentary on the rationale for excluding SDPD from DSM-5.

For teaching points, please click here.

Key Teaching points:

• Be careful about exuding sympathy, which can reinforce implicit beliefs that pain is a good route to a warm attachment with another human being. Self-defeating patients need to learn that you will remain interested when they self-advocate and try to solve problems, and not just when they are hurt or overwhelmed

• Try not to suggest alternatives to patients' self-defeating actions (they will usually be ignored); instead, dispassionately observe the price they pay for their behavior and wonder aloud what motives impel such choices

• Don't model masochism. However compelling your countertransference rescue fantasies, suppress inclinations to promise more availability than you have or to agree to a lower fee than you can comfortably offer. The patient needs to identify with someone who exemplifies self-care