Self Defeating Personality Disorder

Self-defeating patients are often depressed, suffering, and self-sacrificing. They repeatedly make bad choices that lead to failure or pain. This diagnostic category was eliminated from DSM-IV-TR because of a gender bias (female) and an inability to reach a general agreement for the diagnostic features. However, it is included in this chapter because patients who are self-defeating are frequently seen and present difficult clinical problems for many physicians that still need to be addressed. A common physician reaction to self-defeating patients is an urge to rescue them from their own self-destructiveness. Trying too vigorously to help these patients often results in a worsening of their hypochondriasis or somatic complaints. This often leaves the physician frustrated, angry, defeated, self-doubting, self-blaming, or hopeless; alternatively, the physician may fantasize about the patient suffering or dying. Self-defeating patients are excessively dependent on love,

The complete reference list is available online at www.expertconsult.com.

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001935 National Center for Biotechnology Information Reviews of the major personality disorders and treatments www.nmha.org/go/information/get-info/personality-disorders Mental Health America

Consumer information about personality disorders www.nice.org.uk/search/guidancesearchresults.jsp?keywords=Personailty+ Disorders&newSearch=true&searchType=Guidance National Institute for Health and Clinical Excellence (NICE) Practice guidelines for personality disorders support, and acceptance from others. They cannot directly express their anger and may be harshly self-judgmental. They fear recovery, which to them means losing love and care. Improvement of their medical condition often leads to the development of new complaints that have no somatic basis.

Mildly self-defeating patients can make the physician feel mildly guilty that the physician is causing pain or suffering or not helping enough. The patient and the physician both suffer. However, these patients ultimately can be helped and can express genuine gratitude toward the physician. The patients with a severe self-defeating personality disorder may passive-aggressively reject the help of their physicians and make the physician feel helpless and responsible for the patients' severe suffering or self-destructiveness.

Physicians can manage self-defeating patients by empathizing with the patient's realistic medical suffering, symptoms, or complaints from the illness. It should not be suggested that the patient's symptoms are psychological or that they will improve or be cured quickly. These optimistic predictions by the physician may paradoxically increase the patient's symptoms, complaints, telephone calls, and office visits. Potential recovery can be presented as a likely but distant reality. If patients cannot permit or admit relief of the symptoms, they can be asked to speak less about their symptoms for the benefit of other family members.

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