Different Sides of the Same Coin

Significant overlap between depressive and masochistic personalities may impact disorder classification and treatment, pilot study suggests

It’s not yet decided if depressive personality disorder (DPD) and masochistic personality disorder (MPD), often called self-defeating personality disorder (MPD/SDPD), are mutually exclusive constructs or are a singular construct with characteristics of both disorders.

While the international psychoanalytic community has yet to reach a classification consensus on these disorders, a recent pilot study analyzed the data and hypothesizes that the truth likely lies in a third concept—a combo personality disorder construct.

The idea of a merged classification evolved after a recent pilot study found that at higher (healthier) levels of organization, these two personality disorders overlap considerably while at lower levels of organization, DPD and MPD/SDPD diverge.

The pilot study, presented during APA 2021 and titled Evaluating the Relationship Between Depressive and Masochistic Personalities, was co-authored by Brady C. Malone, doctoral student in clinical psychology at the University of Detroit Mercy, and Steven K. Huprich, PhD, Psychologist, Northville, Michigan. Malone was the presenting author.

(Not So) Great Divide

Backing up a bit, Malone presented a brief review of DPD and MPD/SDPD and why the psychoanalytic community has yet to agree on whether the two constructs are one in the same or more like distant cousins.

Depressive personality disorder presents in a variety of contexts, with five or more of the following:

  1. Persistent low mood
  2. Brooding behaviors
  3. Poor self-concept centered around beliefs of inadequacy, worthlessness, and low self esteem
  4. Excessive levels of guilt
  5. Harsh inner critic or overly punitive super ego
  6. Negativistic or critical attitudes towards others
  7. Pessimistic outlook towards life

Masochistic personality disorder presents in a variety of contexts, with five or more of the following:

  1. Choosing people and situations that lead to disappointment, failure, or mistreatment—even when better options are clearly available
  2. Rejecting others offer to help
  3. Rejecting potentially pleasurable activities and experiences
  4. After experiencing pleasure, guilt or self-sabotage typically follows.
  5. Inciting angry or rejecting responses from others—and then feeling hurt defeated or humiliated afterwards
  6. Failing to accomplish critical tasks related to personal development, despite having demonstrated the ability to do so
  7. Appearing uninterested in people who consistently treat them well
  8. Engaging in excessive and unsolicited self-sacrifice

Traditionally, the two disorders have been presented as “unique disorders with similar yet different criteria,” Malone said. However, he continued, there is an increasingly popular split in thinking.

For example, Otto Friedmann Kernberg, MD, Director of the Personality Disorders Institute at the New York-Presbyterian Westchester Behavioral Health Center and Professor of Psychiatry at Weill Cornell Medicine, prefers treating the disorders as overlapping and reflective of a singular depressive masochistic personality construct, or DMP.

In this way, DMP personifies the two disorders’ common features that tend to co-occur when aggression is directed at the self. The DMP construct has its own set of features, which include:

  1. Extremely punitive and overactive super ego
  2. Self-defeating behaviors
  3. Disavowed needs
  4. Overwhelming guilt
  5. Excessive dependency
  6. Low self-esteem.

Nancy McWilliams, PhD, ABPP, professor at Rutgers University’s Graduate School of Applied & Professional Psychology, and in private practice, views DPD and MPD/STPD as two unique and independent personality styles. Following suit, she argues that each disorder requires distinctly different treatment approaches.

Dr. McWilliams suggests that masochistic personalities need a therapist who cultivates a space for the transition between self-inflicted suffering to self-assertion. Depressive personalities respond better to a therapist who is internalized as non-judgmental, open minded, and steadfast.

Bring It Home

In writing the pilot study results, Malone and Dr. Huprich found that the similarities between Dr. Kernberg and Dr. McWilliams’ camps “are more synergistic and complimentary” than expected.

For example, the pilot study authors expressed, Dr. McWilliams states that the disorders’ differences tend to be most apparent as the client’s overall personality organization decreases.

In Kernberg’s model of personality disorders, he positions the singular depressive masochistic personality construct, or DMP, at the highest level of personality organization. “Therefore, according to Dr. Kernberg, DMP may represent a personality style that is more unified at the neurotic level [healthiest level of personality organization], but begins to split off into distinct styles, either depressive or masochistic, as one’s level of organization decreases,” Malone said during the presentation.

So, according to both experts, the two disorders’ differences become most evident as a person’s overall personality organization decreases.

One-Two-Three

Malone introduced another concept that may help clear up—or perhaps confuse—the still-unresolved classification discussion about DPD and MPD/STPD.

“The dimensional variant of depressive personality is labeled malignant self-regard, or MSR. It describes how one views or understands themselves,” Malone said. “So, another way to think of MSR is that it accounts for the shared features and variants across masochistic, depressive personality disorder, and vulnerable narcissism.”

Primary MSR characteristics include:

  1. Chronic depression
  2. Harsh inner criticism, shame, guilt, and feelings of inadequacy
  3. Self-defeating tendencies
  4. Approval seeking behaviors

Studying the Study

The pilot study’s goal was twofold:

  1. Investigate the empirical structure of MSR
  2. Differentiate MSR from similar personality constructs, such as self-defeating and narcissistic personality disorder

After a large sample of undergrads completed a battery of self-report measures focused on various psychological constructs, the results were compared with category or combination variables as well as various criterion variables.

Results pointed out that those who are more self-defeating tend to display lower levels of pathological narcissism, especially in exploitation and entitlement rage. In addition, the pilot study noticed that more self-defeating individuals tend to regulate their self-esteem better. “In this case, we can conclude that self-defeating tendencies protect the self from outside criticism and punishment, leaving little for others to criticize. In other words, they punish the self to avoid dysregulated external criticism,” Malone said.

A Fresh Premise

Surprisingly, according to Malone, the pilot study results provided “empirical support” for both Dr. McWilliams and Dr. Kernberg’s views about masochistic and depressive personalities.

To begin with, significant main effects were observed for malignant self-regard, which, again, describes how one views themselves and includes shared features and variants across masochistic, depressive PD, and vulnerable narcissism. “At the same time, we found significant main effects for the combination variables, showing that higher levels of self-defeating tendencies suppress narcissistic tendencies and regulate self-esteem,” Malone said.

Therefore, he concluded, future research in overall personality organization needs to examine the hypothesis that with higher levels of organization, these categories will overlap considerably and then begin to diverge at lower levels of organization.