258 Passive-Aggressive Personality Disorder (Negativistic Personality Disorder)

DSM-IV-TR Criteria

• Passive-aggressive behavior is a pattern of expressing your negative feelings in an indirect way.
• A pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following (Rotenstein):
  • Passively resists fulfillment
  • Routine social and occupational tasks
  • Complains of being misunderstood and unappreciated by others
  • Sullen and argumentative
  • Unreasonably criticizes and scorns authority
  • Expresses envy and resentment
  • Toward those apparently more fortunate
  • Voices exaggerated and persistent complaints of personal misfortune
  • Alternates between hostile defiance and contrition
  • Does not occur exclusively during Major Depressive Episodes and is not better accounted for by Dysthymic Disorder
  • Different from previous formulations, the DSM-IV description of the disorder places emphasis on the pattern of sullen and irritable moods and negativistic attitudes (DSM-IV, APA, 1994).

Associated Features

• It is a long-term (chronic) condition in which a person seems to actively comply with the desires and needs of others, but actually passively resists them. In the process, the person becomes increasingly hostile and angry (Moore & Jefferson, 2004).
• These individuals are often overtly ambivalent, wavering indecisively from one course of action to its opposite.
• They may follow an erratic path the causes endless tension with others and disappointments for themselves.
• An intense conflict between dependence on others and the desire for self-assertion are characteristics of these individuals.
• Their self-confidence is often poor despite a superficial boldness.
• They foresee the worst possible outcome for most situations, even those that are going well.
• They have an outlook of always being defeated, which can evoke hostile and negative responses from others who are subjected to the complaints of these individuals.
• They will typically not confront others directly about problems, but will instead attempt to undermine their confidence or their success through comments and actions that can be explained away easily so as not to place any blame on themselves.
• This pattern of behavior often occurs in individuals with Borderline, Histrionic, Paranoid, Dependent, Antisocial, and Avoidant Personality Disorders.
• Manifest itself as: resentment, stubbornness, procrastination, sullenness, dawdling, deliberate inefficiency, pretended forgetfulness, unreasonable criticism of people in authority, or intentional failure at doing requested tasks.
  • For example: They might take so long to get ready for a party that they don’t want to go to, that by the time they are ready, the party is nearly over.
• It is often seen in people who view themselves as peaceful.
  • Expressing their anger this way is morally favorable to direct confrontation.
• Symptoms often include:
  • putting things off
  • “forgetting” to do things others ask
  • being stubborn
  • disliking people who are in charge, or having a bad attitude about them
  • complaining frequently
  • purposely working poorly or slowly
  • feeling unappreciated
  • blaming problems on others
  • being irritable
  • disliking the ideas of other people, even if they are useful
  • arguing frequently
  • (McCrae, 1994)

Gender and Cultural Differences in Presentation

• Although little research has dealt with gender differences regarding PAPD, Mair and colleagues(1992) have noted that PAPD tends to be more frequently diagnosed in females.
• The passive-aggressive style may be a way for women to avoid the social stigma and rejection that are often associated with women who are seen as challenging or aggressive in advocating for their own need and wants.

Epidemiology

• The prevalence rate for Passive-Aggressive Personality Disorder is 3.3%

Etiology

• The exact cause is still unknown due to a lack of research in this area however some have suggested that this disorder, like most personality disorders, hails from a combination of genetic and environmental factors.
  • May also be a result of society’s conditioning of individuals.
  • Society teaches that direct confrontation can lead to harmful consequences.
• Childhood abuse and/or neglect as well as sexual abuse has appeared to contribute to this disorder.

Empirically Supported Treatments

• The most common, is psychological treatment for those individuals who do not see themselves as having a problem. They are usually forced into treatment, e.g., family, employers, or the legal system. These clients with PAPD have minimal insight; they fail to admit that they are a major factor in the problems they have.
• Counseling is useful in helping the person identify and change the behavior.
• Cognitive therapy and antidepressant drugs are very effective to control negative attitude (McCrae, 1994).

Typical beliefs

• I am self-sufficient, but I do need others to help me reach my goals.
• The only way I can preserve my self-respect is by asserting myself indirectly, for example, by not carrying out instructions exactly.
• I like to be attached to people but I am unwilling to pay the price of being dominated.
• Authority figures tend to be intrusive, demanding, interfering, and controlling.
• I have to resist the domination of authorities but at the same ti me maintain their approval and acceptance.
• Being controlled or dominated by others is intolerable.
• Making deadlines, complying with demands, and conforming are direct blows to my pride and self-sufficiency.
• If I follow the rules the way people expect, it will inhibit my freedom of action.
• It is best not to express my anger directly but to show my displeasure by not conforming.
• I know what’s best for me and other people shouldn’t tell me what to do.
• Rules are arbitrary and stifle me.
• Other people are often too demanding.
• If I regard people as too bossy, I have a right to disregard their demands.

(Beck & Freeman, 1990)

In Terms of the 5-Factor Model of Personality

• They have:
  • High neuroticism
  • High extroversion
  • Low openness
  • Low Agreeableness
  • High conscientiousness

(McCrae, 1994)

Fun Fact

The term “passive-aggressive” arose in the U.S. military during World War II, when officers noted that some soldiers shirked their duties by adopting these types of behaviors.

DSM-V Changes

• Passive-Aggressive (Negativistic) Personality Disorder will be represented and diagnosed by a combination of core impairment in personality functioning and specific pathological personality traits, rather than as a specific type.
• Personality Traits
• Oppositionality, Hostility, Guilt/shame

(APA, 2010)