Passive–aggressive personality disorder

The previous edition of the Diagnostic and Statistical Manual of Mental Disorders, the revision IV (DSM-IV) described **passive–aggressive personality disorder** as a proposed disorder involving a "pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance" in a variety of contexts. The current version of the no longer uses this phrase or label, and it is not one of the ten listed specific personality disorders.

Passive-aggressive behavior is the obligatory symptom of the passive–aggressive personality disorder. Persons with passive–aggressive personality disorder are characterized by procrastination, covert obstructionism, inefficiency and stubbornness.

## Causes

Passive–aggressive disorder may stem from a specific childhood stimulus (e.g., alcohol/drug addicted parents, bullying, abuse) in an environment where it was not safe to express frustration or anger. Families in which the honest expression of feelings is forbidden tend to teach children to repress and deny their feelings and to use other channels to express their frustration. For example, if physical and psychological punishment were to be dealt to children who express anger, they would be inclined to be passive aggressive.

Children who sugarcoat hostility may have difficulties being assertive, never developing better coping strategies or skills for self-expression. They can become adults who, beneath a "seductive veneer," harbor "vindictive intent," in the words of Timothy F. Murphy and Loriann Oberlin. Alternatively individuals may simply have difficulty being as directly aggressive or assertive as others. Martin Kantor suggests three areas that contribute to passive–aggressive anger in individuals: conflicts about dependency, control, and competition, and that a person may be termed passive–aggressive if they behave so to few people on most occasions.

Murphy and Oberlin also see passive aggression as part of a larger umbrella of hidden anger stemming from ten traits of the angry child or adult. These traits include making one's own misery, the inability to analyze problems, blaming others, turning bad feelings into angry ones, attacking people, lacking empathy, using anger to gain power, confusing anger with self-esteem, and indulging in negative self-talk. Lastly, the authors point out that those who hide their anger can be nice when they wish to be.

## Diagnosis

### Diagnostic and Statistical Manual

With the publication of the DSM-5, this label has been largely disregarded. The equivalent DSM-5 diagnostic label would be “Other specified personality and unspecified personality disorder,” as the individual may meet general criteria for a personality disorder, but does not meet the trait-based diagnostic criteria for any specific personality disorder (p645).

Passive–aggressive personality disorder was listed as an Axis II personality disorder in the DSM-III-R, but was moved in the DSM-IV to Appendix B ("Criteria Sets and Axes Provided for Further Study") because of controversy and the need for further research on how to also categorize the behaviors in a future edition. According to DSM-IV, people with passive–aggressive personality disorder are "often overtly ambivalent, wavering indecisively from one course of action to its opposite. They may follow an erratic path that causes endless wrangles with others and disappointment for themselves." Characteristic of these persons is an "intense conflict between dependence on others and the desire for self-assertion." Although exhibiting superficial bravado, their self-confidence is often very poor, and others react to them with hostility and negativity. This diagnosis is not made if the behavior is exhibited during a major depressive episode or can be attributed to dysthymic disorder.

### ICD-10

The 10th revision of the International Classification of Diseases (ICD-10) of the World Health Organization (WHO) includes passive–aggressive personality disorder in the "other specific personality disorders" rubric (description: "a personality disorder that fits none of the specific rubrics: F60.0–F60.7"). ICD-10 code for "other specific personality disorders" is F60.8. For this psychiatric diagnosis a condition must meet the general criteria for personality disorder listed under F60 in the clinical descriptions and diagnostic guidelines.

The general criteria for personality disorder includes markedly disharmonious behavior and attitudes (involving such areas of functioning as affectivity – ability to experience affects: emotions or feelings, involving ways of perceiving and thinking, impulse control, arousal, style of relating to others), the abnormal behavior pattern (enduring, of long standing), personal distress and the abnormal behavior pattern must be clearly maladaptive and pervasive. Personality disorder must appear during childhood or adolescence and continue into adulthood.

Specific diagnostic criteria of the passive–aggressive personality disorder in the "Diagnostic criteria for research" by WHO is not presented.

### Millon's subtypes

The psychologist Theodore Millon has proposed four subtypes of 'negativist' ('Passive–aggressive'). Any individual negativist may exhibit none or one of the following:

 **Discontented negativist** | Including depressive features
 **Circuitous negativist** | Including antisocial and dependent features
 **Abrasive negativist** | Including sadistic features

## Treatment

Psychiatrist Kantor suggests a treatment approach using psychodynamic, supportive, cognitive, behavioral and interpersonal therapeutic methods. These methods apply to both the passive–aggressive person and their target victim.

## History

In the first version of the *Diagnostic and Statistical Manual of Mental Disorders*, DSM-I, in 1952, the Passive–aggressive was defined in a narrow way, grouped together with the passive-dependent.

The DSM-III-R stated in 1987 that Passive–aggressive disorder is typified by, among other things, "fail[ing] to do the laundry or to stock the kitchen with food because of procrastination and dawdling."