Passive Aggressive Personality Disorder Dsmivtr Appendix B

Clinical Description

The Passive-Aggressive Personality Disorder has been in the DSM since its inception in 1952. Only in 1994 with the advent of DSM-IV was the Passive-Aggressive Personality Disorder removed from Axis II and placed in an appendix. The reasons for its drop in diagnostic status are uncertain; however, Appendix B of DSM-IV-TR is intended to foster research that may result in a refinement of the diagnosis and its criteria, so it is possible the type may reappear in revised form in future versions of the DSM.

A major problem is immediately evident from an examination of the criteria for the two personality disorders in the appendix of DSM-IV-TR (depressive and passive-aggressive). The Passive-Aggressive Personality Disorder's alternate label is Neg-ativistic Personality Disorder yet none of the 7 criteria lists negativism as a symptom. Negativism, however, is listed as Criterion 5 for the Depressive Personality Disorder. This anomaly is certain to cause some confusion in the minds of clinicians and researchers who may either be attempting to use the criteria to diagnose either of these disorders or to research potential similarities and differences between the two disorders. Indeed, concerns about construct validity may be one of the reasons the passive-aggressive type was dropped from the official list.

The first DSM noted that Passive-Aggressive Personality Disorder was characterized by three types: passive-dependent, aggressive, and passive-aggressive. The passive-dependent type has seemingly evolved into the current Dependent Personality Disorder because the first version of the DSM listed feelings of helplessness, indecisiveness, and a tendency to cling childlike to a parentlike figure. The aggressive type appears to share many symptoms of the modern Borderline Personality Disorder such as temper tantrums, recurrent anger, irritability, and destructive behavior. It is the third, passive-aggressive type, that appears to have evolved into the modern Passive-Aggressive Personality Disorder with historical and current features of stubbornness, procrastination, inefficiency, and passive obstructivism.

Most conceptualizations of passive-aggressive individuals suggest that the issue of autonomy versus external control is paramount. They begin to counter their resentment to any restriction of their free will with passive resistance to fulfill even routine social and occupational demands. Ironically, they often feel misunderstood and unappreciated by others and feel they have been unfairly singled out for more than their fair share of the work when the opposite is often true. They will even balk at being asked to do less than their fair share, although they do not view it that way. Thus, they are frequently scornful and critical of authority figures and easily become sullen and argumenta-

Table 5.4 Research Criteria for Passive-Aggressive Personality Disorder (DSM-IV-TR, Appendix B)

A. 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:

(1) passively resists fulfilling routine social and occupational tasks

(2) complains of being misunderstood and unappreciated by others

(3) is sullen and argumentative

(4) unreasonably criticizes and scorns authority

(5) expresses envy and resentment toward those apparently more fortunate

(6) voices exaggerated and persistent complaints of personal misfortune

(7) alternates between hostile defiance and contrition

B. Does not occur exclusively during Major Depressive Episodes and is not better accounted for by Dysthymic Disorder.

Source: From Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, American Psychiatric Association, 2000, Washington, DC: Author. Copyright 2000 by American Psychiatric Association. Reprinted with permission.

tive when given any task. They are highly envious of others and resent it when others seem to have any good fortune. They tend to complain bitterly to others about their own personal misfortunes and can exaggerate their hardships to gain sympathy, which they then exploit. They also vacillate between their automatic defiance reactions and later become contrite and penitent about their initial behavior. Table 5.4 lists the DSM-IV-TR diagnostic criteria for Passive-Aggressive Personality Disorder.

Potential Age-Bias of Criteria

Because symptoms of the passive-aggressive type mostly involve negative mood states, verbal behavioral patterns (e.g., voices complaints, is argumentative, expresses resentment), and the absence of productive behaviors (passively resists fulfilling tasks), it appears that aging per se would not impact the expression of the symptoms. Criterion 5 (expresses envy and resentment toward those apparently more fortunate) may be more easily met among older adults who have experienced the most severe losses with age and are, in fact, less fortunate than most around them. Finally, whereas occupational opportunities to display passive-aggressive behaviors may be reduced somewhat with advancing age, the passive-aggressive individual's opportunities to display resistant behavior in relationships with family, peers, and health care professionals are likely to remain abundant. New demands that appear in the context of aging will likely serve to heighten passive-aggressive reactions.

Theorized Pattern in Later Life and Possible Impact of Aging A particular challenge for the passive-aggressive person will be increased dependence on health care systems and other institutional organizations. Passive-aggressive behaviors are likely to become more evident as the aging person becomes more reliant on others and is forced to meet the expectations of doctors, caregivers, and congregate living staff. Whereas family members may have long learned to deal with the passive resistance and stubbornness of these individuals, for example by withdrawal, care providers who work with these older persons might be more likely to confront directly such behavior than family members, fostering even greater resistance. The frail passive-aggressive older adult will likely have noteworthy difficulty complying with medication and physical rehabilitation regimes, deriving some degree of power or control by passively failing to comply and making others irritated or perplexed.

As noted throughout this book, many of the stressors that often accompany aging such as physical illness or disability, reduced independence, sensory and cognitive declines, changes in physical appearance, social losses, and financial pressures, frequently serve to exacerbate underlying personality disorder features and traits. The Passive-Aggressive Personality Disorder is probably among the most likely of the personality disorders to become more apparent during the aging process, as the loss of autonomy that often accompanies aging heightens the ambivalence that fuels passive-aggressive traits. Given a far-from-perfect health care system, it seems probable that those who have a history of trouble dealing with external authority figures will have additional problems as they age and become increasing more reliant on those systems.

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