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Appendix: Dual Diagnosis and the Passive-Aggressive Personality Disorder

Table of Contents

The Passive-Aggressive Personality Disorder Treating the The Passive-Aggressive Personality Disorder Dual Diagnosis Treatment: Treating the Addicted Passive-Aggressive Personality Disorder For references, see the Bibliography page

The Passive-Aggressive (Negativistic) Personality Disorder (PAPD) Essential Feature

The passive-aggressive (negativistic) personality disorder is located in Appendix B: "Criteria Sets and Axes Provided for Further Study" of the DSM-IV. It is being considered for inclusion in future revisions but was removed from the Axis II Personality Disorders (DSM-IIIR) because there is controversy regarding the category. Kantor (1992, p. 177) notes that the term passive-aggressive clearly describes a discrete behavior, but it is not certain that it describes a discrete diagnostic category. Millon (1996, p. 198) proposes a more comprehensive concept of a negativistic personality that is not so narrowly focused upon the one essential passive-aggressive trait of resistance to external demands. He believes that the negativistic personality reflects both this general contrariness and disinclination to do as others wish but also presents with a capricious impulsiveness, an irritable moodiness, and an unaccommodating, fault-finding pessimism.

The DSM-IV (1994, p. 733) describes the PAPD essential feature as a pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance in social and occupational settings. The pattern must not occur exclusively during periods of major depression nor can it be accounted for by dysthymia.

The ICD-10 lists the passive-aggressive (negativistic) personality disorder in Annex 1. To be diagnosed with this disorder, individuals must meet the general criteria of a personality disorder and at least five of the following: procrastination and delay in completing essential tasks -- particularly those that others seek to have completed; unjustified protests that others make unreasonable demands; sulkiness, irritability or argumentativeness when asked to do something that the individual does not want to do; unreasonable criticism or scorn for authority figures; deliberately slow or poor work on unwanted tasks; obstruction of the efforts of others even as these individuals fail to do their share of the work; and avoidance of obligations by claiming to have forgotten them (ICD-10, 1994, pp. 329-330).

The passive-aggressive personality disorder was first introduced in a U.S. War Department technical bulletin in 1945. The term was coined by wartime psychiatrists who found themselves dealing with reluctant and uncooperative soldiers who followed orders with chronic, veiled hostility and smoldering resentment. Their style was a mixture of passive resistance and grumbling compliance (Stone, 1993, p. 361).

In early literature, individuals similar to those covered by the designation of passive-aggressive personality disorder were referred to as:

dissatisfied people who acted as if they were perpetually wounded (Aschaffenburg, 1922);

fussy people with sour dispositions (Hellpach, 1920);

depressives with ill tempers who were spiteful, malicious, and pessimistic (Schneider, 1923);

people with irritable moods (Bleuler, 1924); and

people who took everything hard and felt the unpleasantness in every situation (Kraepelin, 1913). (Millon & Radovanov, Livesley, ed., 1995, pp. 314-316). The current criteria for the passive-aggressive personality disorder as proposed by the Personality Disorders Work Group for the DSM-IV includes:

passive resistance to fulfilling social and occupational tasks through procrastination and inefficiency;

complaints of being misunderstood, unappreciated, and victimized by others;

sullenness, irritability, and argumentativeness in response to expectations;

angry and pessimistic attitudes toward a variety of events;

unreasonable criticism and scorn toward those in authority;

envy and resentment toward those who are more fortunate;

self-definition as luckless in life and an inclination to whine and grumble about being jinxed;

alternating behavior between hostile assertion of personal autonomy and dependent contrition (Millon & Radovanov, Livesley, ed., 1995, p. 321). Millon suggests that the most essential features of PAPD are irritable affect; behavioral contrariness, obstructiveness, and sulking; discontented self-image, e.g. feels unappreciated and misunderstood; deficient regulatory control, i.e. poorly modulated emotional expression; and interpersonal ambivalence. They are noted for their interpersonal conflict, verbal aggressiveness, and manipulative behavior. Suicidal gestures and a lack of attention to everyday responsibilities are common (Millon, 1996, p. 198).

PAPD resistance to external demands is manifested in oppositional and obstructive behaviors. These individuals resent having to conform to the standards set by others. On the other hand, they fear direct confrontation. The combination of resentment and fear leads to passive, provocative behavior (Beck & Freeman, 1990, p. 333) and defiant compliance (Benjamin, 1994, p. 276).

Stone (1993, p. 362) suggests several subtypes of PAPD:

those with anxiety or depression (about one third);

those who are self-defeating and locked into punishing relationships;

those who are vindictive; and

those who begrudgingly put their lives on hold to care for others, e.g. an ill parent. Individuals with OCPD and PAPD share a deeply rooted ambivalence about themselves and others. While people with OCPD resolve their ambivalence by compliant behavior and holding tension within, those with PAPD have virtually no resolution. As a result, they are characterized by vacillating behavior. They are indecisive; they fluctuate in their attitudes, oppositional behaviors, and emotions. They are generally erratic and unpredictable (Millon, 1981, p. 244).

The passive-aggressive (negativistic) pattern is similar to that of the Oppositional Defiant Disorder. ODD should be considered for children. PAPD is limited to adults (DSM-IV, 1994, p. 734). Individuals with PAPD are also prone to anxiety disorders, depressive disorders with agitation, and chronic pain disorders. Correctional settings may have many individuals with PAPD who have committed explosive acts of violence (Richards, 1993, p. 260). Alcoholism and drug dependence are associated with both PAPD and PAPD families of origin (Oldham & Morris, 1990, pp. 215-216) (Beck & Freeman, 1990, p. 336).

Self-Image

Individuals with PAPD view themselves as self-sufficient but feel vulnerable to control and interference from others (Pretzer & Beck, Clarkin & Lenzenweger, eds., 1996, p. 60). They believe that they are misunderstood and unappreciated, a view that is exacerbated by the negative responses they receive from others for their consistent defeatist stance. They expect the worst in everything, even situations that are going well, and are inclined toward anger and irritability (Beck & Freeman, 1990, p. 339) (DSM-IV, 1994, p. 734).

Individuals with PAPD are often disgruntled and declare that they are not treated as they should be. On the other hand, they are just as likely to express feeling unworthy of good fortune. They have a basic conflict concerning their self-worth; they oscillate between self-loathing and entitlement or moral superiority. Either side of this oscillation can be projected onto the environment. The chaotic nature of this experience of self and others often leads to people beginning to avoid or minimize contact with people with PAPD out of self-protection (Richards, 1993, p. 259). View of Others

Individuals with PAPD see others as intrusive, demanding, interfering, controlling, and dominating. They believe that other people interfere with their freedom. They experience control by others as intolerable; they have to do things their own way (Pretzer & Beck, Clarkin & Lenzenweger, eds., 1996, p. 60). These individuals are determined that they will not be subject to the rules of others (Beck & Freeman, 1990, p. 227). They resent, oppose, and resist demands to meet expectations from others in a behavioral pattern seen in both work and social settings (DSM-IV, 1994, p. 733). Their main coping strategies are passive resistance, surface submissiveness, evasion, and circumventing of rules (Pretzer & Beck, Clarkin & Lenzenweger, eds., 1996, p. 60).

Relationships

Individuals with passive-aggressive (negativistic) personality disorder are ambivalent within their relationships and conflicted between their dependency needs and their desire for self-assertion. They waver between expressing hostile defiance toward people they see as causing their problems and attempting to mollify these people by asking forgiveness or promising to do better in the future (DSM-IV, 1994, p. 734).

These individuals are noted for the stormy nature of their interpersonal relationships. They engage in a combination of quarrelsomeness and submissiveness. Their affect is sullen and they engage in deliberate rudeness. They are resentfully quarrelsome and irritable. They often feel like a victim. Central to the disorder is a pervasive pattern of argumentativeness and oppositional behavior with defeatist and negative attitudes (Millon & Radovanov, Livesley, ed., 1995, p. 317). Richards (1993, p. 260) believes that PAPD may be the most miserable personality disorder. These individuals inflict a great deal of discomfort on others through the use of their anxiety and emotional symptoms. They can become so destructive in their attitudes and so unable to provide rewards to others that they become socially isolated.

Individuals with PAPD struggle between their desire to act out defiantly and their awareness that they must curtail their resentment. They engage in grumbling, moody complaints, and sour pessimism; these behaviors serve as both a vehicle for tension discharge (relieving them of mounting anger) and as a means of intimidating others and inducing guilt (providing them with a sense of retribution for the wrongs they believe they have experienced). These socially maladaptive behaviors result in inevitable interpersonal conflict and frustration. After a time, the sullen moodiness and complaining of individuals with passive-aggressive (negativistic) personality disorder alienates others (Millon, 1996, pp. 198-199). These individuals are able to sense the exasperation and growing animosity that others feel toward them; they use their awareness to become even more aggrieved -- without corresponding acceptance that their behavior has contributed to the situation.

For individuals with passive-aggressive (negativistic) personality disorder, being difficult, quixotic, unpredictable, and discontent produces certain rewards and avoids certain discomforts. These individuals can control others by forcing them into an uncomfortable anticipatory stance. People in relationships with PAPD individuals are perpetually waiting for the next struggle, the next grievance, the next round of volatility and carping criticism. Passive-aggressive individuals are able, within their relationships, to trap people into situations wherein whatever they do is wrong. Relating to individuals with PAPD becomes a tense, edgy experience where great caution must be employed to avoid precipitating an angry incident (Millon, 1981, p. 258).

Issues With Authority

For individuals with PAPD, authority figures can become the focus of their discontentment. They often criticize and voice hostility toward authority figures with minimal provocation. Their resistance toward authority is expressed by procrastination, forgetfulness, stubbornness, and intentional inefficiency. These individuals are also envious of and resentful toward peers who succeed or are viewed positively by authority figures (DSM-IV, 1994, pp. 733-734).

Authority figures are seen by individuals with passive-aggressive (negativistic) personality disorder as arbitrary and unfair. When they are faced with the consequences of not adequately meeting obligations, these individuals will become angry at those in authority rather than seeing how their own behavior has contributed to the situation (Beck & Freeman, 1990, p. 339). Authority figures are defined as intrusive, demanding, interfering, controlling, and dominating. On the other hand, individuals with PAPD also see authority figures as capable of being approving, accepting, and caring. A key issue for individuals with PAPD is the desire to get benefits from authority figures while exerting their freedom and autonomy (Beck & Freeman, 1990, p. 45).

The conflict is intense. Individuals with PAPD have a tendency to see any form of power as inconsiderate and neglectful. They are also likely to believe that authorities or caregivers are incompetent, unfair, and cruel. Nevertheless, these individuals are not inclined to rebel directly. They will agree to comply with demands or suggestions but will often fail to perform (or they will perform while experiencing increasing resentment). Then, when there is trouble, these individuals will complain of unfair treatment. They envy and resent others who manage authority situations and who are able to relate to authorities with less difficulty. These individuals believe that their suffering indicts the negligent caregiver or authority figure. They fear control in any form but long for nurturing restitution from those they perceive as having power (Benjamin, 1993, p. 272).

PAPD Behavior

Origin of PAPD behavior:

Stone (1993, p. 361) suggests that the contrary, sulking, and verbal nitpicking behaviors of PAPD appear to have their origin in unending power struggles with parents. The comparative helplessness of youth made it impossible to win in these struggles so the face-saving technique of passive resistance was employed. Parental overcontrol, neglect, or favoring of a sibling can all contribute to the development of the silent protest and grudging obedience associated with PAPD (Stone, 1993, p. 361).

Behavioral Features of PAPD Include:

sullen contrariness with little provocation;

restlessness, unstable and erratic feelings;

inclination to be easily offended by trivial issues;

low frustration tolerance and chronic impatience and irritability unless things go their way;

vacillation from being distraught and despondent to being petty, spiteful, stubborn, and contentious;

short-lived enthusiasm and cheer with ready reversion to being disgruntled, critical, and envious;

begrudging the good fortune of others;

quarrelsome reactions to indifference or minor slights from others;

emotions close to the surface; they may burst into tears at a small upset;

discharging anger or abuse at others with minimal provocation;

impulsivity and explosive unpredictability -- making others uncomfortable;

ability to be pleasantly social with expression of warm affection but then easily provoked into hurt obstinacy and cruel, nasty interaction (Millon, 1981, p. 254). PAPD Ambivalence:

PAPD ambivalence is expressed behaviorally by vacillation between negativism/autonomy and dependency/conformity. However, even when conforming, these individuals tend to be contrary, unaccommodating, sulking, pessimistic, and complaining (Kubacki & Smith, Retzlaff, ed., 1995, p. 175). People with PAPD will behave obediently one time and defiantly the next. They will be self-deprecating and express guilt for failing to meet expectations in one situation and express stubborn negativism and resistance in another. They fluctuate between deference and defiance, between obedience and aggressive negativism. Their behavior will go from explosive anger or stubbornness to periods of guilt and shame (Millon & Davis, Clarkin & Lenzenweger, eds., 1996, p. 309).

PAPD Anger:

PAPD anger may be expressed directly or indirectly. Whether these individuals communicate their anger by omission or commission, they justify their rage with a lofty motive -- making a perfect cover for malicious intent (Kantor, 1992, p. 178).

Indirect expression of anger can take the form of chronic, seething hostility or sadistic carping criticism (Kantor, 1992, p. 179). Irritating, oppositional, and resentful behavior can be demonstrative of a pervasive pattern of passive resistance (Sperry & Carlson, 1993, p. 335). If there is a PAPD pattern of chronic hostility and resistance, no situational provocation may be needed for these individuals to engage in preaching behavior; excusing self by accusing others; bumbling behaviors when competence is actually possible; and using a positive gesture as a vehicle for a negative message, e.g. including relationship grievances in a Christmas card (Kantor, 1992, p. 177).

Other individuals with PAPD will express their rage overtly and directly. Aggressive PAPD behavior is intended to inflict discomfort, hurt, harm, injury, or destruction. These individuals have a disposition toward anger and aggression -- referred to irritability (Lish, et.al., Costello, ed., 1996, p. 32). They may have temper tantrums that release pent-up aggression; if their victim is aggressive in response -- so much the better. That response is then used to vindicate the initial attack. Anger expressed by commission is usually justified by laudable motives, e.g. concern for the well-being of the victim. The expression of the anger is dictated by the desire to wound while concealing the intention to wound -- even the existence of the anger. This is not to spare the feelings of the victim but to wound them more effectively. The intent is to provoke counteranger with such subtlety that the victim blames himself and believes his anger is not justified. That way, people with PAPD can assume the role of innocent victim (Kantor, 1992, pp. 178-180). They may make directly hostile statements because they fail to perceive their own motivating attitude, perceive their hostility too late, or believe that their attitude can be concealed. They may remain unaware of the implications of their behavior or words (Kantor, 1992, p. 178). PAPD avoidance of taking responsibility for the provocative consequences of anger produces paranoid overtones. These individuals are often surprised at the response they provoke; they typically deny having given cause for the angry responses they receive or they accuse others of overreacting. Many of these individuals will endure growing isolation rather than alter or give up what they believe to be their right to free expression (Kantor, 1992, p. 182).

Obstructive and Contrary PAPD Behavior:

Individuals with PAPD actively obstruct others (Kubacki & Smith, Retzlaff, ed., 1995, p. 175) by failing to do their share. Still they complain, feel cheated, unappreciated, and misunderstood. They blame their failures or difficulties on others. They are inclined to be sullen, irritable, impatient, argumentative, cynical, skeptical, and contrary (DSM-IV, 1994, p. 733). These individuals engage in specific retaliation for wrongs that they perceive have been done to them via obstructionistic, petty, difficult behaviors designed to discomfort the recipient, e.g., the wife who points out several similar errors on an occasion when the husband completes an activity successfully (Kantor, 1992, pp. 177-178).

Oldham & Morris (1990, pp 213-215) suggest that individuals with PAPD raise contrariness to an art form. They stall, complain, oppose, forget, and feel cheated by life. They experience life as dark and unpleasurable. To these individuals, thwarting the expectations of others is a victory even if they sabotage their own lives. They are difficult, angry and needy. They see compliance as submission, and submission as humiliation.

PAPD behavior is basically oppositional and provocative. While these individuals may seem, on occasion, to be compliant and agreeable, they are judgmental, irritable, and easily frustrated. They resist adequate performance through stubbornness, forgetfulness, lateness, deliberate inefficiency, and procrastination (Sperry & Carlson, 1993, p. 336). The opposite of the behavior appropriate to a given situation is the one most likely to be expressed by individuals with PAPD -- hence the negativistic personality. Another name for this pattern might be the oppositional personality. Individuals with passive-aggressive (negativistic) personality disorder maintain a consistent attitudinal set toward themselves and others. It is a spoiler attitude that is used to justify fatalism and nihilism. This behavior is often well tolerated in highly conflicted family systems. They will also find a place in work settings where there are relatively few consequences to nonproductive behavior and there are either few rewards or rewards are distributed arbitrarily (Richards, 1993, p. 259).

It is typical for passive-aggressive individuals to be cynical, doubting, and untrusting. They approach most events in their lives with a measure of disbelief and skepticism. Future possibilities are approached with trepidation. Most tend to be whiny and grumbling in their approach to life and voice disdain and caustic comments toward people who are experiencing good fortune (Millon & Davis, 1996, p. 551). These individuals tend to be quite articulate in describing their discomfort but rarely explore or seek to understand what is wrong. They do not recognize their own inner conflicts as contributing to their difficulties. They are often preoccupied with personal inadequacies, body ailments, and guilt; this alternates with equal preoccupation with social resentment, frustration, and disillusionment. They complain about the sorry state of their lives; they would like to feel better but seem unable or unwilling to find a solution to their difficulties (Millon, 1981, p. 255).

Affective Issues

Individuals with PAPD are vulnerable to anxiety, somatoform disorders, and depression. Major depressive episodes are not uncommon. In the PAPD depressive cycles, there is evidence of a tendency to blame others, a demanding and complaining attitude, and low self-confidence. These individuals are most likely to experience chronic dysthymia. Typically, individuals with PAPD display an agitated dysphoria, shifting between anxious futility and self-deprecation to demanding irritability and bitter discontent (Millon, 1996, pp. 198-199).

Individuals with PAPD experience an undercurrent of perpetual inner turmoil and anxiety. They appear unable to manage their moods, thoughts, and desires internally which results in emotional instability. They suffer a range of intense and conflicting emotions that surge quickly to the surface due to weak controls and lack of self-discipline. They have few unconscious processes they can employ to manage their feelings which emerge into behavior unconcealed, untransformed, and unmoderated. Without self-management skills, PAPD affect tends to be expressed in a pure and direct form, no matter what the consequences (Millon, 1981, p. 256).

PAPD implies, by definition, some level of hostility. Passive-aggressive (negativistic) individuals typically become angry about deprivation; they feel they do not have enough of and are deprived of what they need (Kantor, 1992, p. 179). They also believe they are trapped by their own fate; nothing ever works out for them. They feel envy and resentment over the easy life led by others. They are critical and cynical regarding what others have attained, yet covet what they have achieved. Life has been unkind to them; they feel cheated and unappreciated. They believe that their motives and behaviors have been misunderstood by others. Their pessimism and obstructiveness is merely a reflection of what sensitive people they are to the inconsiderateness of others or the medical concerns they have. They may, on occasion, express feeling remorseful because they have a bad temper. The struggle between their guilt and their resentment permeates their lives (Millon, 1981, p. 255).

The passive-aggressive personality disorder might be described as a compulsive personality with an attitude. These individuals express an irritable or sour mood; aggression is usually pouting and complaining. They are frequently depressed or sulking and gain perverse pleasure in raining on everyone's parade -- even their own (Richards, 1993, p. 258). These individuals focus on the negative; they are moody and pessimistic (Beck & Freeman, 1990, p. 334).

Defensive Structure

Individuals with passive-aggressive (negativistic) personality disorder utilize three main strategies to defend themselves: displacement, externalization, and opposition. The most consistent PAPD defense mechanism is displacement. These individuals shift their anger away from more powerful targets to those of lesser significance. They express their hostility toward others who are less likely to be able to retaliate or reject them. They often vent their resentment by substitute means such as acting inept or being forgetful. They can be both stubborn and exasperating. They have a very thin veneer of resentful compliance that masks their aggression toward others and disdain toward themselves. Passive-aggression and displacement, both defenses, involve overidealization of the self and devaluation of others (Millon & Davis, 1996, p. 552) (Kubacki & Smith, Retzlaff, ed., 1995, p. 175) (Richards, 1993, p. 259).

People with PAPD externalize their focus and cannot accept blame for any of their shortcomings (Stone, 1993, p. 361). They deny or refuse awareness of their own provocative behavior, the serious negative consequences of their maladaptive responses, and responsibility for the behavioral choices they make. Instead, they focus on the many grievances they have toward others. They focus on the behavior of others and externalize responsibility for their destructive actions.

Individuals with PAPD frequently employ the strategy of opposition; they fortify their autonomy through devious opposition to authority figures while overtly seeking favor from them (Beck & Freeman, 1990, p. 46). They attempt to keep their rebellion covert enough to maintain a sense of safety and allow themselves to deny malicious intent.

Table of Contents

Treating the Passive-Aggressive (Negativistic) Personality Disorder The Passive-Aggressive (Negativistic) Personality Disorder Coming Into Treatment

There are two major ways for individuals with PAPD to enter treatment. The first, and most common, is externally leveraged treatment for those individuals who do not see themselves as having a problem. Someone forced them 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. The second method for individuals with PAPD to enter treatment is via self-referral for vague complaints, e.g. "I'm just not getting anywhere" (Turkat, 1990, pp. 87-88).

All of the personality disorders are composed mostly of abrasive traits that are negative in nature. Maladaptive traits are usually favored over adaptive traits (though there are adaptive traits within all personality disorders) (Kantor, 1992, p. 10). PAPD is a particularly abrasive personality and interpersonal problems are readily identifiable. However, individuals with PAPD do not frequently seek treatment for relationship issues as they consistently blame others for the problems they have. Even if they do come in for treatment for a marital or parent and child problem, they will uniformly demand that the treatment providers "fix" the other person or persons who are at fault for the problems within the relationship.

Medication Issues

Medication has not been found to be helpful for PAPD unless there is also anxiety or depression (Stone, 1993, p. 363).

Treatment Provider Guidelines

Passive-aggressive behaviors often brought forth in the treatment setting:

Intrusive and unnecessary phone calls.

ole reversal with evaluation of the treatment providers -- discussing their good and bad points (usually with the balance being on the inadequate side).

Projection of anger and then criticism of that anger.

Absorbing nothing; responses to identification of passive-aggressive behaviors being denial, minimization, changing the subject, or denying hostile motivation.

Absorbing everything and refusing to apply it.

Doing the opposite of what the service providers expect.

Using insight against both themselves and the service providers (Kantor, 1992, pp 183-185). Consequently, service providers should not allow themselves to feel apologetic for setting and enforcing limits or reinforcing boundaries between clients with PAPD and staff (Ries, TIP #9, 1994, p. 72). In treatment, these individuals are inclined to skip sessions, pay late, arrive late, and then announce that they are leaving treatment because not much is happening anyway (Stone, 1993, p. 363). While limits and requirements of the treatment process may well elicit PAPD outrage and protestations of mistreatment, these individuals must learn to manage expectations in a positive manner if they are to be successful in changing their most maladaptive behaviors. They may engage in a sit-down strike against parents, spouses, or other authority figures (including service providers) -- refusing to progress in any direction. That defeats the parents or authority figures but also defeats their own ambitions or dreams. Young individuals with PAPD have actually refused to progress in any area of their lives to win the battle with their parents by disappointing them totally (Stone, 1992, p. 362). In treatment, the consequences of self-destructive choices can be pointed out and reflected upon. However, pressure to be more constructive is likely to provoke intensified passive-aggressive resistance.

Transference and Countertransference Issues

The classic passive-aggressive transference pattern is to comply (sort of) with the therapeutic recommendation, and then to declare triumphantly that it was a very poor suggestion and failed miserably. These individuals are programmed to ask for help and then both to defy it and to suffer from it. Clients with PAPD expect to be injured by a negligent and cruel caregiver (Benjamin, 1993, pp. 282-285).

A common countertransference issue with these clients is outrage or punitive anger. They are manipulative individuals who are consistently stubborn, demanding, help-rejecting, critical, and inclined to ridicule both the treatment process and the service providers. It can be quite difficult to maintain a sense of balance in the face of such willful maliciousness. Consultation, supervision, or peer supervision can be quite helpful in venting emotional responses to these individuals and planning a realistic and appropriate treatment approach. It is imperative that service providers do not become so angry that they use limits to punish, e.g. discharging from treatment when it is not clinically appropriate to do so. It takes considerable therapeutic resilience to reflect limits, maintain expectations, and facilitate a cooperative response to the environmental pressures faced by these individuals. On the other hand, service providers must also ascertain when therapeutic empathy becomes permission for these individuals to be interpersonally abusive to program staff. This is neither acceptable behavior nor does permissiveness of this kind foster more adaptable client behavior at home or work. Treatment may need to be terminated if clients with PAPD will not curtail their spiteful behavior. The reason for doing so must be direct, clear, and stated without counter aggression.

Treatment Techniques

When assessing individuals with PAPD, address the following areas:

survival skills and self-care

use of OTC drugs

all other providers being seen for treatment

psychosocial and AOD history

mental status

coexisting anxiety disorders

medication evaluations for antidepressants

identification of typical passive-aggressive maneuvers (Ries, TIP #9, 1994, p. 71). Treatment for individuals with PAPD involves openly exploring the ways they indirectly and unassertively express aggression and neediness toward others by being contrary. Understanding this aggression can allow discovery of the depressive and invalidating experiences underneath -- which lead to a fear of loss of autonomy when others want to be close and a fear of loss of connectedness when others want to be alone (Kubacki & Smith, Retzlaff, ed., 1995, p. 175). Determine which situations or experiences are most difficult for individuals with PAPD in the direct expression of their feelings or beliefs. Identify all avoidance and anxiety-arousing situations. Address these issues with anxiety-management behavioral intervention techniques (Turkat, 1990, pp. 88-89). Cognitive therapy can help these individuals understand that they expect the worst from others and then proceed to behave in such a way that brings out the worst from these same people (Stone, 1993, p. 363).

Group therapy provides individuals with PAPD with an opportunity to learn how to manage their hostility. When their hostility emerges, group leaders can comment on hostile behavior and encourage other group members to respond. The group leader can assist these individuals to process what it is they want or need at that moment and to rehearse appropriate behavior within the group context (Ries, TIP #9, 1994, p. 72). However, clients with PAPD will not do well in group if they refuse to accept responsibility for their hostility and alienate the other group members. When that happens, these individuals often leave or become isolated within the group (Stone, 1993, p. 363).

Whether clients with PAPD are in group or individual treatment, it is important to identify and highlight examples of passive-aggressive behavior. Reflect on how the behavior is more maladaptive than adaptive. Give examples of how It creates more problems than it solves. Use illustrations from within the immediate treatment process as these individuals will use oppositional techniques and devalue treatment providers in response to real or perceived expectations (Kantor, 1992, p. 183).

Treatment Goals

Several treatment goals effectively address areas of concern for individuals with passive-aggressive (negativistic) personality disorder. These include:

providing these individuals with a benign experience with authority figures (treatment providers) who are genuinely concerned about their welfare and who are not determined to emerge and remain superior to the clients with PAPD (Stone, 1993, p. 363); addressing the issue of control by teaching these individuals that they can attain one type of control by giving up another, maladaptive type of control (Ries, TIP #9, 1994, p. 72); assisting individuals with PAPD who are parents to diminish the destructiveness of their overcontrolling, unpredictable, and hostile behavior with their children (Ries, TIP #9, 1994, p. 72); addressing behavior in all relationships, e.g., contrary, stubborn, devaluing behavior toward others (Ries, TIP #9, 1994, p. 73); and encouraging these clients to give up their agenda of suffering and work toward achieving and sustaining greater contentment and personal efficacy (Benjamin, 1993, p. 290). As with any of the personality disorders, individuals with PAPD cannot achieve a personality style that does not fit them temperamentally, nor is it realistic to work toward a personality change that is extraordinarily different than what they already are. Oldham & Morris (1990. pp. 195-202) suggest that the leisurely personality style is the non-personality disordered version of the passive-aggressive or negativistic individual. The traits of the leisurely personality style are:

the belief that these individuals have a right to enjoy themselves on their own terms in their own time; the inclination to deliver what is expected of them and no more; "enough is enough;" resistance to exploitation; comfortable refusal to meet unreasonable demands; relaxed attitude toward time; and resistance to feeling awe toward authority figures. Individuals with a leisurely personality style hold the independence of self as a first priority. They are comfortable with themselves and skeptical of others, especially authorities. They are watchful of people asking too much of them and skilled at saying no. They own their own time and use time as they want. They do not put the needs of others first nor do they go too far out of their way to please people. These are functional behaviors and would be compatible with the basic attitudes and beliefs of individuals with PAPD. As such, they could form the basis of treatment goals directed at behavioral change.

Table of Contents

Dual Diagnosis Treatment: Treating The Addicted Passive-Aggressive (Negativistic) Personality Disorder Incidence of Co-Occurring Substance Abuse Disorders

The incidence of co-occurring substance abuse with PAPD is high. Both Beck & Freeman (1990, p. 336) and Oldham & Morris (1990, p. 216) note the frequent association of substance abuse with this personality disorder.

Individuals with PAPD are prone to use drugs to regulate mood states; it is consistent with their general attitudes and beliefs that they see themselves as entitled to an external solution to problems. These individuals are likely to display their addictions in a loud uproar, rather than keeping it a secret. They use their addictions interpersonally to justify their angry or violent behavior or to provide a rationale for nonperformance, incapacitation, or inaccessibility. Substance abuse in individuals with passive-aggressive (negativistic) personality disorder may trigger a change from stubborn minimal compliance to aggressive defiance or self-loathing (Richards, 1993, p. 261).

Drugs of Choice for the Passive-Aggressive (Negativistic) Personality Disorder

Milkman & Sunderwirth (1987, p. xiv) propose that the drug of choice for anyone is actually a pharmacologic defense mechanism; it is chosen by how well it fits with individuals' usual style of coping and how effectively it bolsters already established patterns for managing psychological threat. However, Richards (1993, p. 260) suggests that almost any of the drug classes will suit individuals with a passive-aggressive (negativistic) personality disorder. Prescribed pain killers and antianxiety agents, in combination with alcohol, is probably the most common pattern of abuse. In fact, individuals with PAPD may come into treatment needing to be detoxed from benzodiazepines and other sedative-hypnotics (Ries, TIP #9, 1994, p. 71).

Dual Diagnosis Treatment for the Passive-Aggressive (Negativistic) Personality Disorder

Richards (1993, pp. 261-278) suggests that treatment failures for the dually diagnosed are often a result of neglecting to consider the function of the addiction, including the drug of choice, within the context of the psychopathology dominant in the individual. Dual diagnosis treatment must involve recognition of needs, behaviors and attitudes that foster addictive behavior. Individuals with PAPD will feel entitled to recovery but will refuse to work toward it because they either believe that they are owed normalcy or that the treatment staff are flawed and incompetent. Because of these attitudes, these individuals are extremely difficult to motivate or maintain in substance abuse treatment. They are easily demoralized and may feel entitled to relapse because they have been tempted by the cruel forces of fate.

Individuals with passive-aggressive (negativistic) personality disorder may complicate their recovery with compulsive eating or spending. Ongoing monitoring for compulsive behaviors and use of alcohol, prescribed medication, and OTC drugs is important. Verifying all prescribed medications and working with all prescribing physicians can prevent medical emergencies for these individuals. Addicted clients with PAPD must be urged to inform their physicians of their involvement in AOD or dual diagnosis treatment. As they are willing to do so, they begin the process of accepting personal responsibility for their recovery (Ries, TIP #9, 1994, p. 71).

Individuals with PAPD can benefit from 12-Step Groups, but they must be encouraged to avoid romantic involvement to escape existing bad relationships. If they will join same-sex support groups, they may better be able to avoid relationships built on a mutual need to avoid recovery (Ries, TIP#9, 1994, p. 72). Also, involvement in self-help groups will be self-defeating without assistance on how to use these groups without alienating everyone (Richards, 1993, p. 262).

In treatment groups, clients with passive-aggressive (negativistic) personality disorder engage in exploiting other group members without reciprocity or mutuality. They often do not report or show progress and engage others in a destructive manner. They can undermine the efforts, morale, and good faith of both staff and group members (Richards, 1993, p. 261). If these individuals will not accept limits on their behavior and they substantially reduce the effectiveness of the group for all participants, termination from the group should be considered.

Coercion or legal leverage is often needed to establish compliance with treatment for clients with PAPD. Clear consequences and specific limits are necessary. Drug testing is of crucial importance -- these individuals are second only to people with antisocial personality disorders in insisting they are abstinent when they are using daily. Care must be taken to be in touch with all sources of medication. Attendance in treatment should be carefully monitored. Low credibility should be given to self-reports regarding behavior (Richards, 1993, p. 262).

Confrontation will appear to be necessary to breach the sullen non-compliance in individuals with PAPD. However, they are inclined to use confrontation as proof that they are being treated badly and that the staff are incompetent. It is more likely to be effective to calmly state expectations, clearly define consequences, and enforce program policies. The impact of negative consequences will likely also be blamed on treatment staff but it is the most promising method to achieve compliance with treatment expectations.

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Sharon C. Ekleberry, 2000