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Chapter: Essentials of Psychiatry: Personality Disorders

Passive–Aggressive (Negativistic) Personality Disorder

Passive–aggressive personality disorder (PAPD) is a pervasive pattern of negativistic attitudes and passive resistance to author-ity, demands, responsibilities, or obligations.

Passive–Aggressive (Negativistic) Personality Disorder




Passive–aggressive personality disorder (PAPD) is a pervasive pattern of negativistic attitudes and passive resistance to author-ity, demands, responsibilities, or obligations (American Psy-chiatric Association, 2000). PAPD would be diagnosed by the presence of four or more of the seven criteria presented in DSM-IV-TR criteria for PAPD.


PAPD is in the appendix of DSM-IV because there has been little research to support its validity. There was concern that the DSM-III-R diagnosis described a situational reaction rather than a pervasive and chronic personality disorder, and the crite-ria were revised substantially for DSM-IV-TR to describe a more general and pervasive negativism. Compelling objections were.


Etiology and Pathology


Central to the psychopathology of PAPD appears to be bitter resent-ment. Passive–aggressive persons have a hostile, angry and bitter attitude towards the world. There are no data on its heritability or psychosocial etiology. It has been suggested that passive–aggressive behavior is due in part to conflicts concerning dependency and resentment, or a history of mistreatment and neglect. One might find a history of being exploited, neglected, mistreated, or abused by persons upon whom the person with PAPD relied. Negativistic traits may also be modeled by parental figures.


Assessment and Differential Diagnosis


Most of the DSM-IV semi-structured interviews include items for the assessment of PAPD. It is particularly important when assessing for PAPD to recognize that passive–aggressive be-havior might be confined to settings in which persons have lost freedom, responsibility, or decision-making authority that was previously available to them and overt expressions of assertive-ness or opposition are being discouraged. For example, it would not be surprising to observe passive–aggressive behavior within the military, prison, or some inpatient hospitals. It is important in such settings to verify that the negativistic behavior was evident earlier and is currently evident within other situations.


Epidemiology and Comorbidity


Approximately 1 to 2% of the community will meet the DSM-III-R criteria for PAPD. Up to 5% of patients were diagnosed with PAPD earlier. The rate was higher when semi-structured interviews were used but still low compared with most other per-sonality disorders. The prevalence rate with the DSM-IV crite-ria are likely to be higher, given the expansion of the disorder from simply a passive resistance to demands for adequate perfor-mance to a more general negativism. The broader formulation of negativism resembles closely the general trait of oppositionalism (characterized by the tendency to be complaining, discontented, grumbling, whining and argumentative) which does appear to occur more often in males than in females (Costa and McCrae, 1992).




Many persons with PAPD may have met the criteria for an oppo-sitional defiant disorder during childhood, which is also charac-terized by the tendency to be irritable, complaining, oppositional, argumentative and negativistic (American Psychiatric Associa-tion, 1980). As adults, impairment is likely to be most evident with respect to employment. Persons with PAPD are irrespon-sible, lax and negligent employees, as well as resistant, opposi-tional and even hostile. Resolution of interpersonal conflicts is difficult due to the tendency of the passive–aggressive person to blame others. They are argumentative, sullen and critical of their peers and friends, who may not tolerate their antagonism.



Persons with PAPD rarely enter treatment to make effective changes to their personality or behavior. They are more likely to seek treatment for Axis I disorders (e.g., depression, anxiety, or somatoform disorder), or for marital, family, or occupational problems. The initiation of treatment is often at the insistence of a spouse, relative, or employer. They can be very difficult patients to treat due to their tendency to be blaming, argumentative, pes-simistic and passively resistant. It is important for the therapist to remain supportive and empathic; carefully and benignly offering observations, suggestions, and reflections on the patient’s ten-dency to be their own worst enemy. Cognitive treatment can be useful directly to address the false perceptions, assumptions and attributions (Beck and Freeman, 1990) as long as the therapist is not drawn into unproductive disagreements and arguments. It is common for therapists to become frustrated, impatient and de-fensive in response to the negativism, criticism and complaints. Periodic consultation with colleagues are advisable. Group ther-apy is often helpful once the patient has developed a commitment to the group, as the various members can provide consistent and confirmatory feedback regarding the negativistic and passive– aggressive behavior. There is no known pharmacologic treatment for PAPD.


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