Passive-Aggressive Personality Disorder

PASSIVE-AGGRESSIVE PERSONALITY DISORDER

Clinical Picture

Passive-aggressive personality disorder is characterized by a negative attitude and a pervasive pattern of passive resistance to demands for adequate social and occupa-tional performance. It occurs in 1% to 3% of the general population and in 2% to 8% of the clinical population. It is thought to be slightly more prevalent in women than in men (APA, 2000).

These clients may appear cooperative, even ingratiat-ing, or sullen and withdrawn, depending on the circum-stances. Their mood may fluctuate rapidly and erratically, and they may be easily upset or offended. They may alter-nate between hostile self-assertion such as stubbornness or fault finding and excessive dependence, expressing contrition and guilt. There is a pervasive attitude that is negative, sullen, and defeatist. Affect may be sad or angry. The negative attitude influences thought content: Clients perceive and anticipate difficulties and disappointments where none exist. They view the future negatively, believ-ing that nothing good ever lasts. Their ability to make judgments or decisions is often impaired. Clients are fre-quently ambivalent and indecisive, preferring to allow others to make decisions that these clients then criticize. Insight is also limited: Clients tend to blame others for their own feelings and misfortune. Rather than accepting reasonable responsibility for the situation, these clients may alternate blaming behavior with exaggerated remorse and contrition.

Clients experience intense conflict between depen-dence on others and a desire for assertion. Self-confidence is low despite the bravado shown. Clients may complain they are misunderstood and unappreciated by others and may report feeling cheated, victimized, and exploited. They habitually resent, oppose, and resist demands to function at a level expected by others. This opposition occurs most frequently in work situations but also can be evident in social functioning. They express such resistance through procrastination, forgetfulness, stubbornness, and intentional inefficiency, especially in response to tasks assigned by authority figures. They also may obstruct the efforts of coworkers by failing to do their share. In social or family relationships, these clients may play the role of the martyr who “sacrifices everything for others” or who may be aggrieved and misunderstood. These behaviors sometimes are effective in manipulating others to do as clients wish, without clients needing to make a direct request.

These clients often have various vague or generalized somatic complaints and may even adopt a sick role. They then can be angry or bitter, complaining, “No one can fig-ure out what’s wrong with me. I just have to suffer. It’s my bad luck!”

Nursing Interventions

The nurse may encounter much resistance from the client in identifying feelings and expressing them directly. Often, clients do not recognize that they feel angry and may express it indirectly. The nurse can help them examine the relationship between feelings and subsequent actions. For example, a client may intend to complete a project at work but then procrastinates, forgets, or becomes “ill” and misses the deadline. Or the client may intend to partici-pate in a family outing but becomes ill, forgets, or has “an emergency” when it is time. By focusing on the behavior, the nurse can help the client to see what is so annoying or troubling to others. The nurse also can help the client to learn appropriate ways to express feelings directly, espe-cially negative feelings such as anger. Methods such as having the client write about the feelings or role-play are effective. If the client is unwilling to engage in this pro-cess, however, the nurse cannot force him or her to do so.