Appendix: Passive-Aggressive Personality Disorder

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29 March, 2000

Appendix: PASSIVE-AGGRESSIVE PERSONALITY DISORDER (PAPD)

Mental Health Issues Treatment Issues PAPD & Addiction:
Dual Diagnosis Treatment Issues

Essential Feature: A pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance (DSM-IV?).
Self Image: PAPDs view themselves as self-sufficient but feel vulnerable to control and interference from others (Pretzer & Beck).
View of Others: Others are seen as intrusive, demanding, interfering, controlling, and dominating. Others interfere with personal freedom (Pretzer & Beck).
Relationships: PAPDs are ambivalent within their relationships and conflicted about their dependency needs and their desire for self-assertion (DSM-IV?).
Authority Issues: Authority figures can be the focus of PAPD discontent. PAPDs criticize and voice hostility toward authority figures with minimal provocation (DSM-IV?).
Behavior: PAPDs are sullen, contrary, restless, unstable, easily offended, chronically impatient, and irritable. They vacillate between guilt and despondency and being petty, spiteful, stubborn, and envious. They envy the good fortune of others and discharge anger or abuse with little provocation (Millon).
Affective Issues: PAPDs are vulnerable to anxiety, somatoform disorders, and depression. When depressed, PAPDs are likely to blame others, be demanding, and have low self-confidence. PAPDs often experience an agitated dysphoria (Millon).
Defensive Structure: PAPDs utilize displacement, externalization, and opposition to defend themselves. Their defenses involve overidealization of self and devaluation of others (Millon & Davis, Kubacki & Smith, Richards).
The PAPD Coming Into Treatment: PAPDs may enter treatment via external leverage or self-referral with vague complaints, e.g. "I'm not getting anywhere" (Turkat). If help is sought for relationship issues, PAPDs will ask that the others be "fixed" so there will be no further problems.
Medication Issues: Medication has not been found to be helpful for PAPD unless there is also anxiety or depression (Stone).
Treatment Provider Guidelines: Service providers should not feel apologetic for setting and enforcing limits or reinforcing boundaries between clients with PAPD and staff (Ries). Limits and requirements may elicit PAPD rage but these individuals must learn to manage expectations in a constructive manner for significant change to take place.
These individuals may engage in a sit-down strike against parents, spouses, or other authority figures and bring about their own failure in the service of thwarting the expectations of others (Stone).
Countertransference Issues: Classic PAPD transference is to sabotage treatment and then declare it a failure (Benjamin). Countertransference can be outrage and punitive anger. Consultation and/or supervision may be needed to avoid venting emotional responses to the PAPD clients. Service providers will need substantial therapeutic resilience to maintain an emotional balance and a clinically sound approach.
Treatment Techniques: Treatment must involve openly exploring the ways PAPDs express aggression and neediness toward others by being contrary (Kubacki & Smith). Group therapy may be helpful if these individuals will accept responsibility for their hostility and refrain from alienating the other group members. If not, they may both fail to progress in the group and undermine the efforts of the other group members and staff (Stone).
Treatment Goals: Address issues with authority, constructive parenting, control, contrary, stubborn, and devaluing behavior toward others, and personal efficacy without oppositional defenses.
Incidence of Co-Occurring SA Disorders: The incidence of co-occurring substance abuse with PAPD is high. These individuals are prone to use drugs to regulate mood states. They believe they are entitled to an external solution to problems and are likely to use their addictions to justify their angry or violent behavior or to provide a rationale for nonperformance, incapacitation, or inaccessibility. Substance abuse for PAPDs may trigger a change from stubborn minimal compliance to aggressive defiance or self-loathing (Richards).
PAPD Drugs of Choice: Almost any of the drug classes will suit individuals with PAPD. Prescribed pain killers and antianxiety agents, in combination with alcohol, is probably the most common pattern of abuse. PAPDs may come into treatment needing to be detoxed from benzodiazepines and other sedative-hypnotics (Richards) (Ries).
Dual Diagnosis Treatment: PAPDs feel entitled to recovery but may refuse to work toward it because they believe that the treatment staff is flawed and incompetent. Accordingly, PAPDs are extremely difficult to motivate or maintain in substance abuse treatment (Richards).
PAPDs 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 (Ries). PAPDs can benefit from 12 Step Groups but must be encouraged to use the experience constructively. They will need assistance not to alienate others with their negative behaviors (Richards).
Coercion or legal leverage is often needed to establish compliance with treatment for PAPDs. Clear consequences and specific limits are necessary. Drug testing is crucial; PAPDs are second only to antisocial personality disordered individuals in insisting they are abstinent when they are using daily (Richards).
Confrontation will appear to be necessary to breach the sullen non-compliance in PAPDs, but 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.

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Appendix: PASSIVE-AGGRESSIVE PERSONALITY DISORDER (PAPD)
Mental Health Issues	Treatment Issues	PAPD & Addiction: Dual Diagnosis Treatment Issues
Essential Feature: A pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance (DSM-IV?). Self Image: PAPDs view themselves as self-sufficient but feel vulnerable to control and interference from others (Pretzer & Beck). View of Others: Others are seen as intrusive, demanding, interfering, controlling, and dominating. Others interfere with personal freedom (Pretzer & Beck). Relationships: PAPDs are ambivalent within their relationships and conflicted about their dependency needs and their desire for self-assertion (DSM-IV?). Authority Issues: Authority figures can be the focus of PAPD discontent. PAPDs criticize and voice hostility toward authority figures with minimal provocation (DSM-IV?). Behavior: PAPDs are sullen, contrary, restless, unstable, easily offended, chronically impatient, and irritable. They vacillate between guilt and despondency and being petty, spiteful, stubborn, and envious. They envy the good fortune of others and discharge anger or abuse with little provocation (Millon). Affective Issues: PAPDs are vulnerable to anxiety, somatoform disorders, and depression. When depressed, PAPDs are likely to blame others, be demanding, and have low self-confidence. PAPDs often experience an agitated dysphoria (Millon). Defensive Structure: PAPDs utilize displacement, externalization, and opposition to defend themselves. Their defenses involve overidealization of self and devaluation of others (Millon & Davis, Kubacki & Smith, Richards).	The PAPD Coming Into Treatment: PAPDs may enter treatment via external leverage or self-referral with vague complaints, e.g. "I'm not getting anywhere" (Turkat). If help is sought for relationship issues, PAPDs will ask that the others be "fixed" so there will be no further problems. Medication Issues: Medication has not been found to be helpful for PAPD unless there is also anxiety or depression (Stone). Treatment Provider Guidelines: Service providers should not feel apologetic for setting and enforcing limits or reinforcing boundaries between clients with PAPD and staff (Ries). Limits and requirements may elicit PAPD rage but these individuals must learn to manage expectations in a constructive manner for significant change to take place. These individuals may engage in a sit-down strike against parents, spouses, or other authority figures and bring about their own failure in the service of thwarting the expectations of others (Stone). Countertransference Issues: Classic PAPD transference is to sabotage treatment and then declare it a failure (Benjamin). Countertransference can be outrage and punitive anger. Consultation and/or supervision may be needed to avoid venting emotional responses to the PAPD clients. Service providers will need substantial therapeutic resilience to maintain an emotional balance and a clinically sound approach. Treatment Techniques: Treatment must involve openly exploring the ways PAPDs express aggression and neediness toward others by being contrary (Kubacki & Smith). Group therapy may be helpful if these individuals will accept responsibility for their hostility and refrain from alienating the other group members. If not, they may both fail to progress in the group and undermine the efforts of the other group members and staff (Stone). Treatment Goals: Address issues with authority, constructive parenting, control, contrary, stubborn, and devaluing behavior toward others, and personal efficacy without oppositional defenses.	Incidence of Co-Occurring SA Disorders: The incidence of co-occurring substance abuse with PAPD is high. These individuals are prone to use drugs to regulate mood states. They believe they are entitled to an external solution to problems and are likely to use their addictions to justify their angry or violent behavior or to provide a rationale for nonperformance, incapacitation, or inaccessibility. Substance abuse for PAPDs may trigger a change from stubborn minimal compliance to aggressive defiance or self-loathing (Richards). PAPD Drugs of Choice: Almost any of the drug classes will suit individuals with PAPD. Prescribed pain killers and antianxiety agents, in combination with alcohol, is probably the most common pattern of abuse. PAPDs may come into treatment needing to be detoxed from benzodiazepines and other sedative-hypnotics (Richards) (Ries). Dual Diagnosis Treatment: PAPDs feel entitled to recovery but may refuse to work toward it because they believe that the treatment staff is flawed and incompetent. Accordingly, PAPDs are extremely difficult to motivate or maintain in substance abuse treatment (Richards). PAPDs 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 (Ries). PAPDs can benefit from 12 Step Groups but must be encouraged to use the experience constructively. They will need assistance not to alienate others with their negative behaviors (Richards). Coercion or legal leverage is often needed to establish compliance with treatment for PAPDs. Clear consequences and specific limits are necessary. Drug testing is crucial; PAPDs are second only to antisocial personality disordered individuals in insisting they are abstinent when they are using daily (Richards). Confrontation will appear to be necessary to breach the sullen non-compliance in PAPDs, but 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.