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Passive-aggressive behavior

Passive-aggressive behavior is a pattern of indirectly expressing negative feelings, such as anger, resentment, or frustration, rather than addressing them openly and directly.^[1] This form of expression often manifests through actions or words that appear neutral, accidental, or innocuous on the surface but subtly convey hostility, resistance, or sabotage.^[2] It differs from overt aggression by avoiding direct confrontation, instead using indirect methods to undermine or frustrate others while maintaining a facade of compliance or innocence.^[3] The term "passive-aggressive" originated in 1945 within the U.S. military, coined by psychiatrist Colonel William Menninger in a War Department technical bulletin to describe soldiers who resisted authority through passive means, such as deliberate inefficiency, forgetfulness, or procrastination, without openly defying orders.^[4] This concept was later formalized in psychiatric literature, appearing as "passive-aggressive personality disorder" in the DSM-III (1980), characterized by a pervasive pattern of negativistic attitudes, resentment of authority, and contradictory behaviors like complaining while resisting tasks.^[5] However, due to diagnostic challenges and overlap with other conditions, the disorder was removed from the main criteria in subsequent editions; it appeared in the appendix of DSM-IV for further study and was not retained as a distinct disorder in DSM-5, where the pattern may be diagnosed under other specified personality disorder; passive-aggressiveness is now viewed primarily as a behavioral style rather than a standalone personality disorder.^[6] Common manifestations of passive-aggressive behavior include the silent treatment, sarcasm, intentional delays or mistakes, sulking, and vague or ambiguous responses that shift blame.^[7] These behaviors often arise in interpersonal relationships, workplaces, or families, where direct expression of anger may be discouraged or punished, leading individuals to channel resentment indirectly to avoid conflict or accountability.^[8] Such patterns can erode trust and communication, contributing to strained relationships, increased stress, and even mental health issues like anxiety or depression for both the perpetrator and those affected.^[9] While not always pathological, chronic passive-aggressiveness may stem from learned coping mechanisms in childhood environments marked by high expectations or emotional suppression.^[10]

Definition and characteristics

Definition

Passive-aggressive behavior refers to a pattern of indirectly expressing hostility, anger, or resentment through subtle, non-confrontational actions rather than overt communication.^[2] This form of expression often manifests in ways that appear innocuous or accidental on the surface but serve to undermine others or evade responsibility, allowing the individual to avoid direct confrontation while still conveying negativity.^[1] Key elements of passive-aggressive behavior include procrastination, sullenness, obstructionism, and seemingly inadvertent negative actions that disrupt or frustrate others.^[6] For instance, an individual might delay completing a task assigned by an authority figure as a means of expressing resentment without openly defying instructions.^[5] These behaviors stem from an ambivalence toward oneself and others, where underlying aggressive motives are masked by passive or neutral facades.^[6] Passive-aggressive behavior differs from active aggression, which involves direct expressions of hostility such as verbal outbursts or physical confrontations, and from purely passive behavior, which entails complete withdrawal or avoidance without any embedded negativity.^[8] In active aggression, resentment is openly acknowledged and acted upon, whereas passive-aggressive actions cloak hostility in indirectness to maintain plausible deniability; passive behavior, by contrast, lacks the intentional undermining quality and focuses solely on non-engagement.^[3]

Common manifestations

Passive-aggressive behavior commonly manifests through indirect expressions of hostility that avoid direct confrontation, allowing the individual to maintain plausible deniability. Primary signs include sarcasm, where negative feelings are conveyed through ironic or mocking remarks; backhanded compliments that subtly undermine the recipient; and the silent treatment, involving deliberate withdrawal of communication to punish or control others.^[3]^[11] Other key indicators are intentional inefficiency, such as deliberate delays in completing tasks, and weaponized incompetence, where a person feigns inability to avoid responsibilities.^[12]^[13] Verbal cues often involve ambiguous statements that mask resentment, such as responding "Fine, whatever you want" to a suggestion, or vague complaints that express dissatisfaction without seeking resolution. Non-verbal manifestations include sulking, where the individual displays visible unhappiness through facial expressions or body language without verbalizing the issue, and procrastination as a form of subtle resistance. These behaviors enable the expression of anger covertly, often escalating tensions without overt conflict.^[8]^[14] The cycle of passive-aggressive behavior typically begins with subtle hints or indirect signals of discontent, progressing to more overt forms of sabotage like obstruction or neglect, all while preserving the appearance of compliance. This pattern maintains deniability, as the aggressor can claim misunderstanding or lack of intent, perpetuating the cycle through repeated indirect provocations.^[15]^[16] Passive-aggressive behaviors are common in everyday interactions among adults, with estimates suggesting that approximately 10% exhibit such patterns due to suppressed anger.^[17]

Historical development

Origins of the concept

The term "passive-aggressive personality" emerged in 1945 through a U.S. War Department technical bulletin on medical nomenclature for psychiatric disorders, where it was used to classify behaviors observed among soldiers during World War II.^[18] This bulletin, Technical Bulletin, Medical No. 203, formalized the diagnosis to address indirect expressions of resistance in military personnel who avoided overt rebellion against authority.^[19] The concept specifically targeted "willful incompetence" and other subtle forms of defiance, such as chronic lateness or inefficiency, as ways soldiers coped with the stresses of service without direct confrontation.^[20] The early theoretical foundations of passive-aggressive behavior drew heavily from psychoanalytic principles, particularly Sigmund Freud's ideas on unconscious conflict and repressed aggression.^[10] Freud's work posited aggression as an innate instinct that, when suppressed by societal or superego pressures, could manifest indirectly through passive means rather than overt action. In the military context, this repression was seen as a response to rigid hierarchies, where direct aggression risked punishment, leading psychiatrists to view passive-aggression as a neurotic outlet for unresolved internal tensions.^[19] Initial case studies from 1940s military psychiatry illustrated these behaviors through observations of troops who expressed discontent via procrastination, forgetfulness, and dawdling, often in reaction to routine duties or combat-related frustrations.^[21] For instance, soldiers might deliberately delay tasks or feign oversight of orders, interpreting these as immature or emotionally unstable responses to authority rather than deliberate sabotage. These descriptions, documented in wartime psychiatric reports, highlighted how such patterns disrupted unit cohesion and were prevalent enough to warrant a distinct diagnostic category.^[19] Key figures in formalizing the concept included Colonel William C. Menninger, chief of psychiatry for the U.S. Army Air Forces, who played a pivotal role in its wartime application and documentation.^[21] Menninger described passive-aggression as a "neurotic type reaction to routine military stress," emphasizing its roots in emotional immaturity and indirect hostility, and he advocated for its inclusion in standardized diagnostics to better manage troop mental health.^[22] His contributions, detailed in post-war publications like Psychiatry in a Troubled World (1948), helped bridge military observations with broader psychoanalytic frameworks.^[19]

Evolution in psychiatric classification

The concept of passive-aggressive behavior entered formal psychiatric classification with the publication of the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) in 1952, where it was categorized under personality disorders as "passive-aggressive personality" with three distinct subtypes: the passive-aggressive type, marked by sulking and obstructionism; the passive-dependent type, characterized by helplessness and indecisiveness; and the aggressive type, characterized by passivity that gives way to episodes of temper tantrums, quarrelsomeness, or explosive outbursts.^[23] This inclusion built on earlier military observations but represented its initial codification in civilian diagnostics, reflecting a view of it as a pervasive pattern of indirect hostility.^[24] The second edition, DSM-II (1968), retained the category largely unchanged, emphasizing its role in personality disturbances without significant revisions to criteria.^[25] In the third edition, DSM-III (1980), passive-aggressive personality disorder (PAPD) was formalized as a standalone Axis II personality disorder, defined by a pattern of negativistic attitudes such as procrastination, stubbornness, and complaints of being unappreciated, distinguishing it from other disorders through its focus on covert resistance.^[13] The revised third edition, DSM-III-R (1987), expanded the diagnostic criteria to incorporate additional emotional features, including sulking, irritability, and argumentativeness, aiming to capture a broader "negativistic" dimension while retaining the core emphasis on indirect expression of aggression.^[13] These changes were influenced by psychoanalytic and behavioral theories but began to draw scrutiny for conceptual overlap with emerging disorders like borderline and narcissistic personality disorders.^[5] The validity of PAPD faced increasing critique during the 1970s and 1980s, particularly from researchers like Theodore Millon, who argued that the category lacked empirical distinctiveness, showed poor interrater reliability, and overlapped excessively with other personality pathologies, rendering it diagnostically unstable.^[19] Millon's consultations for the DSM-IV workgroup highlighted these issues, contributing to the decision to remove PAPD from the main text of DSM-IV (1994) and relegate it to Appendix B as a proposed "negativistic personality disorder" for further study, due to insufficient scientific evidence supporting its unique status.^[19] This exclusion marked a pivotal shift, as subsequent editions like DSM-5 (2013) omitted it entirely, viewing passive-aggressive features as better integrated into broader criteria for personality disorder traits rather than a discrete entity.^[5] Post-1990s psychiatric research reframed passive-aggressive behavior as a maladaptive coping style embedded within general personality pathology, often assessed dimensionally through traits like antagonism or low agreeableness in models such as the alternative DSM-5 personality disorder hybrid.^[5] The American Psychiatric Association (APA) now regards it primarily as a descriptive behavioral pattern rather than a formal diagnosis, emphasizing its occurrence across various disorders and contexts without endorsing a standalone category.^[6] This evolution reflects a broader move toward evidence-based, dimensional approaches in personality diagnostics, prioritizing empirical validation over categorical rigidity.^[25] Parallel to these psychiatric developments, recognition of passive-aggressive behavior surged in 1980s self-help literature, which popularized it as a common relational dynamic and encouraged assertiveness training to address it. Books like Harriet Lerner's The Dance of Anger (1985) highlighted passive-aggression as a suppressed form of anger in intimate relationships, particularly among women socialized to avoid direct confrontation, thereby influencing public psychology by framing it as a modifiable pattern through self-awareness and communication skills.^[26] This era's assertiveness-focused works, such as those promoting balanced expression over passivity or aggression, further embedded the concept in mainstream discourse, bridging clinical insights with everyday self-improvement.^[27]

Causes and contributing factors

Psychological origins

Passive-aggressive behavior often originates from core psychological mechanisms involving a profound fear of direct confrontation, stemming from low assertiveness and heightened anxiety about potential rejection. Individuals may suppress open expression of anger or needs due to an underlying belief that assertiveness will lead to conflict or abandonment, resulting in the buildup of resentment that manifests indirectly. Perfectionism can exacerbate this process, as unmet high standards foster internal frustration that is redirected passively rather than addressed head-on.^[8] In terms of personality traits, passive-aggressiveness is closely associated with high neuroticism, characterized by emotional instability and negative affectivity, which amplifies sensitivity to perceived threats in social interactions.^[13] It also links to avoidant attachment styles, where individuals employ indirect aggression as a defense mechanism to avoid vulnerability and maintain emotional distance in relationships.^[13] These traits predispose people to interpret interpersonal demands as overwhelming, prompting covert resistance over direct communication. Cognitive patterns underlying passive-aggressiveness frequently involve distorted thinking, leading to emotional suppression, as individuals perceive direct expression as catastrophic, causing bottled-up feelings to emerge through procrastination, sarcasm, or sabotage.^[28] According to cognitive theories like Beck's, these distortions often revolve around beliefs of personal powerlessness, reinforcing a cycle of indirect hostility to regain a sense of control without risking overt rejection.^[28] Neurobiologically, evidence for passive-aggressiveness remains limited and indirect. However, these links are not causally established for passive-aggressive patterns specifically, and further research is needed to clarify any distinct neural underpinnings beyond general aggression or anxiety profiles. Recent studies (as of 2024) have begun redefining passive aggression as a form of indirect or "aggression by omission," calling for more targeted neurobiological investigations.^[29] Passive-aggressive behavior frequently emerges from childhood experiences in environments that discourage direct emotional expression and promote indirect resistance as a survival strategy. In households characterized by authoritarian parenting, where obedience is enforced through strict rules and punishment for overt defiance, children learn to suppress anger and resentment, opting instead for subtle forms of rebellion such as procrastination or forgetfulness to assert autonomy without risking severe repercussions. Similarly, inconsistent discipline—alternating between permissiveness and harsh criticism—creates confusion and insecurity, teaching children that open communication is unreliable and that veiled hostility is a safer outlet for frustration. Emotional suppression in such families, often rooted in parental modeling of unexpressed anger, reinforces the idea that vulnerability invites exploitation, leading to lifelong patterns of indirect conflict.^[30]^[31] Cultural norms significantly shape the development and expression of passive-aggressive behavior by establishing expectations around confrontation and harmony. In collectivist societies, such as those in East Asia, where maintaining social cohesion and avoiding shame are paramount, direct aggression is often stigmatized, encouraging individuals to channel dissatisfaction through non-confrontational means like sarcasm or passive resistance to preserve group unity. Conversely, in high-conflict cultural contexts or environments with rigid hierarchies, such as certain workplace or institutional settings influenced by broader societal values, overt anger may be punished while indirect expressions are overlooked, normalizing behaviors like intentional inefficiency as a form of subtle protest. These norms can intersect with individual psychological traits, amplifying passive-aggressiveness when internal tendencies toward avoidance meet external pressures for conformity.^[32] Through social learning processes, passive-aggressive behaviors are transmitted and reinforced within family and peer groups, where observation and imitation play central roles. Children exposed to parents who employ tactics like backhanded compliments or deliberate delays to cope with stress are likely to internalize these strategies, viewing them as effective ways to navigate power imbalances without direct repercussions. Peers in similar environments may further solidify these patterns by rewarding indirect expressions that evade adult authority, such as group procrastination on shared tasks, thereby providing short-term social reinforcement while avoiding immediate punishment. This modeling effect is particularly potent in dysfunctional families, where unresolved parental conflicts model passive-aggression as a normative response to tension.^[31] Risk factors for passive-aggressive behavior are notably elevated among individuals from dysfunctional family backgrounds, with research highlighting strong associations through attachment theory frameworks. Studies indicate that insecure attachment styles, often resulting from inconsistent caregiving or emotional neglect, correlate with higher rates of passive-aggressiveness in adulthood, as individuals learn to mask needs to avoid rejection. For example, children in families marked by chronic passive-aggression between parents exhibit increased vulnerability to adopting similar relational patterns, with empirical links showing that such environments contribute to interpersonal difficulties later in life. These external influences underscore the nurture-based pathways that perpetuate the behavior across generations.^[33]^[31]

Contexts of occurrence

In personal relationships

Passive-aggressive behavior in romantic relationships frequently involves indirect ways of expressing dissatisfaction or anger to avoid direct confrontation, such as giving the silent treatment after disagreements or intentionally "forgetting" agreed-upon plans like anniversaries or outings.^[34] These actions create confusion and emotional distance, as the partner receiving them may feel punished without understanding the underlying issue. Another common manifestation is guilt-tripping through phrases like "I guess I'll just do it myself," which subtly blames the partner for perceived neglect while maintaining a facade of self-reliance.^[11] In family settings, passive-aggression often emerges through subtle resistance or exclusion that undermines harmony, such as parents delaying compliance with reasonable requests from children, like postponing help with homework despite promises, which can instill feelings of unreliability.^[31] Within friendships, passive-aggressive tendencies appear as veiled criticisms or inconsistent actions, including backhanded compliments like "You're so brave for wearing that outfit" that imply judgment under the guise of praise.^[35] Chronic lateness to social gatherings or vague responses to invitations can also signal indirect disapproval or disinterest, eroding trust over time without explicit communication.^[8] Research indicates that passive-aggressive behavior is a prevalent conflict style in personal relationships, with studies showing it contributes to lower satisfaction levels among couples, where indirect hostility correlates with increased emotional distress and relational instability.^[28] For example, surveys of intimate partners reveal that such behaviors are reported frequently, often exacerbating cycles of misunderstanding in close bonds.^[36]

In professional settings

Passive-aggressive behavior in professional settings often manifests as indirect resistance to tasks or authority, undermining productivity and collaboration without overt confrontation. This form of expression is particularly prevalent in hierarchical environments where direct conflict may be perceived as risky, leading employees to channel frustration through subtle non-cooperation or veiled hostility.^[37]^[38] Workplace sabotage through passive-aggressive means includes procrastination on collaborative projects, where individuals delay contributions to shared goals, creating bottlenecks for teams. Other examples encompass "accidental" errors in reports, such as omitting key details that hinder project accuracy, or feigned agreement in meetings followed by non-compliance with decisions, which erodes trust and efficiency. These behaviors allow the individual to express resentment indirectly while maintaining a facade of compliance.^[39]^[40] Interactions with authority figures frequently involve subtle undermining, such as spreading gossip about supervisors to question their competence or exerting minimal effort on assigned tasks to signal disapproval without explicit challenge. Resistance to feedback may appear as defensiveness masked as confusion, where the employee repeatedly seeks clarification on instructions to avoid accountability. Such tactics preserve power dynamics while fostering resentment toward leadership.^[41]^[42] In team dynamics, passive-aggression disrupts cooperation by withholding critical information from colleagues, impeding collective progress, or employing email trails for passive criticism, such as CC'ing superiors on minor complaints to highlight others' shortcomings. These actions create an atmosphere of suspicion, where indirect barbs replace open dialogue, often escalating minor issues into broader interpersonal tensions.^[43]^[44] Research indicates that passive-aggressive behavior is widespread in organizations, with 73% of employees experiencing it at work and 52% encountering it at least weekly, contributing significantly to workplace conflicts and correlating with elevated turnover rates—23% of individuals report it influencing their decision to leave a job. This prevalence underscores its role in diminishing overall organizational health.^[45]^[46]

Impacts and consequences

Effects on the individual

Individuals who engage in passive-aggressive behavior often experience unexpressed emotions, which can contribute to the development of depressive symptoms through self-control failures and internal conflict.^[47] Studies have shown a strong positive association between self-directed passive-aggressive tendencies and more severe depressive symptoms, where indirect expression of hostility reinforces internal conflict and emotional suppression.^[36] This pattern is further linked to diminished self-esteem, as passive-aggressive strategies stem from and perpetuate negative self-evaluation, leading to a cycle of low self-worth and avoidance of direct emotional confrontation.^[48] On the physical front, the ongoing suppression of anger inherent in passive-aggressive behavior functions as inward-directed hostility, elevating chronic stress levels and contributing to health issues such as hypertension and insomnia.^[49] Longitudinal research indicates that unexpressed anger correlates with increased cortisol production, a stress hormone that, when chronically elevated, is associated with cardiovascular strain and disrupted sleep patterns.^[50] These physiological responses highlight how passive-aggression, by bottling resentment, mirrors the health toll of prolonged emotional inhibition, potentially leading to stress-related disorders over time.^[28] Behaviorally, passive-aggressive patterns reinforce social isolation by hindering authentic communication, as indirect tactics like procrastination or sarcasm erode trust and genuine connections, fostering a self-perpetuating cycle of frustration and withdrawal.^[51] This avoidance of direct expression limits opportunities for resolution, trapping individuals in escalating emotional discord.^[8] In the long term, chronic engagement in passive-aggressive behavior heightens the risk of progressing to more entrenched maladaptive patterns, including higher needs for therapeutic intervention due to associated complications like persistent depression and interpersonal dysfunction.^[52] Data from clinical studies reveal that such behaviors are linked to early dropout from mental health treatment and sustained vulnerability to severe emotional dysregulation, underscoring the importance of addressing these patterns to prevent escalation.^[53]

Effects on relationships and others

Passive-aggressive behavior significantly erodes trust and fosters resentment in interpersonal relationships, as individuals receiving such indirect expressions of hostility often interpret them as deliberate sabotage or manipulation. This leads to communication breakdowns, where open dialogue is avoided to prevent escalation, resulting in unresolved conflicts that accumulate over time. For instance, subtle actions like procrastination or sarcasm create a climate of uncertainty, making partners or colleagues question the sincerity of interactions and ultimately weakening relational bonds.^[54]^[55] Recipients of passive-aggressive behavior frequently experience confusion and self-doubt, akin to gaslighting, as the indirect nature of the hostility denies them clear validation of their feelings. This can induce anxiety, feelings of excessive responsibility for the aggressor's unspoken grievances, and emotional withdrawal as a protective response. Over time, victims may internalize blame, leading to diminished self-esteem and isolation within the relationship.^[56]^[3] In group settings, such as workplaces or social circles, passive-aggression cultivates toxic dynamics by undermining collaboration and promoting a culture of suspicion. Team members may disengage from joint efforts due to fear of veiled criticism or non-cooperation, reducing overall productivity and morale. Research indicates that related conflict behaviors, such as withdrawal, contribute to higher rates of relationship dissolution, including divorces, among affected couples, as chronic indirect conflict exhausts relational resilience.^[57]^[58] The pattern often perpetuates a vicious cycle, where passive-aggressive actions provoke reactive overt aggression from others, escalating tensions without addressing underlying issues. This mutual hostility reinforces defensiveness on both sides, trapping relationships in ongoing discord and preventing constructive resolution.^[59]^[60]

Methods of identification

Identifying passive-aggressive behavior in clinical settings typically involves a combination of structured interviews, self-report questionnaires, and direct observation of behavioral patterns. Clinicians may conduct semi-structured interviews to explore a patient's history of interpersonal conflicts, resentment, and indirect expressions of anger, allowing for the identification of recurring themes such as procrastination or sabotage in response to expectations. Self-report measures, including the Passive Aggression Scale (PAS), a 21-item questionnaire developed to assess traits like resentment and passive resistance, provide quantitative insights into self-perceived behaviors.^[61] Similarly, the Test of Passive Aggression (TPA), comprising 24 items evaluating both self-directed and other-directed passive-aggressiveness, has demonstrated strong internal consistency (Cronbach's α = 0.83–0.90 for subscales) and convergent validity with related constructs like hostility.^[36] Observation focuses on inconsistencies, such as verbal agreement paired with nonverbal cues of reluctance or deliberate inefficiency in tasks. Although passive-aggressive personality disorder was removed from the DSM-5 in 2013, remnants of its DSM-IV criteria continue to inform non-diagnostic evaluations of passive-aggressive patterns. These include at least four indicators of a pervasive negativistic attitude, such as passively resisting fulfillment of social or occupational roles, complaining of being misunderstood or unappreciated by others, expressing sullen or argumentative irritability, and unreasonably criticizing authority figures. Adapted for broader use, these traits help clinicians differentiate passive-aggressiveness from overt aggression or avoidance without implying a full disorder, emphasizing patterns of indirect hostility over rigid diagnostic thresholds. For self-identification outside clinical contexts, individuals can track patterns through journaling, noting instances of suppressed anger expressed via sarcasm, delays, or feigned helplessness, which may reveal underlying resentment. Seeking feedback from close relationships can also highlight discrepancies, such as others perceiving intentional obstruction when direct communication is absent, aiding personal awareness without professional intervention. Challenges in identification stem from the behavior's covert nature, which can mimic other issues like depression or anxiety, leading to subjective interpretations in unstructured settings. However, standardized tools like the PAS and TPA exhibit high test-retest reliability (PAS r = 0.77; TPA r = 0.86), enhancing objectivity in clinical practice.^[61]^[36]

Associations with other disorders

Passive-aggressive behavior often intersects with mood disorders, particularly depression, where it can present as masked irritability or indirect expressions of resentment that exacerbate depressive symptoms. Studies have identified passive-aggressive traits as showing a modest correlation with mood disorders (r = 0.09), including major depressive disorder, where overlaps with depressive personality traits can complicate symptom presentation and prognosis.^[5] Significant associations also exist with personality disorders, including borderline personality disorder (BPD) and narcissistic personality disorder (NPD). Research demonstrates moderate to high correlations between passive-aggressive patterns and BPD's emotional dysregulation, with passive-aggression serving as a maladaptive coping mechanism for intense affective instability (r = .68). Similarly, it overlaps with NPD through subtle manipulative tactics that avoid direct confrontation while maintaining control, with correlation coefficients around .54 in dimensional assessments. These comorbidities highlight how passive-aggressive behavior may function as a relational strategy within broader personality pathology.^[5] Passive-aggressive behavior shows notable co-occurrence with anxiety disorders, influencing symptom severity and treatment response. Clinical studies report comorbidity rates ranging from 20% to 35% in anxiety disorder populations, where indirect hostility amplifies anxious rumination and avoidance behaviors. For instance, in samples with generalized anxiety disorder, passive-aggressive traits were present in approximately 21.5% of cases, often intensifying interpersonal conflicts that perpetuate anxiety cycles.^[62]^[63] Important differentiations exist to avoid misdiagnosis. Unlike oppositional defiant disorder (ODD), which features overt anger, argumentativeness, and defiance primarily in youth, passive-aggressive behavior is more covert and relational, emphasizing procrastination and sullen resistance rather than explicit rebellion. In autism spectrum disorder, what may appear as passive-aggressive communication—such as bluntness or withdrawal—stems from neurodevelopmental challenges in social reciprocity and literal expression, not deliberate hostility or resentment.^[64]^[65] These associations contributed to the de-emphasis of passive-aggressive personality disorder (PAPD) as a standalone diagnosis in the DSM. The American Psychiatric Association relegated PAPD to the appendix in DSM-IV due to poor diagnostic reliability, symptom heterogeneity, and substantial overlap with other conditions like depression, BPD, and anxiety disorders, which better capture the underlying pathology. In DSM-5, it was entirely removed, reflecting a shift toward dimensional models that integrate passive-aggressive features into broader personality and mood disorder criteria.^[5]

Treatment and management

Professional interventions

Professional interventions for passive-aggressive behavior primarily involve structured psychotherapies aimed at addressing underlying cognitive patterns, interpersonal dynamics, and emotional regulation challenges associated with the behavior. These approaches are typically delivered by licensed mental health professionals, such as psychologists or psychiatrists, and are evidence-based, drawing from clinical trials and guidelines for personality-related difficulties. Treatment often begins with a thorough assessment to tailor interventions, ensuring they target the individual's specific manifestations of passive-aggression, such as indirect resistance or resentment buildup.^[66] Cognitive-behavioral therapy (CBT) is a cornerstone intervention, focusing on identifying and reframing negative thought patterns that fuel passive-aggressive responses, such as assumptions of rejection or helplessness in conflicts. Techniques include cognitive restructuring to challenge irrational beliefs, behavioral experiments to practice direct expression of needs, and skills training in assertive communication to interrupt cycles of resentment and avoidance. Clinical studies demonstrate that CBT significantly reduces passive-aggressive functioning styles and associated depressive symptoms, with improvements observed in personality disorder parameters post-treatment. For instance, in randomized controlled trials, CBT has led to enhanced assertive behavior and decreased indirect hostility in individuals exhibiting these traits.^[66]^[67] Interpersonal therapy (IPT), particularly variants like metacognitive interpersonal therapy (MIT), emphasizes building healthier relationship skills and fostering direct expression of emotions and needs, which is crucial for those with passive-aggressive tendencies often linked to comorbid conditions like depression. This approach explores interpersonal roles, communication barriers, and grief or role transitions that contribute to indirect aggression, using techniques such as role analysis and empathy-building exercises to promote openness. MIT, delivered individually or in groups, has shown feasibility and preliminary efficacy in reducing symptoms among patients with personality disorders featuring passive-aggressive traits, including improved mentalization of others' intentions and reduced interpersonal conflicts. It is especially beneficial when depression co-occurs, as it addresses relational patterns that exacerbate both issues.^[68]^[69] Dialectical behavior therapy (DBT) is another evidence-based approach, particularly effective for individuals with passive-aggressive behavior involving emotion dysregulation and interpersonal challenges. DBT teaches skills in mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness to replace indirect expressions of anger with direct, assertive communication. Studies indicate DBT reduces dysregulated anger and aggressive behaviors transdiagnostically, with benefits for passive-aggressive patterns through improved self-control and relationship functioning.^[70]^[71] Group therapy offers unique advantages for passive-aggressive behavior by providing a safe, interactive setting to observe and practice social dynamics, often incorporating elements from CBT or psychodynamic approaches. Participants engage in role-playing real-life scenarios to rehearse assertive responses, receive feedback on defensive or evasive behaviors, and develop empathy by witnessing others' perspectives, which helps diminish chronic defensiveness and resentment. Short-term intensive psychodynamic group therapy, for example, has been compared favorably to cognitive-behavioral group formats in treating personality disorders, including passive-aggressive types, with benefits in emotional insight and relational functioning. Schema-centered group psychotherapy further supports these gains by targeting maladaptive schemas through shared experiences, leading to measurable reductions in dysfunctional interpersonal styles.^[72]^[73] Pharmacological support plays an adjunctive role rather than a primary one, targeting underlying symptoms like anxiety or irritability that may perpetuate passive-aggressive patterns, but it is not a standalone treatment for the behavior itself. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine or sertraline, are sometimes prescribed to alleviate comorbid anxiety or depressive features, potentially reducing associated impulsivity and indirect aggression through modulation of serotonergic pathways. Evidence from studies on personality disorders indicates modest efficacy of SSRIs in diminishing irritability and impulsive elements within aggressive behaviors, though direct trials for passive-aggression are limited. Medication decisions require careful monitoring for side effects and integration with psychotherapy for optimal outcomes.^[74]^[75]

Self-management techniques

Self-management of passive-aggressive behavior involves practical strategies that individuals can implement independently to foster awareness, improve direct communication, set boundaries, and incorporate supportive lifestyle practices. These techniques emphasize personal accountability and gradual behavioral change without requiring professional intervention. Building awareness is a foundational step, where individuals engage in daily reflection to identify triggers for passive-aggressive responses, such as feelings of resentment or fear of conflict. Journaling indirect behaviors, like procrastination or sarcasm, helps uncover recurring patterns and underlying emotions, enabling proactive recognition before escalation.^[76] This practice, rooted in self-monitoring principles, promotes ownership of one's actions and reduces automatic indirect expressions.^[77] Enhancing communication skills counters passive-aggression by practicing direct expression through structured exercises. Using "I" statements, such as "I feel frustrated when plans change without notice because I value preparation," shifts focus from blame to personal feelings, facilitating clearer interactions.^[78] Role-reversal exercises, where one imagines and verbalizes the other person's perspective, build empathy and encourage assertive responses over veiled hostility.^[49] Assertiveness training incorporating these methods has demonstrated effectiveness, with one study of college freshmen showing the training group achieving 86.5% positive self-reported assertiveness responses post-intervention, compared to 41.6% in the control group.^[79] Setting boundaries assertively prevents the buildup of unexpressed resentment that fuels passive-aggression. Techniques include practicing firm but respectful refusals, such as "I can't take on that task right now as it conflicts with my priorities," to honor personal limits without guilt.^[78] Regularly seeking feedback from trusted individuals about one's communication style further reinforces accountability and adjusts indirect habits.^[76] These approaches, drawn from assertiveness skill development, help maintain relational balance by prioritizing open dialogue. Lifestyle supports like mindfulness meditation and stress reduction techniques address emotional suppression at its core. Mindfulness practices, involving focused breathing to observe thoughts non-judgmentally, lower the tendency toward indirect aggression by enhancing emotional regulation.^[80] A study on mindfulness training in adolescents found it significantly reduced impulsive and aggressive behaviors in classroom settings, with participants showing improved self-control.^[80] Similarly, assertiveness training paired with relaxation methods has led to notable gains, including up to a 45% relative increase in self-reported assertive behaviors in intervention groups versus controls.^[79] If these self-directed efforts prove insufficient, escalating to professional interventions may provide additional structure.

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THE DIAGNOSIS "passive-aggressive personality" in 1945 was incorporated into a War Department Technical Bulletin1 which dealt with medical nomenclature.
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Comorbidity
Passive-Aggressive Personality Disorder ... Narcissistic Personality Disorder and Histrionic, Borderline, Antisocial, and Paranoid Personality Disorders.
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The development of a repertoire of assertive behavior as opposed to passive or aggressive behavior would ... Also included is the percent of improvement.<|separator|>
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