Passive-aggressive personality traits stood out in the DSM classification, starting with its first version. The core line of patients is a permanent installation to a hidden obstruction, passive resistance to the leadership, behind the facade of which there is aggression not allowed to manifestexpression. They have a low level of self-affirmation, they cannot stand up for themselves, directly talk about their needs and desires. At the same time, they are always dissatisfied, annoyed and disappointed with someone or something. Patients are constantly looking for flaws in the authoritarian figures to which they are subordinate, and at the same time make no attempt to break free from their dependent position. Delays in the work are plausible excuses in varying degrees. At the same time, patients believe that they work much better than others think about it, reacting with indignation to the assumption that their productivity could be higher.
When forced to achieve success in work, or when, for some other reason, their internal aggression loses ground, they are clearly worried. They have a specific, hostile-subordinate character of communicative behavior, which manifests itself not only in work, but also in communication in general.They impose on others the position of their own dependence in such a way that it is perceived by others as punishment and manipulation. Those with whom the patients are in a relationship, are rarely calm and happy. Patients can, for example, spoil the party with their complaints and claims, without making any excuses without making their positive contribution to it.
Others eventually have to fulfill instructions for them and take their share of responsibility. Friends and relatives have to intervene in the process of therapy, expressing those claims to the wrong, in the opinion of the patient, treatment that he himself does not make to the doctor. Since patients are constantly focused on the presentation of claims, it is often difficult to formulate how the situation in which they would be satisfied should look like. Naturally, negative reactions of others to the behavior of the patient close the vicious circle, being for patients a subjective confirmation of the validity of their pessimism and negativism. Suicidal threats are common, but rarely accompanied by suicidal attempts.
High comorbidity with alcoholism, depression and somatization disorder. High level of employment and maladjustment: less than half of patients with a longitudinal observation catamnesis retain manufacturing jobs or domestic work.
To diagnose a passive-aggressive disorder, the condition must meet at least five of the following criteria: 1) non-compliance with the deadlines, delaying and postponing the completion of the daily tasks performed, especially when the completion is stimulated by others; 2) unreasonable protest against just demands and comments of others, statements about the illegality of these claims; 3) stubbornness, irritability or conflict with the forced need to perform undesirable tasks for the patient; 4) unfounded criticism or contempt for the authorities, responsible persons; 5) intentionally slow or bad work when performing unwanted tasks; 6) hindering the efforts of others due to the non-performance of their part of the work; 7) Avoiding fulfillment of obligations with reference to forgetfulness.
Differential diagnosis. Despite the known external similarity, the behavior in passive-aggressive disorder is less spectacular, dramatic, emotional and aggressive than in cases of hysterical and borderline disorders.
Treatment. Patients of this type rarely see the cause of their social maladjustment within themselves and, therefore, have no motivation for treatment. The structure of the personality makes the patient, who wants to get help, outwardly fight against this as against an imposed, degrading task. In any case, they bring their own communicative style into communication with the doctor. Maintaining psychotherapeutic contact with patients of the passive-aggressive type is extremely difficult: concessions to their requirements are anti-therapeutic , and refusal of them threatens the loss of contact.Psychotherapy therefore runs the risk of degenerating into the constant presentation of claims to the doctor for not wanting to accept the addiction of the patient.
A suicidal threat, as a rule, should not be interpreted as a depressive reaction to the loss of love, but as an indirect expression of anger. Nevertheless , a sufficient severity of melancholic affect is an indication for the appointment of antidepressants.
Cognitive- behavioral techniques that confront the patient with the social consequences of his behavior are more effective than correct interpretations of his mechanisms. It is more productive to focus on cognitive techniques; pure coping training programs come up against the evading reactions of patients in which they are very skilled. Purely behavioral techniques of group therapy and social skills training are also successful here. The constant opposition of patients can be used in the paradoxical methods of managing them, when the doctor deliberately suggests doing the opposite of what he wants from the patient.
Dissociative (conversion) disorders
Common to this category of disorders are transient disturbances in the integration of functions of memory, consciousness, self-identity and motility, including the loss of some part of these functions. These disorders are known to mankind from time immemorial. Similar conditions are described in ancient Egyptian papyruses about 2 thousand years BC, where their appearance in women was associated with the “wandering of the uterus” (hence the term hysteria). Hippocrates and Galen linked them to sexual abstinence. In the 19th century, the French physician Briquet first identified them as dysfunction of the nervous system as a result of psychological stress. Charcot considered hysteria a consequence of hereditary degenerative changes in the central nervous system and, despite such an organic interpretation, he successfully treated her psychologically – with hypnosis. Janet (1989) advanced the theory of psychic dissociation, according to which, as a result of constitutional genetic causes, the synthetic activity of the psyche may decrease, while certain ideator and affective components are no longer recognized, manifesting themselves in sensory-motor effects through unconscious mechanisms. Breuer (1985), unlike Janet , considered the process of dissociation not as passive, but as initiated by the patient himself. He called this special state of only partial awareness of disintegrated mental processes autohypnosis .
Freud’s discovery of the basis of the mechanism of dissociation — the active process of psychological defense, the phenomenon of repressing threatening or undesirable content elements from consciousness — was extremely important . The emotion that could not be expressed turned out to be turned into a physical symptom, thus representing a compromise between an unconscious desire to express a thought or feeling and the fear of possible consequences. The symptoms, as it turned out, allowed not only to mask unwanted emotions, but also represented a kind of self- imposed punishment for forbidding the desire or removing oneself from a frightening situation. The same symptoms were responsible for obtaining secondary benefits from the role of the patient. The “somatic language” of symptoms can also be used as a means of communication when the latter is obstructed by unconscious, conscious, or socio-cultural factors. This way of communication is especially characteristic of infantile, immature, dependent individuals with a low level of education and intelligence. The communicative effect of the symptom is also manifested in the fact that, by transforming the conflict in different spheres of a person’s relationship into a physical disease, it allows the patient to manipulate the social environment, to some extent reducing the painfulness of the conflict situation.
The elimination of the blockade in the way of emotion, the subsequent emotional unloading (catharsis) and, consequently, the disappearance of the physical symptom, deprived of its unconscious emotional support, was the original basis of the psychoanalytic method. Unfortunately, the relationship between the extensive phenomenology of dissociative disorders and the laboratory study of dissociation is still far from being a clear concept.