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									 SMALL,          SMALL,           AUG.          AND      MOORE                                                                                                                                      973

      Usage,     Arch.    Gen. Psychiat.                     14:225-232,         1966.                             parative         Study       in    North         Carolina,        London         and
 2.   Pittenger,       R. E., Hockett,                  C.     F., and        Danehy,       J. J.:                 Glasgow,      Brit. J. Psychiat.       114:1-9,      1968.
      The       First   Five         Minutes.         Ithaca,         N.Y.:      Paul     Marti-              4.   Sandifer,      M. G., Jr., Hordern,           A., Timbury,            G. C.,
      neau,       1960.                                                                                            and Green,         L. M.: Similarities           and Differences          in
 3. Sandifer,           M.     G.,     Jr., Hordern,             A., Timbury,             G. C.,                   Patient     Evaluation     by U.S. and U.K.              Psychiatrists,
      and      Green,        L.      M.: Psychiatric             Diagnosis:             A Com-                     Amer.     J. Psychiat.    126:206-212,          1969.

                                  Passive-Aggressive                                                  Personality                            Disorder:
                                                A Search                                           for a Syndrome

                                                 BY       IVER           F.   SMALL,               M.D.,     JOYCE            G.   SMALL,            M.D.,
                                          VINCENT                B.      ALIG,          M.D.,        AND      DONALD               F.   MOORE,               M.D.

 This paper          presents          data from            a seven-        to                              of Mental              Disorders of the American                                     Psy-
 15-year     follow-up           study       of 100 patients             hos-                               chiatric         Association                retained             the category,
pitalized        with a diagnosis               of passive-aggres-                                          including           it among            the personality                  disorder,
sive personality                diiorder,          who       were      com-                                 in both the first and second                            editions         (1, 2). V
pared       with 50 matched                  controls         with other                                        According               to the current                        manual,             this
psychiatric          diagnoses.            The clinical          features                                   label     is reserved              for persons              who exhibit                be-
of the         subjects          were        remarkably             homo-                                   havior        patterns           characterized                   by both             pas-
geneous         both      on cross-sectional                  and longi-                                    sivity       and         aggressiveness,                     understood                  in
tudinal       evaluations.             Their      psychopathology                                          terms         of interpersonal                     difficulties            with         ex-
was most          prominent             in disturbances               of in-                                pressing           hostility          and finding                 gratification.
terpersonal           relationships            and social           behav-                                 As with other                 conditions             categorized               as per-
ior, affective            reactions,          and somatic              com-                                sonality            disorders,              such          patients             display
plaints;        some          also        had       problems            with                               deeply          engrained,              generally               lifelong           char-
depressive          episodes and/or                   alcohol abuse.                                       acteristic          maladaptive               patterns           of behavior.
 The clinical          features         were       relatively        stable                                     The passive-aggressive                             personality               disor-
over time,         although          some       patients        appeared                                   der has received                     very       little       scientific           atten-
to have         improved            with      outpatient psycho-                                            tion despite            its prevalence                 and the paucity                   of
therapy.                                                                                                   objective            data       presently             available            about          it.
                                                                                                            Very      few clinical               papers           have        appeared              on
                                                                                                           the subject.              One topical                paper         by Whitman
        ASSIVE-AGGRESSIVE                     personality               dis-                                and      associates              appeared               in 1954            that        re-
 I      order     appears        to be a relatively                  com-                                   viewed         the clinical             attributes             of 400 outpa-
 mon condition.             In 1966, 3.1 percent                   of pa-                                   tients     with various                diagnoses,               including             155
tients     in public         mental       hospitals,          one per-                                      with        passive-aggressive                           personalities(19).
cent of patients           in private        facilities,      and nine                                     The authors                concluded             that the latter                 condi-
percent       of outpatients          received         this psychiat-                                       tion was probably                     culturally            determined.                At
ric diagnosis         (7, 8). The term              was first listed                                       times       their       patients           improved              with environ-
in a formal           system        of nosologic            classifica-                                    mental           structuring,              but they             tended           to de-
tion in the 1949 publication                   of the U.S. Joint                                           velop      neurotic            features         under          stress.        In 1965
Armed        Services        Nomenclature                and Method                                        Rabkin           offered         speculations                 about         the con-
of Recording             Psychiatric           Conditions             (18).                                tribution            of parental               attitudes              to passive-
Later     the Diagnostic            and Statistical             Manual                                     aggressive             personality                maldevelopment                       (9).
                                                                                                           In Europe              both        Monro            and Tolle              have         in-
    The authors      are with the department               of psychiatry,
                                                                                                           vestigated             mixed           groups            of patients                 with
Larue   D. Carter      Memorial      Hospital,     Indiana       University
School    of Medicine,          1315 W. 10th        St.,     Indianapolis                                  personality             disorders            (5, 17). Monro                     used a
Ind. 46202,     where     Dr. Iver Small       and Dr. Joyce             Small                             factor       analytic           approach              to categorize                 indi-
are professors       of psychiatry.      Dr. Alig is assistant              pro-
fessor  of psychiatry,       and Dr. Moore        is professor         of psy-
                                                                                                           viduals            with         various            personality                 distur-
chiatry  and medical      director    of the hospital.                                                     bances         in terms            of their          coping          behavior            or

Amer.         J. Psychiat.            /26:7,      January             1970                                                                                                                         [97]
  974                                                                                            PASSIVE-AGGRESSIVE                    PERSONALITY               DISORDER

  life style.                 c
                   Toll#{233}onducted             long-term           follow-             with detailed               inquiries        about        interim         history
  up studies        of the clinical           course       and outcome                    that were concluded                       with the completion                       of
  of patients         with character              disorders,          finding             a second            set of ratings              and check            lists. (In-
  that     many       became           worse       with      the passage                  ter-rater          reliability          on each           of these          check
  of time.                                                                                list items           of 0.8 or better                 with direct            inter-
       Thus     there      is much           more        to be learned                    viewing         had been            previously            established,              so
  about      the nosologic,              therapeutic,            and prog-                a second             examiner             was not employed                        for
  nostic     implications             of the diagnosis                of pas-             this part of the study.                    Also,       levels      of congru-
  sive-aggressive               personality             disorder.          The            ent validity              between           patients         and relatives
  aim of the present                  study      was to seek              more            had been determined                        prior      to the project,               so
  information           about         these      issues,        employing                 relatives         were not exposed                   to the same             inter-
  as many         safeguards           as feasible          to obtain        re-          view questions                 [13, 16]. Some               aspects         of the
  liable    data.      Our particular              goal was to iden-                      predictive            validity        of data         from       this sort of
  tify the fundamental                    diagnostic           features        of         examination                have        been       described            by Sha-
  this syndrome              (or syndromes)                  to facilitate                gass       [12].)       Whenfamily                  members              accom-
  more      systematic,             less intuitive            recognition                 panied         the patients,               as they           were        encour-
  and management                 of the disorder.                                         aged        to do,           a detailed            history          of family
                                                                                          background               and physical              and mental               status
  Method                                                                                  of other          kin was elicited.                 When          direct       con-
                                                                                          tact      with       the ex-patient                was not achieved,
       The setting           of this investigation                   is a teach-
                                                                                          outside        information              was sought             from        family
  ing      and       research          psychiatric               hospital           lo-
                                                                                          members,              hospitals,          physicians,            local       agen-
  cated       on the           Indiana           University              Medical
                                                                                          cies, credit           bureaus,          and any other               available
   School         campus.           Patients            are      referred           by    sources.
   physicians          throughout             the state           and are se-
   lected      for admission               on the basis              of the pa-           Results
   tient’s      need       for acute,            intensive           treatment
  and the case material                      requirements                 of a va-             The        100 probands                 were        selected          from        a
   riety    of multidisciplinary                    teaching,           training,          total       adult         inpatient           population              of 3,682
  and research            programs.                                                        persons         admitted            during        the study           period        of
       The subjects             for this study                were       selected          more        than ten years.                 Thus        “passive-aggres-
   from all patients               admitted           in the decade               fol-     sive”       patients          represented              nearly       three      per-
   lowing       the opening             of the hospital                  in 1952.          cent      of the total.              Despite          this large          intake,
   Patients        assigned         a final psychiatric                   diagno-          only      50 controls               were        found         who met             the
  sis of personality                disorder,           personality             trait      previously            stated       matching            criteria.       The ma-
  disturbance,            or passive-aggressive                       personal-           jority        of patients               in the total               population,
  ity (code         numbers          000-x52           and 301.81)             were        and in the subject                    and control              groups,        were
  accumulated              in progressive                order        of admis-            original         entries        to the hospital.               Only       11 per-
  sion date until a group                      of 100 probands                   was      cent of the total,                  ten percent             of the passive-
  obtained.           A control            group         was formed                 by     aggressive             subjects,          and six percent                  of the
  selecting         patients        with other            diagnoses            indi-      controls           had been              admitted           to this facility
  vidually         matched          with the subjects                    for age,          more than once.
  sex, educational                status,        and quarter               year of             The identifying                  characteristics               of the 100
  admission.                                                                               subjects         assigned          a final diagnosis               of passive-
       Two psychiatrists                 independently                 reviewed            aggressive            personality            disorder          are shown            in
  all case records.              After a study of the hospital                             table        1 with         comparative                 percentage            data
  charts,        they       completed              ratings         and       check         from the total                population.            (These        figures        ex-
  lists     of diagnostic               criteria,           historical           fea-      clude       patients         admitted          to special           units such
  tures,     and other           items,       using       a standard             for-      as child          and adolescent                   treatment            services
  mat previously              described           (14, 15).                                and        research              wards.)          The          demographic
       In 1966,         1967, and 1968, intensive                           efforts       characteristics                of the subjects               were generally
#{149}      made        to contact            all subjects             and con-            similar        to those          of the other            hospital        entries.
  trols     and to arrange                 for direct           examination               There         were         more        women            than       men.       Most
  by one of the authors.                           These          evaluations             were        young          adults         or in middle               adult      life.
  consisted          of standard             psychiatric            interviews            The       subjects           were       somewhat              younger          than
  [98]                                                                                                         Amer.       J. Psychiat.         126.7,     January        1970
SMALL         SMALL,         ALIG,         AND      MOORE                                                                                                                                 975

                                                                                          TABLE        1
                                                                            Identifying      Characteristics
                                                                                (Group      Percentages)

                                                    AGE               SEX           MARITAL         STATUS          EDUCATION                               OCCUPATION
                                     N           (iYEARS)        M            F      M          S    OTHER            (iYEARS)             UNEMPLOYED              UNSKILLED         SKILLED

    sample                           100           26.7          37         63      60         15       25               11.2                     42                    32              20
    population                   3,682             32.4          33         67       58        17       25               13.1                     25                    42              33

the others               on the average,                      but their             ages            matched            controls            revealed          the following                  di-
ranged         from          17 to 62 years.                 The only other                         agnoses:          schizophrenia,                  20; affective              psycho-
differences               between             the      subjects              and       the          Sis,     7; psychoneurosis,                      12; sociopathic                    per-
total      population                  appeared            in the data                   on         sonality          disorder,              usually         with         alcoholism
 educational               and occupational                       status.          More             or addiction,                  7; organic             brain         disorder,             2;
 of the passive-aggressive                            group          were still in                  and undiagnosed                      psychiatric          illness,         2.
 the process                of completing                   their         education                       Next,      the check              lists and ratings                 of the in-
 and      had         not yel qualified                      for other              than            dex hospital               data        were considered                     in terms
 casual      employment.                                                                            of general               categories               of clinical               features
     First we screened                      the coded            data from the                      such as appearance                        and behavior,                 social       and
 systematic             independent                reviews           of the index                   interpersonal                relationships,               and other              head-
hospital          records           to determine                 retrospective-                     ings contained                  in table          2. Even the tallying
 ly whether              on not any alternate                          psychiatric                  of these          items          revealed           subject-control                  dif-
diagnosis            could       be entertained.                  Items         agreed              ferences.            The         psychiatrists              who          evaluated
upon       by both             chart         examiners               were        scruti-            the      charts          found           more         manifestations                     of
 nized in each case to determine                                     if they “fit”                  mental         disorder            in the passive-aggressive                          pa-
 the diagnostic                 requirements                  of other            noso-             tients       than        in the controls-an                           average            of
 logic syndromes,                    defined         in terms            of criteria                 18.3 checked               items         per subject            as compared
 set down elsewhere(3,                           4, 10, 11). These                    op-           with       12.4 for controls.                    However,               the distri-
 erations         revealed            that the original                  sample           of        bution        of these             psychopathological                       features
 100 subjects              could          be readily           separated             into           was quite             different            in the two groups.                       The
three       subgroups.                In group           A there             were        52         subjects         had most numerous                          disturbances                 in
subjects         who met operational                          criteria          for the             the area of social                    and interpersonal                    relation-
presence           of significant                mental         disorder           (four            ships.        Abnormalities                     of affect              were        next
or more            signs or symptoms),                         but the distri-                      most         frequent,                with       somatic             complaints
bution        of these            manifestations                    did not sug-                    ranking third. In the control group, most
gest        any          specific            psychiatric                syndrome.                   common              indications              of mental             illness        were
Group          B, comprised                      of 18 subjects,                     dis-           in the area                of disorders                 of thinking,                 fol-
played        similar           clinical          features           but in addi-                   lowed         by intellectual                   and       organic             impair-
tion met criteria                    for a diagnosis                   of alcohol-                  ments,         deviant            social       and interpersonal                       re-
ism.      Group             C contained                 30 patients                 with            lationships,               and         delusions            and         hallucina-
psychologic,                 vegetative,               and/or             historical                tions.
evidences            of a depressive                 episode           at the time                        Table      2 indicates               the distribution                 of some
of hospitalization                      in addition             to clinical            at-          of these          manifestations                   in the three                subject
tributes         similar           to those            of the other                 sub-            groups         and the controls.                      Each        of the listed
groups.          Identifying                characteristics                   such       as         features         was agreed                upon by the two psychi-
age and             sex were               essentially             the same               in        atrists,         who          independently                   evaluated               the
groups        A, B, and C. There                        were no other                   in-         hospital         charts           and used           explicit          criteria          to
dications            in the data               that alternate                  psychi-              define       each item.                Only      those        attributes            that
atric      diagnoses               could          be entertained.                    The            were characteristic                      of at least one-fourth                       the
itemized            records            did not suggest                      illnesses               members              of each subgroup                      are listed. Thus
such      as schizophrenia,                        psychoneurosis,                     so-          the table          represents              a clinical         profile          of gen-
ciopathy,            hysteria,            organic         brain          disorders,                 eral characteristics                     rather       than the attributes
or mental            deficiency.                                                                    of any single               individual.            Nevertheless,                 many
     Similar          evaluations              of the charts               of the 50                of these          features            were typical               of most           sub-

Amer.        J. Psychiat.         126.7,         January      1970                                                                                                                        [99J
976                                                                                                                      PASSIVE-AGGRESSIVE                             PERSONALITY                      DISORDER

                                                                                             TABLE                  2
                                                                                   Index     Clinical Profiles
                                                                                           (Chart Data)

                                                                               PASSIvE-AGGRESSIVE                       SUBJECTS
                                                        A                                                 B                                            C                                                  D
 GENERAL           CATEGORIES                      (N   -    62)                                   (N         18)                               (N     =     30)                                    (N    =    50)
 OF      CHECK        LIST   ITEMS    NO OTHER              DIAGNOSIS                    PLUS      ALCOHOLISM                          PLU5      DEPRESSION                         MATCHED                   CONTROLS

Interview         appearance          Poor       grooming                and          Same        as A                              Same        as A                               Anxious,               suspicious.
      and behavior                       hygiene                                                                                                                                         guarded.              evasive.
Social      and                       Impulsive,              neglects                Same         as      A;        bender         Bender           drinking.           fre-      Social                isolation.
      interpersonal                      responsibilities;                                 drinking;            jailed       for       quent         job changes.                        physical                  aggres-
      relationships                      stormy,              verbally                     drinking;            injury         to      injury           to         health.               sion,            changes
                                         aggressive.                  suici-               health,            socioeco-                soc io e con                  o m ic              jobs        frequently.
                                         dal      gestures.             ma-                nomic          and           com-           and       community                               neglects              responsi-
                                         nipulative                                        munity         functioning                  functioning                    fro m              bilities
                                                                                           from         drinking                       drinking
Affective                            Angry,        cries        often                 Same         as A;            gloomy          Gloomy,                sad.         rn-        Blunted.               inappropri-
      reaction                                                                                                                         table,         hostile                            ate.       gloomy
Delusions          and                None                                            None                                          None                                           Paranoid                   delusions.
      hallucinations                                                                                                                                                                     ideas       of reference,
                                                                                                                                                                                         auditory              hallucina-
Thought                               None                                            None                                          Suicidal         ruminations                   Perplexity,                     suicidal
   disturbance                                                                                                                                                                           ruminations
Somatic                               Multiple               somatic                  Sameas              A                         Same         as         A;       sleep         Multiple                   somatic
      complaints                         complaints                                                                                    di s t u r b a n c e;                             complaints
                                                                                                                                       weight              loss
Intellectual and                      None                                            None                                          None                                           Poor         comprehension.
      organic      impairment                                                                                                                                                            unable               to      calcu-
History of                           Adolescent                    onset,             Same        as A                              Same        as     A;          precipi-        Adolescent                       onset;
   illness                               previous             episodes                                                                 tati n g            f a ct o r 5;                 previous               episodes
                                         of      similar           illness;                                                            acute         onset                               of     similar              illness,
                                         family             history         of                                                                                                           introverted                   pre-
                                         alcoholism                                                                                                                                      morbid           personality

jects;      for example,                multiple          somatic          com-                                the       hospital          document.                Both         men        and
 plaints      appeared           in all of them.            Also, 90 per-                                      women            indulged          in frequent               outbursts          of
cent of the subjects                   were described              as untidy                                   anger         and      tearfulness            and       complained              of
and      poorly         groomed.            Seventy-five               percent                                 numerous              physical         symptoms                without         in-
were       considered              to be impulsive,                   stormy,                                  volvement            of any specific             organ        system.        The
and neglectful             of responsibilities.                                                                onset        of illness           was       in adolescence,                  and
     Considered             in this way,            four clinical           pro-                               most         subjects          had       experienced                previous
files are shown               in table       2. Group          A, the pas-                                     episodes          with similar           manifestations,                gener-
 sive-aggressive                subjects        without          any other                                     ally      without         hospitalization.                Family         histo-
 psychiatric           diagnosis,           were        frequently             de-                             ries of alcoholism                were present              in 30 percent
 scribed       as untidy,           disheveled,           and neglectful                                       of the cases.
of personal             appearance             and hygiene.               Scor-                                     Groups         B and C resembled                         group        A in
ing of this item required                       that such chart                no-                             the majority              of these        respects,           as shown          in
tations       be made            by more          than one observer                                            table      2. In addition,              they       displayed           typical
and on more                than       one occasion.              They       also                               features         of alcoholism           or depression.
displayed          impulsive            behavior         (historical         and                                    The profile           of the controls               revealed         a dif-
observed           sudden,           unpremeditated                  actions).                                 ferent       constellation            of signs and symptoms.
Other        attributes            were      those         of neglect            of                            Even in the category                    of social          and interper-
personal          responsibilities,              frequent         outbursts                                    sonal       relationships,            where         both groups              dis-
of verbal          (not physical)             aggression,             suicidal                                 played        much pathology,                 the items          were qual-
gestures,         and manipulative                  interpersonal              be-                             itatively         and quantitatively                  different.         There
 havior,       the latter          as defined         by Murphy              and                               was much              more       social        isolation         and with-
 Guze (6), with                the requirement                  that these                                     drawal         in the controls,             whereas           the subjects
actions        be directly           observed         and recorded               in                            were socially            involved,         albeit      in tempestuous

[100]                                                                                                                                Amer.           J. Psychiat.               126:7,          January                1970
SMALL            SMALL,       ALIG,         AND        MOORE                                                                                                                                  977

                                                                                           TABLE           3
                                                           The   Index    Hospitalization               a nd Years       of Follow-Up

                                                                                                            PASSIVE-AGGRESSIVE             SUBJECTS
                                                                                       GROUP    A                             GROUP    B                 GROUP     C           CONTROLS
                                                                                         (N-52l                                lN-=18l                     (P4-30)               (N-SO)

Duration        of index    hospitalization                                              59.5                                   50.7                        46.0                    94.3
        (mean      days)
Major      treatment       approach
        Milieu therapy                                                                   20                                       5                         20                           8
        Psychotherapy                                                                    32                                     13                            7                     25
       ECT                                                                                 0                                      0                           3                     17
        Regular     discharge                                                            48                                     17                          28                      42
        AMA                                                                                3                                      1                           2                         3
        Transfer     to other institution                                                     1                                   0                          0                           5
Mean     years     between         hospital       admission
   andfollow-up                                                                           10.5                                   11.2                       11.5                     12.9
Range      in years of follow-up              period                                     7-14                                   7-15                       9-13                     7-14

and      quarrelsome              ways.                                                                  Our experience                   with the controls                 was very
      In table          3 some          details       about       the index                              different.         They         were      a much            more        mobile
 hospitalization                 and       follow-up           period        are                         group       and only 21 of them                    could        be located,
 provided.            The      three       subgroups           of passive-                               despite         equally         intensive        search.         Thus,       fol-
 aggressive           patients        shared       a very similar           hos-                         low-up        material           from the control                group       was
 pital experience,                which       differed       from that of                                insufficient          for comparative               purposes.
 the controls.             Most       of the subjects             were hos-                                   In table 4 the status                  of the subjects             on fol-
 pitalized         for a relatively             brief period         of time.                             low-up       contact         is summarized.                Fifty-eight          of
  Milieu        therapy,          with or without               short-term                               the group           had persisting              psychiatric           difficul-
 supportive             psychotherapy,                 was      the      major                           ties. Only nine were considered                               to be symp-
 treatment            modality.          ECT was given                to only                            tom free and without                       indications            of psychi-
 three      of the depressed                  subjects.        In the con-                               atric illness.           Of the others,            31 were receiving
 trol group,           somatic        treatment          was used much                                    medical        care-li            in psychiatric            hospitals,         13
 more        frequently,            and more            of the patients                                  as psychiatric                 outpatients,            and        seven        for
 required           long-term           hospitalization.             The in-                             physical         problems,           mostly       infirmities           of age.
 terval       of time         from       the index         admission            to                       The 27 others                were also experiencing                        emo-
 follow-up            ranged         from       no less than             seven                           tional       difficulties          but were         not in treatment
 years      to a maximum                   of 15 years.          The dura-                               at the time of the follow-up                         study.       Six of the
 tion of the follow-up                    period      was the same              in                       subjects         were        known         to have          died,     one by
 all groups.                                                                                             suicide.        The death             rate was probably                   com-
     We were able to trace                        73 of the 100 sub-                                     parable         to age-adjusted               death        rates     in actu-
jects      on an average               of 11 years         after the first                               arial      tables         and      compared             favorably           with
hospitalization.                 Sixty      of them          were       exam-                            the four known               dead among             the controls.
ined personally                  either      at the hospital              or in                              In the intervening                    years       since       the index
their       homes,          and considerable                   outside        in-                        hospitalization,               28 of the subjects                  had been
 formation             was       obtained           about       13 others.                               readmitted              to psychiatric                facilities         for      a
                                                                                          TABLE            4
                                                           FolIo w-Up     Status       of Passive-Aggressive                    Subjects

                                                                                                                                                                             LOST        TO
                                               RECOVERED                          PERSISTING           PSYCHIATRIC        IMPAIRMENT                        DEAD           FOLLOW-UP

Subjects                      N                                    Hospitalized           Outpatient                 Physical           Untreated
   GroupA                     52                       5                   4                       6                     4                   15                  3               15
   GroupB                     18                       3                   2                       5                      1                   3                  1                  3
   GroupC                     30                       1                   5                       2                     2                    9                  2                  9

        Totals               100                       9                 11                       13                      7                 27                   6               27

Amer.       J. Psychiat.           /26:7,       January          1970                                                                                                                       [101]
978                                                                                                      PASSIVE-AGGRESSIVE                PERSONALITY                  DISORDER

total       of 73 times.                    Rehospitalization                  was           complaints             were numerous                 and had become
 more        frequent           in index           groups        B and C-                     more      specific,        with different             emphasis           in the
that is, the subjects                  with additional              diagnoses                three      groups          of subjects.            Mild       to moderate
of alcoholism                or depressive             episodes.          Six pa-            organic          and      intellectual            impairments               were
tients      in group           B and 12 in group                   C were re-                also present,            mostly         in the older patients.
admitted            a total        of 45 times,               as compared                        The       clinical          manifestations                observed          in
with ten subjects                    in group           A who were               re-         most of the subjects                    still did not fit any of the
hospitalized              a total         of 28 times.             Moreover,                 established           psychiatric            syndromes.            In groups
rehospitalizations                     in group             A tended              to         B and C there                were generally                 fewer      criteria
cluster        close       to the time of the index                        hospi-            of alcoholism                  and/on          depressive            episodes
talization,          whereas            readmissions              for psychi-                on follow-up                than        there       had       been       at the
atric illness            in groups            B and C were                spread             time      of initial          admission.            Only        11 patients
over the entire               follow-up           period.                                    had changed                to the extent               that      other       psy-
      Data      from the direct                 psychiatric           examina-               chiatric        illnesses         were judged             to be present.
tions       of the subjects                  on follow-up               are dis-             This      kind of diagnostic                    reversal          was more
played         in table         5, again         in the form of group                        prone       to occur         in groups           B and C and in pa-
clinical        profiles.         As in table 2, the only items                              tients     who were             18 to 25 years               of age at the
 listed     are those            that were present                  in at least              time of the index admission.
25 percent             of the patients.                Some        changes         in            Four       of the patients               who developed                 a dif-
symptomatology                     and other            clinical        features             ferent      psychiatric            illness      with the passage                of
had occurred                 oven time.             The      patients         were           time were in the original                         group        A. Three         of
now tense             and overtalkative                   rather       than un-              them            became           frankly           schizophrenic,                 and
tidy. Interpersonal                     difficulties          persisted         and          two were hospitalized                  with such disorders              at
even        increased,             with        social       isolation          now           the time         of follow-up.           All of these        patients
present          in all groups.                In addition,            group        B        had been under              22 years of age at the time of
 showed            continued,              although            less       severe,            the index           admission,          with   premorbid            per-
drinking          problems             as well as sexual                promis-               sonalities        described         as stormy        or schizoid.
cuity.       In all three             subgroups             mood        was de-              The       schizophrenic           illnesses      developed           one
scribed         as anxious,              depressed,           and irritable.                 to five years          after    the initial     hospitalization.
There         were        still no hallucinations                      or delu-              Another          in group         A received         a follow-up
sions,        but disorders                 of thinking             were       now           diagnosis          of alcoholism;            there        had      been
present,           particularly              in group           A. Somatic                   some indication              of a drinking       problem         at the

                                                                                   TABLE          5
                                                                      Follow-Up       Clinical        Profiles
                                                                             (Interview          Data)

                                                                                    PASSIVE-AGGRESSIVE                SUBJECTS
 GENERAL         CATEGORIES                           GROUP      A                                         GROUP      B                                    GROUP        C
 OF     CHECK      LIST   ITEMS                        (N-31l                                                (N-12)                                            (N-17)

Interview        appearance           Overtalkative.       tense                          None                                             Same       as A
      and   behavior
Social and                            Stormy.      neglects          responsi-            Heavy drinking,    promiscuous.                  Same       as A
   interpersonal                         bilities.  suicidal         gestures.              social isolation
   relationships                         social isolation
Affective                             Anxious,        feelings       of   hope-           Same        as A                                 Same       as A
      reaction                            lessness,       gloomy,         sad.
Delusions        and                  None                                                None                                             None
Thought                               Suicidal      ruminations,          con-            Somatic         preoccupations                   Suicidal      ruminations
   disturbance                           Crete thinking,         religiosity.
Somatic                               Multiple    somatic      complaints.                Multiple    somatic        complaints.           Multiple    somatic     complaints.
  complaints                             back and joint pain.                de-             dizziness.     palpitation.      gen-            back and joint         pain. pan-
                                         creased      sex interest.          de-             eral malaise,       bowel      symp-             aesthesias.       weight       loss.
                                         creased energy                                      toms.      sleep disturbances                    conversion      symptoms
Intellectual        and               Unable to recall test phrases.                      Unable to recall test phrases.                   Same as B
    organic       impairment             poor comprehension                                 unable to calculate

[1021                                                                                                                 Amer.      J. Psychiat.         /26:7,      January     /970
SMALL,          SMALL,       ALIG,       AND       MOORE                                                                                                                      979

time        of the first admission,                        but there               were        and economic                   adjustment,       using      five-point
insufficient criteria for a firm diagnosis.                                                    graded        scales            of occupational,            financial,
      Two patients               in group          B had another                     dis-      family,      social,          recreational,      and community
tinct      psychiatric             disorder         on follow-up.                   One        performance,                 were     compared       for the index
 died by suicide                  during         a depressive                illness.          and follow-up                periods.       Mean   scores      on each
  She was not considered                           to be depressed                       at    of these      scales          were very similar           on the two
  the time of index hospitalization                               but was de-                   occasions.              There       were        prominent              distur-
  scribed          as a volatile,               impulsive            individual                 bances          in family        adjustment,              interpersonal
  who had made                  two previous              attempts             to kill          relation        ships,    recreational              adjustment,             and
  herself        in fits of rage.                 However,              the final               community             participation,              with relatively            less
  successful           suicide         was not done               in anger              or      impairment             in areas          of occupational                adjust-
  impulsively             but was accomplished                           during            a    ment       and       management                  of funds.          Greatest
 severe        depression.             Another          patient          in group               improvement                in these         areas       occurred          in the
  B presented                numerous              features           of socio-                 patients       who received               continued            or intermit-
 pathic        personality             disorder         on follow-up,                    in     tent outpatient              supportive           psychotherapy.
  marked            contrast          to his original                 symptom                       Other        features,          more        subjective          than      the
 profile.           The       index          hospital           chart           docu-          coded        material,           were       evident          from      the fol-
 mented           that he had not been expelled                                   from          low-up        examinations.                  As previously                  men-
 school,         had done            rather       well at work,                 had a          tioned,       the subjects            were not a mobile                    group
 good conduct                discharge          from the Army,                       and       and were             relatively           easy      to trace.          On the
 had never              been      arrested.          He had not been                           other      hand,        their      cooperation               was very dif-
 physically            aggressive            toward        anyone            at that           ficult     to achieve,            much         more        so than in the
 time,       although           he did exhibit               such behavior                     controls         whom          we did find or in our experi-
 later,      along        with numerous                  other        antisocial               ence       with        other        follow-up             studies.         Many
 features          that developed               approximately                   three          times       the patients               failed       to keep          appoint-
years         after       his release             from         the hospital.                    ments,       refused          to return           questionnaires,               or
Only        one member                  of group         B was still con-                      would        agree        to participate               in examinations
sidered          to exhibit            enough         indications                for a         and then back                 out at the last minute.                       They
diagnosis            of alcoholism.                                                            imposed            innumerable                 obstructions              in the
      In Group            C there          were five patients                      with        way of gathering                 these      data. All of the inves-
new psychiatric                  diagnoses.           One was a clear-                         tigators        were       impressed             with this aspect                of
cut alcoholic,                who probably                 had this prob-                      the subjects’             ability       to manipulate               and mis-
lem at the time of index                          admission              but with              construe           interpersonal                situations.           Particu-
insufficient documentation                            in the chart. Two                        larly     disturbing             was the propensity                      of the
others          had       severe          schizophrenic                illnesses.              subjects        to complain              to the police             when pre-
One        of them            had exhibited                extreme              rages          arranged,            authorized             visits       were       made         to
and was unable                    to tolerate           authority              at the          their homes!
time of the first hospitalization;                              the other,             as           Nevertheless,              the majority              of the subjects
far as could              be determined,                exhibited              no in-
                                                                                               retained     an           active     interest       in interpersonal
dications             of impending                  psychosis              at       that
                                                                                               involvement.                They      were       capable      of giving
time.        Another             patient         developed              a manic
                                                                                               and         receiving         affection,        and    most     of their
illness        in his mid-40s,                   and a fifth became
                                                                                               relatives          and     friends       continued       to hold them
senile in old age.
      Thirty-two             of the 73 patients                     were            em-        in esteem.         In many        instances         this was despite
ployed          full time           either       as wage           earners             or      frequent        verbal       battles        and emotional           out-
homemakers,                   ten were able to work part-                                      bursts,      with the patients                trying     to influence
time,        and 25 were unemployed.                              Inability             to     and coerce           others.        The quality           of the sub-
work was associated                        with older           age and also                   jects’    interactions           with other          people    seemed
was more prominent                         in group         C, the patients                     to be intense,         variable,        and manipulative             but
who        had co-existing                    depressions              on index                with     enduring         relationships             over long peri-
hospitalization.                 In this group,                 12 of the 19                   ods of time.       The       social     isolation  seen                           on
patients           who were interviewed                         were         unable            follow-up     was     mostly        due to a failure                               to
to work,              primarily            because          of psychiatric                     make      new relationships,           not a breaking                             up
difficulties.             Quantitative                  ratings          of     social         or withdrawal      from old ones.

Amer.       J. Psychiat.          126.7,      January         /970                                                                                                          [103]
    980                                                                                                  PASSIVE-AGGRESSIVE                    PERSONALITY             DISORDER

    Summary                and      Conclusions                                                 hospitalized            they did well with minimal                     ther-
                                                                                                apeutic          intervention           and     returned           to     the
     .   In this paper                we have described                     the expe-
                                                                                                community               in a relatively            short      period         of
    riences         and findings                of a seven-              to 15-year
    follow-up            study         of 100 patients                 who had an                   When          followed         over    several       years,       some
    index        hospital            diagnosis            of passive-aggres-
                                                                                                clinical       changes         that seemed         to be associated
    sive personality                  disorder.           In the search               for a
                                                                                                mostly         with advancing             age were noted.                The
    definitive           syndrome,               we employed                    system-         interpersonal               focus    of symptomatology                     re-
    atic methods               of chart          and interview                data col-         mained,           but more ‘anxiety                and      manifesta-
    lection,        striving           for as much                reliability           and
                                                                                                tions        of depression              appeared          over        time.,
    objectivity           as possible.              Although            we devoted              There         were      still no delusions             or hallucina-
    much       attention             to the meaning                  of terms           and     tions,       but thought            processes         became          more
    the reliability               of clinical            judgments,               we did        constricted,            with suicidal         ruminations,              con-
    not attempt                to quantify               and analyze                all of      crete       thinking,           religiosity,          and      tangentiality.
    the enormous                    amount            of clinical            data       col-    Mild   organic    impairments           also                     appeared            in
    lected.        We aimed                instead           at focusing             upon
                                                                                                the older      age groups.        Somatic                         complaints
    those      features            that were most                  common              to a     became      even   more      pronounced                           and persis-
    cohort         assembled               only         on the basis                of an
                                                                                                tent,  now focusing          on one or                           more     organ
    ambiguous               clinical         diagnosis           assigned           many         systems.
    years ago. In this way we sought                                   to ascertain                   Over      all, the illness               for most           patients       was
    whether            or not this                diagnostic             label        does
                                                                                                 only intermittently                     incapacitating.                The vast
    represent            an illness            or disease            entity       with a
                                                                                                 majority           spent        relatively          little      time       in psy-
    typical        clinical         profile,        course,        and outcome.
                                                                                                 chiatric        hospitals,           although           those        who made
    Alternatively                we wondered                   if this series              of
                                                                                                 the best adjustment                       did receive             psychother-
    patients          would          be quite          heterogeneous,                  with
                                                                                                 apy on an outpatient                       basis.      Nevertheless,               on
    frequent            development                  of other           psychiatric              follow-up           there        were only nine persons                        who
    disorders             and         wide        variations             in clinical             were judged              to have entirely                 recovered.           Two
    course        and outcome.                                                                   subgroups             were        identified           within         the index
         Viewed           in this general                   context          bur find-
                                                                                                 cohort,        which         although           sharing          many        of the
    ings indicated               that the passive-aggressive                             pa-     clinical        attributes            previously              described,           al-
    tients     did have some characteristic                                 attributes           so displayed              manifestations                either       of depres-
    that     did not,            either         originally           or longitudi-               sive episodes               on alcoholism.                 The subgroups
    nally,       seem         to be part of other                       psychiatric
                                                                                                 had       a somewhat                    different           outlook,           with
    syndromes.                Despite          considerable                individual            more impairment                     in terms         of ability          to work,
    variability,            we found             that most            of these           pa-     number           of rehospitalizations                      for psychiatric
    tients         developed                 emotional               disturbances                problems,             development                 of different             psychi-
    during          adolescence,                  often         with        a family             atric      disorders,            and      other        measures             of ad-
    background                of alcoholism.                   The illness              was     justment.            Diagnostic              change-that                 is, a de-
    as likely         to occur in males                     as in females               and      veloping           clinical          picture          typical          of other
    was       characterized                  by interpersonal                      strife,
                                                                                                 psychiatric            illnesses,            occurred           in 11 cases.
    verbal         (not       physical)            aggressiveness,                   emo-
                                                                                                This tended               to occur           more       in the subgroups
    tional       storms,          impulsivity,              and manipulative                     with alcoholism                  or depression               and also in pa-
/   behavior.            Suicidal           gestures           and lack            of at-        tients      who were very young                        at the time of the
    tention          to everyday                   responsibilities                  com-        original         admission.             Only        one patient              in the
    monly          accompanied                   this intensive                style       of
                                                                                                series      committed              suicide.
    relating4         In both sexes there                      were prominent
                                                                                                     Some    of the findings        of this study          support
    disturbances                of affect,            generally           consisting
                                                                                                the observations        of other         investigators.           We
    of frequent,             short-lived             outbursts          of anger           or
                                                                                                found,    as did Whitman,             that environmental
    rage and often                   accompanied                 by tearfulness.
    Early      in the illness                there       were no significant                    factors    could     be influential         in the course            of
    disorders            of thinking,               delusions,            hallucina-            the disease;      for example,          outpatient         psycho-
    tions,         or       organic            impairments.                    Somatic          therapy     was apparently          beneficial        (19). How-
    complaints              of all kinds             were common,                    with-      ever, we also confirmed              Tolf#{233}’s  observations
    out any specific                    symptos                 or involvement                  that    many     such patients         demonstrate             grad-
    of a single organ                  system.         When         patients          were      ual      worsening              over      time(17).            Many         of the
    (104]                                                                                                               Amer.    J. Psychiat.         /26:7,     January        /970
SMALL,            SMALL,           AUG.        AND          MOORE                                                                                                                                                         981

kinds             of    coping       behavior                             described                  by                        Psychiatric             Clinics,        P.H.S.        publication          No.      1854,
Monro              were      evident     in our                            subjects,                but
                                                                                                                        8.     National            Institute         of Mental            Health:        Patients        in
inter-individual                         variability               was        too       great             to                    Mental         Institutions,           Parts      II and III, P.H.S.              publi-
include           detailed               accounts            in this          paper(S).                                        cation       No. 1818, 1966.
    To       us the clinical    characteristics          of this                                                        9.      Rabkin,          L.Y.:       Passive       Aggressiveness               and Learn-
group         and the longitudinal          course     of their                                                                ing, Exceptional                Child.      32 1-3, 1965.
                                                                                                                       10.      Retterstol,          N.: Paranoid            Psychoses:          The Stability           of
illness        were  in some     ways       suggestive      of a
                                                                                                                               Nosological               Categories           Illustrated          by a Personal
condition               occupying                      an       intermediate                      posi-                        Follow-Up               Investigation,              Brit.     J. Psychiat.            I 14:
tion    between        the extremes            of the sociopathic                                                              553-562,          1968.
personality          and the affective               psychoses.         As                                             1 1.    Robbins,           L.M.:       Deviant        Children         Grown        Up. Balti-
                                                                                                                               more:        Williams          and Wilkins            Co., 1966.
with     the sociopath,              there      was a failure            of
                                                                                                                       12.     Shagass,          C., and Bittle,              R.M.:       Therapeutic           Effects
social     learning,       disturbed         interpersonal          rela-                                                      of LSD:           A Follow-Up                Study,        J. Nerv.       Ment.       Dis.
tionships,         and      persisting           maladaptive           be-                                                      144:471-478,             1967.
havior.         However,            unlike         in    sociopathy,                                                   13.     Small,        I.F.,Estevez,            CM.,        Small,       J.G.,and        French,
there      was some          preservation            of appropriate                                                             RN.:        Do Patients            Tell It Like It Is? Longitudinal
                                                                                                                                Reliability           and Validity             of Structured             Psychiatric
interpersonal            behavior          and certainly           much                                                        Interview           Data,      Dis. Nerv.          Syst. 3&.333-337,              1969.
involvement            in the         lives     of other        people.                                                14.     Small, IF., Small, J.G., and Assue,                                C.M.:      The Fate
 Moreover,         these      patients       expressed        extreme                                                          of the         Mentally              Ill    Physician,          Amer.          J. Psychiat.
discomfort                   and         personal           anguish,                particular-                                 125:1333-1342,   1969.
ly during     times     of more prominent            symptom                                                           15.     Small, IF., Small, J.G., Gonzalez,       CR., and Gyn-
                                                                                                                               ther, M.D.: Content     Reliability of a Structured Psy-
display.      The     resemblance         to the affective                                                                     chiatric         Interview,                Arch.         Gen.      Psychiat.           11:192-
psychoses       was in the prominence              of somatic                                                                  196, 1964.
complaints,        the inability      to modulate        affect,                                                      16.      Small,       J.G.,   Small,      IF.,    and Gonzalez,           CR.:     The
the longitudinal           course      of remissions          and                                                              Contribution          of the Informant            in Psychiatric        Eval-
                                                                                                                               uation,      Int. J. Neuropsychiat.            1:446-451,       1965.
exacerbations         with relatively       little deteriora-
                                                                                                                      17.      Toll#{233},R.: The         Mastery       of Life by Psychopathic
tion,    and           the absence                     of    severe      disorders                        of                   Personalities,         Psychiat.      Clin. 1:1-14, 1968.
thinking              on impairment                         of intellectual                     func-                 18.      United States Joint Armed Services:                       Nomenclature
tions.                                                                                                                         and Method           of Recording           Psychiatric       Conditions.
                                                                                                                               Washington,          D.C.,    1949.
       However,               there          is need            for      more          intensive
                                                                                                               ‘j9.            Whitman,           R.M., Trosman,              H., and       Koenig,       R.:
investigation            of patients       who    display       the                                                            Clinical Assessment                        of Passive-Aggressive                   Personal-
clinical      attributes       we have described.           Com-                                                               ity, Arch. Neurol.                    Psychiat.          72:540-549,           1954.
parative       evaluations        of suitable   controls       and
family       studies       are also necessary          to deter-                                                                                          DISCUSSION
mine       whether         or not a passive-aggressive
                                                                                                                           SAMUEL        L. SAFIRSTEIN,        M.D. (New York, N.Y.).
disease       entity      or illness     exists  that     can be
                                                                                                                       --Anyone             who dares enter the difficult           area     of
explicitly        defined     and separated        from     other
                                                                                                                       psychiatric        diagnosis     deserves    a lot of praise, es-
psychiatric disorders.                                                                                                pecially       when he endeavors            to apply a more ob-
                                                                                                                      jective      method       of investigation     and modern         tools
                                                                                                                      of data processing              to assess findings.     This team
  1.     American             Psychiatric           Association:       Diagnostic      and.                           has accomplished              a great piece of work, which re-
         Statistical           Manual          of Mental         Disorders,        1st ed.                            quired      effort     and dedication.       The purpose        of the
         Washington,              D.C.,       1952.                                                                   study was to investigate             a syndrome     longitudinally
 2.      American             Psychiatric           Association:       Diagnostic      and                            and horizontally            and to lift the paucity       of knowl-
         Statistical           Manual          of Mental         Disorders,       2nd ed.                             edge      about          it and         the         confusion            overhanging              it by
         Washington,             D.C.,        1968.
                                                                                                                      establishing   objective  criteria  for its recognition.
 3.      Grinker,        R.R.,           Sr., Werble,           B., and Drye, R.C.: The                                   I have been intrigued    by this syndrome.       It is one
         Borderline             Syndrome.               New        York: Basic   Books,
                                                                                                                      of the few (if not the only one) that spells        out con-
                                                                                                                      flict    in   its    very      title.           Most        of     our     diagnostic            cate-
 4.      Guze,        SB.,
                         Tuason,      YB., Gatfield,        P.D., Stewart,
         MA., and Picker,        B.: Psychiatric      Illness    and Crime                                            gories        contain         conflict,        hidden be-
                                                                                                                                                                            but   it is usually
         with Particular      Reference       to Alcoholism,        J. Nerv.                                          hind a descriptive     label. The passive and aggres-
         Ment. Dis. 134:512-521,          1967.                                                                       sive parts in the passive-aggressive     personality      de-
 .       Monro,         A.B.:       The       Inadequate              Personality           in Psy-                   note a descriptive    quality but at the same time in-
         chiatric      Practice,            Brit. J. Psychiat.            105:44-50,           1959.                  dicate that there is a battle between       the two. It is
 6.      Murphy,          G.E.,            and    Guze,     SB.:           Setting           Limits,                  a live battle that rages almost constantly,         a battle
         Amer.        J. Psychother.                14:30-47,         1960.                                           that tears the individual      apart and in the process
 7.      National            Institute         of      Mental         Health:          Outpatient                     generates    one of the most painful and crippling         af-

Amer.        J. Psychiat.                 /26:7,       January           1970                                                                                                                                           [105]
982                                                                                              PASSIVE-AGGRESSIVE                         PERSONALITY                  DISORDER

fects, anxiety.  The               passive-aggressive individual                         Anxiety,    controllable       and hidden in the past, be-
has great difficulty               in using a common     defense                         came visible       and clinically       diagnosable.        Gloom
against      anxiety,       repression.         By repressing           one    arm       and doom overcame             the spirit to fight. A feeling
of the conflict, either the passive-dependent                              trends        of hopelessness          crept in, and suicidal           thinking
or the aggressive-expansive                       ones, the individual                   could be detected          in all three groups.        Flexibility
can escape         the pain of anxiety.               The repressive             Ca-     and originality       were being replaced            by rigidity,
pacity of the passive-aggressive                       subject seems im-                 fixity, and tangentiality,          while regressive         trends
paired; the best he can do is to temporarily                                   sup-      were being expressed             in multiple     somatic       com-
press one or the other side of the conflict, with the                                    plaints.  The most marked            changes     were manifest
attendant        outbursts         of anger or the sinking                     into      in    the      area     of    interpersonal                 relationships.                   Here
indolent      passivity        while resentment                accumulates               the gradual       withdrawal         from human           relatedness
until it is ready to burst out again.                                                    followed     the numerous         rejections      these people had
     Look how differently                the two subgroups                  in the       to endure      because     of their erratic          behavior      in re-
patient     sample,       the alcoholics             and the depressed,                  lation   to others.      Defensively,         rather than expose
handle their anxiety.              The alcoholic            uses alcohol in              themselves       to more rejections,               they eventually
two ways-to             maintain        repression          when it begins               gave up and resigned            themselves         to a life of rela-
to break         through,        bringing          with it anxiety,               or,    tive isolation.     Intellectual        deterioration         began to
when the anxiety is quiescent                      and he begins to feel                 follow the other regressive              manifestations.         One is
deadness         and boredom,              to bring about               “excite-         impressed             by the high              morbidity         rate         accompany-
ment,”      which he can accomplish                       by activating          the     ing this as well as many other psychiatric                                  syn-
repressed         aggressiveness.              Of course,          alcohol          in   dromes.
sufficient quantity          always brings with it cortical                      de-         All research,            even the purest,          has the built-in
cerebration          and unconsciousness,                     which       means          hope that sooner                or later it will serve mankind.
doing away with conflict on any level.                                                   Diagnosis          is no exception.           As a part of medicine
     The depressed            individual          has seemingly               done       diagnosis         endeavors          to contribute       to the body of
away with his aggressive                   and self-assertive               traits.      medical         knowledge            so that more effective               mea-
The only aggression                 he is capable             of is the one              sures can be found to alleviate                    and reduce human
turned      against       himself         in the form of suicidal                        suffering.       I have been interested              in the therapeutic
thoughts        and action-if            his depression             is not too           possibilities         of this study of the passive-aggressive
deep as to cancel out any potential                         for action. The              personality. Having a vested interestin aftercare,
individual        temporarily           retreats         from life and is                I have been looking                  for data indicating           aftercare
preoccupied          with self-hatred             for failing to achieve                 in this follow-up             study. There were 13 patients                    re-
his idealized        version of himself.                However,         as soon         ceiving      outpatient          psychotherapy.          However,          I as-
as the depression               lifts, he is once again in the                           sume that the treatment                    they were receiving              was
throes      of the struggle                between          his dependent                not part of an aftercare                    program       following          dis-
needs, which pull him in the direction                          of passivity,            charge        from        the hospital          but something              they
and his expansive            needs, which pull him in the di-                            sought      out because             of their later need for help.
rection of aggressiveness.                                                               There is some evidence                    that consistent          aftercare
     This brief and almost                 schematic          outline       of the       on a prolonged               and if necessary           repetitive        basis
dynamic          forces      behind          the passive-aggressive                      not only contributes                  to better     functioning         in the
group helps one to understand                            the changes           that      community              but also prevents             or decreases             the
occur with the passage                of time, as described                  in the      need for rehospitalizations.
paper. Life exerts its wear and tear on everyone.                                            If my assumption                is correct,    many of the 73 re-
At best it allows for the acceptance                            of the inevi-            hospitalizations could perhaps have been avoided.
table decline in old age. In the group of maladap-                                       Sometimes            the knowledge           that the aftercare          clinic
 tive personality         disorders,          the wear is greater and                    is available           to    the     patient        any      time        he     needs         it is
the tear may become                   incapacitating.             Coping         ca-     enough    to keep him functioning.       If not, one or
pacity may be overcome                     by the necessity              to seek         several psychotherapy     sessions in the familiar  sur-
refuge in a world of psychosis;                       some can function                  roundings   of the clinic may be all that is needed to
with the help of psychiatric                    treatment;         the major-            reestablish           his    shaky        psychic          homeostasis                  so    that
ity, however,          are able to maintain                  a modicum              of   he can continue          to remain       and function       in the
limping      functioning         despite the handicaps                   of their        community.
chronic      psychiatric        illness.       Some have even man-                           Diagnosis      as a science      is in constant      flux and
aged to throw off the shackles                          of their affliction              change.     The art of diagnosing           or the capacity       to
and are able to be judged                      as without          psychiatric           diagnose      by intuition     after years of experience           is
illness.                                                                                 not enough.       We need some well-defined           criteria to
     All the passive-aggressive                      subjects        displayed           be able to decide in what territory             we are with our
changes        in symptomatology                     and other           clinical        patients.     This is what this study is all about. On
features      that can be attributed                   to a lessening            de-     the other       hand,    diagnostic      categories    can also
 fensive     capacity       to handle            conflict      and anxiety.              contribute       to pigeonholing        and labeling,        which
[106]                                                                                                           Amer.         J. Psychiat.           126:7,       January             1970
ELI ROBINS                   AND          SAMUEL               B. GUZE                                                                                                                                                                               983

carry        ready-made                     assumptions                     and         implications.                     many            different                     types           of     diagnostic                     systems,                de-
Until        not       too          long       ago         the         diagnosis             of      schizo-              pending                    on         one’s           point              of         view     and            particular
phrenia            carried            with          it     hopelessness                     concerning                    frame               of      reference-descriptive,                                         dynamic,                    cogni-
any successful                   therapeutic                      outcome,    and depres-                                 tive,        etc.          But        we       cannot              do without                a system                   of di-
sions carried                 the implication                       that only ECT could                                   agnosis                  that         is accepted                   by        all     in the        field         at     least
be      useful.         It     is    only          after          getting          to      know            each           for certain                     purposes.      The APA       Diagnostic    and
individual             patient              that         we       realize          that           very      few           Statistical                  Manual       of Mental   Disorders    serves this
schizophrenics                      are       therapeutically                        hopeless               and           purpose.                   This    study    has lit a light in a tiny corner
very    few depressed                        patients        need             ECT.                                        of the          manual                  that         heretofore                      was    dark.           The         team
   Until we are able to diagnose   according to eti-                                                                      of investigators                           set        out      in        search            of a syndrome.                         I
ology and pathogenesis    there will be a need for                                                                        think         they              found          it.

Establishment                                                  of Diagnostic                                         Validity                                in Psychiatric                                                   Illness:

                                                         Its           Application                                   to        Schizophrenia

                                                     BY          ELI        ROBINS.                M.D..          NI)       SA%1LEL                        B.      GUZE,                M.D.

A method             for achieving              diagnostic           validity                                                 One of the reasons                      that diagnostic           classi-
in psychiatric            illness       is described,           consisting                                                fication        has        fallen         into       disrepute       among
of five       phases:         clinical        description,           labora-                                              some psychiatrists                   is that diagnostic           schemes
tory study,           exclusion          of other        disorders,        fol-                                           have been largely                  based       upon a priori          princi-
low-up        study,      and family            study.       The method                                                   ples     rather         than         upon       systematic          studies.
was applied            in this paper           to patients          with the                                              Such      systematic               studies         are necessary,            al-
diagnosis            of     schizophrenia,                 and       ii was                                               though       they may be based                      upon different          ap-
shown        by follow-up              and J’anzily          studies       thai                                           proaches.          We have found                    that the approach
poor      prognosis            cases       can be validly               sepa-                                             described           here        facilitates           the development
rated      clinically        from         good      prognosis          cases.                                             of a valid           classification              in psychiatry.          This
The authors              conclude           that good           prognosis                                                 paper       illustrates             its     usefulness          in schizo-
“schizophrenia”                 is not mild             schizophrenia,                                                    phrenia.
but a different           illness.
                                                                                                                          The           Five               Phases

 S        INCE        BLEULER   (3), psychiatrists         have rec-
                                                                                                                                  In     general,
                                                                                                                                                  the first step is to describe                     the
       ognized       that the diagnosis            of schizophre-
                                                                                                                          clinical     picture       of the disorder.               This may be
 nia includes          a number         of different     disorders.
                                                                                                                          a single     striking        clinical        feature       or a combi-
 We are interested              in distinguishing        these var-
                                                                                                                          nation     of clinical          features         thought       to be as-
 ious disorders            as part       of our long-standing
                                                                                                                          sociated      with one another.                   Race,      sex, age at
 concern        with      developing          a valid    classifica-
                                                                                                                          onset,     precipitating            factors,        and other        items
 tion    for psychiatric             illnesses(6,      7, 10, 11).
                                                                                                                          may      be used         to define           the clinical          picture
 We believe         that a valid classification             is an es-
                                                                                                                          more precisely.            The clinical            picture     thus does
 sential      step      in science.           In medicine,           and
                                                                                                                          not include        only symptoms.
 hence      in psychiatry,          classification       is diagno-
 sis.                                                                                                                     2.      Laboratory                            Studies
                                                                                                                                  Included                        among                  laboratory                       studies                    are
   The authors      are with the department                 of psychiatry,                                                chemical,                             physiological,                                radiological,                         and
Washington      University       School     of Medicine,       4940 Audu-
                                                                                                                          anatomical                       (biopsy                findings.  and      autopsy)
bon Ave.,    St. Louis,        Mo. 63110,       where       Dr. Robins     is
Wallace    Renard      professor      and head      of the department                                                     Certain                    psychological               shown         tests,
                                                                                                                                                                                              to          when
and Dr. Guze is professor.              Dr. Robins       is also psychia-
                                                                                                                          be reliable       and     reproducible,         may       also     be
trist-in-chief,               Barnes          and          Renard            Hospitals,              and       Dr.
Guze is associate             psychiatrist.                                                                               considered       laboratory           studies    in this        con-
     This         work was supported                            in part    by Public     Health
                                                                                                                          text. Laboratory          findings       are generally         more
Service            grants     MH-l3002                        and     MH-0708l       from      the
National            Institute   of Mental                     Health.                                                     reliable,                       precise,                and         reproducible                            than           are

 Amer.        J. Psychiat.                 /26.7,          January             /970                                                                                                                                                                [107]

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