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Science Tuesday - Passive Aggressive? And the attack of the Scientific/Medical Historians...
Oh, Fine, You're Right. I'm Passive-Aggressive
By BENEDICT CAREY, The New York Times, November 16, 2004
The marriage seemed to come loose at the seams, one stitch at a time, often during the evening hour between work and dinner. She would be preparing the meal, while he kept her company in the sun room next to kitchen, usually reading the paper. At times the two would provoke each other, as couples do - about money, about holiday plans - but those exchanges often flared out quickly when he would say, simply, "O.K., you're right," and turn back to the news.
"Looking back, instead of getting angry, I was doing this as a dismissive way of shutting down the conversation," said Peter G. Hill, 48, a doctor in Massachusetts who has recently separated from his wife. Even reading the paper at that hour was his way of adamantly relaxing, in defiance of whatever it was she thought he should be doing.
"It takes two to break up, but I have been accused of being passive-aggressive, and there it is," he said.
Everyone knows what it looks like. The friend who perpetually arrives late. The co-worker who neglects to return e-mail messages. The very words: "Nothing. I'm just thinking."
Yet while "passive-aggressive" has become a workhorse phrase in marriage counseling and an all-purpose label for almost any difficult character, it is a controversial concept in psychiatry.
After some debate, the American Psychiatric Association dropped the behavior pattern from the list of personality disorders in its most recent diagnostic manual - the DSM IV - as too narrow to be a full-blown diagnosis, and not well enough supported by scientific evidence to meet increasingly rigorous standards of definition.
The decision is likely to have more effect on teaching guidelines and research than on treatment and insurance coverage.
But psychologists and psychiatrists with long experience treating this kind of behavior say it is hard to study precisely because it is so covert, common and widely variable.
These experts make a distinction between passive-aggressive behavior, which most people display at times, and passive-aggressive personality, which is ingrained and habitual. In milder forms it can come across as a maddening blend of evasiveness and contrition, agreeableness and impudence, and in severe cases is often masked by more obvious mental illness, like depression.
Yet whether pathological or not, they say, the pattern is often traceable to a distinct childhood experience. New research suggests that in many cases it stems from a positive, socially protective instinct - to keep peace at home, avoid costly mistakes at work, even preserve some self-respect.
"Some of the people being demeaned as passive-aggressive are in fact being extremely careful not to commit mistakes, a strategy that has been successful for them," if not entirely conscious, said Dr. E. Tory Higgins, director of the Motivation Science Center at Columbia University. They become difficult, he said, "when their cautious instincts are overwhelmed by demands that they perceive as unreasonable."
The classic description of the behavior captures a stubborn malcontent, someone who passively resists fulfilling routine tasks, complains of being misunderstood and underappreciated, unreasonably scorns authority and voices exaggerated complaints of personal misfortune.
But the phrase itself has its roots in the military. Near the end of World War II, a colonel in the United States War Department used it to describe an "immature" behavior among enlisted men, many of them at the end of long tours: "a neurotic type reaction to routine military stress, manifested by helplessness, or inadequate responses, passiveness, obstructionism or aggressive outbursts."
This kind of insolence, among adults protecting themselves from what they saw as unreasonable, arbitrary authority, was in part an adaptive behavior, psychologist say, an effort to preserve some independence amid extreme pressure to conform.
A similar family dynamic accounts for early development of the behavior, some researchers argue. Dr. Lorna Benjamin, co-director of a clinic at the University of Utah's Neuropsychiatric Institute in Salt Lake City, said people with strong passive tendencies often grew up in loving but demanding families, which gave them responsibilities they perceived to be unmanageable.
First-born children are prime candidates, she said: when younger siblings are born, the oldest may suddenly be expected to take on far more extra work than he or she can handle, and over time begin to resent parents' demands without daring to defy them.
This hostile cooperation is at the core of passive-aggression, she and other researchers say, and in later in life it is habitually directed at any authority figure, whether a boss, a teacher or a spouse making demands. These passive-aggressive people, Dr. Benjamin said, "are full of unacknowledged contradiction, of angry kindness, compliant defiance, covert assertiveness."
This history hardly excuses the multitude of hedging, foot-dragging mopes that populate everyday life, but it can help explain some of their exploits. One Los Angeles woman, who asked not to be identified (and swore she was not being passive-aggressive), described a former co-worker who intentionally made assignments late to employees when she didn't approve of a project.
At the end of some days, she wrote, this archetypal passive-aggressive used to hide under her desk to avoid saying goodnight to people.
Sometimes, however, mild passive-aggressive behavior can be an effective means to avoid potentially costly confrontations. In such cases the cooperation is more significant than the underlying resentment or hostility.
"A joke can be the most skillful passive-aggressive act there is,'' said Dr. Scott Wetzler, a clinical psychologist at Montefiore Medical Center in the Bronx and the author of "Living With the Passive-Aggressive Man." "They recognize a coming confrontation, and have found a clever way to release the tension."
It is just this instinctive ability to pre-empt and defuse that, paradoxically, may lead to more problematic passive-aggressive behavior.
Dr. Higgins of Columbia has described a personal quality he calls prevention pride, a kind of native caution in the face of new challenges, an effort to avoid all errors. He assesses whether a person is high or low in this style by asking a battery of questions, like how often they broke their parents rules, how often they take risks, how often they have been in trouble by not being careful enough. The style is adaptive, he said, in that it allows people with a certain temperament to avoid failure and embarrassment.
In one recent experiment, Dr. Higgins and Dr. Ozlem Ayduk, an assistant professor of psychology at the University of California at Berkeley, tested how these especially cautious people reacted to conflict in relationships. The researchers had 56 couples who had been together at least two months keep detailed diaries, answering questions about conflicts, thoughts about the relationship, moods and their partners' behavior.
After three weeks, the researchers compared the diaries and found that people who had a highly cautious personal style and were especially sensitive to rejection were significantly more likely than the others to respond to conflicts by going silent, withdrawing their affection and acting cold.
"The people in this study were not the type who would ever say, 'I hate you' to the person's face because they are so careful not to do something that puts them out there," and directly offend their partner, Dr. Ayduk said.
The evidence that this sensitivity can be appealing, at least for a while, is recorded in millions of relationships that have lasted for years. A 45-year-old college instructor in Hawaii recently broke off a long relationship with a man she said was a "wonderful, devoted listener, an extremely sensitive person."
But in time, she said, it was apparent that he was also passive-aggressive. On one occasion, she said, he gave away her seat on an airplane while she was finding a storage compartment for her luggage, saying he thought she had taken another seat. On others, he would arrive home early from work and finish off meals they normally shared, without explanation. And when he was in one of his moods, the listening ceased; she may as well not have been in the room.
"The challenging thing was, you never know what you did wrong," she said. "That's the difficulty, all these scenarios, I could not point to what I did. I never knew."
The person who has become hostile may not know exactly why, either. In some cases, psychologists say, people unable to recognize or express their annoyance often don't feel entitled to it; they instinctually let the "little things" pass without taking the time to find out why they are so angry about them. Unsure of themselves, they take care not to offend a spouse, a co-worker or friend. The anger remains.
When the behavior pattern is deeply ingrained and compulsive, it is neither adaptive nor merely bewildering, but can be dangerous, some experts say. At her clinic in Salt Lake City, Dr. Benjamin treats many people with multiple diagnoses, from attention deficit disorder to obsessive-compulsive disorder to intractable depression, many of them with other problems, like substance abuse or multiple suicide attempts.
"And I would say that in close to half of them this passive-aggressive behavior is running the whole show," she said.
When and if they do get therapy, psychiatrists say, people with strong passive-aggressive instincts are usually determined to fail: the therapist becomes the scorned authority figure. The patients will take their medications and then report with relish that they don't work. The patients will follow advice and then complain that it is senseless, useless. "They are not doing this on purpose; it's part of a deep-seated ambivalence about getting better," a determination to expose the authority as incompetent, said Dr. Marjorie Klein, a psychiatrist at the University of Wisconsin.
It is left to the individual therapist's skill to deflect or disarm this determination and get patients to at least experiment with an alternate strategy to engage their lives. In one, called cognitive behavior therapy, they learn to monitor their thoughts, moment by moment, to recognize when they are angry, and to challenge unexamined assumptions about confrontation. For example, some people assume that confronting their boss about a raise will be a catastrophe, said Dr. Wetzler of Montefiore, but it often simply is not the case, especially if they have prepared themselves by learning the market value of their skills at other companies.
Yet Dr. Benjamin said that often the childhood roots of the behavior must be faced and felt, and that means revisiting the parental relationship and learning that it does not have to set the pattern for all relationships with authority. "The main challenge is to help them shift from winning by losing to winning by winning," she said, "to see that it is they who benefit most when they win, not their therapist, their spouse or their boss."
Just living with the behavior in someone else can be as tough as treating it. To manage garden variety passive-aggressive behavior, psychiatrists often advise a kind of protective engagement: don't attack the person; that only reinforces your position as an authority making demands. Take into account the probable cause of the person's unexpressed anger and acknowledge it, if possible, when being stonewalled during a discussion.
And be sure to be on guard against likely retaliation.
"If he agrees to go over to your relatives' place for Thanksgiving, but you know he's upset about it, make sure you have alternate transportation to get over there," Dr. Wetzler said.
"He may take the car and not manage to get home in time to make it."
Smart or Misguided? The Proactive Doctor
ESSAY
By BARRON H. LERNER, M.D., The New York Times, November 16, 2004
Not so long ago, patients went to doctors only when something was bothering them. But then came the rise of preventive medicine - the idea that it was the job of the physician to search for diseases and treat them before they caused symptoms.
Recent studies have pushed this view further, suggesting it is necessary to decrease blood pressure and cholesterol to levels well below those previously considered normal.
But must I, as a doctor, always be proactive with my patients? How did medicine go from providing physical relief to a search mission for potential harms? And is it ever acceptable for my patients to tell me that we should just leave well enough alone?
The impetus for seeking out early disease came from public health. When health officials dealing with tuberculosis in the early 1900's began to trace the contacts of sick people, they were able to find many early cases of the disease. On average, these patients with early diagnoses did better.
The American Society for the Control of Cancer, later the American Cancer Society, developed its list of "danger signals" in the 1920's. The message was clear: unexplained lumps in the breast or elsewhere, or seemingly innocent bleeding, needed to be quickly evaluated by doctors. Early cancers, it was argued, were more curable.
After World War II, the Framingham Heart Study solidified the "risk factor" model of disease. People with high blood pressure, high cholesterol, diabetes and a smoking habit, the study found, were more likely to have heart attacks and stroke.
Thanks to Framingham, eliminating cardiac risk factors has become a basic component of medical practice. In part as a result of these efforts, mortality from heart disease has declined significantly.
In recent years, our ability to discover information at early stages has rapidly increased. Some healthy people now undergo full-body C.T. scans, assuming they will discover early, treatable diseases.
The world of genetics offers even greater possibilities. It is now possible to find genetic mutations that make people more likely to develop certain cancers. But there is no guarantee that discovering a mutated gene will prevent them from getting - or dying from - cancer.
So how far should we push in our search for potentially harmful disorders? One potential answer lies in evidence-based medicine, which relies on sophisticated statistical studies to determine what's effective. Although "evidence-based" sounds definitive, available data on a given procedure or treatment may still be disputed.
The recent studies are a perfect example. A paper last week in The Journal of the American Medical Association found that treating patients whose blood pressure readings were in the range previously considered normal lowered their risk of cardiac problems, like heart attacks or stroke, by 15 to 31 percent.
Other studies have recently suggested that the target readings for L.D.L. cholesterol, the type associated with disease risk, should be 80 to 100 units, rather than under 130, as previously recommended. A study published in The New England Journal of Medicine in April found that cardiac patients receiving aggressive cholesterol treatment had death rates 28 percent lower than those receiving standard therapy.
What should patients do? It depends on whom you ask. Dr. Jonathan Sackner-Bernstein, a cardiologist at North Shore University Hospital on Long Island and the author of "Before It Happens to You," argues that these are exactly the sort of statistics that should encourage people to be proactive.
Dr. Sackner-Bernstein, who has done research and given talks for drug companies, goes so far as to advise patients how to persuade reluctant doctors, suggesting that they tell the physician, "Since our goal right now is the optimal benefit-to-risk ratio for me, and not society, I wanted to talk to you about getting my cholesterol profile to optimal levels."
Dr. Sackner-Bernstein makes a similar argument for aggressive treatment of high blood pressure. His book, he tells readers, has a simple goal: to save their lives.
Yet for every Dr. Sackner-Bernstein there is a Dr. H. Gilbert Welch, an internist and epidemiologist at Dartmouth Medical School and the author of "Should I Be Tested for Cancer?" Studies show, Dr. Welch argues, that mammography; testing for prostate specific antigen, or P.S.A.; and other cancer screening tools often lead to ambiguous diagnoses and unnecessary treatment.
Dr. Welch challenges what he calls the "culture of medicine," questioning the "widespread presumption that it never hurts to look." Patients, he believes, should be skeptics, asking their doctors: "Why are you ordering the test?" "Has there been a randomized trial of screening for this?" "What will we do if my test is positive?"
What then should I tell my patients? I increasingly find myself discussing with them the kind of people they are: are they "seekers," who want to know every possible piece of information and try the latest treatments, or are they "waiters," who want more data before acting?
When the statistics are ambiguous, both options may be good ones.
Barron H. Lerner is a medical historian and an internist at Columbia University.
A CONVERSATION WITH MARTHA MCCLINTOCK: The Chemistry (Literally) of Social Interaction
By CLAUDIA DREIFUS, The New York Times, November 16, 2004
CHICAGO - For much of her career, Dr. Martha McClintock, the experimental psychologist, has been stunning the scientific world with research on how social interactions affect biology in humans and animals.
The director of the University of Chicago's Institute for Mind and Biology, Dr. McClintock tends to investigate matters that are at once important and obvious.
In 1971 she published her first scientific paper - a study showing that women living together in a Wellesley College dormitory tended to menstruate at the same time. The idea grew out of her own undergraduate observations. Dr. McClintock, 57, has demonstrated chemical communication between humans in laboratory experiments, again in influencing menstrual cycles. Whether pheromones play a role in human life outside the lab remains unknown. In animals pheromones affect the whole panoply of behavior - mating, aggression and fear.
In other work with colleagues, she has proved that rats that fear change have shorter lives than their more flexible counterparts, and that social isolation can also affect the longevity of rodents.
"I've focused my work on downward causation, the idea that the social and psychological world changes the fundamental mechanisms of biology, and vice versa," Dr. McClintock said on a recent afternoon at her offices at the University of Chicago. "I've tried to situate biology in a rich social and psychological context and make it simple."
Q. You recently made news with your discovery of an airborne chemical that increases sexual desire in women, a compound usually found in breast-feeding women and their infants. Why is the finding important?
A. This is the first natural compound to be found that can increase libido in women, other than hormones. It is also the first found human social chemosignal or pheromone to affect this type of behavior. Until my lab confirmed their existence in humans in 1998, pheromones were only thought to exist in the animal world.
Q. Mothers have long maintained that breast-feeding is sexy. Does your research confirm this?
A. No, that's a different phenomenon. Here, we were looking at the effect of chemosignals from a breast-feeding woman and her infant on other women who smelled them. It was the non-breast-feeding women who were aroused by the chemosignal. Molecules produced by a person or animal that can change behaviors of others, even though they are not detected as an odor.
What we did was that for two months, we exposed nonlactating women to this breast-feeding compound, which is found naturally in nursing mothers and infants. Women with regular sex partners reported a 24 percent increase in sexual desire; those without partners increased their sexual fantasies by 17 percent. Julie Mennella, who studies breast-feeding women, designed the study with me after hearing anecdotes from breast-feeding women suggesting that their ovarian cycles were affected by this. I had observed something similar with rats.
From an evolutionary perspective, it made sense that we'd find increased sexual motivation in women who were spending time around lactating mothers and smelling their chemosignals. Childbearing has always been risky and the presence of another breast-feeding woman in your immediate environment is an excellent indicator that now is a good time to conceive your own child.
Q. When you published your first scientific paper in 1971 - the one that showed how women living together in a college dormitory tended to synchronize their times of menstruation - it created a huge sensation among scientists. Why so strong an impact?
A. Because in the 1970's, it was a new idea that a menstrual cycle could be affected by social interactions. Pheromones happen to be the reasons for that, though there may be other factors involved. I felt that looking at women's menstrual cycles as a purely biological phenomenon, independent of what else women were doing, was wrong.
In the 1970's, some scientists were only looking at bodily mechanisms. And others were looking at the natural world. I wanted to put everything together. It's pretty obvious that what happens inside the skin is affected by what happens outside, which is why biologists need to work with social scientists. My entire career has been devoted to showing that psychology has a big role in the biological sciences.
Evolutionary biology shows that an organism is selected because of his/her behavioral interactions with the environment. When I first began working, I used to feel like a salmon swimming upstream. But now, this idea of connecting the social with the genetic and everything in between to attack diseases is catching on.
Q. Your institute has just received $7.3 million from the federal government to study the social and medical aspects of breast cancer among African-American women who live in the neighborhoods around the University of Chicago. What do you and your colleagues hope to learn from them?
A. We have social workers, physicians, psychologists and geneticists looking at different aspects of one question: Why do some African-American and Nigerian women develop a highly aggressive form of breast cancer, which they typically get prior to menopause. White women typically get breast cancer after menopause.
Our hypothesis is that some of it comes because of a genetic mutation in black women here and in Nigeria. But that can't be all of it. Less than 25 percent of the women with this cancer have this inherited mutation, according to my colleague Funmi Olopade. So it's dysfunction of the genes that have been activated during the woman's lifetime. What is the route from outside of the body in?
My part involves looking at psychological and social factors that might change the genes: loneliness, hypervigilance. In this laboratory, we've shown how rats who suffer hypervigilance and social isolation have shorter lives than those who do not. We want to see if this applies to humans. We want to know what is the psychological state that changes the neuroendrocrine system to the point where it changes the way cancer-promoting genes function.
Q. Black writers have long maintained that the everyday indignities of racism can set off illness. Are you trying to use science to prove that?
A. We're asking about getting this disease because you feel isolated, or if you get it because the demands in your life outstrip your social supports? Does getting the disease have something to do with the timing of puberty and breast development, something that sets up a risk in the mammary tissue? Is it that the social structure of the household, which is often headed by women, somehow, is changing the biology? I can't give you any answers yet.
Q. Your study includes a comparison group of women who live in Nigeria, a society where almost everyone is black. What specifically do you hope to learn from them?
We're going to Nigeria to look at a population that is black, but isn't in a minority. Life may be stressful there, but nobody is lonely in an African village - or so anthropologists tell me. They may well be lonely after they move into African cities, but we will have to investigate that further. The bottom line is that women in Nigeria also have this genetic mutation and so we can look at isolation and hypervigilance in a context different from that of black Americans.
Q. You began your training in the early 1970's, when it was unusual for a woman to enter science. What made you go for a scientific career?
A. I was, from a very young age, interested in molecular biology. When I was in grade school, my father took me to see Watson and Crick, when they first came out with the double helix. My father was an M.I.T. professor and my mother is a naturalist. When I chose a college, I picked Wellesley because I knew I could get a good education there without the pressures of "girls don't do science."
I only ran into discrimination at graduate school - Harvard, where, because I was a woman, I was barred from the stacks at the Widener Library. I remember a moment when the chairman of the psychology department took his first-year students to lunch at the faculty club. I had to sit at a card table in the vestibule because I wasn't allowed into the dining room. But Harvard also gave me the chance to study with E. O. Wilson - a wonderful mentor.
Things have changed since then. A woman was just named president of M.I.T. I head an institute here. Culturally, these facts mean that it's now easier for women who are truly interested in science to do it.
By BENEDICT CAREY, The New York Times, November 16, 2004
The marriage seemed to come loose at the seams, one stitch at a time, often during the evening hour between work and dinner. She would be preparing the meal, while he kept her company in the sun room next to kitchen, usually reading the paper. At times the two would provoke each other, as couples do - about money, about holiday plans - but those exchanges often flared out quickly when he would say, simply, "O.K., you're right," and turn back to the news.
"Looking back, instead of getting angry, I was doing this as a dismissive way of shutting down the conversation," said Peter G. Hill, 48, a doctor in Massachusetts who has recently separated from his wife. Even reading the paper at that hour was his way of adamantly relaxing, in defiance of whatever it was she thought he should be doing.
"It takes two to break up, but I have been accused of being passive-aggressive, and there it is," he said.
Everyone knows what it looks like. The friend who perpetually arrives late. The co-worker who neglects to return e-mail messages. The very words: "Nothing. I'm just thinking."
Yet while "passive-aggressive" has become a workhorse phrase in marriage counseling and an all-purpose label for almost any difficult character, it is a controversial concept in psychiatry.
After some debate, the American Psychiatric Association dropped the behavior pattern from the list of personality disorders in its most recent diagnostic manual - the DSM IV - as too narrow to be a full-blown diagnosis, and not well enough supported by scientific evidence to meet increasingly rigorous standards of definition.
The decision is likely to have more effect on teaching guidelines and research than on treatment and insurance coverage.
But psychologists and psychiatrists with long experience treating this kind of behavior say it is hard to study precisely because it is so covert, common and widely variable.
These experts make a distinction between passive-aggressive behavior, which most people display at times, and passive-aggressive personality, which is ingrained and habitual. In milder forms it can come across as a maddening blend of evasiveness and contrition, agreeableness and impudence, and in severe cases is often masked by more obvious mental illness, like depression.
Yet whether pathological or not, they say, the pattern is often traceable to a distinct childhood experience. New research suggests that in many cases it stems from a positive, socially protective instinct - to keep peace at home, avoid costly mistakes at work, even preserve some self-respect.
"Some of the people being demeaned as passive-aggressive are in fact being extremely careful not to commit mistakes, a strategy that has been successful for them," if not entirely conscious, said Dr. E. Tory Higgins, director of the Motivation Science Center at Columbia University. They become difficult, he said, "when their cautious instincts are overwhelmed by demands that they perceive as unreasonable."
The classic description of the behavior captures a stubborn malcontent, someone who passively resists fulfilling routine tasks, complains of being misunderstood and underappreciated, unreasonably scorns authority and voices exaggerated complaints of personal misfortune.
But the phrase itself has its roots in the military. Near the end of World War II, a colonel in the United States War Department used it to describe an "immature" behavior among enlisted men, many of them at the end of long tours: "a neurotic type reaction to routine military stress, manifested by helplessness, or inadequate responses, passiveness, obstructionism or aggressive outbursts."
This kind of insolence, among adults protecting themselves from what they saw as unreasonable, arbitrary authority, was in part an adaptive behavior, psychologist say, an effort to preserve some independence amid extreme pressure to conform.
A similar family dynamic accounts for early development of the behavior, some researchers argue. Dr. Lorna Benjamin, co-director of a clinic at the University of Utah's Neuropsychiatric Institute in Salt Lake City, said people with strong passive tendencies often grew up in loving but demanding families, which gave them responsibilities they perceived to be unmanageable.
First-born children are prime candidates, she said: when younger siblings are born, the oldest may suddenly be expected to take on far more extra work than he or she can handle, and over time begin to resent parents' demands without daring to defy them.
This hostile cooperation is at the core of passive-aggression, she and other researchers say, and in later in life it is habitually directed at any authority figure, whether a boss, a teacher or a spouse making demands. These passive-aggressive people, Dr. Benjamin said, "are full of unacknowledged contradiction, of angry kindness, compliant defiance, covert assertiveness."
This history hardly excuses the multitude of hedging, foot-dragging mopes that populate everyday life, but it can help explain some of their exploits. One Los Angeles woman, who asked not to be identified (and swore she was not being passive-aggressive), described a former co-worker who intentionally made assignments late to employees when she didn't approve of a project.
At the end of some days, she wrote, this archetypal passive-aggressive used to hide under her desk to avoid saying goodnight to people.
Sometimes, however, mild passive-aggressive behavior can be an effective means to avoid potentially costly confrontations. In such cases the cooperation is more significant than the underlying resentment or hostility.
"A joke can be the most skillful passive-aggressive act there is,'' said Dr. Scott Wetzler, a clinical psychologist at Montefiore Medical Center in the Bronx and the author of "Living With the Passive-Aggressive Man." "They recognize a coming confrontation, and have found a clever way to release the tension."
It is just this instinctive ability to pre-empt and defuse that, paradoxically, may lead to more problematic passive-aggressive behavior.
Dr. Higgins of Columbia has described a personal quality he calls prevention pride, a kind of native caution in the face of new challenges, an effort to avoid all errors. He assesses whether a person is high or low in this style by asking a battery of questions, like how often they broke their parents rules, how often they take risks, how often they have been in trouble by not being careful enough. The style is adaptive, he said, in that it allows people with a certain temperament to avoid failure and embarrassment.
In one recent experiment, Dr. Higgins and Dr. Ozlem Ayduk, an assistant professor of psychology at the University of California at Berkeley, tested how these especially cautious people reacted to conflict in relationships. The researchers had 56 couples who had been together at least two months keep detailed diaries, answering questions about conflicts, thoughts about the relationship, moods and their partners' behavior.
After three weeks, the researchers compared the diaries and found that people who had a highly cautious personal style and were especially sensitive to rejection were significantly more likely than the others to respond to conflicts by going silent, withdrawing their affection and acting cold.
"The people in this study were not the type who would ever say, 'I hate you' to the person's face because they are so careful not to do something that puts them out there," and directly offend their partner, Dr. Ayduk said.
The evidence that this sensitivity can be appealing, at least for a while, is recorded in millions of relationships that have lasted for years. A 45-year-old college instructor in Hawaii recently broke off a long relationship with a man she said was a "wonderful, devoted listener, an extremely sensitive person."
But in time, she said, it was apparent that he was also passive-aggressive. On one occasion, she said, he gave away her seat on an airplane while she was finding a storage compartment for her luggage, saying he thought she had taken another seat. On others, he would arrive home early from work and finish off meals they normally shared, without explanation. And when he was in one of his moods, the listening ceased; she may as well not have been in the room.
"The challenging thing was, you never know what you did wrong," she said. "That's the difficulty, all these scenarios, I could not point to what I did. I never knew."
The person who has become hostile may not know exactly why, either. In some cases, psychologists say, people unable to recognize or express their annoyance often don't feel entitled to it; they instinctually let the "little things" pass without taking the time to find out why they are so angry about them. Unsure of themselves, they take care not to offend a spouse, a co-worker or friend. The anger remains.
When the behavior pattern is deeply ingrained and compulsive, it is neither adaptive nor merely bewildering, but can be dangerous, some experts say. At her clinic in Salt Lake City, Dr. Benjamin treats many people with multiple diagnoses, from attention deficit disorder to obsessive-compulsive disorder to intractable depression, many of them with other problems, like substance abuse or multiple suicide attempts.
"And I would say that in close to half of them this passive-aggressive behavior is running the whole show," she said.
When and if they do get therapy, psychiatrists say, people with strong passive-aggressive instincts are usually determined to fail: the therapist becomes the scorned authority figure. The patients will take their medications and then report with relish that they don't work. The patients will follow advice and then complain that it is senseless, useless. "They are not doing this on purpose; it's part of a deep-seated ambivalence about getting better," a determination to expose the authority as incompetent, said Dr. Marjorie Klein, a psychiatrist at the University of Wisconsin.
It is left to the individual therapist's skill to deflect or disarm this determination and get patients to at least experiment with an alternate strategy to engage their lives. In one, called cognitive behavior therapy, they learn to monitor their thoughts, moment by moment, to recognize when they are angry, and to challenge unexamined assumptions about confrontation. For example, some people assume that confronting their boss about a raise will be a catastrophe, said Dr. Wetzler of Montefiore, but it often simply is not the case, especially if they have prepared themselves by learning the market value of their skills at other companies.
Yet Dr. Benjamin said that often the childhood roots of the behavior must be faced and felt, and that means revisiting the parental relationship and learning that it does not have to set the pattern for all relationships with authority. "The main challenge is to help them shift from winning by losing to winning by winning," she said, "to see that it is they who benefit most when they win, not their therapist, their spouse or their boss."
Just living with the behavior in someone else can be as tough as treating it. To manage garden variety passive-aggressive behavior, psychiatrists often advise a kind of protective engagement: don't attack the person; that only reinforces your position as an authority making demands. Take into account the probable cause of the person's unexpressed anger and acknowledge it, if possible, when being stonewalled during a discussion.
And be sure to be on guard against likely retaliation.
"If he agrees to go over to your relatives' place for Thanksgiving, but you know he's upset about it, make sure you have alternate transportation to get over there," Dr. Wetzler said.
"He may take the car and not manage to get home in time to make it."
Smart or Misguided? The Proactive Doctor
ESSAY
By BARRON H. LERNER, M.D., The New York Times, November 16, 2004
Not so long ago, patients went to doctors only when something was bothering them. But then came the rise of preventive medicine - the idea that it was the job of the physician to search for diseases and treat them before they caused symptoms.
Recent studies have pushed this view further, suggesting it is necessary to decrease blood pressure and cholesterol to levels well below those previously considered normal.
But must I, as a doctor, always be proactive with my patients? How did medicine go from providing physical relief to a search mission for potential harms? And is it ever acceptable for my patients to tell me that we should just leave well enough alone?
The impetus for seeking out early disease came from public health. When health officials dealing with tuberculosis in the early 1900's began to trace the contacts of sick people, they were able to find many early cases of the disease. On average, these patients with early diagnoses did better.
The American Society for the Control of Cancer, later the American Cancer Society, developed its list of "danger signals" in the 1920's. The message was clear: unexplained lumps in the breast or elsewhere, or seemingly innocent bleeding, needed to be quickly evaluated by doctors. Early cancers, it was argued, were more curable.
After World War II, the Framingham Heart Study solidified the "risk factor" model of disease. People with high blood pressure, high cholesterol, diabetes and a smoking habit, the study found, were more likely to have heart attacks and stroke.
Thanks to Framingham, eliminating cardiac risk factors has become a basic component of medical practice. In part as a result of these efforts, mortality from heart disease has declined significantly.
In recent years, our ability to discover information at early stages has rapidly increased. Some healthy people now undergo full-body C.T. scans, assuming they will discover early, treatable diseases.
The world of genetics offers even greater possibilities. It is now possible to find genetic mutations that make people more likely to develop certain cancers. But there is no guarantee that discovering a mutated gene will prevent them from getting - or dying from - cancer.
So how far should we push in our search for potentially harmful disorders? One potential answer lies in evidence-based medicine, which relies on sophisticated statistical studies to determine what's effective. Although "evidence-based" sounds definitive, available data on a given procedure or treatment may still be disputed.
The recent studies are a perfect example. A paper last week in The Journal of the American Medical Association found that treating patients whose blood pressure readings were in the range previously considered normal lowered their risk of cardiac problems, like heart attacks or stroke, by 15 to 31 percent.
Other studies have recently suggested that the target readings for L.D.L. cholesterol, the type associated with disease risk, should be 80 to 100 units, rather than under 130, as previously recommended. A study published in The New England Journal of Medicine in April found that cardiac patients receiving aggressive cholesterol treatment had death rates 28 percent lower than those receiving standard therapy.
What should patients do? It depends on whom you ask. Dr. Jonathan Sackner-Bernstein, a cardiologist at North Shore University Hospital on Long Island and the author of "Before It Happens to You," argues that these are exactly the sort of statistics that should encourage people to be proactive.
Dr. Sackner-Bernstein, who has done research and given talks for drug companies, goes so far as to advise patients how to persuade reluctant doctors, suggesting that they tell the physician, "Since our goal right now is the optimal benefit-to-risk ratio for me, and not society, I wanted to talk to you about getting my cholesterol profile to optimal levels."
Dr. Sackner-Bernstein makes a similar argument for aggressive treatment of high blood pressure. His book, he tells readers, has a simple goal: to save their lives.
Yet for every Dr. Sackner-Bernstein there is a Dr. H. Gilbert Welch, an internist and epidemiologist at Dartmouth Medical School and the author of "Should I Be Tested for Cancer?" Studies show, Dr. Welch argues, that mammography; testing for prostate specific antigen, or P.S.A.; and other cancer screening tools often lead to ambiguous diagnoses and unnecessary treatment.
Dr. Welch challenges what he calls the "culture of medicine," questioning the "widespread presumption that it never hurts to look." Patients, he believes, should be skeptics, asking their doctors: "Why are you ordering the test?" "Has there been a randomized trial of screening for this?" "What will we do if my test is positive?"
What then should I tell my patients? I increasingly find myself discussing with them the kind of people they are: are they "seekers," who want to know every possible piece of information and try the latest treatments, or are they "waiters," who want more data before acting?
When the statistics are ambiguous, both options may be good ones.
Barron H. Lerner is a medical historian and an internist at Columbia University.
A CONVERSATION WITH MARTHA MCCLINTOCK: The Chemistry (Literally) of Social Interaction
By CLAUDIA DREIFUS, The New York Times, November 16, 2004
CHICAGO - For much of her career, Dr. Martha McClintock, the experimental psychologist, has been stunning the scientific world with research on how social interactions affect biology in humans and animals.
The director of the University of Chicago's Institute for Mind and Biology, Dr. McClintock tends to investigate matters that are at once important and obvious.
In 1971 she published her first scientific paper - a study showing that women living together in a Wellesley College dormitory tended to menstruate at the same time. The idea grew out of her own undergraduate observations. Dr. McClintock, 57, has demonstrated chemical communication between humans in laboratory experiments, again in influencing menstrual cycles. Whether pheromones play a role in human life outside the lab remains unknown. In animals pheromones affect the whole panoply of behavior - mating, aggression and fear.
In other work with colleagues, she has proved that rats that fear change have shorter lives than their more flexible counterparts, and that social isolation can also affect the longevity of rodents.
"I've focused my work on downward causation, the idea that the social and psychological world changes the fundamental mechanisms of biology, and vice versa," Dr. McClintock said on a recent afternoon at her offices at the University of Chicago. "I've tried to situate biology in a rich social and psychological context and make it simple."
Q. You recently made news with your discovery of an airborne chemical that increases sexual desire in women, a compound usually found in breast-feeding women and their infants. Why is the finding important?
A. This is the first natural compound to be found that can increase libido in women, other than hormones. It is also the first found human social chemosignal or pheromone to affect this type of behavior. Until my lab confirmed their existence in humans in 1998, pheromones were only thought to exist in the animal world.
Q. Mothers have long maintained that breast-feeding is sexy. Does your research confirm this?
A. No, that's a different phenomenon. Here, we were looking at the effect of chemosignals from a breast-feeding woman and her infant on other women who smelled them. It was the non-breast-feeding women who were aroused by the chemosignal. Molecules produced by a person or animal that can change behaviors of others, even though they are not detected as an odor.
What we did was that for two months, we exposed nonlactating women to this breast-feeding compound, which is found naturally in nursing mothers and infants. Women with regular sex partners reported a 24 percent increase in sexual desire; those without partners increased their sexual fantasies by 17 percent. Julie Mennella, who studies breast-feeding women, designed the study with me after hearing anecdotes from breast-feeding women suggesting that their ovarian cycles were affected by this. I had observed something similar with rats.
From an evolutionary perspective, it made sense that we'd find increased sexual motivation in women who were spending time around lactating mothers and smelling their chemosignals. Childbearing has always been risky and the presence of another breast-feeding woman in your immediate environment is an excellent indicator that now is a good time to conceive your own child.
Q. When you published your first scientific paper in 1971 - the one that showed how women living together in a college dormitory tended to synchronize their times of menstruation - it created a huge sensation among scientists. Why so strong an impact?
A. Because in the 1970's, it was a new idea that a menstrual cycle could be affected by social interactions. Pheromones happen to be the reasons for that, though there may be other factors involved. I felt that looking at women's menstrual cycles as a purely biological phenomenon, independent of what else women were doing, was wrong.
In the 1970's, some scientists were only looking at bodily mechanisms. And others were looking at the natural world. I wanted to put everything together. It's pretty obvious that what happens inside the skin is affected by what happens outside, which is why biologists need to work with social scientists. My entire career has been devoted to showing that psychology has a big role in the biological sciences.
Evolutionary biology shows that an organism is selected because of his/her behavioral interactions with the environment. When I first began working, I used to feel like a salmon swimming upstream. But now, this idea of connecting the social with the genetic and everything in between to attack diseases is catching on.
Q. Your institute has just received $7.3 million from the federal government to study the social and medical aspects of breast cancer among African-American women who live in the neighborhoods around the University of Chicago. What do you and your colleagues hope to learn from them?
A. We have social workers, physicians, psychologists and geneticists looking at different aspects of one question: Why do some African-American and Nigerian women develop a highly aggressive form of breast cancer, which they typically get prior to menopause. White women typically get breast cancer after menopause.
Our hypothesis is that some of it comes because of a genetic mutation in black women here and in Nigeria. But that can't be all of it. Less than 25 percent of the women with this cancer have this inherited mutation, according to my colleague Funmi Olopade. So it's dysfunction of the genes that have been activated during the woman's lifetime. What is the route from outside of the body in?
My part involves looking at psychological and social factors that might change the genes: loneliness, hypervigilance. In this laboratory, we've shown how rats who suffer hypervigilance and social isolation have shorter lives than those who do not. We want to see if this applies to humans. We want to know what is the psychological state that changes the neuroendrocrine system to the point where it changes the way cancer-promoting genes function.
Q. Black writers have long maintained that the everyday indignities of racism can set off illness. Are you trying to use science to prove that?
A. We're asking about getting this disease because you feel isolated, or if you get it because the demands in your life outstrip your social supports? Does getting the disease have something to do with the timing of puberty and breast development, something that sets up a risk in the mammary tissue? Is it that the social structure of the household, which is often headed by women, somehow, is changing the biology? I can't give you any answers yet.
Q. Your study includes a comparison group of women who live in Nigeria, a society where almost everyone is black. What specifically do you hope to learn from them?
We're going to Nigeria to look at a population that is black, but isn't in a minority. Life may be stressful there, but nobody is lonely in an African village - or so anthropologists tell me. They may well be lonely after they move into African cities, but we will have to investigate that further. The bottom line is that women in Nigeria also have this genetic mutation and so we can look at isolation and hypervigilance in a context different from that of black Americans.
Q. You began your training in the early 1970's, when it was unusual for a woman to enter science. What made you go for a scientific career?
A. I was, from a very young age, interested in molecular biology. When I was in grade school, my father took me to see Watson and Crick, when they first came out with the double helix. My father was an M.I.T. professor and my mother is a naturalist. When I chose a college, I picked Wellesley because I knew I could get a good education there without the pressures of "girls don't do science."
I only ran into discrimination at graduate school - Harvard, where, because I was a woman, I was barred from the stacks at the Widener Library. I remember a moment when the chairman of the psychology department took his first-year students to lunch at the faculty club. I had to sit at a card table in the vestibule because I wasn't allowed into the dining room. But Harvard also gave me the chance to study with E. O. Wilson - a wonderful mentor.
Things have changed since then. A woman was just named president of M.I.T. I head an institute here. Culturally, these facts mean that it's now easier for women who are truly interested in science to do it.