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ORIGINAL RESEARCH published: 26 April 2021 doi: 10.3389/fpsyg.2021.579183 Development and Psychometric Properties of the Test of Passive Aggression 1 1 1 2 Christian G. Schanz , Monika Equit , Sarah K. Schäfer , Michael Käfer , 1 1 Hannah K. Mattheus and Tanja Michael * Clinical Psychology and Psychotherapy, Department of Psychology, Saarland University, Saarbruecken, Germany, MediClin Bliestal-Clinics, Blieskastel, Germany Background: To date, most research on aggression in mental disorders focused on active-aggressive behavior and found self-directed and other-directed active aggression to be a symptom and risk-factor of psychopathology. On the other hand, passive-aggressive behavior has been investigated less frequently and only in research on psychodynamic defense mechanisms, personality disorders, and dysfunctional self-control processes. This small number of studies primarily reﬂects a lack of a reliable and valid clinical assessment of passive-aggressive behavior. To address this gap, we developed the Test of Passive Aggression (TPA), a 24-item self-rating scale for the assessment of self-directed and other-directed passive-aggressive behavior. Edited by: Xavier Noel, Method: Study 1 examined the internal consistency and factorial validity of the TPA in an Université libre de Bruxelles, Belgium inpatient sample (N = 307). Study 2 investigated the retest-reliability, internal consistency, Reviewed by: and construct validity (active aggression, personality traits, impulsivity) of the TPA in a Snezana Smederevac, student sample (N = 180). University of Novi Sad, Serbia Marco Tommasi, Results: In line with our hypothesis, Exploratory Structural Equation Modeling revealed University of Studies G. d’Annunzio an acceptable to good ﬁt of a bi-factorial structure of the TPA (Chi-square-df-ratio= 1.98; Chieti and Pescara, Italy RMSR = 0.05, ﬁt.off = 0.96). Both TPA scales showed good to excellent internal *Correspondence: Tanja Michael consistency (α = 0.83–0.90) and 4-week retest-reliability (r = 0.86). Correlations with tt email@example.com well-established aggression scales, measures of personality, and impulsivity support discriminant and convergent validity of the TPA. Specialty section: This article was submitted to Conclusions: The TPA is a reliable and valid instrument for the assessment of Psychopathology, a section of the journal self-directed and other-directed passive-aggressive behavior. Frontiers in Psychology Keywords: aggressive behavior, passive aggression, self-directed aggression, depression, test development Received: 02 July 2020 Accepted: 15 March 2021 Published: 26 April 2021 INTRODUCTION Citation: Schanz CG, Equit M, Schäfer SK, Aggressive behavior is any behavior intended to harm oneself or others directly or indirectly (Buss, Käfer M, Mattheus HK and Michael T 1961). It can be diﬀerentiated into active and passive forms (Allen and Anderson, 2017). Active (2021) Development and aggressive behavior comprises all forms of behavior including active engagement in the application Psychometric Properties of the Test of of psychological or physical impairment, e.g., insulting someone or deliberate self-harm. Passive Passive Aggression. Front. Psychol. 12:579183. aggressive behavior is characterized by harmful inactivity and omission of active engagement, doi: 10.3389/fpsyg.2021.579183 e.g., a lack of social support or neglect of one’s own psychological needs. Therefore, aggression Frontiers in Psychology | www.frontiersin.org 1 April 2021 | Volume 12 | Article 579183 Schanz et al. The Test of Passive Aggression per se characterizes harmful behavior, but not to a personality concept or not. Given that research into other psychological trait (e.g., impulsivity), emotion (e.g., anger), or cognition (e.g., ﬁelds [e.g., organizational psychology (Baron and Neuman, 1996; hostile attribution; Baron and Richardson, 2004). However, Neuman and Baron, 1998)] demonstrated ﬁrmly the relevance aggressive behavior tends to be stable over the life course and of passive-aggressive behavior, it is also important to re-examine is thus assumed to represent a trait-like behavioral tendency passive-aggressive behavior from a clinical perspective. Apart (Huesmann et al., 2009). Although aggressive behavior is an from nosological research into passive-aggressive personality evolutionary-based human problem-solving behavior (Buss and disorder, mainly two theoretical approaches have inspired Shackelford, 1997), which can be adaptive in some contexts clinical research into passive-aggressive behavior: Research on (Georgiev et al., 2013; Edmondson et al., 2016), it is also other-directed passive-aggressive behavior mainly originated from associated with high individual and societal costs (Laing and psychodynamic research into defense mechanisms (Cramer, Bobic, 2002; Heilbron and Prinstein, 2008). Among other 2015), and research on self-directed passive-aggressive behavior— relevant risk factors for aggressive behavior [e.g., childhood sometimes also referred to as self-harm by omission (Turp, sexual abuse (Fliege et al., 2009), hopelessness (Fox et al., 2007)—mainly focused on self-control processes in depressive 2015), impulsivity (Bresin, 2019)], aggressive behavior is related disorders (Rehm, 1977). to psychopathology (Genovese et al., 2017). Prevalence rates of aggressive behavior in clinical samples exceed those of the general population, for both self-directed aggressive behavior Passive-Aggression in Clinical Research [e.g., life-time prevalence of self-harm: 21 vs. 4% (Briere and Gil, In psychodynamic research, defense mechanisms are deﬁned 1998)] and other-directed aggressive behavior [e.g., 12 months as unconscious processes protecting the ego from emotional prevalence of other-directed violence: 8–37% vs. 2% (Swanson disturbance (e.g., fear) and instinctive urges (e.g., active et al., 2015)]. However, it is important to note that the vast aggression; Freud, 1936). Defense mechanisms are supposed to majority of individuals aﬀected by mental disorders does not represent relatively stable traits (Bond, 2004), which are activated show higher levels of aggressive behavior than the general by internal or external conﬂicts (Segal et al., 2007). According population (Varshney et al., 2016). Nevertheless, individuals to their capability to resolve conﬂicts, they are classiﬁed into with mental disorders are an important population for research mature, neurotic, and immature defenses (Andrews et al., into aggressive behavior and for prevention of self-directed and 1993), with immature defense mechanisms being associated with other-directed aggressive behavior (Taft et al., 2012; Dutton and childhood trauma or neglect (Romans et al., 1999; Nickel and Karakanta, 2013; Hawton et al., 2013; Augsburger and Maercker, Egle, 2006). Passive-aggressive behavior is conceptualized as an 2020). immature defense mechanism due to its negativistic and covert Active aggressive behavior has been investigated extensively, nature (Andrews et al., 1993; Schauenburg et al., 2007), thereby which is reﬂected in the existence of well-established theoretical contributing to the suppression of emotional conﬂicts and frameworks and many psychometric tests (Parrott and Giancola, impaired problem-solving capabilities (Cramer, 2015). Higher 2007). For detailed information and reviews regarding active levels of passive-aggressive defense mechanisms are associated aggressive behavior in mental disorders, see, for e.g., Caﬀerky with more severe symptoms of anorexia nervosa (Tordjman et al., et al. (2018), Dutton and Karakanta (2013), Hawton et al. (2013), 1997), acute stress disorder (Santana et al., 2017), adjustment and Taft et al. (2012). By contrast, research on passive-aggressive disorder (Ghazwin et al., 2017), borderline personality disorder behavior is relatively scarce, resulting in a smaller number of (Zanarini et al., 2013), and deliberate self-harm (Baykara and theories and a lack of psychometric tests (Parrott and Giancola, Alban, 2018). 2007). The term passive aggression was ﬁrst used to characterize The self-control theory of depression is based on Kanfer’s (1971) behavior of soldiers in World War II who acted in non- behavioral self-control model that proposes that individuals compliant ways to their superior’s orders (Millon, 1993). In the control their behavior using a feedback loop of self-monitoring, aftermath, passive-aggressive personality disorder was included self-evaluation, and self-reinforcement. These processes are in the ﬁrst version of the Diagnostic and Statistical Manual of assumed to be distorted in patients with depressive symptoms Mental Disorders (DSM) and was characterized primarily by a due to dysfunctional cognitive biases and negative attributional set of behavioral symptoms (e.g., procrastination) (American styles (Rehm, 1977), which are supposed to develop in late Psychiatric Association, 1952). However, during various revisions childhood and get activated in stressful situations (Wang et al., of the DSM, the concept lost its substantive distinctiveness and 2010; Hu et al., 2015; Schierholz et al., 2016). The tendency was later renamed negativistic personality disorder. Thereby, of depressed patients to selectively focus on adverse stimuli aﬀective symptom (e.g., moodiness) and cognitive characteristics and events (De Raedt and Koster, 2010) and to attribute (e.g., negativistic attitudes) were included and resulted in a these in a dysfunctional way (Hu et al., 2015) results in a large overlap with other personality disorders (Hopwood and negative self-evaluation (Orchard and Reynolds, 2018). Such a Wright, 2012). This lack of clarity ultimately led to less negative self-evaluation, in turn, is supposed to lead to excessive research on passive-aggressive personality disorder and ﬁnally self-punishment and low levels of self-reward (Ciminero and to its exclusion from DSM-5 (American Psychiatric Association, Steingarten, 1978; Rozensky et al., 1981). Notably, the latter 2013). Therefore, for a long time it was also diﬃcult to represents a form of self-directed passive-aggressive behavior and capture the clinical signiﬁcance of the concept, since associated contributes to the development of depression (Fuchs and Rehm, characteristics (e.g., moodiness) were partly subject to the 1977). Frontiers in Psychology | www.frontiersin.org 2 April 2021 | Volume 12 | Article 579183 Schanz et al. The Test of Passive Aggression In summary, both approaches, in line with research on (unpleasant feeling) + (passive-aggressive behavioral reaction). passive-aggressive personality disorder (Hopwood and Wright, The scenarios were chosen to ﬁt diﬀerent backgrounds and 2012; Newton-Howes et al., 2015; Hopwood, 2018), assume thus reﬂect a broad range of daily scenarios (e.g., an argument that passive-aggressive behavior constitutes a relatively stable with a partner, conﬂicts at work, or personal failure) to be behavioral tendency that gets activated when individuals are more inclusive than previous instruments that were limited to exposed to internal or external stressors. Furthermore, passive- speciﬁc contexts (e.g., conﬂicts at work). Even though all items aggressive behavior is supposed to result from dysfunctional were formulated by the ﬁrst author (CS), previous assessment monitoring and evaluation processes, which are supposed to of passive-aggressive defense mechanisms and passive-aggressive arise from negative childhood experiences. Therefore, passive personality disorder served as a basis for item generation of the aggression is assumed to be both a risk factor for and a result of TPA-OD scale (e.g., Andrews et al., 1993; Kuhl and Kazén, 1997). psychopathology and interpersonal conﬂicts. Items of the TPA-SD scale followed the rationale of the self- control theory of depression and therefore focused on behavioral Psychometric Tests on Passive-Aggressive patterns which deny one-self rewards, reinforcement, or self- satisfaction (Rehm, 1977; Mezo and Short, 2012). To reﬂect the Behavior stable character of passive-aggressive behavior, a ﬁve-point scale The availability of a valid psychometric test is important for ranging from “1 = very unlikely” to “5 = very likely” was used, the development of a research ﬁeld. To give an example, asking the respondents to estimate the probability to react in resilience research is closely related to the development of the the described manner in general. Initially, 16 items each for the sense of coherence questionnaire (Antonovsky, 1987; Eriksson assessment of self-directed and other-directed passive-aggression and Lindström, 2006). The development of psychometric tests were developed. At this point, 32 items for the assessment of needs to follow the assumptions of the classical or probabilistic active aggression had been formulated but were discarded in the test theory (Hambleton and Jones, 1993). Moreover, tests following steps due to expert ratings and test statistics (mean need to fulﬁll quality criteria (i.e., objectivity, reliability, and item severity <0.20). Third, a pilot study was conducted to validity). Although psychometric tests originated from the above- provide primarily information on test statistics (i.e., item severity, mentioned research traditions show good overall psychometric inter-item correlation) in a sample of adult (age ≥ 18 years) properties, their suitability for assessing passive-aggressive psychology students [N = 102, 86.27% females, M(age) = 21.44 behavior is limited by their item content (e.g., Fydrich et al., years, SD(age) = 3.29]. For additional information on the pilot 1997; Kuhl and Kazén, 1997; Mezo and Short, 2012). To date, data, see Supplementary Material A. Based on these results, the clinical tests (i.e., of passive-aggressive personality disorders, defense mechanisms, or self-control mechanisms) assess broader authors (CS, EM, SS, HM, TM) reﬁned the items and increased their number to 18 per scale (see Table 1 for the 36-item version nosological categories (including cognitions, emotions, and of the TPA). Fourth, we analyzed the factorial structure in a larger personality traits) instead of passive-aggressive behavior only. clinical sample (Study 1), and ﬁfth, we examined retest-reliability Additionally, psychometric tests from other psychological ﬁelds and construct validity of the TPA (Study 2). assess passive-aggressive behavior in very speciﬁc contexts (i.e., at the workplace) or from victim instead of perpetrator perspective (e.g., regarding social ostracism), and are thus not applicable STUDY 1 in the clinical context (Williams and Sommer, 1997; Neuman and Baron, 1998, 2005). Therefore, in order to facilitate clinical Study 1 aimed at initially validating and reﬁning the 36-item research into passive-aggressive behavior, the current research version of the TPA. For this purpose, it examined the project aimed at developing and validating the Test of Passive assumed bi-factorial structure of the TPA as well as its Aggression (TPA), a behavior-based test for the assessment of both internal consistency and the relationships between other-directed self-directed and other-directed passive aggression. and self-directed passive-aggression and depressive symptoms, somatoform symptoms, anxiety, and global psychopathological symptom severity. METHODS Materials and Methods of Study 1 Scale and Item Construction Development of the TPA followed guidelines for the development Participants and Procedure of psychometric tests according to the classical test theory A total of 319 patients 18 years and older participated in Study (Hambleton and Jones, 1993). First, the authors (CS, ME, SKS, 1. Patients were recruited at a German psychosomatic clinic HM, and TM) agreed on the deﬁnition of self-directed and other- (MediClin Bliestal-Clinics, Blieskastel), where they received directed passive-aggressive behavior: Passive-aggressive behavior a 5-to-6-week multidisciplinary inpatient treatment. Twelve is a stable behavioral disposition to harm oneself or others by patients were excluded due to more than four missing values omission in reaction to internal or external stressors. The test on the TPA. For the characteristics of the ﬁnal sample see was supposed to consist of one scale for the assessment of Table 2. Participants gave written informed consent according self-directed passive aggression (TPA-SD) and another scale for to the Declaration of Helsinki (World Medical Association, the assessment of other-directed passive-aggression (TPA-OD). 2013) and completed the assessments described below on Second, the ﬁrst author (CS) created a set of items, all of which their arrival (M1) and again at their discharge (M2). Study followed the following pattern: (internal or external stressor) + 1 was preregistered at the German Clinical Trials Register Frontiers in Psychology | www.frontiersin.org 3 April 2021 | Volume 12 | Article 579183 Schanz et al. The Test of Passive Aggression TABLE 1 | Items of the 36-item version of the TPA. Item Item content Scale 1 If I am feeling down, I do not allow myself to do things or activities that would have actually been good for me TPA-SD 2 If I am successful at something, I overthink that success until I ﬁnd something bad about it TPA-SD 3 If I want to teach someone a lesson, I do not respond to his/her contact attempts and ignore his/her messages TPA-OD 4 If I performed well at work/at study, I avoid talking about it with my family, because I do not think I really deserve TPA-SD any commends on it 5 If someone has hurt my feelings, I refuse to support that person in difﬁcult situations TPA-OD 6 When I am irritated and notice that a friend is sad or upset, I do not ask what is bothering him/her TPA-OD 7 If I have information that is useful to a person, I do not like, I still forward the information to that person* TPA-OD 8 If I receive a present from someone, I will accept it, even when I have the feeling that I do not really deserve it* TPA-SD 9 If I feel I have upset someone close to me, I subsequently forgo planned enjoyable activities, such as a good meal TPA-SD or wellness 10 When someone takes time to support me in a stressful situation, I resist accepting the help because I cannot TPA-SD imagine truly deserving this support 11 If I could help a person I do not like with a problem, I refuse from doing it TPA-OD 12 When I plan my free time, I do not do what I assume is enjoyable for me, but rather I go by what other people, TPA-SD such as friends or family members, want me to do 13 If I am angry at someone, I ignore that person and their needs TPA-OD 14 If I am feeling down, I throw myself into taking care of everyday responsibilities, for e.g., work or housekeeping, TPA-SD instead of consciously doing something good for myself 15 If I fail at something, I cancel planned leisure activities, for e.g., going to the cinema or going for shopping TPA-SD 16 If I feel the need for interpersonal affection or an uplifting activity, I still continue in my daily routine instead of TPA-SD fulﬁlling that need 17 If I have made a mistake, I refuse emotional support from other people afterwards TPA-SD 18 If I am sad, I refuse to participate in activities that could cheer me up TPA-SD 19 If someone at work/at university annoys me, I reduce my involvement in our teamwork TPA-OD 20 If I am dissatisﬁed with someone’s behavior, I do not address him/her directly, but react coolly or disinterestedly to TPA-OD his/her behavior 21 If I have resources, for e.g., money or time, at my free disposal, I use them to make myself feel good* TPA-SD 22 If I am angry at someone, I will not provide that person with emotional support TPA-OD 23 When someone important to me has hurt me emotionally, I suspend existing habits with him/her, such as going for TPA-OD walks together or talking on the phone regularly 24 If I am dissatisﬁed with the commitment of my colleagues in a team effort, I start performing at the minimum level TPA-OD required afterwards 25 If someone has denied helping me with a problem, I am still willing to help that person with similar problems* TPA-OD 26 If I know that someone I am upset with is about to make a mistake I do not make him/her aware of it TPA-OD 27 If my partner does not see my needs, I pay him/her back by, for e.g., doing the shopping or cooking just for me TPA-OD 28 Even when I am feeling bad, I still care more about other people’s needs than my own TPA-SD 29 If I am upset with a friend, I exclude him/her from enjoyable activities, for e.g., from trips or going to the cinema TPA-OD 30 Even though I’ve had a particular wish for years, such as going on vacation or trying a new leisure activity, I always TPA-SD miss out on opportunities to fulﬁll that wish 31 After an argument with someone close to me, I still try to give the day a positive turn afterwards, for e.g., by TPA-SD engaging in a hobby or some other pleasant leisure activity* 32 When I doubt whether I have done a task well, I refuse to be complimented or rewarded by other people for this TPA-SD accomplishment 33 After an argument with my partner, I refuse to show him/her any tenderness TPA-OD 34 If I am upset with someone at work/at study, I do not give that person praise that they would have actually TPA-OD deserved 35 When someone gives a kind comment to me, I am convinced that person just wants to be nice TPA-SD 36 If a friend has disappointed me, I wait until he/she makes the ﬁrst step toward me before getting back to him/her TPA-OD Both studies used German versions of the Test of Passive Aggression. SD, self-directed aggression; OD, other-directed aggression. * inverse formulation. Frontiers in Psychology | www.frontiersin.org 4 April 2021 | Volume 12 | Article 579183 Schanz et al. The Test of Passive Aggression TABLE 2 | Descriptive sample characteristics Study 1. Statistical Analysis Exploratory Structural Equation Modeling (ESEM) was M1 M2 performed using R (Gascon et al., 2013) and the psych package (Revelle, 2015). All remaining statistical analyses were conducted Female 70.7% 68.0% using IBM SPSS Statistics version 25 (IBM Corp, 2017). Age mean 53.21 years 53.25 years Age SD 7.86 7.68 Item Reduction Age range 20–74 years 20–72 years As also indicated in the preregistration, Study 1 aimed to reduce Adjustment disorders 39.60% 40.80% items per scale to 12 for optimizing scales economy for use Mood disorders 29.35% 31.61% in clinical settings. For both subscales, item reduction followed Somatoform disorders 17.41% 15.52% a three-step procedure. First, all items with an item diﬃculty Anxiety disorders 9.56% 10.35% below 0.20 and above 0.80 were eliminated. Items severity was Comorbidity rate 48.50% 46.10% calculated by dividing the mean value per item by the maximum Total N = 307; Total N = 180. SD, Standard Deviation. Psychological M1 M2 value per item (i.e., lower values represent higher item diﬃculty). diagnoses according to ICD-10. Comorbidity rate indicates the rate of at least one Second, all items with an inter-item correlation below 0.30 were comorbid diagnosis. removed. Third, a primary axis factoring was conducted. The primary axis factoring was used for item reduction in order to choose the most representing items of each scale (i.e., items with the highest loading on the one factor solution). Subsequently, (www.drks.de, ID: DRKS00014002), an online platform for the bi-factorial structure of the reﬁned TPA was analyzed using preregistration of clinical studies. ESEM (see below). Factorial Validity Measures The model-ﬁt of the reﬁned bi-factorial solution was analyzed using ESEM, which combines exploratory factor analysis with The 36-item version of the TPA was used as a self-report assessment of passive-aggressive behavior. This TPA version the assessment of model ﬁt using structural equation modeling (SEM; Revelle, 2015). ESEM was found to be more appropriate consisted of 18 items for the assessment of self-directed passive- aggressive behavior and 18 items for the assessment of other- than SEM for analyzing psychological instruments (Marsh et al., 2010, 2014). With respect to the current study, it is of particular directed passive-aggressive behavior. Therefore, a bi-factorial structure—with one factor representing self-directed passive- importance that ESEM does not require zero cross-loadings, as aggressive behavior and the other factor representing other- other-directed and self-directed aggressive behavior are known directed passive-aggressive behavior—was assumed. to be strongly related (O’Donnell et al., 2015). All analyses The Beck Depression Inventory–II (BDI-II) assessed the used minimum residual estimations with pairwise exclusion and severity of depressive symptoms according to the Diagnostic and oblimin rotation. As the primary measures provided by the psych Statistical Manual of Mental Disorders-IV (DSM-IV; American package, Chi-square-df-ratio (good ﬁt < 2), Root Mean Square Psychiatric Association, 1994; Beck et al., 1996; Hautzinger et al., of the Residuals (RMSR, good ﬁt > 0.05), and ﬁt based upon oﬀ 2009). Each of the 21 items is rated on a 0 to 3 scale, with higher diagonal values (ﬁt.oﬀ, good ﬁt > 0.95) were used as ﬁt indices (Hu and Bentler, 1999). Models were estimated for M1 and M2. scores indicating more severe depressive symptoms. The BDI- II is a well-established measure of depression with acceptable Internal Consistency and Item-Total Correlation to excellent retest-reliability (r = 0.73 to 0.96; Wang and tt Gorenstein, 2013) and high validity (Hautzinger et al., 2009). Internal consistency was calculated using Cronbach’s alpha (α; The Beck Anxiety Inventory (BAI) is a screening instrument Cronbach, 1951) and McDonald’s omega (ω; McDonald, 1999). to assess anxiety symptoms (Beck and Steer, 1993; Margraf and According to Mallery and George (2003), internal consistencies Ehlers, 2002). It consists of 21 items, rated on a 0 to 3 scale, with were interpreted as follows: >0.90 = excellent; >0.80 = good; >0.70 = acceptable; >0.60 = questionable; >0.50 = poor; and higher scores indicating more severe levels of anxiety. Whereas, the BAI shows excellent internal consistency (α = 0.91) and high <0.50 = inacceptable. Internal consistencies as well as item-total correlations were analyzed for both points of assessment. validity, its retest-reliability is acceptable (r = 0.78; Geissner and tt Huetteroth, 2018). Association Between Passive-Aggressive Behavior and The Hamburg Modules for the Assessment of Psychosocial Health in Clinical Practice (HEALTH-49; Rabung et al., 2007) Symptom Clusters assesses nine mental health-related subscales [somatoform Bivariate associations between passive-aggressive behavior and complaints (SOM), depressiveness (DEP), phobic anxiety (PHO), psychopathological symptom severity (BDI-II, BAI, SOM, DEP, psychological well-being, interactional problems, self-eﬃcacy, PHO, and GSI) were analyzed using Pearson correlations. activity and participation, social support, and social stress]. The Given the strong correlation between depressive symptoms, scores of SOM (α = 0.82), DEP (α = 0.88), and PHO (α = 0.82– somatoform symptoms, and anxiety symptoms (Rabung et al., 86) can be combined to a global symptom severity index (GSI, α 2009), two multiple regression analyses were conducted to assess = 0.89; Rabung et al., 2009). the incremental proportion of variance of passive-aggressive Frontiers in Psychology | www.frontiersin.org 5 April 2021 | Volume 12 | Article 579183 Schanz et al. The Test of Passive Aggression TABLE 3 | Model ﬁt of ESEM. TABLE 4 | Bivariate correlations of both TPA scales and symptom severities. RMSR Fit.off Chi-square Chi-square-df-ratio TPA-OD TPA-SD M1 0.05 0.96 452.83 1.98 HEALTH-49-GSI 0.19* 0.39** M2 0.06 0.96 372.09 2.46 HEALTH-49-DEP 0.15* 0.39** HEALTH-49-SOM 0.14* 0.34** RMSR, Root Mean Square of the Residuals; Fit.off, Fit based upon of diagonal values. HEALTH-49-PHO 0.17* 0.26** BDI-II 0.14* 0.40** BAI 0.09 0.39** behavior explained by each symptom domain (SOM, DEP, and PHO), under mutual control for the other symptom domains. HEALTH-49, The Hamburg Modules for the Assessment of Psychosocial Health in Clinical Practice; GSI, general symptom index; SOM, somatoform complaints; DEP, Thereby, we aimed at investigating the unique association depressiveness, PHO, phobic anxiety; BDI-II, Beck-Depression Inventory–II; BAI, Beck- between depressive symptoms and passive-aggressive behavior Anxiety Inventory. *p < 0.05; **p < 0.001. irrespective of general psychopathology. Results of Study 1 TABLE 5 | Multiple regression for prediction of TPA-SD. Item Reduction Beta T p One item of the TPA-OD was removed due to an item diﬃculty below 0.20 (item 27). Another ﬁve items were removed since all HEALTH-49-DEP 0.27 3.79 <0.001 inter-item correlations fell below 0.30 (items 6, 7, 24, 25, 26). HEALTH-49-SOM 0.17 2.46 0.014 All remaining items demonstrated factor loadings above 0.30 on HEALTH-49-PHO 0.05 0.41 0.679 the one-factor solution of a principal axis factoring. All items Criterium is the self-directed passive-aggression scale of the TPA. HEALTH-49, The of the TPA-SD showed an item diﬃculty above 0.20 and below Hamburg Modules for the Assessment of Psychosocial Health in Clinical Practice; GSI, 0.80. Four items were removed since all inter-item correlations general symptom index; SOM, somatoform complaints; DEP, depressiveness, PHO, were below 0.30 (items 1, 8, 21, 31). All remaining items showed phobic anxiety. Model: F = 19.01; R = 0.17; p < 0.001. (3,280) factor loadings above 0.30 on the one-factor solution of a primary axis factoring. In order to reduce the number of items to 12, the two items exhibiting the lowest factor loading were removed TABLE 6 | Multiple regression for prediction of TPA-OD. (items 4, 28). Beta T p Model-Fit of the Two-Factor Solution HEALTH-49-DEP 0.06 0.78 0.439 Fit indices of both measure points are presented in Table 3. HEALTH-49-SOM 0.05 0.70 0.485 Overall, ESEM revealed an acceptable to good model ﬁt for the HEALTH-49-PHO 0.12 1.68 0.094 bi-factor solution of the reﬁned TPA. Factor loadings of all items on the respective factor ranged between 0.45 and 0.69 at M1 Criterium is the other-directed passive-aggression scale of the TPA. HEALTH-49, The Hamburg Modules for the Assessment of Psychosocial Health in Clinical Practice; GSI, and between 0.38 and 0.77 at M2. The correlation between TPA- general symptom index; SOM, somatoform complaints; DEP, depressiveness; PHO, SD and TPA-OD was strong at M1 (r = 0.52) and medium phobic anxiety. Model: F = 3.44; R = 0.04; p = 0.017. (3,280) at M2 (r = 0.38). Internal Consistency and Item-Total Correlation for the prediction of self-directed and other-directed passive- Internal consistencies were good at M1 (α = 0.83; other−directed aggressive behavior based on depressive, phobic, and somatic ω = 0.83; α = 0.84; ω = 0.85) other−directed self−directed other−directed symptoms are presented in Tables 5, 6. In line with self- and M2 (α = 0.86; ω = 0.86; α other−directed other−directed self−directed control theory of depression, self-directed passive-aggressive = 0.89; ω = 0.89). Item-total correlations at M1 self−directed behavior demonstrated a particularly strong unique association ranged between 0.40 and 0.61 for the TPA-OD and the TPA-SD. with depressive symptoms. By contrast, for none of the Similarly, at M2 item-total correlations ranged from 0.36 to 0.66 symptom domains a unique association with other-directed for the TPA-OD and from 0.38 to 0.73 for the TPA-SD. Further passive-aggressive behavior was detected. item characteristics are presented as Supplementary Material B. Association Between Passive-Aggressive Behavior Discussion of Study 1 and Symptom Clusters In Study 1, the 36-items version of the TPA was evaluated Bivariate correlations between both TPA scales and and reduced to its ﬁnal 24-items form. Applying ESEM, we psychopathological symptom levels are presented in Table 4. conﬁrmed the bi-factorial structure of the TPA, consisting of In line with our hypotheses, both self-directed and other- TPA-SD and TPA-OD. Additionally, Study 1 veriﬁed good directed passive-aggressive behavior were associated with all internal consistencies for both scales. symptom domains. However, an association of other-directed Study 1 also revealed small to moderate associations passive-aggressive behavior with anxiety levels was represented between passive-aggressive behavior and psychopathological in the BAI only. Results of the multiple regression analyses symptom severity in a clinical inpatient sample. Other-directed Frontiers in Psychology | www.frontiersin.org 6 April 2021 | Volume 12 | Article 579183 Schanz et al. The Test of Passive Aggression TABLE 7 | Descriptive sample characteristics Study 2. passive-aggression was associated with global psychopathological symptom severity, but not with speciﬁc symptom domains. These M1 M2 M3 results are in line with previous research showing that active other-directed aggressive behavior (Genovese et al., 2017) as well N 180 140 133 as passive-aggressive personality (Laverdière et al., 2019) and Women 75.6% 77.1% 77.4% passive-aggressive defense style (Bond, 2004) are relevant in a Age mean 21.55 years 21.64 years 21.53 years broad range of mental disorders. Thus, other-directed passive- Interval to M1 mean – 12.44 days 26.90 days aggressive behavior might represent a reaction to general mental Interval to M1 range – 7–20 days 21–34 days distress. This view also contributed to the removal of passive- Age range for all measure points was 18–32 years. aggressive personality disorder from DSM-5 (Wetzler and Jose, 2012). By contrast, in addition to its association with global psychopathological symptom burden, self-directed passive- measures (Beck and Steer, 1993; Beck et al., 1996; Rabung aggressive behavior exhibited speciﬁc unique associations et al., 2007), psychiatric diagnoses were based on unstructured with depressive and somatoform symptoms. In bivariate and clinical interviews known to be less accurate than structured interviews (Miller et al., 2001). Therefore, our main analyses multivariate analyses, depressive symptoms were the numerically strongest correlates for self-directed passive-aggressive behavior. regarding associations between self-reported passive-aggressive The association of self-directed passive-aggressive behavior behavior and symptom clusters were based on regression models and depressive symptoms is in line with the self-control relying on standardized measures instead of group comparisons. theory postulating that dysfunctional self-monitoring and self- Future studies in clinical samples should use structured clinical evaluation processes in depressed patients lead to a lack of interviews to enable valid analyses of group diﬀerences of self-reinforcing behavior (i.e., self-harm by omission; Fuchs and passive-aggressive behavior. Rehm, 1977; Rehm, 1977; Rozensky et al., 1977; Roth and Rehm, 1980). Furthermore, this association corresponds to previous STUDY 2 research on active aggressive behavior indicating that both forms of self-directed aggressive behavior are strongly related Study 1 resulted in the ﬁnal 24-item version of the TPA and to depression severity (Hawton et al., 2013; Plener et al., 2015; demonstrated its factorial validity and internal consistency. Harford et al., 2018). However, data on test-retest reliability and construct validity Like depressive symptoms, somatoform symptoms explained were still missing. Therefore, Study 2 aimed at closing this gap. an incremental proportion of variance in self-directed passive- aggressive behavior. Correspondingly, former research found Materials and Methods of Study 2 high rates of comorbidity between somatoform disorders and Participants and Procedure passive-aggressive personality disorder (Bass and Murphy, 1995; Participants of Study 2 were adult (age≥ 18 years) undergraduate Noyes et al., 2001). Since associations between somatization students, recruited in psychology lectures at Saarland University. and self-directed passive-aggressive behavior have not yet been Participants received course credits for their participation. After examined in previous research, our result needs to be replicated given written informed consent in line with the Declaration of in further studies. Helsinki (World Medical Association, 2013), data was collected using the online survey platform SoSci Survey (Leiner, 2014). Limitations To assess the test-retest-reliability of the TPA, participants The following limitations have to be taken into account: received survey links at three 14-day intervals via email. In contrast to internal consistency, methods of Study 1 Additionally, participants completed German versions of the did not allow a valid examination of retest-reliability. The Short Questionnaire for the Assessment of Components of analysis of retest-reliability would have required a time Aggression [K-FAF, Heubrock and Petermann (2008)], the NEO interval, in which the concept of interest is supposed to Five Factor Inventory [NEO-FFI, Borkenau and Ostendorf be relatively stable. However, patients of Study 1 received a (1994), Costa and McCrae (1989)], and the short version of multidisciplinary intervention, including psychotherapeutic and the Barratt Impulsiveness Scale [BIS-15, Meule et al. (2011)] psychopharmacological treatment, and therefore interventions at the ﬁrst point of assessment (M1). See Table 7 for sample suﬃcient to change levels of aggressive behavior (Jones R. M. characteristics. Study 2 was also preregistered at the German et al., 2011; Karakurt et al., 2016; Kothgassner et al., 2020). Clinical Trials Register (www.drks.de, ID: DRKS00014607). Thus, there is the need of another study to further examine the Measures retest-reliability of the TPA in a non-clinical context. Given that, an additional assessment of other constructs (e.g., Self-directed and other-directed passive-aggressive behavior were active aggression, impulsivity) would have exceeded capacities of assessed using the 24-item version of the TPA (see Study 1). clinical staﬀ, we were also not able to assess construct validity in The K-FAF includes 49 items assessing aggression on Study 1. ﬁve dimensions (spontaneous aggression, reactive aggression, Another limitation refers to the diagnostic process in Study irritability, auto-aggression, aggression inhibition; Heubrock and 1. Whereas, symptom severity was assessed using standardized Petermann, 2008). The K-FAF was chosen because its scales Frontiers in Psychology | www.frontiersin.org 7 April 2021 | Volume 12 | Article 579183 Schanz et al. The Test of Passive Aggression TABLE 8 | Retest-reliability of the TPA scales. allow for an economic assessment of self- and other-directed aggression. However, the internal consistencies of the K-FAF M1 M2 M3 scales are only poor (aggression inhibition; α = 0.55) to good (irritability; α = 0.84). We hypothesized that convergent validity a c M1 – 0.86 0.86 of the TPA-OD should be reﬂected in at least medium-sized b e M2 0.84 – 0.91 relationships between the TPA-OD and the active aggression c d M3 0.86 0.90 – scales of the K-FAF (i.e., spontaneous and reactive aggression). Correlations above the diagonal are retest-reliabilities for the self-directed passive- Self-directed passive-aggressive behavior is supposed to result aggressive behavior scale. Correlations beneath the diagonal are retest-reliabilities for from negative self-monitoring and self-evaluation processes a b c the other-directed passive-aggressive behavior scale. n = 140, n = 139, n = 133, d e in depression (Rehm, 1977). Therefore, it should be closely n = 120, n = 119. related to self-conscious emotions (Laye-Gindhu and Schonert- Reichl, 2005), self-reproach (Jinting and Hairong, 2019), and TABLE 9 | Internal consistencies of the TPA scales. self-criticism (Gilbert et al., 2010). The auto-aggression scale of the K-FAF comprises these aspects. Thus, we expected the M1 M2 M3 TPA-SD and the auto-aggression scale to show an at least α ω α ω α ω medium-sized correlation. The NEO-FFI is a short version of the Revised NEO a a b b c c Self-directed 0.85 0.85 0.87 0.87 0.90 0.90 Personality Inventory (Costa and Mac Crae, 1992) and a a b b c c Other-directed 0.84 0.84 0.87 0.89 0.89 0.89 assesses ﬁve personality traits (openness, conscientiousness, a b extraversion, agreeableness, neuroticism) using 60 items (Costa Coefﬁcients are internal consistencies for each measure point. n = 180, n = 139, n = 133. and McCrae, 1989; Borkenau and Ostendorf, 1994). The NEO-FFI is a well-established and widely used instrument in research on the relationship between personality traits and aggressive behavior (Burton et al., 2007; Grumm and small correlation between the TPA scales and the BIS-15 as von Collani, 2009; Carvalho and Nobre, 2019). The internal further support of discriminant validity. consistencies of its scales are questionable (openness; α = Data Analysis 0.61 to 0.71) to good (neuroticism, α =0.81 to 0.85). Given All analyses were performed using IBM SPSS Statistics 25 (IBM that other-directed passive-aggressive behavior has been Corp, 2017). For the evaluation of test-retest-reliability, Pearson shown to be associated with interpersonal conﬂicts (Laverdière correlations for both TPA scales were calculated for all points of et al., 2019), convergent validity of the TPA-OD would be reﬂected in an at least medium-sized negative correlation assessment. Internal consistencies were analyzed for all measure points using α (Cronbach, 1951) and ω (McDonald, 1999). As with agreeableness (Jones S. E. et al., 2011). Neuroticism in Study 1, internal consistencies were interpreted as follows: is related to lower levels of internal control, self-esteem, >0.90 = excellent; >0.80 = good; >0.70 = acceptable; >0.60 = and general self-eﬃcacy (Judge et al., 2002). Thereby, it questionable; >0.50 = poor; and <0.50 = inacceptable (Mallery reﬂects one facet of self-evaluation (Chang et al., 2012). and George, 2003). To evaluate construct validity Pearson Thus, we expected an at least medium-sized relationship correlations were calculated for both TPA scales with the BIS-15 between neuroticism and TPA-SD to evidence convergent and the subscales of the K-FAF and the NEO-FFI. validity (Brown, 2009). Since conscientiousness is closely related to delayed gratiﬁcation (a construct that needs to be distinguished from self-directed passive-aggression; Results of Study 2 Furnham and Cheng, 2019), an at the most small correlation Reliability between conscientiousness and TPA-SD should reﬂect its For both TPA scales retest-reliabilities were good to excellent (see discriminant validity. Table 8). The internal consistencies of TPA-OD were good and The BIS-15 is a short version of the Barratt Impulsiveness the TPA-SD showed good to excellent internal consistencies (see Scale−11 (Patton et al., 1995; Preuss et al., 2008), the standard Table 9). assessment of impulsivity (Stanford et al., 2009). Its economic 15-item version showed good reliability (α = 0.81; Meule et al., Validity 2011). Impulsivity, a predisposition for rash and spontaneous Bivariate correlations between the TPA scales, the BIS-15, the behavior, is a strong predictor for active other-directed (Bresin, subscales of the NEO-FFI, and the K-FAF are presented in 2019) and self-directed (Gvion and Apter, 2011; Hamza Table 10. Construct validity of the TPA-OD was supported et al., 2015) aggressive behavior. By contrast, passive-aggressive by signiﬁcant medium to large correlations with spontaneous behavior is supposed to harm by omission and should thus aggression and reactive aggression as well as a negative medium be explicitly characterized by a lack of impulsive action (Buss, correlation with agreeableness. Discriminant validity of the 1961; Parrott and Giancola, 2007). However, given passive- TPA-OD was conﬁrmed by a non-signiﬁcant association with aggressive behavior is also positively associated with active impulsiveness. Furthermore, construct validity of the TPA- aggressive behavior, we expected passive-aggressive behavior to SD was supported by large signiﬁcant correlations with auto- be independent from impulsiveness, reﬂected in an at the most aggression and neuroticism. Moreover, discriminant validity of Frontiers in Psychology | www.frontiersin.org 8 April 2021 | Volume 12 | Article 579183 Schanz et al. The Test of Passive Aggression TABLE 10 | Construct validity of the TPA scales. TABLE 11 | Examples for retest-reliabilities and internal consistencies of aggression questionnaires. Other-Directed Self-Directed r (interval) α tt K-FAF TPA other-directed 0.86 (26.90 days) 0.83–0.89 Spontaneous aggression 0.42** 0.22** TPA self-directed 0.86 (26.90 days) 0.84–0.90 Reactive aggression 0.54** 0.21** AQ (Herzberg, 2003) 0.69–0.81 (31 days) 0.65–0.88 Irritability 0.38** 0.21** STAXI-2 AX-O (Rohrmann et al., 0.81 (6 weeks) 0.86 Auto-Aggression 0.27** 0.66** 2013) Aggression inhibition −0.10 0.16* STAXI-2 AX-I (Rohrmann et al., 0.80 (6 weeks) 0.81 NEO-FFI 2013) Openness −0.11 0.07 K-FAF spontaneous aggression – 0.77 Conscientiousness 0.03 0.13 (Heubrock and Petermann, Extraversion −0.23** −0.47** 2008) Agreeableness −0.43** −0.14 K-FAF reactive aggression – 0.77 (Heubrock and Petermann, Neuroticism 0.25** 0.58** 2008) BIS-15 0.13 0.03 K-FAF auto-aggression – 0.82 K-FAF, Kurzfragebogen zur Erfassung von Aggressivitätsfaktoren (short questionnaire for (Heubrock and Petermann, the assessment of components of aggression); NEO-FFI, NEO Five Factor Inventory; 2008) BIS-15, Barratt Impulsiveness Scale–Short Version. *p < 0.05, **p < 0.01. a DSHI (Gratz, 2001) 0.68 (3.3 weeks) 0.82 SIQ (Santa Mina et al., 2006) 0.88 (2 weeks) 0.83 AQ, Buss and Perry Aggression Questionnaire; STAXi-2, State-Trait-Anger-Expression the TPA-SD was conﬁrmed by non-signiﬁcant associations with Inventory-2; K-FAF, Kurzfragebogen zur Erfassung von Aggressivitätsfaktoren (short impulsiveness and conscientiousness. questionnaire for the assessment of components of aggression); DSHI, Deliberate Self- Harm Inventory; SIQ, Self-Injury Questionnaire; Φ. Discussion of Study 2 Study 2 revealed high correlations between passive-aggressive interpersonal conﬂicts (McCann, 1988). Therefore, the negative behavior and active aggression, neuroticism, and agreeableness association between TPA-OD and agreeableness is in line with (inverse) as well as small insigniﬁcant correlations between theoretical considerations. The same applies to the relationship passive-aggressive behavior and impulsivity and consciousness, between TPA-SD and neuroticism that supports the notion that thereby demonstrating convergent and discriminant validity of self-directed passive-aggressive behavior might be driven by both the TPA-OD and TPA-SD scale. dysfunctional self-evaluation (Rehm, 1977; Chang et al., 2012). As aggression is supposed to represent a trait-like behavioral A lack of self-reinforcement could not only represent a form tendency, which should remain stable over time (Huesmann of self-directed aggressive behavior but also the capability for et al., 2009), substantial retest-reliability is of critical relevance for delayed gratiﬁcation, which is associated with consciousness its assessment. Both the TPA-OD and the TPA-SD scale showed (Furnham and Cheng, 2019). Therefore, given that it is essential good to excellent retest-reliabilities over a period of ∼4 weeks. to aggressive behavior that it is committed with intention (Allen Moreover, both TPA scales showed good to excellent internal and Anderson, 2017), our ﬁnding of a small and insigniﬁcant consistencies. Compared to well-established scales assessing association between the TPA-SD and consciousness supports the active aggressive behavior, the TPA exhibits comparable or even discriminant validity of the scale. higher reliability (see Table 11). Convergent validity of the TPA was supported by medium Limitations to high correlations between the corresponding TPA and K- In contrast to Study 1, Study 2 allowed for the analysis of test- FAF scales, which are well-established assessments of aggressive retest reliability and construct validity of the TPA by the use behavior. These associations underline the notion that passive- of a student sample. However, ﬁndings on the transferability of aggressive behavior represents a form of aggressive behavior, even results from student samples to clinical samples or the general though it is characterized by the absence of active behavioral population are mixed (Henry, 2008; Boals et al., 2020). Therefore, engagement. Furthermore, in contrast to active aggressive future studies should examine the test-retest-reliability and behavior (Bresin, 2019), the TPA scales were not signiﬁcantly construct validity of the TPA in a waiting list sample. correlated with impulsivity. This result provides further evidence for an increment of the assessment of passive-aggressive behavior above the general assessment of aggressive behavior. GENERAL DISCUSSION According to the DSM-IV, individuals with passive- aggressive personality disorder are supposed to let others Study 1 and Study 2 showed that the TPA is a reliable and down, provide less social support, and be not trustworthy valid assessment of other-directed and self-directed passive- (American Psychiatric Association, 1994). These behavioral aggressive behavior. In contrast to previous scales for the tendencies are assumed to lay the foundation for high rates of assessment of other-directed passive-aggressive behavior that Frontiers in Psychology | www.frontiersin.org 9 April 2021 | Volume 12 | Article 579183 Schanz et al. The Test of Passive Aggression were mostly targeting broader nosological categories, e.g., indicates that passive-aggressive behavior occurs independently passive-aggressive personality disorder, the TPA-OD scale does from impulsiveness. Self-directed passive-aggressive behavior not assess personality traits (e.g., hostility) or emotions (e.g., is signiﬁcantly associated with depressive and somatoform feelings of anger) but passive-aggressive behavior directly. This is symptoms. Future studies should assess both active- and passive- a major advantage for investigating precursors and consequences aggressive behavior in clinical samples to provide further insights of other-directed passive-aggressive behavior because it helps into the relationships between aggressive behavior, intra- and to minimize confounders. For example, when investigating interpersonal conﬂicts, and psychopathological symptoms. the association between psychopathological symptoms and aggressive behavior, emotional confounders like anger or sadness DATA AVAILABILITY STATEMENT are particularly relevant. Therefore, future studies should make use of this advantage of the TPA and investigate which (internal The raw data supporting the conclusions of this article will be or external) variables predict other-directed passive-aggressive made available by the authors, without undue reservation. behavior and to what extent other-directed passive-aggressive behavior has a predictive value for the development and course ETHICS STATEMENT of mental disorders. Moreover, in contrast to previous assessments of passive- The studies involving human participants were reviewed and aggressive behavior, the TPA is the ﬁrst to include an assessment approved by the ethics comitee of the Saarland University. The of self-directed passive-aggressive behavior, which may be of patients/participants provided their written informed consent to major relevance in the context of depressive disorders (Rehm, participate in this study. 1977). The unique association of self-directed passive-aggressive behavior with depressive symptoms in Study 1 provided ﬁrst AUTHOR CONTRIBUTIONS evidence for this notion. Future clinical studies should investigate the longitudinal relationship between self-directed passive- CS designed the study, organized sample recruitment, analyzed aggressive behavior and depressive symptoms. These studies and interpreted the data, drafted the article, and prepared the should also use structured clinical interviews to examine if self- ﬁnal manuscript. MK helped to design the study and contributed directed passive-aggressive behavior occurs more frequently in to sample recruitment. TM, ME, SS, and HM contributed to depressive disorders than in other mental disorders. conception and design of the study, supported the interpretation As outlined in the introduction, passive-aggressive behavior of the data, and commented on manuscript drafts. All authors is one dimension of the broader construct of aggressive read and approved the ﬁnal manuscript. behavior. Therefore, one might expect that many of the general assumptions on aggression also apply to passive-aggressive ACKNOWLEDGMENTS behavior (e.g., its emotional and cognitive precursors or its stability over the life course). Nevertheless, future studies We gratefully thank the staﬀ of the Clinic for Psychosomatic need to test this hypothesis by investigating which personal Medicine of the MediClin Bliestal-Clinics, Blieskastel. We thank and/or situational factors contribute to diﬀerent expressions of all therapists for their support in carrying out this study. We aggressive behavior. In this context, Study 2 provided ﬁrst insight thank our students Lisa Ludwig and Sören Samadi for their by demonstrating passive-aggressive behavior to be independent support in the course of data collection. from impulsivity. SUPPLEMENTARY MATERIAL CONCLUSION The Supplementary Material for this article can be found The TPA is a reliable and valid self-report instrument for online at: https://www.frontiersin.org/articles/10.3389/fpsyg. the assessment of other-directed and self-directed passive- 2021.579183/full#supplementary-material aggressive behavior. The current study indicates a substantial Data Sheet 1 | Supplementary Material A and B. overlap between passive- and active-aggressive behavior, but it REFERENCES American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders. 5th Edn. American Psychiatric Association. Allen, J. J., and Anderson, C. A. (2017). “Aggression and violence: doi: 10.1176/appi.books.9780890425596 deﬁnitions and distinctions,” in The Wiley Handbook of Andrews, G., Singh, M., and Bond, M. (1993). The defense style questionnaire. J. Violence and Aggression, 1–14. doi: 10.1002/9781119057574.whb Nerv. Ment. 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Defense mechanism open-access article distributed under the terms of the Creative Commons Attribution diﬀerences between younger and older adults: a cross-sectional investigation. License (CC BY). The use, distribution or reproduction in other forums is permitted, Aging Ment. Health 11, 415–422. doi: 10.1080/13607860600963588 provided the original author(s) and the copyright owner(s) are credited and that the Stanford, M. S., Mathias, C. W., Dougherty, D. M., Lake, S. L., Anderson, N. E., and original publication in this journal is cited, in accordance with accepted academic Patton, J. H. (2009). Fifty years of the barratt impulsiveness scale: an update and practice. No use, distribution or reproduction is permitted which does not comply review. Pers. Individ. Dif. 47, 385–395. doi: 10.1016/j.paid.2009.04.008 with these terms. Frontiers in Psychology | www.frontiersin.org 13 April 2021 | Volume 12 | Article 579183
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