Comprehensive Psychiatry (Official Journal of the American Psychopathological Association)
VOL. 31, NO. 6
NOVEMBER/DECEMBER
Correlates of DSM-III Personality Disorder Obsessive-Compulsive Disorder Matig Mavissakalian,
1990
in
Mary Sue Hamann, and Bruce Jones
Forty-three patients with primary obsessive-compulsive disorder (OCD) completed the Personality Diagnostic Questionnaire (PDQ), a self-rating scale designed to assess axis II personality disorders (PD) from DSM-III. Results showed that 53% of the patients received at least one PD diagnosis. The most frequent diagnoses were avoidant (30%), histrionic (26%). dependent (19%). and schizotypal (16%). Consideration of the personality traits irrespective of diagnostic category showed that in addition to avoidant and dependent personality characteristics, the sample had strong passive aggressive and compulsive tendencies and substantial histrionic, paranoid, and schizotypal traits. Patients exhibiting a greater number of personality traits were also significantly more symptomatic. However, anxiety, phobic, and obsessive-compulsive symptoms were not selected as unique predictors of any personality variables in the regression analyses. Rather, the most important correlate of PD in these patients consisted of dysphoric mood as assessed by the Beck Depression Inventory (BDI) and, to a lesser degree, younger age or shorter duration of illness. These findings do not support a specific link between OCD and PD in general and compulsive PD in particular. 0 1990 by W. 6. Saunders Company.
HE RELATIONSHIP between personality disorder (PD) and neurosis in general, and obsessive-compulsive disorder (OCD) in particular, is not well understood. Even the link between obsessive-compulsive personality and OCD, the prime example of the traditional view that obsessional symptoms are manifestations of the basic “anal-erotic character”1-3 has been the focus of controversy for some time. In an earlier and excellent study of the premorbid personality of 47 obsessive-compulsive patients, Rosenberg4 found evidence of obsessive-compulsive personality in only 53% of the cases. The “immature” (primarily dependent) and schizoid personalities accounted for a further 30% of cases. That obsessivecompulsive personality can be statistically differentiated from OCD with the use of factor analysis5 further suggests that obsessive-compulsive personality, and by extension any PD, is neither necessary nor sufficient for the development of OCD. The adoption of a completely descriptive classification system by the Diagnostic and Statistical Manual of Mental Disorders (DSM-III)6 has encouraged studies of the relationship of axis I and axis II PDs without ascribing an underlying “genetic” meaning to the personality classes identified. In this report, we outline the
T
From the Department of Psychiatry, The Ohio State University, College of Medicine, Columbus, OH. Address reprint requests to Matig Mavissakalian. M.D., The Ohio State University, Department of Psychiatry, 473 W 12th Ave. Columbus, OH 43210. o 1990 by W.B. Saunders Company. OOIO-440X/90/3106-0008$03.00/0 Comprehensive
Psychiatry,
Vol. 3 1, No. 6 (November/December),
1990: pp 48 l-489
481
482
MAVISSAKALIAN,
HAMANN,
AND JONES
application of clinically relevant DSM-III axis II criteria to 43 OCD patients and discuss our findings in the context of recent explorations of DSM-III PDs in OCD patients. In addition, the present report explores the demographic, clinical, and phenomenological correlates of DSM-III PDs and seeks to delineate the relevant symptomatological variables, including anxiety, phobias, obsessions, compulsions, and depression; that correlate with or predict the personality profiles of patients suffering from primary OCD. METHOD Subjects The subjects were 43 consecutive referrals for clomipramine treatment who met DSM-III diagnostic criteria for OCD and who had a complete assessment data set. Demographically, the sample was 70% female, with a mean age of 34.8 (* 11.4) years (range, 19 to 61) and a duration of illness of 12.5 (k9.0) years (range, 2 to 30). The sample had a mean score of 8.3 (k4.6) on the 17 item Hamilton Depression Scale and only four (9%) patients met criteria for concurrent major depression.
Assessments The Personality Diagnostic Questionnaire (PDQ),7-9 as well as a battery of tests assessing anxiety, depression, and obsessive-compulsive symptoms, was administered. The procedure for administering and scoring the PDQ has been described in an earlier report.’ Briefly, the PDQ is a self-rating questionnaire of 162 true or false items, designed to assess the 11 personality disorders from axis II of the DSM-III (paranoid, schizoid, schizotypal, histrionic, narcissistic, antisocial, borderline, avoidant, dependent, compulsive, passive-aggressive). Three variables were derived: a diagnosis for each of the disorders, the presence or absence of each personality trait irrespective of diagnostic category, and a personality profile consisting of the percentage of endorsements of the items in each diagnostic category. Moreover, a personality trait score that was based on traits frequently encountered in the sample was developed. Patient-rated measures of obsessive-compulsive symptomatology reported herein are the ObsessiveCompulsive Neurotic Scale (OCNS),” the Maudsley Obsessional-Compulsive Scale (MOC),” with subfactors of checking, washing, slowness, doubting, and the Lynfield Obsessional-Compulsive Questionnaire (LYN).” Other patient-rated measures were the Fear Questionnaire (FQ),” with subfactors of agoraphobia (FQAG), blood-injury phobia (FQBI), social phobia (FQSOC), and an overall rating of phobic severity (SRS), the Beck Depression Inventory (BDI),14 the Zung Anxiety Scale (ZAS),” and a life events survey (PERI),16 which had measures of the number of events in the past year, the overall stress of the last year, the sum of the ratings for desirable events, and the sum of the ratings for undesirable events. Clinician-rated scales included the Yale-Brown Obsessive-compulsive Scale (YBOCS),” the Global Obsessive-compulsive Scale (GOC),‘* and the 17 item Hamilton Scale for Depression (HAMD).19
RESULTS Diagnoses Forty-six PD diagnoses were assigned and the frequency of each PD category is shown in Table 1. These diagnoses were distributed among 23 patients; thus slightly more than half (53%) of the patients received at least one PD diagnosis. Ten patients received a single diagnosis from the set of avoidant (four patients), dependent (three patients), histrionic (two patients), and paranoid (one patient). Six patients met diagnostic criteria for two disorders: histrionic and dependent in two cases, schizotypal and avoidant in two cases, histrionic and avoidant in one case, and histrionic and borderline in one case. Four patients received three diagnoses: schizotypal, antisocial, and avoidant; schizotypal, avoidant, and dependent; schizo-
PERSONALITY
DISORDER AND OCD
Table 1. Number
Disorder
and Percentage
No. (%) of Patients Meeting Diagnostic Criteria
Paranoid
3 17)
Schizoid
0
Schizotypal
7 (16)
Histrionic
11 (26)
Narcissistic
0
Borderline
2 (5)
Avoidant
13 (30)
Dependent
8 (19)
Compulsive
1 (2)
Passiveaggressive
0
483
of 43 OCD Patients Trait Axis II Criteria
Meeting
DSM-Ill
Major DSM-III Traits A. Suspiciousness and mistrust B. Hypersensitivity C. Restricted affectivity A. Emotional coldness B. Indifference to praise/criticism C. Few close friendships Al. Magical thinking A2. Ideas of reference A3. Social isolation A4. Recurrent illusions A5. Odd speech A6. Inadequate rapport A7. Suspiciousness A8. Undue social anxiety A. Dramatic behavior B. Disturbed relationships A. Self-importance B. Preoccupation with fantasies C. Exhibitionism D. Indifferent or angry responses E. Disturbed relationships Al. lmpulsivity or unpredictability A2. Unstable and intense relations A3. Intense or uncontrolled anger A4. Identity disturbance A5. Affective instability A6. Intolerance of being alone A7. Physically self-damaging acts A8. Feeling empty or bored A. Hypersensitivity to rejection B. Unwillingness to enter relationships C. Social withdrawal D. Desire for affection E. Low self-esteem A. Allows others responsibility B. Subordinates own needs C. Lacks self-confidence 1. Restricted emotional expression 2. Perfectionism 3. Insistence on own way 4. Excessive devotion to work 5. Indecisiveness A. Resistance to demands B. Indirect resistance C. Social and occupational ineffectiveness D. Persistence of behavior
Diagnostic
and
No. (%) of Patients Meeting Trait Criteria 21 (491 31 (72) 3 (7) 4 (9) o5 (12) o5 (12) 8 (19) o11 (26) 9 (21) 21 (49) 17 (40) 15 (35) 24 156) 6 (14) 10 (23) 6 (14) 2 (5) 10 (23) 11 (26) 1 (2) 19 (44) 3 (7) 27 (63) 11 (26) 1 (2) 24 (56) 37 (86) 23 (53) 22 (51) 42 (98) 42 (98) 22 (51) 17 (40) 30 (70) 2: 3 12 25 4 30 30 7
(49, (7) (28) (58) (9) (70) (70) (16)
484
MAVISSAKALIAN,
HAMANN,
AND JONES
typal, histrionic, and avoidant; and paranoid, histrionic, and compulsive. Finally, three patients met criteria for four disorders: paranoid, histrionic, avoidant and dependent; schizotypal, histrionic, avoidant and dependent; and schizotypal, histrionic, borderline, and avoidant. Traits We were also interested in the traits common to our sample, irrespective of diagnostic category. As can be seen in Table 1, the criteria for 20 traits were met by at least 33% of the patients. (Note that the criteria for paranoid-A are identical to those for schizotypal-A7 and this trait is counted only once.) These included all traits from the avoidant and dependent categories. Other frequently encountered traits were hypersensitivity from paranoid, disturbed relationships from histrionic, affective instability and feeling empty or bored from borderline, indirect resistance and occupational ineffectiveness from passive-aggressive and perfectionism (49%), and indecisiveness (58%) from compulsive. The remaining traits from the compulsive category were less frequent: excessive devotion to work (28%), insistence on own way (7%), and restricted emotional expression (0%). To measure the clinical significance of the traits, patients were grouped by trait score. Each patient was given a score from 0 to 20 for the presence of each of the 20 major traits. The mean trait score was 12.1, and the median was also 12. Thus, a low-trait group of 18 patients with scores of 11 or less and a high-trait group of 21 patients with scores of 13 or greater were formed. Those four patients with scores of 12 were not included in either group. Table 2 presents group differences in dependent measures and demographics. For those measures of obsessive-compulsive symptomatology, the high-trait group was more severe on the OCNS, YBOCSobsessive factor, and the GOC. The high-trait group was also significantly more severe on all other patient rated measures except the blood-injury factor of the FQ and the sum of the ratings of positive events on the PERI. Finally, there was a trend toward an age difference such that the low-trait group was older and had a significantly longer duration of illness than the high-trait group. Projile Many of our findings are represented graphically in Fig 1, which shows the personality profile derived by calculating the percentage of positive endorsements (from the total number of questions) within each personality category. The profile reflects the importance of avoidant, dependent, compulsive and to a lesser degree of paranoid, histrionic, and passive-aggressive features in this sample. Regression Analysis To examine the relationships between the personality variables and our other measures in greater detail, a series of stepwise regression analyses was performed (Table 3). The trait score was first regressed against the demographic and clinical variables; the duration of illness emerged as a significant negative correlate, indicating that high-trait scores were associated with short durations of illness. Next, the patient-rated measures of OCD symptomatology were treated as independent measures; the OCNS emerged as the only significant predictor. From the clinician-rated OCD measures, the YBOCS-obsessions factor was significant.
PERSONALITY DISORDER AND OCD
Table 2. Comparison
485 of Low- and High-Trait
Groups
Cell Means (SD) Low-Trait (n = 18) Demographic/clinical variables Age (vr) Sex (female) Age of onset Duration of illness Life events (past year) Overall stress ( l-5) No. of events Sum of positive ratings Sum of negative ratings Symptom rating scales OCD measures OCNS (25 100) MOC-Check (O-9) Wash (O- 11) Slow (O-7) Doubt (O-7) Lynfield-Resistance (20- 100) Interference (20- 100) Y-8OCS Obsessions (O-20) Compulsions (O-20) GOC (l-15) Phobic measures FGAG (O-40) FQBI (O-40) FQSOC (O-40) SRS (O-8) Anxiety measure ZAS (20-80) Depression measures 8DI (O-63) HAMD (O-50)
37.9 (13.6) 72% 20.2 (I 1 .O) 16.0 (9.6)
High-Trait (n = 21)
r (37)
P
1.84 -
3 1.4 (8.0) 62% 23.6 (8.8) 8.0 (5.6)
1.06 3.25
.07 NS NS
VOL. 31, NO. 6
NOVEMBER/DECEMBER
Correlates of DSM-III Personality Disorder Obsessive-Compulsive Disorder Matig Mavissakalian,
1990
in
Mary Sue Hamann, and Bruce Jones
Forty-three patients with primary obsessive-compulsive disorder (OCD) completed the Personality Diagnostic Questionnaire (PDQ), a self-rating scale designed to assess axis II personality disorders (PD) from DSM-III. Results showed that 53% of the patients received at least one PD diagnosis. The most frequent diagnoses were avoidant (30%), histrionic (26%). dependent (19%). and schizotypal (16%). Consideration of the personality traits irrespective of diagnostic category showed that in addition to avoidant and dependent personality characteristics, the sample had strong passive aggressive and compulsive tendencies and substantial histrionic, paranoid, and schizotypal traits. Patients exhibiting a greater number of personality traits were also significantly more symptomatic. However, anxiety, phobic, and obsessive-compulsive symptoms were not selected as unique predictors of any personality variables in the regression analyses. Rather, the most important correlate of PD in these patients consisted of dysphoric mood as assessed by the Beck Depression Inventory (BDI) and, to a lesser degree, younger age or shorter duration of illness. These findings do not support a specific link between OCD and PD in general and compulsive PD in particular. 0 1990 by W. 6. Saunders Company.
HE RELATIONSHIP between personality disorder (PD) and neurosis in general, and obsessive-compulsive disorder (OCD) in particular, is not well understood. Even the link between obsessive-compulsive personality and OCD, the prime example of the traditional view that obsessional symptoms are manifestations of the basic “anal-erotic character”1-3 has been the focus of controversy for some time. In an earlier and excellent study of the premorbid personality of 47 obsessive-compulsive patients, Rosenberg4 found evidence of obsessive-compulsive personality in only 53% of the cases. The “immature” (primarily dependent) and schizoid personalities accounted for a further 30% of cases. That obsessivecompulsive personality can be statistically differentiated from OCD with the use of factor analysis5 further suggests that obsessive-compulsive personality, and by extension any PD, is neither necessary nor sufficient for the development of OCD. The adoption of a completely descriptive classification system by the Diagnostic and Statistical Manual of Mental Disorders (DSM-III)6 has encouraged studies of the relationship of axis I and axis II PDs without ascribing an underlying “genetic” meaning to the personality classes identified. In this report, we outline the
T
From the Department of Psychiatry, The Ohio State University, College of Medicine, Columbus, OH. Address reprint requests to Matig Mavissakalian. M.D., The Ohio State University, Department of Psychiatry, 473 W 12th Ave. Columbus, OH 43210. o 1990 by W.B. Saunders Company. OOIO-440X/90/3106-0008$03.00/0 Comprehensive
Psychiatry,
Vol. 3 1, No. 6 (November/December),
1990: pp 48 l-489
481
482
MAVISSAKALIAN,
HAMANN,
AND JONES
application of clinically relevant DSM-III axis II criteria to 43 OCD patients and discuss our findings in the context of recent explorations of DSM-III PDs in OCD patients. In addition, the present report explores the demographic, clinical, and phenomenological correlates of DSM-III PDs and seeks to delineate the relevant symptomatological variables, including anxiety, phobias, obsessions, compulsions, and depression; that correlate with or predict the personality profiles of patients suffering from primary OCD. METHOD Subjects The subjects were 43 consecutive referrals for clomipramine treatment who met DSM-III diagnostic criteria for OCD and who had a complete assessment data set. Demographically, the sample was 70% female, with a mean age of 34.8 (* 11.4) years (range, 19 to 61) and a duration of illness of 12.5 (k9.0) years (range, 2 to 30). The sample had a mean score of 8.3 (k4.6) on the 17 item Hamilton Depression Scale and only four (9%) patients met criteria for concurrent major depression.
Assessments The Personality Diagnostic Questionnaire (PDQ),7-9 as well as a battery of tests assessing anxiety, depression, and obsessive-compulsive symptoms, was administered. The procedure for administering and scoring the PDQ has been described in an earlier report.’ Briefly, the PDQ is a self-rating questionnaire of 162 true or false items, designed to assess the 11 personality disorders from axis II of the DSM-III (paranoid, schizoid, schizotypal, histrionic, narcissistic, antisocial, borderline, avoidant, dependent, compulsive, passive-aggressive). Three variables were derived: a diagnosis for each of the disorders, the presence or absence of each personality trait irrespective of diagnostic category, and a personality profile consisting of the percentage of endorsements of the items in each diagnostic category. Moreover, a personality trait score that was based on traits frequently encountered in the sample was developed. Patient-rated measures of obsessive-compulsive symptomatology reported herein are the ObsessiveCompulsive Neurotic Scale (OCNS),” the Maudsley Obsessional-Compulsive Scale (MOC),” with subfactors of checking, washing, slowness, doubting, and the Lynfield Obsessional-Compulsive Questionnaire (LYN).” Other patient-rated measures were the Fear Questionnaire (FQ),” with subfactors of agoraphobia (FQAG), blood-injury phobia (FQBI), social phobia (FQSOC), and an overall rating of phobic severity (SRS), the Beck Depression Inventory (BDI),14 the Zung Anxiety Scale (ZAS),” and a life events survey (PERI),16 which had measures of the number of events in the past year, the overall stress of the last year, the sum of the ratings for desirable events, and the sum of the ratings for undesirable events. Clinician-rated scales included the Yale-Brown Obsessive-compulsive Scale (YBOCS),” the Global Obsessive-compulsive Scale (GOC),‘* and the 17 item Hamilton Scale for Depression (HAMD).19
RESULTS Diagnoses Forty-six PD diagnoses were assigned and the frequency of each PD category is shown in Table 1. These diagnoses were distributed among 23 patients; thus slightly more than half (53%) of the patients received at least one PD diagnosis. Ten patients received a single diagnosis from the set of avoidant (four patients), dependent (three patients), histrionic (two patients), and paranoid (one patient). Six patients met diagnostic criteria for two disorders: histrionic and dependent in two cases, schizotypal and avoidant in two cases, histrionic and avoidant in one case, and histrionic and borderline in one case. Four patients received three diagnoses: schizotypal, antisocial, and avoidant; schizotypal, avoidant, and dependent; schizo-
PERSONALITY
DISORDER AND OCD
Table 1. Number
Disorder
and Percentage
No. (%) of Patients Meeting Diagnostic Criteria
Paranoid
3 17)
Schizoid
0
Schizotypal
7 (16)
Histrionic
11 (26)
Narcissistic
0
Borderline
2 (5)
Avoidant
13 (30)
Dependent
8 (19)
Compulsive
1 (2)
Passiveaggressive
0
483
of 43 OCD Patients Trait Axis II Criteria
Meeting
DSM-Ill
Major DSM-III Traits A. Suspiciousness and mistrust B. Hypersensitivity C. Restricted affectivity A. Emotional coldness B. Indifference to praise/criticism C. Few close friendships Al. Magical thinking A2. Ideas of reference A3. Social isolation A4. Recurrent illusions A5. Odd speech A6. Inadequate rapport A7. Suspiciousness A8. Undue social anxiety A. Dramatic behavior B. Disturbed relationships A. Self-importance B. Preoccupation with fantasies C. Exhibitionism D. Indifferent or angry responses E. Disturbed relationships Al. lmpulsivity or unpredictability A2. Unstable and intense relations A3. Intense or uncontrolled anger A4. Identity disturbance A5. Affective instability A6. Intolerance of being alone A7. Physically self-damaging acts A8. Feeling empty or bored A. Hypersensitivity to rejection B. Unwillingness to enter relationships C. Social withdrawal D. Desire for affection E. Low self-esteem A. Allows others responsibility B. Subordinates own needs C. Lacks self-confidence 1. Restricted emotional expression 2. Perfectionism 3. Insistence on own way 4. Excessive devotion to work 5. Indecisiveness A. Resistance to demands B. Indirect resistance C. Social and occupational ineffectiveness D. Persistence of behavior
Diagnostic
and
No. (%) of Patients Meeting Trait Criteria 21 (491 31 (72) 3 (7) 4 (9) o5 (12) o5 (12) 8 (19) o11 (26) 9 (21) 21 (49) 17 (40) 15 (35) 24 156) 6 (14) 10 (23) 6 (14) 2 (5) 10 (23) 11 (26) 1 (2) 19 (44) 3 (7) 27 (63) 11 (26) 1 (2) 24 (56) 37 (86) 23 (53) 22 (51) 42 (98) 42 (98) 22 (51) 17 (40) 30 (70) 2: 3 12 25 4 30 30 7
(49, (7) (28) (58) (9) (70) (70) (16)
484
MAVISSAKALIAN,
HAMANN,
AND JONES
typal, histrionic, and avoidant; and paranoid, histrionic, and compulsive. Finally, three patients met criteria for four disorders: paranoid, histrionic, avoidant and dependent; schizotypal, histrionic, avoidant and dependent; and schizotypal, histrionic, borderline, and avoidant. Traits We were also interested in the traits common to our sample, irrespective of diagnostic category. As can be seen in Table 1, the criteria for 20 traits were met by at least 33% of the patients. (Note that the criteria for paranoid-A are identical to those for schizotypal-A7 and this trait is counted only once.) These included all traits from the avoidant and dependent categories. Other frequently encountered traits were hypersensitivity from paranoid, disturbed relationships from histrionic, affective instability and feeling empty or bored from borderline, indirect resistance and occupational ineffectiveness from passive-aggressive and perfectionism (49%), and indecisiveness (58%) from compulsive. The remaining traits from the compulsive category were less frequent: excessive devotion to work (28%), insistence on own way (7%), and restricted emotional expression (0%). To measure the clinical significance of the traits, patients were grouped by trait score. Each patient was given a score from 0 to 20 for the presence of each of the 20 major traits. The mean trait score was 12.1, and the median was also 12. Thus, a low-trait group of 18 patients with scores of 11 or less and a high-trait group of 21 patients with scores of 13 or greater were formed. Those four patients with scores of 12 were not included in either group. Table 2 presents group differences in dependent measures and demographics. For those measures of obsessive-compulsive symptomatology, the high-trait group was more severe on the OCNS, YBOCSobsessive factor, and the GOC. The high-trait group was also significantly more severe on all other patient rated measures except the blood-injury factor of the FQ and the sum of the ratings of positive events on the PERI. Finally, there was a trend toward an age difference such that the low-trait group was older and had a significantly longer duration of illness than the high-trait group. Projile Many of our findings are represented graphically in Fig 1, which shows the personality profile derived by calculating the percentage of positive endorsements (from the total number of questions) within each personality category. The profile reflects the importance of avoidant, dependent, compulsive and to a lesser degree of paranoid, histrionic, and passive-aggressive features in this sample. Regression Analysis To examine the relationships between the personality variables and our other measures in greater detail, a series of stepwise regression analyses was performed (Table 3). The trait score was first regressed against the demographic and clinical variables; the duration of illness emerged as a significant negative correlate, indicating that high-trait scores were associated with short durations of illness. Next, the patient-rated measures of OCD symptomatology were treated as independent measures; the OCNS emerged as the only significant predictor. From the clinician-rated OCD measures, the YBOCS-obsessions factor was significant.
PERSONALITY DISORDER AND OCD
Table 2. Comparison
485 of Low- and High-Trait
Groups
Cell Means (SD) Low-Trait (n = 18) Demographic/clinical variables Age (vr) Sex (female) Age of onset Duration of illness Life events (past year) Overall stress ( l-5) No. of events Sum of positive ratings Sum of negative ratings Symptom rating scales OCD measures OCNS (25 100) MOC-Check (O-9) Wash (O- 11) Slow (O-7) Doubt (O-7) Lynfield-Resistance (20- 100) Interference (20- 100) Y-8OCS Obsessions (O-20) Compulsions (O-20) GOC (l-15) Phobic measures FGAG (O-40) FQBI (O-40) FQSOC (O-40) SRS (O-8) Anxiety measure ZAS (20-80) Depression measures 8DI (O-63) HAMD (O-50)
37.9 (13.6) 72% 20.2 (I 1 .O) 16.0 (9.6)
High-Trait (n = 21)
r (37)
P
1.84 -
3 1.4 (8.0) 62% 23.6 (8.8) 8.0 (5.6)
1.06 3.25
.07 NS NS
