Standardized Assessment of Personality Disorders in Obsessive-Compulsive Disorder Lee Baer, PhD; Michael A. Jenike, MD; Joseph N. Ricciardi II, MEd; Amy D. Holland; Ralph J. William E. Minichiello, EdD; M. Lynn Buttolph, MD, PhD
Seymour;
\s=b\ We assessed 96 patients with obsessive-compulsive disorder for DSM-III personality disorder diagnoses with a standardized interview instrument (Structured Interview for the DSM-III Personality Disorders). Fifty patients (52%) met criteria for at least one personality disorder, with mixed, dependent, and histrionic personality disorders most frequently diagnosed. Compulsive personality disorder was diagnosed in only 6 patients (6%), 5 of whom had had onset of obsessive-compulsive symptoms before the age of 10 years, indicating that DSM-III compulsive personality disorder is not invariably a premorbid condition for the development of obsessive-compulsive disorder. Schizotypal personality disorder, at 5%, was found to be less common than in past samples, reflecting differences in either assessment meth-
relatives regarding the patients' premorbid personalities. Ten patients (32%) had "marked obsessional traits," and 4 (13%) had no obsessional traits. This study concluded that obsession¬ al personality and illness are intimately connected.8 It is likely that the number of patients without premorbid traits was underestimated because patients with an early onset of OCD were eliminated from analysis. Slade4 reviewed a number of psychometric studies of obses¬ sive patients and concluded otherwise: "The evidence pre¬ sented seems to support fairly strongly the distinction be¬ tween obsessional personality traits and obsessional neurosis." A more recent review of the literature led to the conclusion that obsessive-compulsive symptoms can be statistically dif¬ ferentiated via factor analysis from obsessive-compulsive symptoms as distinct phenomena, with obsessive-compulsive symptoms positively related to measures of neuroticism while
years have seen renewed interest in the prevalence of various personality disorders in obsessive-compulsive disorder (OCD). Among the reasons for this renewed interest is the suggestion that certain severe personality disorders (eg, schizotypal) may predict poor outcome to a variety of treat¬ ments. 12 In addition, as interest in the mechanisms and epide¬ miology of OCD has grown, the widely held belief that OCD is invariably related to obsessional personality (obsessive-com¬ pulsive personality disorder in DSM-III-R3) has been ques¬
that
ods or sampling. (Aren Gen Psychiatry. 1990;47:826-830)
Recent
tioned."
In the traditional psychoanalytic explanation of obsessional disorders, obsessional personality had been seen as a predis¬ posing feature of obsessional neurosis, with the two conditions existing side by side along a continuum.7 On this continuum (which is assumed to arise from conflicts over bowel training), individuals with obsessional personality (characterized by or¬ derliness, parsimoniousness, and obstinacy8) differ from those individuals with obsessive-compulsive symptoms (obsessions and compulsions) only in that they are nonsymptomatic.8 In an early report, Ingrani8 studied 31 inpatients with OCD by means of subjective descriptions by patients, clinicians, and
Accepted for publication August 7,1989. From the Massachusetts General Hospital
and Harvard Medical
Boston.
Reprint requests to WACC-717,
MA 02114 (Dr Baer).
Massachusetts General
School,
Hospital, Boston,
obsessive-compulsive personality was not.5 Pollack6 concluded although obsessive-compulsive personality has been re¬ ported to occur premorbidly, it is neither a necessary nor a sufficient factor for the development of OCD.
The studies reviewed above examined the obsessional per¬ sonality or anal-erotic character described by Freud.8 More recent studies, however, have investigated the DSM-III entity of compulsive personality disorder, which has been suggested to be "a much more pathological entity than the classical obsessive-compulsive character. "9 Schizotypal personality disorder, which, along with schizoid and paranoid personality disorders, forms cluster A of DSMIII-R personality disorders, has been reported to be geneti¬ cally related to schizophrenia.10,n In a retrospective study of 43 consecutive patients with OCD, Jenike et al1 reported that a subgroup of 14 treatment-resistant patients (33%) were found by chart review to meet DSM-III criteria for schizotypal personality disorder, with negative implications for treatment outcome.12 Many of these patients had been previously misdiagnosed as schizophrenic and had not benefited from neurolep¬ tic treatment.12 With the availability of more objective criteria for diagnosis of personality disorders,13 empiric explorations have begun into the relationship between OCD and a variety of DSM-III personality disorders. In a study of 44 outpatients with OCD, Rasmussen and Tsuang14 reported that 29 (66%) manifested an Axis II diagnosis, with 55% meeting criteria for compulsive, 9% for histrionic, 7% for schizoid, 5% for dependent, and 0%
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for schizotypal personality disorder. Diagnosis was based on a broad semistructured interview that included symptom checklists from DSM-III Axis II criteria. Joffee et al15 administered a computer-scored Million Clini¬ cal Multiaxial Inventory to 23 patients with OCD and found that 19 (83%) met criteria for a personality disorder, with only 1 patient (4%) meeting criteria for compulsive personality disorder and 4 (17%) patients meeting criteria for schizotypal personality disorder. Avoidant (44%), passive-aggressive (44%), and dependent (35%) personality disorders were most common. It is possible that this instrument may have overesti¬ mated sample prevalences of personality disorders since in the same report 20 (87%) of 23 patients with a lifetime diagnosis of major depressive disorder met criteria for at least one person¬ ality disorder.15 Steketee16 administered the Personality Diagnostic Ques¬ tionnaire (PDQ), a self-report instrument, to relatives of 26 patients with OCD and found that only 1 patient (4%) met criteria for compulsive personality disorder, and 9 patients (35%) met criteria for schizotypal personality disorder. De¬ pendent (39%), histrionic (31%), and avoidant (27%) personal¬ ity disorders were also frequently diagnosed. Black et al17 also administered the Personality Diagnostic Questionnaire to 21 patients with OCD and 42 age- and sex-matched normal con¬ trols. These authors found that 52% of the patients with OCD had DSM-III cluster Bls (dramatic) personality diagnoses or traits, compared with 7% of the controls, a statistically signifi¬ cant difference. The two groups did not differ in prevalence of cluster A (eccentric) or cluster C (anxious) diagnoses or traits. Dependent, histrionic, and borderline personality disorders (all 24%) were most frequent. No patient with OCD was diagnosed with compulsive personality disorder, and 3 (14%) were diagnosed with schizotypal personality disorder. The above conflicting studies used various standardized and nonstandardized assessment methods for measuring person¬ ality traits and disorders. All standardized scales used previ¬ ously had employed self-report; the use of structured inter¬ views keyed to DSM-III criteria for diagnosis of personality disorders may help in overcoming the traditional problems of low reliability and validity in personality diagnosis18 and may assist in clarifying this area. In the present study we used the Structured Interview for the DSM-III Personality Disorders (SIDP)*20 in a systematic investigation of the prevalence of DSM-III Axis II personality disorders in a consecutive sample of patients meeting DSMIII criteria for OCD. Our interest was in clarifying the fre¬ quency of occurrence of various personality disorders in OCD, with particular attention to compulsive and schizotypal per¬ sonality disorders. SUBJECTS AND METHODS Patients A total of 96 consecutive outpatients seeking either pharmacologie behavioral treatment were evaluated in the OCD Clinic and Re¬ search Unit at Massachusetts General Hospital, Boston. Those meet¬ ing DSM-III criteria for OCD were interviewed. The sample included 46 men (48%) and 50 women (52%), ranging in age from 19 to 75 years (mean ± SD, 37.1 ± 11.2 years). Patients had a mean age at onset of OCD of 18.1 ± 11.0 years and a mean duration of OCD symptoms of 18.2 ±11.7 years. or
Personality Questionnaire The SIDP is a structured interview designed specifically to diag¬ all DSM-III personality disorders.18 It consists of 160 questions, which are asked by a trained interviewer, and requires 60 to 90 minutes to complete.18 This instrument has been demonstrated to have adequate interrater reliability for presence of any personality disorder ( .71 for simultaneous interviews with two raters and .66 for separate interviews in a test-retest format). The coeffinose
=
=
cients (based on simultaneous interviews) for specific personality disorders ranged from .30 for compulsive to .90 for dependent.19 The reliability ofthe scale is improved when supplemented with a 20- to 45minute interview of a relative or close friend after interview of the subject.20 Comparison of SIDP diagnoses with scores on the Minneso¬ ta Multiphasic Personality Inventory and the Marke-Nyman Tem¬ perament Scale has provided evidence of the ability of the SIDP to discriminate between presence and absence of the personality disor¬ der, as well as among the three DSM-III personality disorder
clusters.18 A patient is diagnosed with an Axis II personality disorder if the requisite number of criteria specified in DSM-III are met. To qualify for the diagnosis of mixed personality disorder, the subject must have missed the requisite number of criteria by one, for two or more personality disorders, and must not have met full criteria for any other personality disorder.18 The diagnosis of passive-aggressive per¬ sonality disorder is rarely made on the SIDP because the presence of any other personality disorder disallows this diagnosis in DSM-III.18 Procedures All interviews
were
performed by
one
of two research assistants
(A. D. ., R. J. S. ), both trained and experienced in the use of the SIDP
for double-blind drug trials and both with bachelor's degrees in psy¬ chology and more than 5 years of experience in inpatient and outpa¬ tient psychiatric settings. Patients were asked to participate in the SIDP interview, which was part of a more comprehensive interview lasting approximately 2 to 2V2 hours, to provide additional informa¬ tion for their treatment. Eighty-seven patients (91%) were interviewed before beginning any pharmacologie or behavioral treatment. As a result of scheduling difficulties, 8 of the remaining 9 patients were interviewed within 1 month, and 1 patient within 2 months, of beginning treatment. Because the interview of an informant (usually a family member) is often important in the scoring of the SIDP,20 the research assistant administering the structured interview asked the patient for permis¬ sion to interview an informant in person or, if this was impossible, via telephone. In 54 (56%) of 96 cases, an interview with the informant was conducted. Of the 42 patients whose SIDP interviews were scored without an informant interview, 20 refused permission to interview an informant, 21 informants could not be reached by tele¬ phone after three or more attempts, and one informant was unable to provide the required information. To assess reliability, 16 patients were interviewed by one rater and simultaneously rated by a second rater, who sat in the room while the other interviewed the subject and later the informant. In the week before the SIDP interview, patients completed the selfadministered Maudsley Obsessional-Compulsive Questionnaire and the 21-item Beck Depression Inventory. On the day of the SIDP interview, patients were administered the Yale-Brown Obsessive Compulsive Scale, and age at onset and duration of OCD symptoms were determined during a semistructured clinical interview. RESULTS
Frequency of Personality Disorders Fifty (52%) of 96 patients received one or more Axis II personality diagnosis on the basis of the SIDP interview. If mixed personality disorder is excluded, 35 patients (36%) met full criteria for one or more of the personality disorders. Patients had a mean ± SD Yale-Brown Obsessive Compulsive Scale score of 21.1 ± 7.2 and mean Maudsley Obsessional-Compulsive Questionnaire score of 14.7 ±6.2 at the time of interview, indicating moderate OCD symptoms. Mean Beck Depression Inventory score was 17.6 ±10.0, indicating mild to moderate depression. The Figure illustrates frequencies for all DSM-III personality dis¬ order diagnoses. Mixed personality disorder (personality not other¬ wise specified in DSM-III-R) was most frequently diagnosed (15%), followed in frequency by dependent (12%), histrionic (9%), compul¬ sive (6%), and, with equal frequencies, schizotypal, paranoid, and avoidant personality disorders (5% each). No patients received a diagnosis of antisocial, narcissistic, or passive-aggressive personality disorders. The Figure divides the personality disorders into the three clusters introduced in DSM-III, illustrating that the majority of diagnoses were within cluster C (patients described in DSM-III as disorder
"anxious or fearful"13).
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3
Dependent Compulsive
Table 2.—Personality Features of 15 Patients With Mixed Personality Disorder
Cluster C
Avoidant
Histrionic Borderline Narcissistic
Cluster
Antisocial
Schizotypal Cluster A
Paranoid Schizoid
12
Mixed
Diagnoses
Patient
Passive-Aggressive |
2
0
4
6
8
10
12
14
Avoidant, dependent
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Avoidant, schizoid Borderline, schizotypal Compulsive, histrionic
Compulsive, histrionic
Borderline, schizotypal Avoidant, dependent, compulsive, schizoid Avoidant, compulsive, schizotypal, paranoid Avoidant, dependent, compulsive, schizotypal, paranoid Avoidant, compulsive Avoidant, dependent Avoidant, compulsive, histrionic, passive-aggressive
Compulsive, dependent
Avoidant, dependent Histrionic, schizotypal
16
Frequency, % of diagnosis
of all DSM-III Frequency and percentage personality disorders in a sample of 96 patients with obsessivecompulsive disorder by Structured Interview for the DSM-III Personality Disorders assessment. Clusters A, B, and C are groupings of related personality disorders specified in DSM-III.
Table 3.—Results for 16 Simultaneous
Diagnosis Patient
Rater 1
1-7
8
1.—Personality Disorders Diagnosed in Six Patients Meeting Criteria for Multiple Disorders Diagnoses Avoidant, paranoid Borderline, dependent, schizotypal Borderline, dependent Compulsive, histrionic, paranoid, schizoid Dependent, histrionic Avoidant, borderline, schizotypal
Patient 1 2
3 4 5 6
Presence of a personality disorder was not sex related.
Twenty-five
(54%) of the 46 men and 25 (50%) of the 50 women received an Axis II
diagnosis ( 2[1] 0.2, not significant). To determine whether patients assessed with =
and without infor¬
frequencies of personality disorders in these two groups were also analyzed separately and compared via 2 test. The two groups did not significantly differ on the presence or absence of any personality disorder ( 2[1] 0.13, not significant), the presence of compulsive personality disorder (corrected 2[1] 0.55, not significant), or the presence of schizotypal personality disorder (corrected 2[1] 0.41, not significant). Six patients (6%) met criteria for two or more personality disorders. The personality disorders codiagnosed in these patients are listed in Table 1. All three patients diagnosed with borderline personality disorder also met criteria for at least one other personality disorder. Fifteen patients (15%) met criteria for mixed personality disorder. The significant personality features in these patients are listed in Table 2, which indicates that avoidant (n 9), compulsive (n 8), dependent (n 6), and schizotypal (n 5) features were most mant interview
differed,
the
=
=
=
=
=
=
=
common.
Relation to Other Factors Presence of a personality disorder was found to be related to duration of OCD; patients with duration of OCD of 20 years or more were significantly more likely to have at least one Axis II diagnosis than were those with durations less than 20 years (65% vs 41%,
.02). respectively; 2[1] 5.1, To clarify this relationship to duration of OCD, separate contingen¬ cy analyses were conducted for each of the three DSM-III-R clusters =
=
Rater 2
None
None
Borderline, dependent, schizoid, compulsive
Borderline, dependent
Dependent
Dependent
10
None
Mixed
11
Mixed
Mixed
12 13
Dependent Schizotypal, borderline, dependent
Dependent Schizotypal, borderline, dependent
14
Avoidant
Avoidant
15
Avoidant
Mixed
16
Histrionic
Histrionic
9
Table
Reliability Interviews
of personality diagnoses and for mixed personality disorder. No sig¬ nificant relationship was found between duration of OCD and frequen¬ cy of either cluster A, B, or C diagnoses. There was, however, a highly significant relationship between duration of OCD and frequency of diagnosis of mixed personality disorder; this diagnosis was present in 2 patients (4%) with OCD of less than 20 years' duration and in 12 patients (30%) with OCD of greater than 20 years' duration
(X2[l] 11.7, P=.001). =
Unlike duration, age at onset of OCD was not significantly related to the presence of a personality disorder. Patients with onset before the age of 20 years were not significantly more likely to have a personality disorder than were those with onset at 20 years of age or later (58% vs 42%, 2[1] 2.4, F=.ll). Similarly, age at onset was not significantly related to presence of mixed personality disorder =
( [1] 2.1, not significant). Among the six patients diagnosed with compulsive personality disorder, five had onset of OCD symptoms before the age of 10 years, =
and the sixth had onset at 19 years. The severity of OCD symptoms was not significantly related to the presence of a personality disorder: patients with Yale-Brown Obses¬ sive Compulsive Scale scores below 20 did not have significantly more personality disorder diagnoses than did those with scores of 20 or above ( 2[1] 0, not significant). =
Reliability Table 3 shows the results of 16 reliability interviews performed by the two raters. The overall agreement for the presence or absence of at least one Axis II disorder was 15 of 16 (94%), yielding an acceptable of .88.21 In 13 (81%) of the 16 interviews, the two raters agreed
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perfectly on specific personality disorder. Too few patients were diagnosed with specific personality disorders to allow calculation of individual values for specific personality disorders. COMMENT
Axis II disorders, as diagnosed by a standardized assess¬ ment instrument, occurred in 52% of our patients with OCD,
with mixed, dependent, histrionic, and compulsive personal¬ ity disorders being most common. Mavissakalian and Ha¬ mann22 found dependent, avoidant, and histrionic personality disorders to be most
common
in
a
sample of 60 agoraphobic
patients.22 Dependent and histrionic personality disorders may be relatively common in a variety of anxiety disorders,
although in neither sample was the frequency of any of these personality disorders greater than 15%. No patient in our sample met criteria for narcissistic, antisocial, or passiveaggressive personality disorders. The finding that the presence ofmixed personality disorder was more likely with longer duration of OCD suggests that patients who do not have premorbid personality disorders may develop significant personality traits (especially avoid¬ ant, compulsive, and dependent), which may be related to behavioral and life-style changes that are secondary to OCD. Since our purpose in the present study was to describe the prevalence of personality disorders in a consecutive sample for outpatients with OCD, we made no attempt to assess a control group with other psychiatric diagnoses. When the results in our sample are compared with those of the group of 131 nonpsychotic psychiatric patients used to assess reliabil¬ ity and validity of the SIDP, no significant differences were found in the presence of at least one personality disorder (52% vs 51%, respectively; [1] 0), the prevalence of compulsive personality disorder (6% vs 5%, respectively; 2[1] 0.1), or the prevalence of schizotypal personality disorder (5% vs 9%, respectively; 2[1] 1.2). We did not compare SIDP diagnoses with those of experi¬ enced clinicians because the reliability of Axis II diagnoses made by experienced clinicians on the basis of clinical inter¬ view is pooi^3,24 and, according to the developers of the SIDP, provides "an unacceptable standard for comparison with the SIDP"18 Specifically, the for presence of a personality disorder has been reported to be between .4123 and . ß24 for experienced clinicians; both reliabilities are lower than the of .66 reported for the SIDP administered in separate inter¬ views.18 Thus, as yet there remains no accepted "gold stan¬ dard" for personality diagnosis. =
=
=
Schizotypal Personality Disorder
Only 5% of our sample met criteria for schizotypal personal¬ ity disorder. This sample prevalence is lower than those in several previous reports.1,15,16 This relatively low prevalence may reflect either a difference between methods used to diagnose this personality disorder or a sampling bias. In at¬ tempting to explain the lower prevalence of schizotypal per¬
sonality disorder in the present sample vs an earlier sample in clinic,1 we hypothesize that this difference may be in part due to the fact that we are seeing a healthier population of patients and see fewer of these "sicker" patients at present our
than
did in the past, when treatments for this disorder less readily available. With the recent publicity concern¬ ing OCD, we are seeing a broader spectrum of patients who are often self-referred. Our findings, together with those of past studies, confirm that schizotypal personality disorder and features occur in a significant proportion of patients with OCD. When all cluster A personality disorders are combined, our sample prevalence was 11%. This relationship is of inter¬ est because of the familial link between these personality disorders and schizophrenia.10,n we
were
Differences Between DSM-III and DSM-III-R Personality Disorder Criteria
The SIDP generates diagnoses for DSM-III Axis II disor¬ ders rather than for the current DSM-III-R.3 Significant changes have been made in the DSM-III-R diagnostic criteria for many of the personality disorders; among the greatest changes have been in criteria for compulsive personality disor¬ der (obsessive-compulsive personality disorder in DSM-I1IR). Rather than the DSM-III requirement of four of five criteria, DSM-III-R requires five of nine criteria to meet the diagnosis. New criteria have been also added for overconscientiousness and scrupulosity, lack of generosity, and hoarding of unimportant objects. Because such changes in criteria may affect the prevalence of this and other personality disorders in the OCD population, we have begun to administer a version of the SIDP that has been revised to generate DSM-III-R diagnoses (SIDP-R)
(Bruce Pfohl, MD, personal communication, February 3, 1989). To date we have administered the SIDP-R to an addi¬
tional 59 consecutive patients meeting criteria for OCD and found that 15 (25%) met criteria for obsessive-compulsive personality disorder, which is significantly higher than the prevalence of 6 (6%) of 96 in the present study ( 2[1] 11.5, =
Compulsive Personality Disorder
Compulsive personality disorder was diagnosed in six pa¬
tients (6%), all with onset of OCD before the age of 20 years. These results replicate two earlier studies15,16 in finding that compulsive personality disorder is less frequent in OCD than was once thought. The prevalence of compulsive personality disorder of 4% to 6% in outpatients with OCD in these studies indicates that compulsive personality disorder, as defined by DSM-III, is not a necessary condition for the development of OCD and, in fact, is not the most common personality disorder in OCD. When patients with significant compulsive features are combined with this personality disorder diagnosis (ie, including the mixed personality disorder with compulsive features), our sample prevalence increased to only 14%. These conclusions are limited to the DSM-III diagnosis of compulsive personality disorder, rather than the traditional psychodynamic concept of obsessional personality. As noted below, changes in the diagnostic criteria in DSM-III-R3 have moved the diagnostic entity of obsessive compulsive person¬ ality disorder somewhat closer to the traditional concept.9
P
Seymour;
\s=b\ We assessed 96 patients with obsessive-compulsive disorder for DSM-III personality disorder diagnoses with a standardized interview instrument (Structured Interview for the DSM-III Personality Disorders). Fifty patients (52%) met criteria for at least one personality disorder, with mixed, dependent, and histrionic personality disorders most frequently diagnosed. Compulsive personality disorder was diagnosed in only 6 patients (6%), 5 of whom had had onset of obsessive-compulsive symptoms before the age of 10 years, indicating that DSM-III compulsive personality disorder is not invariably a premorbid condition for the development of obsessive-compulsive disorder. Schizotypal personality disorder, at 5%, was found to be less common than in past samples, reflecting differences in either assessment meth-
relatives regarding the patients' premorbid personalities. Ten patients (32%) had "marked obsessional traits," and 4 (13%) had no obsessional traits. This study concluded that obsession¬ al personality and illness are intimately connected.8 It is likely that the number of patients without premorbid traits was underestimated because patients with an early onset of OCD were eliminated from analysis. Slade4 reviewed a number of psychometric studies of obses¬ sive patients and concluded otherwise: "The evidence pre¬ sented seems to support fairly strongly the distinction be¬ tween obsessional personality traits and obsessional neurosis." A more recent review of the literature led to the conclusion that obsessive-compulsive symptoms can be statistically dif¬ ferentiated via factor analysis from obsessive-compulsive symptoms as distinct phenomena, with obsessive-compulsive symptoms positively related to measures of neuroticism while
years have seen renewed interest in the prevalence of various personality disorders in obsessive-compulsive disorder (OCD). Among the reasons for this renewed interest is the suggestion that certain severe personality disorders (eg, schizotypal) may predict poor outcome to a variety of treat¬ ments. 12 In addition, as interest in the mechanisms and epide¬ miology of OCD has grown, the widely held belief that OCD is invariably related to obsessional personality (obsessive-com¬ pulsive personality disorder in DSM-III-R3) has been ques¬
that
ods or sampling. (Aren Gen Psychiatry. 1990;47:826-830)
Recent
tioned."
In the traditional psychoanalytic explanation of obsessional disorders, obsessional personality had been seen as a predis¬ posing feature of obsessional neurosis, with the two conditions existing side by side along a continuum.7 On this continuum (which is assumed to arise from conflicts over bowel training), individuals with obsessional personality (characterized by or¬ derliness, parsimoniousness, and obstinacy8) differ from those individuals with obsessive-compulsive symptoms (obsessions and compulsions) only in that they are nonsymptomatic.8 In an early report, Ingrani8 studied 31 inpatients with OCD by means of subjective descriptions by patients, clinicians, and
Accepted for publication August 7,1989. From the Massachusetts General Hospital
and Harvard Medical
Boston.
Reprint requests to WACC-717,
MA 02114 (Dr Baer).
Massachusetts General
School,
Hospital, Boston,
obsessive-compulsive personality was not.5 Pollack6 concluded although obsessive-compulsive personality has been re¬ ported to occur premorbidly, it is neither a necessary nor a sufficient factor for the development of OCD.
The studies reviewed above examined the obsessional per¬ sonality or anal-erotic character described by Freud.8 More recent studies, however, have investigated the DSM-III entity of compulsive personality disorder, which has been suggested to be "a much more pathological entity than the classical obsessive-compulsive character. "9 Schizotypal personality disorder, which, along with schizoid and paranoid personality disorders, forms cluster A of DSMIII-R personality disorders, has been reported to be geneti¬ cally related to schizophrenia.10,n In a retrospective study of 43 consecutive patients with OCD, Jenike et al1 reported that a subgroup of 14 treatment-resistant patients (33%) were found by chart review to meet DSM-III criteria for schizotypal personality disorder, with negative implications for treatment outcome.12 Many of these patients had been previously misdiagnosed as schizophrenic and had not benefited from neurolep¬ tic treatment.12 With the availability of more objective criteria for diagnosis of personality disorders,13 empiric explorations have begun into the relationship between OCD and a variety of DSM-III personality disorders. In a study of 44 outpatients with OCD, Rasmussen and Tsuang14 reported that 29 (66%) manifested an Axis II diagnosis, with 55% meeting criteria for compulsive, 9% for histrionic, 7% for schizoid, 5% for dependent, and 0%
Downloaded From: http://archpsyc.jamanetwork.com/ by a Karolinska Institutet University Library User on 09/19/2015
for schizotypal personality disorder. Diagnosis was based on a broad semistructured interview that included symptom checklists from DSM-III Axis II criteria. Joffee et al15 administered a computer-scored Million Clini¬ cal Multiaxial Inventory to 23 patients with OCD and found that 19 (83%) met criteria for a personality disorder, with only 1 patient (4%) meeting criteria for compulsive personality disorder and 4 (17%) patients meeting criteria for schizotypal personality disorder. Avoidant (44%), passive-aggressive (44%), and dependent (35%) personality disorders were most common. It is possible that this instrument may have overesti¬ mated sample prevalences of personality disorders since in the same report 20 (87%) of 23 patients with a lifetime diagnosis of major depressive disorder met criteria for at least one person¬ ality disorder.15 Steketee16 administered the Personality Diagnostic Ques¬ tionnaire (PDQ), a self-report instrument, to relatives of 26 patients with OCD and found that only 1 patient (4%) met criteria for compulsive personality disorder, and 9 patients (35%) met criteria for schizotypal personality disorder. De¬ pendent (39%), histrionic (31%), and avoidant (27%) personal¬ ity disorders were also frequently diagnosed. Black et al17 also administered the Personality Diagnostic Questionnaire to 21 patients with OCD and 42 age- and sex-matched normal con¬ trols. These authors found that 52% of the patients with OCD had DSM-III cluster Bls (dramatic) personality diagnoses or traits, compared with 7% of the controls, a statistically signifi¬ cant difference. The two groups did not differ in prevalence of cluster A (eccentric) or cluster C (anxious) diagnoses or traits. Dependent, histrionic, and borderline personality disorders (all 24%) were most frequent. No patient with OCD was diagnosed with compulsive personality disorder, and 3 (14%) were diagnosed with schizotypal personality disorder. The above conflicting studies used various standardized and nonstandardized assessment methods for measuring person¬ ality traits and disorders. All standardized scales used previ¬ ously had employed self-report; the use of structured inter¬ views keyed to DSM-III criteria for diagnosis of personality disorders may help in overcoming the traditional problems of low reliability and validity in personality diagnosis18 and may assist in clarifying this area. In the present study we used the Structured Interview for the DSM-III Personality Disorders (SIDP)*20 in a systematic investigation of the prevalence of DSM-III Axis II personality disorders in a consecutive sample of patients meeting DSMIII criteria for OCD. Our interest was in clarifying the fre¬ quency of occurrence of various personality disorders in OCD, with particular attention to compulsive and schizotypal per¬ sonality disorders. SUBJECTS AND METHODS Patients A total of 96 consecutive outpatients seeking either pharmacologie behavioral treatment were evaluated in the OCD Clinic and Re¬ search Unit at Massachusetts General Hospital, Boston. Those meet¬ ing DSM-III criteria for OCD were interviewed. The sample included 46 men (48%) and 50 women (52%), ranging in age from 19 to 75 years (mean ± SD, 37.1 ± 11.2 years). Patients had a mean age at onset of OCD of 18.1 ± 11.0 years and a mean duration of OCD symptoms of 18.2 ±11.7 years. or
Personality Questionnaire The SIDP is a structured interview designed specifically to diag¬ all DSM-III personality disorders.18 It consists of 160 questions, which are asked by a trained interviewer, and requires 60 to 90 minutes to complete.18 This instrument has been demonstrated to have adequate interrater reliability for presence of any personality disorder ( .71 for simultaneous interviews with two raters and .66 for separate interviews in a test-retest format). The coeffinose
=
=
cients (based on simultaneous interviews) for specific personality disorders ranged from .30 for compulsive to .90 for dependent.19 The reliability ofthe scale is improved when supplemented with a 20- to 45minute interview of a relative or close friend after interview of the subject.20 Comparison of SIDP diagnoses with scores on the Minneso¬ ta Multiphasic Personality Inventory and the Marke-Nyman Tem¬ perament Scale has provided evidence of the ability of the SIDP to discriminate between presence and absence of the personality disor¬ der, as well as among the three DSM-III personality disorder
clusters.18 A patient is diagnosed with an Axis II personality disorder if the requisite number of criteria specified in DSM-III are met. To qualify for the diagnosis of mixed personality disorder, the subject must have missed the requisite number of criteria by one, for two or more personality disorders, and must not have met full criteria for any other personality disorder.18 The diagnosis of passive-aggressive per¬ sonality disorder is rarely made on the SIDP because the presence of any other personality disorder disallows this diagnosis in DSM-III.18 Procedures All interviews
were
performed by
one
of two research assistants
(A. D. ., R. J. S. ), both trained and experienced in the use of the SIDP
for double-blind drug trials and both with bachelor's degrees in psy¬ chology and more than 5 years of experience in inpatient and outpa¬ tient psychiatric settings. Patients were asked to participate in the SIDP interview, which was part of a more comprehensive interview lasting approximately 2 to 2V2 hours, to provide additional informa¬ tion for their treatment. Eighty-seven patients (91%) were interviewed before beginning any pharmacologie or behavioral treatment. As a result of scheduling difficulties, 8 of the remaining 9 patients were interviewed within 1 month, and 1 patient within 2 months, of beginning treatment. Because the interview of an informant (usually a family member) is often important in the scoring of the SIDP,20 the research assistant administering the structured interview asked the patient for permis¬ sion to interview an informant in person or, if this was impossible, via telephone. In 54 (56%) of 96 cases, an interview with the informant was conducted. Of the 42 patients whose SIDP interviews were scored without an informant interview, 20 refused permission to interview an informant, 21 informants could not be reached by tele¬ phone after three or more attempts, and one informant was unable to provide the required information. To assess reliability, 16 patients were interviewed by one rater and simultaneously rated by a second rater, who sat in the room while the other interviewed the subject and later the informant. In the week before the SIDP interview, patients completed the selfadministered Maudsley Obsessional-Compulsive Questionnaire and the 21-item Beck Depression Inventory. On the day of the SIDP interview, patients were administered the Yale-Brown Obsessive Compulsive Scale, and age at onset and duration of OCD symptoms were determined during a semistructured clinical interview. RESULTS
Frequency of Personality Disorders Fifty (52%) of 96 patients received one or more Axis II personality diagnosis on the basis of the SIDP interview. If mixed personality disorder is excluded, 35 patients (36%) met full criteria for one or more of the personality disorders. Patients had a mean ± SD Yale-Brown Obsessive Compulsive Scale score of 21.1 ± 7.2 and mean Maudsley Obsessional-Compulsive Questionnaire score of 14.7 ±6.2 at the time of interview, indicating moderate OCD symptoms. Mean Beck Depression Inventory score was 17.6 ±10.0, indicating mild to moderate depression. The Figure illustrates frequencies for all DSM-III personality dis¬ order diagnoses. Mixed personality disorder (personality not other¬ wise specified in DSM-III-R) was most frequently diagnosed (15%), followed in frequency by dependent (12%), histrionic (9%), compul¬ sive (6%), and, with equal frequencies, schizotypal, paranoid, and avoidant personality disorders (5% each). No patients received a diagnosis of antisocial, narcissistic, or passive-aggressive personality disorders. The Figure divides the personality disorders into the three clusters introduced in DSM-III, illustrating that the majority of diagnoses were within cluster C (patients described in DSM-III as disorder
"anxious or fearful"13).
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3
Dependent Compulsive
Table 2.—Personality Features of 15 Patients With Mixed Personality Disorder
Cluster C
Avoidant
Histrionic Borderline Narcissistic
Cluster
Antisocial
Schizotypal Cluster A
Paranoid Schizoid
12
Mixed
Diagnoses
Patient
Passive-Aggressive |
2
0
4
6
8
10
12
14
Avoidant, dependent
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Avoidant, schizoid Borderline, schizotypal Compulsive, histrionic
Compulsive, histrionic
Borderline, schizotypal Avoidant, dependent, compulsive, schizoid Avoidant, compulsive, schizotypal, paranoid Avoidant, dependent, compulsive, schizotypal, paranoid Avoidant, compulsive Avoidant, dependent Avoidant, compulsive, histrionic, passive-aggressive
Compulsive, dependent
Avoidant, dependent Histrionic, schizotypal
16
Frequency, % of diagnosis
of all DSM-III Frequency and percentage personality disorders in a sample of 96 patients with obsessivecompulsive disorder by Structured Interview for the DSM-III Personality Disorders assessment. Clusters A, B, and C are groupings of related personality disorders specified in DSM-III.
Table 3.—Results for 16 Simultaneous
Diagnosis Patient
Rater 1
1-7
8
1.—Personality Disorders Diagnosed in Six Patients Meeting Criteria for Multiple Disorders Diagnoses Avoidant, paranoid Borderline, dependent, schizotypal Borderline, dependent Compulsive, histrionic, paranoid, schizoid Dependent, histrionic Avoidant, borderline, schizotypal
Patient 1 2
3 4 5 6
Presence of a personality disorder was not sex related.
Twenty-five
(54%) of the 46 men and 25 (50%) of the 50 women received an Axis II
diagnosis ( 2[1] 0.2, not significant). To determine whether patients assessed with =
and without infor¬
frequencies of personality disorders in these two groups were also analyzed separately and compared via 2 test. The two groups did not significantly differ on the presence or absence of any personality disorder ( 2[1] 0.13, not significant), the presence of compulsive personality disorder (corrected 2[1] 0.55, not significant), or the presence of schizotypal personality disorder (corrected 2[1] 0.41, not significant). Six patients (6%) met criteria for two or more personality disorders. The personality disorders codiagnosed in these patients are listed in Table 1. All three patients diagnosed with borderline personality disorder also met criteria for at least one other personality disorder. Fifteen patients (15%) met criteria for mixed personality disorder. The significant personality features in these patients are listed in Table 2, which indicates that avoidant (n 9), compulsive (n 8), dependent (n 6), and schizotypal (n 5) features were most mant interview
differed,
the
=
=
=
=
=
=
=
common.
Relation to Other Factors Presence of a personality disorder was found to be related to duration of OCD; patients with duration of OCD of 20 years or more were significantly more likely to have at least one Axis II diagnosis than were those with durations less than 20 years (65% vs 41%,
.02). respectively; 2[1] 5.1, To clarify this relationship to duration of OCD, separate contingen¬ cy analyses were conducted for each of the three DSM-III-R clusters =
=
Rater 2
None
None
Borderline, dependent, schizoid, compulsive
Borderline, dependent
Dependent
Dependent
10
None
Mixed
11
Mixed
Mixed
12 13
Dependent Schizotypal, borderline, dependent
Dependent Schizotypal, borderline, dependent
14
Avoidant
Avoidant
15
Avoidant
Mixed
16
Histrionic
Histrionic
9
Table
Reliability Interviews
of personality diagnoses and for mixed personality disorder. No sig¬ nificant relationship was found between duration of OCD and frequen¬ cy of either cluster A, B, or C diagnoses. There was, however, a highly significant relationship between duration of OCD and frequency of diagnosis of mixed personality disorder; this diagnosis was present in 2 patients (4%) with OCD of less than 20 years' duration and in 12 patients (30%) with OCD of greater than 20 years' duration
(X2[l] 11.7, P=.001). =
Unlike duration, age at onset of OCD was not significantly related to the presence of a personality disorder. Patients with onset before the age of 20 years were not significantly more likely to have a personality disorder than were those with onset at 20 years of age or later (58% vs 42%, 2[1] 2.4, F=.ll). Similarly, age at onset was not significantly related to presence of mixed personality disorder =
( [1] 2.1, not significant). Among the six patients diagnosed with compulsive personality disorder, five had onset of OCD symptoms before the age of 10 years, =
and the sixth had onset at 19 years. The severity of OCD symptoms was not significantly related to the presence of a personality disorder: patients with Yale-Brown Obses¬ sive Compulsive Scale scores below 20 did not have significantly more personality disorder diagnoses than did those with scores of 20 or above ( 2[1] 0, not significant). =
Reliability Table 3 shows the results of 16 reliability interviews performed by the two raters. The overall agreement for the presence or absence of at least one Axis II disorder was 15 of 16 (94%), yielding an acceptable of .88.21 In 13 (81%) of the 16 interviews, the two raters agreed
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perfectly on specific personality disorder. Too few patients were diagnosed with specific personality disorders to allow calculation of individual values for specific personality disorders. COMMENT
Axis II disorders, as diagnosed by a standardized assess¬ ment instrument, occurred in 52% of our patients with OCD,
with mixed, dependent, histrionic, and compulsive personal¬ ity disorders being most common. Mavissakalian and Ha¬ mann22 found dependent, avoidant, and histrionic personality disorders to be most
common
in
a
sample of 60 agoraphobic
patients.22 Dependent and histrionic personality disorders may be relatively common in a variety of anxiety disorders,
although in neither sample was the frequency of any of these personality disorders greater than 15%. No patient in our sample met criteria for narcissistic, antisocial, or passiveaggressive personality disorders. The finding that the presence ofmixed personality disorder was more likely with longer duration of OCD suggests that patients who do not have premorbid personality disorders may develop significant personality traits (especially avoid¬ ant, compulsive, and dependent), which may be related to behavioral and life-style changes that are secondary to OCD. Since our purpose in the present study was to describe the prevalence of personality disorders in a consecutive sample for outpatients with OCD, we made no attempt to assess a control group with other psychiatric diagnoses. When the results in our sample are compared with those of the group of 131 nonpsychotic psychiatric patients used to assess reliabil¬ ity and validity of the SIDP, no significant differences were found in the presence of at least one personality disorder (52% vs 51%, respectively; [1] 0), the prevalence of compulsive personality disorder (6% vs 5%, respectively; 2[1] 0.1), or the prevalence of schizotypal personality disorder (5% vs 9%, respectively; 2[1] 1.2). We did not compare SIDP diagnoses with those of experi¬ enced clinicians because the reliability of Axis II diagnoses made by experienced clinicians on the basis of clinical inter¬ view is pooi^3,24 and, according to the developers of the SIDP, provides "an unacceptable standard for comparison with the SIDP"18 Specifically, the for presence of a personality disorder has been reported to be between .4123 and . ß24 for experienced clinicians; both reliabilities are lower than the of .66 reported for the SIDP administered in separate inter¬ views.18 Thus, as yet there remains no accepted "gold stan¬ dard" for personality diagnosis. =
=
=
Schizotypal Personality Disorder
Only 5% of our sample met criteria for schizotypal personal¬ ity disorder. This sample prevalence is lower than those in several previous reports.1,15,16 This relatively low prevalence may reflect either a difference between methods used to diagnose this personality disorder or a sampling bias. In at¬ tempting to explain the lower prevalence of schizotypal per¬
sonality disorder in the present sample vs an earlier sample in clinic,1 we hypothesize that this difference may be in part due to the fact that we are seeing a healthier population of patients and see fewer of these "sicker" patients at present our
than
did in the past, when treatments for this disorder less readily available. With the recent publicity concern¬ ing OCD, we are seeing a broader spectrum of patients who are often self-referred. Our findings, together with those of past studies, confirm that schizotypal personality disorder and features occur in a significant proportion of patients with OCD. When all cluster A personality disorders are combined, our sample prevalence was 11%. This relationship is of inter¬ est because of the familial link between these personality disorders and schizophrenia.10,n we
were
Differences Between DSM-III and DSM-III-R Personality Disorder Criteria
The SIDP generates diagnoses for DSM-III Axis II disor¬ ders rather than for the current DSM-III-R.3 Significant changes have been made in the DSM-III-R diagnostic criteria for many of the personality disorders; among the greatest changes have been in criteria for compulsive personality disor¬ der (obsessive-compulsive personality disorder in DSM-I1IR). Rather than the DSM-III requirement of four of five criteria, DSM-III-R requires five of nine criteria to meet the diagnosis. New criteria have been also added for overconscientiousness and scrupulosity, lack of generosity, and hoarding of unimportant objects. Because such changes in criteria may affect the prevalence of this and other personality disorders in the OCD population, we have begun to administer a version of the SIDP that has been revised to generate DSM-III-R diagnoses (SIDP-R)
(Bruce Pfohl, MD, personal communication, February 3, 1989). To date we have administered the SIDP-R to an addi¬
tional 59 consecutive patients meeting criteria for OCD and found that 15 (25%) met criteria for obsessive-compulsive personality disorder, which is significantly higher than the prevalence of 6 (6%) of 96 in the present study ( 2[1] 11.5, =
Compulsive Personality Disorder
Compulsive personality disorder was diagnosed in six pa¬
tients (6%), all with onset of OCD before the age of 20 years. These results replicate two earlier studies15,16 in finding that compulsive personality disorder is less frequent in OCD than was once thought. The prevalence of compulsive personality disorder of 4% to 6% in outpatients with OCD in these studies indicates that compulsive personality disorder, as defined by DSM-III, is not a necessary condition for the development of OCD and, in fact, is not the most common personality disorder in OCD. When patients with significant compulsive features are combined with this personality disorder diagnosis (ie, including the mixed personality disorder with compulsive features), our sample prevalence increased to only 14%. These conclusions are limited to the DSM-III diagnosis of compulsive personality disorder, rather than the traditional psychodynamic concept of obsessional personality. As noted below, changes in the diagnostic criteria in DSM-III-R3 have moved the diagnostic entity of obsessive compulsive person¬ ality disorder somewhat closer to the traditional concept.9
P
