DSM-III-R Personality Disorders in Panic Obsessive-Compulsive Disorder: A Comparison Study

and

Gabriella Sciuto, Giuseppina Diaferia, Marco Battaglia, Giampaolo Perna, Angela Gabriele, and Laura Bellodi Forty-eight patients with panic disorder/agoraphobia (PAD) and 30 with obsessive-compulsive disorder (OCD) were assessed for DSM-III-R axis II personality disorders (PD) and the presence of the same anxiety disorder in the relatives of probands (homotypic disorders). No specific personality disorder was present significantly more often in either of the two groups. Agoraphobia was not associated with higher rates of axis II disorders in PAD patients. Duration of illness did not influence the presence of a PD in patients of both groups. Secondary cases of the same anxiety disorderwere significantly more common among first-degree relatives of PAD patients. A discriminant analysis performed on the most frequent personality traits of both groups provided a correct classification of cases of 97.4%. Our results do not support the hypothesis of PD as secondary to anxiety disorders and confirm previous findings of a lack of specificity between DSM-III-R axis II categories and OCD and PAD. Copyright 0 1991 by W.B. Saunders Company

I

N RECENT YEARS, personality disorders (PD) as defined by the DSM-III’ multiaxial diagnostic system have been extensively studied in patients with anxiety disorders (for a review, see Brooks et al.‘). The aim of these studies was to identify possible specific patterns of personality profiles co-occurring with panic disorder,3-6 social phobia,’ obsessive-compulsive disorder (OCD),‘.I’ and generalized anxiety disorder.” The results from these empirical explorations are not unequivocal, and are difficult to compare because of methodological differences in sample collection and personality assessment. However, the data seem to suggest an excess of some DSM-III cluster III PD (particularly avoidant and dependent) in patients with panic disorder and social phobia. Moreover, there is evidence that coexisting maladaptive personality traits may exert a negative influence on some clinical variables of anxiety disorders, such as outcome and treatment response.13-‘6 However, since PD are generally evaluated and assessed in patients after the onset of clinical syndromes, their possible role as preexisting or even predisposing factors to anxiety states, should be viewed cautiously. In fact, some recent evidence’ suggests that at least some personality traits can be related to behavioral and life-style changes induced by the clinical symptoms during the course of illnesses. In this case, maladaptive personality traits are likely to represent a pathoplastic effect, or a state condition related to the active phase of illness, more than preexisting personologic features. A similar effect of depressive state over personality characteristics has been demonstrated by some investigators.“,” Recently, Mavissakalian et a1.19addressed the question of the specificity of

From the Depatiment of Neuropsyhiatrik Sciences, Istituto Scientif;co S. Raffaele, Universiry of Milan School of Medicine, Milan, Italy. Address reprint requests to Laura Bellodi, M.D., Chair of Psychopathology Ospedale S. Raffaele, 29 via Prinetti, 20127Milano, Italy. Copyright 0 1991 by W. B. Saunders Company 0010-440X~91l3205-000I$03.00f0

450

Comprehensive

Psychiatry,

Vol. 32, No. 5 (September/October),

1991: pp 450-457

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DSM-III-R PD IN PAD AND OCD PATIENTS

the co-presence of DSM-III PD in panic disorders and OCD by a direct comparison among these two discrete and valid diagnostic groups. They administered the Personality Diagnostic Questionnaire (PDQ), a self-report instrument,“.” to 187 patients with panic disorder and 51 OCD. The results show that the major personality characteristics identified in panic disorder/agoraphobic (PAD) patients (ie, avoidant, dependent, histrionic, and borderline) are equally or even more pronounced in patients with OCD, supporting a lack of specificity between panic disorder and PD traits. However, some difficulties leave this question unclear. In fact, for many PD, significant changes have been made in DSM-III-Rz2 diagnostic criteria, with a consequent need to revise standardized instruments for personality assessment. The aim of our study was threefold. First, we wanted to see the distribution of DSM-III-R PD, assessed with a version of the Structured Interview for DSM-III Personality (SIDP)23 revised to generate DSM-III-R diagnoses (SIDP-R) (Pfohl et al., March 30,1989 version), in two anxiety disorders in the focus of attention, namely panic disorder and OCD. Second, we wanted to clarify, by means of a direct comparison of the personality profiles in the two groups of patients, the question of the specificity of the co-presence of PD. This aim was common to the study of Mavissakalian et al.,19 although different instruments for personality assessment were used in patients from different cultures. Third, we wished to investigate the effect of clinical symptoms of panic and OCD on personality structure. SUBJECTS

AND METHODS

Patients A total of 78 consecutive patients who met DSM-III-R diagnostic criteria for either OCD (n = 30) or PAD (n = 48), seeking either pharmacological or behavioral treatment, were evaluated in the Anxiety Disorder Clinic and Research Unit at S. Raffaele Hospital, Milan. Among patients with panic disorder, 31 were also agoraphobic. Five (10.4%) of the PAD patients and 10 (33.3%) of the OCD patients also met diagnostic criteria for major depression in their lifetime.

Assessments The SIDP-R is a revised version of SIDP interview*’ modified to generate DSM-III-R personality disorders diagnoses. It consists of 163 questions, and requires a trained interviewer 60 to 90 minutes to complete. A patient is diagnosed with an axis II personality disorder if the requested number of criteria specified in the DSM-III-R are met. Not only the 11 PD defined in the DSM-III-R, but also the two adjunctive non-official diagnoses proposed in DSM-III-R (self-defeating and sadistic PD), are included in the interview. All interviews were performed by one of the two research assistants (G.P.P., A.G.), both trained and experienced in the use of SIDP-R, blinded to the subject’s diagnosis, after his/her informed consent was obtained. The SIDP-R was administered within 2 months after the beginning of the patient’s treatment, in a recovered phase of the disorder, according to a clinical judgement and the simultaneous administration of the Yale-Brown Obsessive Scalez4 for OCD patients, and the Sheehan’s Panic Attack and Anticipatory Anxiety Scale (PAAS) and Phobia Scale for panic patients. Because the interview of an informant is often important in the scoring of the SIDP-R, we also asked the patients the permission to interview an informant, personally or by telephone. This was possible in 45% (n = 35) of cases. To assess reliability, 14 patients were interviewed by one rater while a second rater sat in the room. The overall agreement for the presence of any PD gave a k value of .86. Information about family history of panic disorder and OCD was collected by means of the same procedures used in a previous study.=

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Statistical Analyses We analyzed the distribution of PD and the single criteria identified by the SIDP-R in PAD patients compared with OCD patients, using a 2 x 2 chi-square test. To identify a possible cluster of traits, significantly related to the axis I diagnoses (PAD v OCD) considered as “group variable,” we performed a discriminant analysis% on the personality features of patients in both groups. Of the 118 possible criteria included in the SIDP-R, we took into account those represented in at least five subjects of both groups. This gave a total of 49 personality features, each corresponding to a definite DSM-III-R criterion of the SIDP-R, to be included in the discriminant analysis. We used the stepwise method and Wilk’s Lambda as the criteria for variable selection. The variables “sex,” “axis I diagnosis,” “ presence/absence of positive family history for homotypic disorder,” and 25 traits included in the discriminant function were then processed using a factor analysis,*’ in order to clarify their mutual relationships.

RESULTS

Table 1 shows the demographic and clinical characteristics of our sample. In both groups of patients, women are more represented; age, educational level, and marital status are similar in the two groups. The age of onset in OCD patients is significantly lower (t = -2.5 P = .015) than in PAD patients, and the duration of illness is also significantly more prolonged in the former group (t = 3.17 P = .002). No differences were found in the two groups regarding percentages of patients without any PD. Secondary cases of homotypic disorders were more frequent in the PAD group, i.e., PAD patients had significantly more first-degree relatives with the same disorder, compared with the OCD probands and their relatives (14/46 v 2/30; x2 = 4.83, df = 1, P = .03). As shown in Fig 1, the only PD not diagnosed in either group was antisocial, while schizoid and schizotypal PD were not diagnosed only in the OCD group. Histrionic PD was the most represented diagnosis in PAD group. Multiple

Table 1. Demographic

and Clinical Characteristics OCD (n = 30) Mean

Age

Educational

level (yr)

Age of onset Duration of illness (yr)

Sex (female) Marital status Single Married Divorced Widowed Absence of any PD Positive family history for homotypic disorder *Student’s t test. Khi-square test.

(SD)

of the Sample PAD (n = 48) Mean

(SD)

P

33.6

(13.6)

34.9

(10.2)

NS

11.0 22.8 11.2

(4.0) (11.5) (10.2)

12.3 29.1 5.4

(4.1) (10.3) (5.7)

NS .015 ,002

n

%

n

%

Pt

21

70

32

66.7

18 11 1 12

60 36.7 3.3 40

24 22 1 1 15

50 46 2 2 31.2

NS NS NS NS NS NS NS

2

6.7

14146

30.4

.03

DSM-III-R

453

PD IN PAD AND OCD PATIENTS

0

1 ii

0 8 e 8 bARA S2ZD S2T COM HIS

OCD(W30) PAD(n=48) Fig 1.

20 0 12.5 4.3

DEP ANS NARAVOiBDL

0 3.3 23.3 13.3 0 2.1 6.3 27.1 12.5 0

PD diagnoses distribution

PASS SAD

SD

MIX

3.3 26.7 3.3 13.3 3.3 3.3 10 4.2 10.4 4.2 10.4 2.1 2.1 12.5

in OCD (m, n = 30) and PAD (B, n = 48) patients.

diagnoses of PD (i.e., more than one axis II diagnosis in the same subject) were present in 10 OCD (33.3%) and 13 PAD (27.1%) patients. No specific PD was significantly more present in any of the two groups, although there was a trend for a higher frequency of avoidant PD among OCD patients (8 v 22) than in PAD patients (5 v 43) (26.6% v 10.4%. x’ = 2.44, df = 1, P = .12). There was no sex difference for the distribution of the “presence of any PD” in the two groups. PAD patients with a duration of illness less than 5 years (21/45) did not significantly differ from patients with a duration of illness more than 5 years (15/45) for the presence or absence of a diagnosis of PD (x’ = .014, df = 1, NS). The same was true for OCD patients with a duration of illness less (12/30) versus more than 5 years (18/30) (x2 = .248, df = 1, NS). Panic patients without agoraphobia do not differ for the presence of PD diagnoses from patients with agoraphobia (lo/12 v 23/36; x2 = .808, df = 1, NS). The two OCD patients with secondary cases of OCD in their families, and 11 of the 14 PAD patients with PAD in their families, had a PD. This finding, even if not statistically significant (x’ = 6.4, df = 3, P = .12), may indicate a trend for PD as predicting factors of familial susceptibility to these anxiety disorders. As no difference was found in the distribution of the different PD in the two groups, we hypothesized a possible pattern of differentiation in the distribution of traits. A discriminant analysis was performed with the 49 personality traits as variables, as described in the Method section. The first and only discriminant function provided by this analysis indicated a high degree of separation with a final Wilk’s Lambda of .25 and a canonical correlation of .87. As shown in Table 2, the discriminant analysis provided a high proportion of correct classification of cases (97.4%), taking the axis I diagnosis as group variable. Table 3 lists the 25 items selected, according to the size of correlation within the canonical function in our sample, with the frequencies of each trait in the two groups. The only traits distributed differently among PAD and OCD patients were (1) excessive social

454

SCIUTO ET AL Table 2. Classification

of Cases According to Discriminant

Analysis

Predicted Group Membership Group

No. of Cases

Group 0

Group 1

0 1

30 48

28 (93.3%) 0

2 (6.7%) 48 (100%)

OCD PAD

NOTE. Percent of grouped cases correctly classified: 97.44%.

anxiety (more frequent in OCD patients), and (2) sexual seductiveness (more frequent in PAD patients). To obtain more concise and informative elements, we analyzed these discriminant variables by means of a factor analysis, including “sex,” “axis I diagnosis,” and “presence of homotypic secondary cases in family” as variables. The six factors extracted by the analysis show the structure depicted in Table 4. The variables “axis I diagnosis” and “presence of homotypic disorder in the family” are associated within factor 2, which also includes personality traits related to the need of constant admiration and attention. Table 3. List of Personality Traits Included in Canonical Function Trait

Score

OCD%

PAD%

Sexually seductive Excessive social anxiety Resistance to demands Fear of being abandoned Easily slighted Questions the loyalty of friends Fear of being embarrassed Reads hidden meanings Preoccupied with details and rules Frequent displays of temper Failure to accomplish crucial tasks Reacts with rage to criticism Self-centered, no tolerance of frustration Reluctant to confide in others No close friends Concerned with physical attractiveness Requires constant admiration Spontaneous self-sacrifices Uncomfortable if not the center of attention Indecisiveness Avoids obligations Inflexibility Reticent in social situations Exaggerates potential difficulties Volunteers unpleasant tasks to get people love him/her

1.26 -1.24 -1.12 1.02 1.01 .90 .89 .83 -.72

6.7 50 23.3 23.3 23.3 20 23.3 20 23.3

27.1* 20.8t 27.1 33.3 41.7 14.6 35.4 22.9 22.9

.72 -.69

26.7 20

37.5 12.5

-.62 .58

56.7 33.3

45.8 33.3

.57 -.56 -.54

16.7 43.3 40

16.7 20.8 39.6

-.54 -.52 -.50

23.3 20 33.3

29.2 14.6 35.4

.45 .44 .42 .37 .31

26.7 20 20 36.7 20

33.3 27.1 37.5 31.3 20.8

.31

10

29.2

PD HIST SZT PA DEP PARA PARA AVOI PARA COMP

A2 A2 A2 A8 A6 A2 A6 A3 A2

BDL SD

A4 A6

NARC HIST

Al A7

PARA AVOI HIST

A5 A2 A3

NARC SD HIST

A7 A8 A5

COMP PA COMP AVOI AVOI

A5 A5 A6 A5 A7

DEP

A5

*Chi-square tChi-square

= 3.46, P = -02. = 5.93, P = .Ol.

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DSM-III-R PD IN PAD AND OCD PATIENTS Table 4. Principal Components Fl coefficient score HIST .70

A7

HIST

A3

.65

NARC .61 F2 coefficient score NARC .74 HIST .64 FH .55 BDL 50 F3 coefficient score SD .70 AVOI .58

From Factor Analysis

Al A7 A5

A4

Self-centered, no tolerance of frustration Concerned with physical attractiveness Reacts with rage to criticism Requires constant admiration Uncomfortable if not the center of attention Positive family history Frequent displays of temper

PARA .51 F4 coefficient score SZT .80 AVOI .76 COMP .56 HIST .51 F5 coefficient score COMP .81

A6

Spontaneous self sacrifices Exaggerates potential difficulties and risks Volunteers unpleasant tasks to get people love him Easily slighted

A2 A5 A5 A2

Excessive social anxiety Reticent in social situations Indecisiveness Sexually seductive

A2

COMP .65 DEP .62 F6 coefficient score PARA .83 PARA .78

A6 A8

Preoccupied with details and rules Inflexibility Fear of being abandoned

A5 A2

Reluctant to confide in others Questions the loyalty of friends

.56

DEP

A8 A7 A5

DISCUSSION

In this study, we used for the assessment of PD an instrument, the SIDP-R, revised to generate personality diagnoses according to diagnostic criteria modified from DSM-III to DSM-III-R. This fact must be taken into account when comparing our present findings on PAD and OCD patients to previous data in the literature. In fact, at least for some axis II diagnoses (e.g., histrionic), the changes in diagnostic criteria from DSM-III to DSM-III-R may account for remarkable discrepancies between studies, and two subjects with the same diagnosis can have consistently different traits according to the DSM-III or III-R criteria. Our PAD patients frequently have one or more co-occurring PD (60%). The more represented among the three DSM-III-R clusters, is cluster C, while the most frequent PD is histrionic (27.1%), from cluster B. OCD patients have a high proportion of co-occurring PD (68.8%) often belonging to cluster C, with avoidant PD most frequently represented, covering 26.7%. Also in these patients we found a high proportion of histrionic PD. The low rate of OCD PD found in our OCD patients suggests some comments. The relationship between obsessive-compulsive personality and OCD, recently reviewed by Pollack,” represents a matter of debate between those who traditionally view obsessive-compulsive personality features along a continuum with obsessive-

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compulsive symptoms (and thus expect a high proportion of OCD patients to have OCD PD characteristicsz9), and those who strongly sustain a distinction between the two elements3’ Differently from Rasmussen and Tsuang,” who found that 55% of 44 DSM-III OCD patients met criteria for compulsive personality disorder, our results report a low rate of such association. This result agrees with a 4% to 6% association found by other investigators”.” using DSM-III criteria, although Baer et al.” found a higher association when DSM-III-R criteria were employed. These results appear similar to those obtained by Mavissakalian et a1.19 Despite the differences in sample size, instruments for personality assessments, and, as already stated, in diagnostic criteria (we used DSM-III-R criteria, while they used DSM-III criteria), we also found a similarity of personality profiles in these two discrete diagnostic categories. Our findings fail to support the hypothesis of a specific link between DSM-III-R PD and these two anxiety disorders, rather suggesting an associated, common personality structure. The DSM-III-R axis II categories appeared to be of limited usefulness, when we looked for specific personality patterns in the patients of our sample. On the contrary, the personality traits seemed to be a more useful tool, providing a predicted group membership of 97.4%, once they were included in the discriminant analysis. Finally, we should consider the hypothesis that PD in patients with anxiety disorders can be an effect of enduring life-style changes induced by the illness. However, when we temptatively explored this possibility, comparing the proportion of PD present in the groups of patients with a duration of illness longer/shorter than 5 years, we did not find any statistically significant difference. Moreover, panic patients with agoraphobia did not differ from those without agoraphobia according to the percentage of PD diagnosed. To further clarify this question, we analyzed the PD distribution in OCD and PAD patients, subdivided according to the presence/absence of a positive family history for homotypic disorder. In fact, we inferred that a possible excess of PD in patients with a positive family history might represent an element against the hypothesis of the illness to cause a personality disorder. On the contrary, the lack of such effect may suggest that personality disorders represent a condition preexisting to axis I diagnoses, or even predictors of familial liability to anxiety disorders. However, we found no significant excess of PD patients with a positive family history neither in OCD nor in PAD (although a slight trend toward this direction was found in the families of the latter). Although many evidences support the link between cluster C PD and anxiety disorders in the same subjects, and some evidences support a familial aggregation conclusive information on this point can only be derived from of cluster C PD,31Z32 family studies of anxiety disorders assessing both axis I and II diagnoses. REFERENCES 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (ed 3). Washington DC, APA, 1981 2. Brooks RB, Baltazar PL, Munjack DJ: Co-occurrence of personality disorder with panic disorder, social phobia, and generalized anxiety disorder: A review of the literature. J Anx Disord :259-286,199O

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agoraphobia. Compr Psychiatry 6:535-544,1988 4. Reich J, Noyes R Jr, Troughton E: Dependent personality disorder associated with phobic avoidance in patients with panic disorder. Am J Psychiatry 144:323-326,1987 5. Friedman CJ, Shear MK, Frances AJ: DSM-III personality disorders in panic patients. J Pers Disord 1:132-135, 1987 6. Klass TE, Di Nardo PA, Barlow DM: DSM-III personality diagnoses in anxiety disorder patients. Compr Psychiatry 3:251-258,1989 7. Reich J, Noyes R, Yates W: Alprazolam treatment of avoidant personality traits in social phobic patients. J Clin Psychiatry 50:91-95,1989 8. Jenike MA, Baer L, Minichiello WE, Schwartz CE, Carey RJ: Concomitant obsessive-compulsive disorder and schizotypal personality disorder. Am J Psychiatry 143:530-532.1986 9. Joffe RT, Swinson RP, Regan JJ: Personality features of obsessive-compulsive disorder. Am J Psychiatry 145:1127-1129,1988 10. Baer L, Jenicke MA, Ricciardi JN II, et al: Standardized assessment of personality disorders in obsessive-compulsive disorder. Arch Gen Psychiatry 47:826-830.1990 11. Rasmussen SA, Tsuang MT: Clinical characteristics and family history in DSM-III obsessivecompulsive disorders. Am J Psychiatry 143:317-322,1986 12. Gasperini M, Battaglia M, Diaferia G, et al: Personality features related to generalized anxiety disorder. Compr Psychiatry 31:363-368,199O 13. Koenigsberg HW, Kaplan RD, Gilmore MM, et al: The relationship between syndrome and personality disorder in DSM-III: Experience with 2,462 patients. Am J Psychiatry 142:207-212, 1985 14. Reich JH, Troughton E: Comparison of DSM-III personality disorders in recovered depressed and panic disorder patients. J Nerv Ment Dis 176:300-304.1988 15. Reich JH: DSM-III personality disorders and the outcome of treated panic disorder. Am J Psychiatry 145:1149-1152, 1988 16. Noyes R Jr, Reich J, Cristiansen J, et al: Outcome of panic disorder. Relationship to diagnostic subtypes and comorbidity. Arch Gen Psychiatry 47:809-818, 1990 17. Joffe RT, Regan JJ: Personality and depression. J Psychiatr Res 22:279-286, 1989 18. Reich JH, Noyes R Jr, Hirschfeld R, et al: State and personality in depressed and panic patients. Am J Psychiatry 144:181-187. 1987 19. Mavissakalian M, Hamann MS, Jones B: A comparison of DSM-III personality disorders in panic-agoraphobia and obsessive-compulsive disorder. Compr Psychiatry 3:238-244,199O 20. Hyler SE, Rieder RO, Spitzer RL, et al: Personality Diagnostic Questionnaire (PDQ). New York, NY, NY State Psychiatric Institute, 1978 21. Reich JH: Update on instruments to measure DSM-III and DSM-III-R personality disorders. J Nerv Ment Dis 177:366-370,1989 22. American Psychiatric Association: Diagnostic and Statistic Manual of Mental Disorders (ed 3, revised). Washington DC, APA, 1987 23. Stangl D. Pfohl B, Zimmermann M, et al: A structured interview for DSM-III personality disorders. Arch Gen Psychiatry 42:591-596,1985 24. Goodman WK et al: The Yale-Brown Obsessive Compulsive Scale. Arch Gen Psychiatry 46:1006-1011, 1989 25. Gruppo Italian0 Disturbi d’Ansia: Familial analysis of panic disorder and agoraphobia. J Affect Disord 17:1-8,1989 26. Klecka WR: Discriminant Analysis. Beverly Hills, CA, Sage Publications, 1980 27. Jae-on-Kim: Factor analysis, in Nie NH, Hadlui Hull C (eds): Statistical Package for the Social Sciences. New York, NY, McGraw Hill, 1975, pp 468-516 28. Pollack J: Relationship of obsessive-compulsive personality to obsessive-compulsive disorder: A review of the literature. J Psycho1 121:137-148,1987 29. Salzman L: Obsessional Personality. New York, NY, Science House, 1968 30. Slade PD: Psychometric studies of obsessional illness and obsessional personality, in Beech HR (ed): Obsessional States. London, England, Methouen, 1974, pp 95-109 31. Reich JH: Familiality of DSM-III dramatic and anxious personality clusters. J Nerv Ment Dis 177:96-100, 1989 32. Reich JH: DSM III personality disorders and family history of mental illness. J Nerv Ment Dis 176:45-49,198s