Journal of Personality Disorders, 28, 2014, 174 © 2014 The Guilford Press

EMOTIONAL FUNCTIONING IN OBSESSIVE-­ COMPULSIVE PERSONALITY DISORDER: COMPARISON TO BORDERLINE PERSONALITY DISORDER AND HEALTHY CONTROLS Maria M. Steenkamp, PhD, Michael K. Suvak, PhD, Benjamin D. Dickstein, PhD, M. Tracie Shea, PhD, and Brett T. Litz, PhD Few studies have investigated emotional functioning in obsessive-­ compulsive personality disorder (OCPD). To explore the nature and extent of emotion difficulties in OCPD, the authors examined four domains of self-­reported emotional functioning—negative affectivity, anger, emotion regulation, and emotion expressivity—in women with OCPD and compared them to a borderline personality disorder (BPD) group and a healthy control group. Data were collected as part of a larger psychophysiological experimental study on emotion regulation and ­ personality. Compared to healthy controls, participants with OCPD ­ ­reported significantly higher levels of negative affectivity, trait anger, emotional intensity, and emotion regulation difficulties. Emotion regulation difficulties included lack of emotional clarity, nonacceptance of emotional responses, and limited access to effective emotion regulation strategies. Participants with OCPD scored similarly to participants with BPD on only one variable, namely, problems engaging in goal-­directed behavior when upset. Results suggest that OCPD may be characterized by notable difficulties in several emotional domains.

Obsessive-­compulsive personality disorder (OCPD) is characterized by excessive perfectionism, orderliness, and control (American Psychiatric Association [APA], 2013). Symptoms include preoccupation with rules and details, rigidity, difficulty delegating tasks, overconscientiousness, miserliness, excessive devotion to work, and an inability to discard worthless items (APA, 2013). Although emotional constriction is a hallmark feature

This article was accepted under the editorship of Robert F. Krueger and John Livesley. From VA Boston Healthcare System (M. M. S., B. D. D., B. T. L.); Boston University School of Medicine (M. M. S., B. T. L.); Suffolk University, Boston, Massachusetts (M. K. S.); and Veterans Affairs Medical Center, Providence, and Brown University, Providence, Rhode Island (M. T. S.). Maria Steenkamp is now at the Department of Psychiatry, New York University. Benjamin Dickstein is now at the VA Cincinnati Healthcare System. Address correspondence to Brett Litz, VA Boston Medical Center, 150 South Huntington Ave. (13B-­71), Jamaica Plain, MA 02130. E-­mail: [email protected]

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of OCPD, very little is known about emotional functioning in OCPD. The rigid overcontrol of emotion characteristic of OCPD stands apart from excessive emotional expressivity and affective lability often present in other personality disorders. Whereas OCPD is often presumed to be less impairing than other personality disorders and has thus received relatively less empirical attention (de Reus & Emmelkamp, 2012), it is possible that the emotional suppression and constriction associated with the disorder reflects broader underlying emotion difficulties that may deleteriously affect functioning. For example, the excessive need for interpersonal control often present in individuals with OCPD has been shown to lead to interpersonal difficulties with spouses and partners (Costa, Samuels, Bagby, Daffin, & Norton, 2005). Although almost no studies have examined emotion difficulties in OCPD directly, there is some limited evidence from related lines of research to suggest the presence of emotion difficulties in OCPD. For example, problems associated with emotion difficulties in other personality disorders, such as child abuse, anger, suicidality, and substance use (e.g., Kehrer & Linehan, 1996; Smoski et al., 2011; Trull, Sher, Minks-­Brown, Durbin, & Burr, 2000; Verona, Patrick, & Joiner, 2001; Zanarini, Gunderson, Frankenburg, & Chauncy, 1990), are associated with OCPD as well. Child maltreatment has been implicated in the development of emotional functioning difficulties (Maughan & Cicchetti, 2002), and in one large study on child abuse across multiple personality disorders, 72% of participants diagnosed with OCPD reported a history of childhood abuse, including 36% endorsing sexual abuse and 81% endorsing neglect (Battle et al., 2004). A recent study of anger across the personality disorders found nearly identical rates of anger in patients with OCPD and those with borderline personality disorder (BPD); of all personality disorders, OCPD and BPD ranked second and third, respectively, in terms of the extent of anger (avoidant personality disorder ranked first; DiGiuseppe et al., 2012). Factor analytic studies of OCPD symptoms have found aggressiveness, along with perfectionism, to be a core dimension of the disorder (Hummelen, Wilberg, Pedersen, & Karterud, 2008), and interpersonal rigidity is associated with anger and aggression in outpatients with OCPD (Ansell et al., 2010). Moreover, OCPD has been associated with suicidal ideation and suicide attempts even after controlling for depression (Diaconu & Turecki, 2009; Raja & Azzoni, 2007), and in one large epidemiological study, 30% of in­dividuals with OCPD met criteria for a substance use disorder (Grant, Mooney, & Kushner, 2012). To explore the nature and extent of emotion difficulties in OCPD, we conducted post-­hoc analyses on self-­report data collected as part of a larger psychophysiological experiment on emotion regulation and personality (see Suvak et al., 2012). We assessed four domains of self-­reported emotional functioning—negative affectivity, anger, emotion regulation, and emotion expressivity—in women with OCPD and compared them to a BPD group and a healthy control (HC) group. These two control groups represent putative opposite ends of the emotional functioning spectrum: Healthy (no psychopathology) controls represent ostensibly normative emotional

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functioning, whereas BPD is well documented to be characterized by multiple and severe emotion functioning difficulties (for reviews, see Carpenter & Trull, 2013; Rosenthal et al., 2008). Although other personality disorders have also been associated with emotion difficulties (e.g., Berenbaum et al., 2006; Rogstad & Rogers, 2008), emotion difficulties in BPD have received by far the most empirical and theoretical attention. We hypothesized that participants with OCPD would in general more closely resemble healthy controls than BPD controls on all four domains of emotion functioning, given the well-­ documented severity of emotional dysfunctional typically associated with BPD. However, we expected that some emotion difficulties would be present in the OCPD group, such that OCPD participants’ scores would generally fall between those of the BPD participants and the healthy controls. In terms of negative affectivity, we hypothesized that participants with OCPD would score higher than healthy controls but lower than participants with BPD, given evidence that higher-­than-­normal neuroticism may be common across personality disorders, but differentiate less well between specific personality disorders (Morey et al., 2002). We expected that OCPD participants would score similarly to participants with BPD on both trait and state anger, given recent studies showing comparable levels of anger in the two disorders (DiGiuseppe et al., 2012). We hypothesized that emotion regulation difficulties would be more pronounced among participants with BPD than participants with OCPD, given the severity of emotion regulation problems typical of BPD. However, we expected greater emotion regulation difficulties in participants with OCPD than healthy controls, based on the association between OCPD and child abuse, suicidality, and substance use. Lastly, we predicted that participants with OCPD would on average report less expressivity of both positive and negative emotions than healthy and BPD controls, because the lack of emotional expressivity is often considered a key clinical feature of OCPD.

RESEARCH DESIGN AND METHODS Data used in the present analyses were collected as part of a larger multimethod experiment of emotional functioning and personality (Suvak et al., 2012). PARTICIPANTS Participants were adult females, 23 with OCPD, 24 with BPD, and 28 with no pathology (healthy controls). To be included, participants who met criteria for BPD could not meet criteria for OCPD, and vice versa. Participants in the healthy control group could not meet lifetime diagnostic criteria for any psychological disorder. Most participants were Caucasian (77.3%) and single (68.0%); the mean age was 32.81 (SD = 12.25) and the mean number of years of education was 15.36 (SD = 2.22). A series of chi-­ square analyses and one-­way ANOVAs indicated that the groups did not

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significantly differ on demographic variables. Most participants were recruited using flyers posted on community and Internet bulletin boards (e.g., “have you been described as rigid or stubborn?”, “do you feel pressure to be perfect?”). Participants had to be at least 18 years old and able to provide informed consent. They were informed that the purpose of the study was to determine how personality affects emotions. Five participants from the BPD group and five from the OCPD group were referred from the Brown University and McLean Hospital sites of the Collaborative Longitudinal Study of Personality Disorders (CLPS; Gunderson et al., 2000). A substantial portion of BPD and OCPD participants reported current use of psychotropic medication (58% and 42%, respectively); none of the healthy control participants reported medication use. Participants were compensated for their time and travel expenses.

PROCEDURE The larger study was conducted over two sessions conducted approximately 1 week apart. The first session was devoted to diagnostic interviews, self-­report questionnaires, and, at the end of the session, the generation of an anger narrative. The second session involved a laboratory assessment of psychophysiological emotional responses to idiographic anger scripts. Only Session 1 self-­report data are used in the present analyses; by design, the sequencing of study procedures aimed to ensure that self-­report measures would not be affected by other study procedures.

DIAGNOSTIC INTERVIEWS To determine diagnostic status, the OCPD and BPD modules of the Diagnostic Interview for Personality Disorders (DIPD-­ IV; Zanarini, Frankenburg, Chauncey, & Gunderson, 1987) and the Structured Clinical Interview for DSM-­IV (SCID; First et al., 1996) were administered by trained doctoral-­or master’s-­level clinical psychologists. The DIPD-­IV is a semistructured diagnostic interview based on DSM-­IV personality disorder criteria. In this interview, symptoms must be present and pervasive for at least 2 years and characteristic of the person during her adult life. The SCID (First et al., 1996) is a widely used semistructured clinical interview designed to assess Axis I disorders. The mood, anxiety, and psychotic modules were used in the current study. Both the DIPD-­IV and SCID have shown excellent psychometric properties (First et al., 2006; Zanarini et al., 1987). All assessments were supervised and checked for diagnostic accuracy by an experienced doctoral-­level psychologist.

MEASURES OF EMOTIONAL FUNCTIONING The Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004), a 36-­item self-­report measure of emotion regulation deficits in six domains

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corresponding with Gratz and Roemer’s multidimensional model of emotion regulation, was administered to assess emotion dysregulation. Subscales assess (a) nonacceptance of emotional responses (e.g., “when I’m upset, I become irritated with myself for feeling that way”; α = .94); (b) difficulties engaging in goal-­directed behavior (e.g., “when I’m upset, I have difficulty getting work done”; α = .92); (c) impulse control difficulties (e.g., “when I’m upset, I lose control over my behaviors”; α = .91); (d) lack of emotional awareness (e.g., “I pay attention to how I feel”, reverse coded; α = .89); (e) limited access to emotion regulation strategies (e.g., “when I’m upset, I believe I will remain that way for a long time”; α = .81); and (f) lack of emotional clarity (e.g., “I have difficulty making sense out of my feelings”; α = .80). The Emotion Regulation Questionnaire (ERQ; Gross & John, 2003) is a 10-­item self-­report measure of two emotion regulation strategies: expressive suppression (inhibiting emotional expression; e.g., “I keep my emotions to myself”; α = .60) and cognitive reappraisal (changing appraisal of a situation so as to change its emotional impact; e.g., “I control my emotion by changing the way I think about the situation I am in”; α = .68). Cognitive reappraisal is considered more psychologically adaptive than expressive suppression. The Berkeley Expressivity Questionnaire (BEQ; Gross & John, 1997) is a 16-­ item questionnaire assessing emotional expressivity, defined as the observable behavioral changes that accompany emotion, such as smiling, screaming, or slamming doors. Three subscales measure (a) impulse strength (the general strength of emotional response tendencies, for example “I experience my emotions very strongly”; α = .75), (b) negative expressivity (the extent to which negative emotional response tendencies are expressed behaviorally, for example “I sometimes cry during sad movies”; α = .71), and (c) positive expressivity (the extent to which positive emotional response tendencies are expressed behaviorally, for example “when I’m happy, my feelings show”; α = .64). The BEQ subscales demonstrate good convergent and discriminant validity (Gross & John, 1997). The State-­T rait Anger Expression Inventory (STAXI; Spielberger, 1988) assesses multiple domains of state and trait anger. It is a widely used measure of anger that consists of 44 items assessing the intensity and frequency of respondents’ experience, expression, and control of anger. We used the Trait and State subscales in the present analyses: The Trait scale measures the respondent’s disposition toward experiencing anger (α = .92), while the State scale measures the individual’s level of anger at the time of completing the measure (α = .90). Trait negative affectivity, which roughly corresponds to the construct of neuroticism (i.e., the tendency to experience negative emotions; Watson, Clark, & Tellegen, 1988), was assessed using the Positive and Negative Affectivity Schedule (PANAS, trait version; Watson et al., 1988). The PANAS is a self-­report measure that lists 20 positive and negative affect mood states and asks respondents to rate how much they generally feel that particular emotion (α = .75).

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The Beck Depression Inventory, second version (BDI-­II; Beck, Steer, Ball, & Ranieri, 1996) is a 21-­item self-­report measure that assesses the cognitive, affective, motivational, and physiological symptoms of depression (α = .96). Each item consists of four statements reflecting severity level, and individuals are requested to select the statement that best describes their recent feelings (i.e., past 2 weeks) and experiences. The BDI-­II has good to excellent psychometric properties in terms of internal consistency, temporal stability, and convergent and discriminant validity. The BDI-­II was included in this study to control for group differences in depression severity. The Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) is a 21-­item measure that asks participants to rate the severity of their symptoms of anxiety within the past week on a 4-­point scale ranging from 0 (not at all) to 3 (severely). Scores on all items are summed to obtain a general severity of anxiety score, indicating the presence of physical and/ or psychological symptoms of anxiety (α = .94). The BAI has been shown to have high test-­retest reliability and to reliably discriminate between anxious and nonanxious diagnostic groups (Beck et al., 1988). The BAI was included to control for group differences in anxiety severity. The 25-­item version of the Inventory of Interpersonal Problems–Personality Disorder Scales (IIP-­PD; Kim & Pilkonis, 1999) assesses the presence of personality pathology, based on the rationale that chronic interpersonal difficulties are good overall markers of personality pathology (e.g., “I am too sensitive to rejection”, “I try to please other people too much”; α = .96). The 25-­item version of the IIP-­PD has been shown to perform comparably to longer versions of the measure, and demonstrates good psychometric properties (Kim & Pilkonis, 1999). The IIP-­PD was included to control for group differences in overall severity of personality pathology.

RESULTS The average number of BPD criteria endorsed across the three conditions was 5.74 (SD = 1.54), 0.38 (SD = 0.62), and 0.00 (SD = 0.00) for the BPD, OCPD, and HC conditions, respectively. The average number of OCPD criteria endorsed across the three conditions was 1.26 (SD = 1.25) 4.38 (SD = 1.09), and 0.21 (SD = 0.50). An initial review of the data revealed some missing values. One participant (1.3%) was missing data on the DERS and BEQ; two (2.7%) were missing data on the STAXI; and four (5.3%) were missing data on the PANAS and ERQ. Given that no more than 5% of participants were missing data on the emotional functioning measures, the default missing data technique found in SPSS version 17, pairwise deletion, was used when comparing emotional functioning across groups (see Buhi, Goodson, & Neilands, 2008). A series of ANOVAs were conducted to examine group differences on all measures of emotional functioning (see Table 1). For several of the outcome variables, Levine’s test indicated that the equality variances assumption of ANOVA was violated. For these variables, Welch’s F-­test and

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15.57 (1.41)b 19.04 (4.42)b 32.17 (8.19) 17.27 (6.01)b 25.35 (6.02) 24.04 (3.35) 30.47 (5.60)b 12.43 (5.83)b 14.13 (4.83)a   9.43 (3.87)b 12.70 (3.97)b 16.17 (6.68)b   9.52 (2.87)b 27.00 (5.84) 10.91 (3.64)

22.70 (12.92)a 23.42 (6.53)a 27.79 (10.19)a 32.39 (8.89)a 22.58 (7.77) 21.96 (4.46) 35.08 (5.19)a 17.79 (6.30)a 16.88 (4.28)a 16.29 (4.91)a 16.42 (5.86)a 23.75 (8.16)a 12.71 (3.11)a 25.17 (6.05)a 13.58 (4.97)

OCPD M (SD )

  8.04 (2.30)c 10.00 (4.25)b   7.32 (1.61)b 10.21 (3.55)b   9.82 (2.07)c   7.07 (1.51)c 30.21 (4.62)b 12.04 (3.97)

24.71 (4.70) 23.39 (2.73) 25.54 (4.65)c

34.85 (6.08)b 11.78 (1.78)c

15.07 (0.38)b 13.00 (2.42)c

Healthy Control M (SD )

28.82w (2, 36.12)*** 15.84 (2, 72)*** 37.20w (2, 35.97)*** 10.55w (2, 44.51)*** 39.94w (2, 33.68)*** 34.75w (2, 39.50)***   5.58 (2, 69)**   2.38 (2, 72)

  .97w (2, 43.69)  1.64w (2, 44.02) 22.50 (2, 72)***

 4.43w (2, 43.30)* 64.98w (2, 31.49)***

 5.27w (2, 31.72)* 38.46w (2, 31.49)***

Fw

−1.07 −.62 −1.88 −.82 −1.25 −2.47 .33 −.63

.44 .59 −.89

.53 −2.47

−.96 −.94

Effect Size OCPD-BPD

.88 .93 .58 .55 1.05 .90 −.59 −.26

.10 .10 .96

−.32 .90

.07 1.29

Effect Size OCPD-HC

Note. Means with different subscripts differ significantly. BPD = Borderline personality disorder. OCPD = Obsessive compulsive personality disorder. w denotes that the Levine’s test indicated that the equality of variances assumption of ANOVA was violated and the Welch F-test and Games-Howell post-hoc tests, which are robust to this violation, were used. Effect Size = (xOCPD – xBPD or HC)/√MSW , where MSw = Mean Square Within, positive numbers indicate the OCPD group has a larger mean, and negative values indicate the OCPD group has a smaller mean, and .20, .50, and .80 indicate small, medium, and large effects, respectively (Cohen, 1988). *p < .05. **p < .01. ***p < .001.

Anger   State anger   Trait anger Positive and negative affectivity   Positive affectivity   Negative affectivity Emotional expressivity   Negative expressivity   Positive expressivity   Impulse strength Emotion regulation   Emotion nonacceptance   Lack of goal behavior   Impulse noncontrol   Emotional nonawareness   Strategy nonaccess   Emotional nonclarity   Cognitive reappraisal   Expressive suppression

Variable

BPD M (SD )

TABLE 1. Means and Standard Deviations of Emotional Functioning Measures According to Group

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Games-­Howell post-­hoc comparisons, which are robust to violations of the equality of variance assumption, were used as omnibus condition and follow-­up tests, respectively. In terms of negative affectivity, participants with OCPD reported higher levels of negative affectivity (PANAS) than healthy controls, but significantly less negative affectivity than participants with BPD. Participants with OCPD did not differ significantly from the other two groups in terms of positive affectivity (PANAS), although the BPD group reported significantly less positive affectivity than healthy controls. Participants with OCPD endorsed more trait anger than the healthy controls, but less trait anger than participants with BPD (STAXI); they endorsed levels of state anger (STAXI) comparable to those of healthy controls, which were both significantly lower than that of the BPD group. With regard to emotion regulation, post-­hoc Tukey comparisons revealed that, compared to healthy controls, participants with OCPD endorsed higher levels of lack of nonacceptance of emotion (DERS), lack of emotional clarity (DERS), and lack of access to emotional regulation strategies (DERS), but comparable levels of impulse control difficulties (DERS) and nonawareness of emotion (DERS). On the DERS, participants with OCPD scored similarly to participants with BPD only in terms of lack of goal-­ directed behavior when upset; they scored lower than participants with BPD on the nonacceptance of emotion, lack of impulse control, lack of emotional awareness, lack of access to emotion regulation strategies, and lack of emotional clarity subscales. Participants with OCPD did not differ from the other two groups on either the use of cognitive reappraisal or expressive suppression (ERQ). In terms of emotion expressivity, participants with OCPD reported greater impulse strength (BEQ) than healthy controls, but less than the BPD group; no group differences emerged between the three groups in terms of positive and negative expressivity (BEQ). The original manuscript from this study (Suvak et al., 2012) reported that BPD participants met diagnostic criteria for depression disorders, panic disorder, and social anxiety disorder (13, 8, and 9 participants, respectively) relative to the OCPD group (5, 4, and 4 participants, respectively). Using the data only from these two conditions (i.e., excluding the healthy control group), we conducted a series of post-­hoc ANCOVAs, controlling for anxiety and depressive symptoms by including the BAI and BDI as covariates to see if comorbid mood and anxiety symptoms could be accounting for some of the differences in emotional processes between the two personality disorder groups. The original analyses indicated significant differences between the OCPD and BPD groups on nine of the outcomes. When including the BAI and BDI as covariates, the BPD-­OCPD difference remained statistically significant for three outcomes (ps < .05; negative affectivity, impulse control difficulties [DERS], and nonacceptance of emotion [DERS]), approached statistical significance for two additional outcomes (ps < .09; state anger and lack of emotional clarity [DERS]), and was no longer statistically significant for four outcomes (ps > .70; trait anger, impulse strength [BEQ], lack of access to emotional regu-

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lation strategies [DERS], and nonawareness of emotion [DERS]). Although conclusions drawn from these post-­hoc analyses must be made very tentatively given our sample size, they suggest that a higher level of comorbid anxiety and depression might account for some, but not all, of the differences in emotional processes between the two personality disorder groups. One final series of post-­hoc analyses was conducted to evaluate whether the differences between the OCPD and BPD conditions might be due to the higher overall levels of personality pathology in the BPD group. The BPD group (M = 1.06, SD = 0.37) reported higher scores on the IIP-­PD than did the OCPD group (M = 0.65, SD = 0.32), F(1, 45) = 16.95, p < .001. Thus, we included IIP-­PDs as a covariate in a series of post-­hoc ANOVAS. The results indicated that significant BPD-­OCPD differences remained for only two outcome variables—negative affectivity and impulse control difficulties (DERS). This suggests that some of the differences in emotional processes documented in the original analyses might be differences due to overall level of personality pathology, of which interpersonal difficulties are most captured in the IIP-­PD. However, even when controlling for these differences, BPD was associated with higher levels of negative affectivity and impulse control problems compared to OCPD. One interesting aspect of our findings was that the variance in almost all of the outcomes was not constant across groups. The BPD group exhibited the most variance, the HC group exhibited the least variance, and the OCPD group fell between the BPD and HC conditions. This prompted a careful examination of the distribution of the outcomes across groups. The general pattern that emerged was that the BPD group exhibited the least skewed, most normal distribution for almost all outcome variables. The HC group exhibited the most positively skewed distributions across the outcomes, with most participants endorsing few emotional processing difficulties. This suggests that the observed mean level differences across the groups were not due to a few outliers in the BPD condition that pulled the mean away from the other two groups.

DISCUSSION We examined self-­reported negative affectivity, anger, emotion regulation, and emotional expressivity in women with OCPD and compared them to a BPD group and a healthy control group. We found that although OCPD is not formally associated with emotion difficulties in the DSM-­5, participants with OCPD endorsed notable emotion difficulties across a number of domains. As hypothesized, the OCPD group’s scores generally fell between those of the BPD group and the healthy controls. Participants with OCPD endorsed stronger-­than-­normal negative affect (including trait anger) that they had difficulty accepting, understanding, and managing effectively. However, they reported being able to control the expression of these emotions and, unlike participants with BPD, reported being able to keep impulses in check.

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COMPARISON TO HEALTHY CONTROLS As predicted, participants with OCPD reported significantly more general negative affectivity than healthy controls, which is consistent with personality theories proposing that negative affectivity/neuroticism is a core dimension cutting across the personality disorders (e.g., Widiger & Simonsen, 2005). Participants with OCPD also reported significantly higher trait (but, unexpectedly, not state) anger compared to healthy controls, adding to a growing number of studies suggesting that anger difficulties may be common in OCPD (e.g., Ansell et al., 2010; DiGuiseppe et al., 2012; Hummelen et al., 2008; Pulay et al., 2008). For instance, Villemarette-­Pittman, Stanford, Greve, Houston, and Mathias (2004) have argued that OCPD symptoms may serve a compensatory function in individuals who are behaviorally dysregulated, such that symptoms such as rigidity represent attempts to manage underlying impulsive aggression. Consistent with this notion of OCPD involving maladaptive compensatory attempts to manage strong underlying negative emotions, participants with OCPD reported stronger-­ than-­ typical general emotional response tendencies (i.e., reported feeling their emotions strongly). They also endorsed three types of emotion regulation problems, suggesting that they have difficulties managing these strongly felt negative emotions. Specifically, participants with OCPD reported difficulty accepting emotion (e.g., “when I’m upset, I feel angry with myself for feeling that way”), difficulty achieving emotional clarity (e.g., “I have difficulty making sense out of my feelings”), and difficulty having access to effective emotion regulation strategies (e.g., “when I’m upset, I believe there is nothing I can do to make myself feel better”). As such, they endorsed finding their emotions unacceptable, confusing, and difficult to manage when upset, possibly helping explain the avoidance of emotion characteristic of this disorder. Conversely, participants with OCPD scored comparably to healthy controls on two DERS emotion regulation subscales. Participants with OCPD did not endorse impulse control difficulties when upset (e.g., “when I’m upset, I become out of control”), which is consistent with the overcontrol associated with OCPD. They also endorsed typical awareness of their emotions (e.g., “I pay attention to how I feel”); it is possible that this intact capacity to attend to and acknowledge their emotions may reflect self-­ monitoring and vigilance of emotions aimed at keeping emotions in check.

COMPARISON TO BPD CONTROLS As expected, participants with OCPD endorsed fewer and less severe emotion difficulties than participants with BPD, and did not evidence greater difficulties than the BPD group on any of the variables assessed. By and large, participants with BPD reported stronger and more negative emotions and greater problems with emotion regulation than participants with OCPD. The only measure on which participants with OCPD scored compa-

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rably to participants with BPD was the “lack of goal-­directed behavior” subscale of the DERS, which measures difficulties accomplishing tasks and concentrating when upset. A possible explanation for this finding is that the items on this subscale suggest a ruminative process (e.g., “when I’m upset, I have difficulty focusing on other things”, “when I’m upset, I have difficulty thinking about anything else”); indeed, a study comparing rumination across various personality disorders found rumination to be uniquely associated with BPD and OCPD traits, suggesting that preoccupational thinking may be characteristic of both disorders (Smith, Grandin, Alloy, & Abramson, 2006). Unexpectedly, there were no clear differences between participants with OCPD and the two control groups on the ERQ, which more broadly assesses two core emotion regulation strategies, namely, cognitive reappraisal and expressive suppression. Compared to healthy controls, one might have expected the BPD and OCPD groups to endorse more expressive suppression (a generally maladaptive strategy that can increase emotional intensity and that might have explained BPD and OCPD participants’ self-­reported greater emotional intensity) and less cognitive reappraisal (a generally adaptive strategy). However, whereas participants with BPD reported using significantly fewer cognitive reappraisal strategies than healthy controls, participants with OCPD did not differ significantly from either group. There were also no significant differences between the groups in terms of positive and negative emotional expressivity on the BEQ. All three groups endorsed behaviorally expressing positive and negative emotions to a similar degree, suggesting some modulation of behavioral expression by the OCPD and BPD groups, who endorsed stronger underlying emotions on the impulse strength subscale. In addition to showing mean level differences across groups, our findings documented differences in variance and distribution in emotional functioning, with the HC group exhibiting the smallest amount of variance but the largest positive skewness, and the BPD group exhibiting the most amount of variance with the least amount of skewness. This corroborates recent efforts focusing on understanding the impact of personality pathology on both mean level and variation in emotional responding (e.g., Jahng, Wood, & Trull, 2008; Trull et al., 2008). Like Trull and colleagues, we encourage researchers to utilize within-­subjects designs that include multiple assessments of emotional responding across time to be able to better analyze both mean level and variation. This approach allows one to separate overall variation into two sources: variation in emotional responding within individuals across time, and variation between individuals.

ROLE OF COMORBIDITY To test the possibility that group differences in comorbid anxiety, depression, and overall severity of personality pathology might account for group differences in emotional functioning, in post-­hoc tests we included as co-

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variates anxiety, depression, and overall severity of personality pathology (particularly interpersonal difficulties). Although these findings are tentative given power limitations associated with testing covariates in our sample size, they highlight the potentially important role of comorbidity in emotional functioning in OCPD, as differences on four outcomes between the BPD and OCPD groups lost statistical significance after controlling for anxiety and depression: trait anger, impulse strength (BEQ), lack of access to emotional regulation strategies (DERS), and nonawareness of emotion (DERS). State anger and lack of emotional clarity (DERS) approached statistical significance (ps < .09). Three variables—nonacceptance of emotion, negative affectivity, and impulse control—remained significantly higher among participants with BPD than participants with OCPD, while only the latter two remained significant after controlling for overall personality pathology severity, suggesting that BPD may be associated with higher levels of negative affectivity and impulse control problems than OCPD even when controlling for Axis I and personality pathology. However, the fact that depression (e.g., Corruble, Ginestet, & Guelfi, 1996) and anxiety (e.g., Skodol et al., 1995) are common in patients with BPD and OCPD complicates the interpretation of these findings, because stripping comorbidity from the phenomenology of OCPD and BPD may artificially distort many patients’ lived experience of these disorders (i.e., what is BPD when one takes away comorbid psychopathology?). This speaks to the need for future research with larger samples to thoroughly assess comorbid conditions to help distinguish emotional functioning abnormalities that are uniquely associated with specific personality disorders from emotional functioning abnormalities that are associated with Axis I and personality pathology more generally.

LIMITATIONS There are several limitations to this study. First, the generalizability of our findings is limited by the relatively small sample size and by the fact that we recruited only female participants. Although gender differences in OCPD symptom presentation have not yet been investigated, gender may be particularly salient in the study of emotional functioning given evidence of gender differences in emotion regulation strategies (e.g., Rusting & Nolen-­Hoeksema, 1998). Second, in terms of personality disorders, participants were assessed only for BPD and OCPD and as such the impact of comorbid personality disorders is not known. It is unknown whether OCPD was the principal personality disorder diagnosis for participants in the OCPD group, which limits the extent to which our findings for this group can be singularly attributed to OCPD. The results speak only to differences between BPD, OCPD, and healthy controls and may differ when comparing OCPD to other personality disorders. Third, data stemmed solely from self-­report measures and were thus subject to the limitations associated with such instruments.

EMOTIONAL FUNCTIONING IN OCPD13

CONCLUSION The present exploratory analyses are among the first to directly examine emotion difficulties in OCPD. The findings suggest that, although not formally associated with emotion difficulties in DSM-­5 diagnostic criteria, OCPD may be characterized by difficulties in several emotional domains. The apparent outward control characteristic of OCPD may belie stronger-­ than-­normal underlying negative emotion that the individual has trouble regulating effectively. In the absence of effective emotion regulation strategies, individuals with OCPD may resort to rigid emotional constriction and overcontrol, in turn preventing learning of more adaptive and flexible emotion regulation strategies that may ultimately promote understanding and acceptance of emotion. Treatments for OCPD may thus benefit from including emotion regulation skills, such as dialectical behavioral therapy (DBT) strategies, and initial case reports have indeed shown DBT to be effective in alleviating OCPD symptoms (Lynch & Cheavens, 2008; Miller & Kraus, 2007). Overall, these preliminary findings suggest several avenues for future research, including further exploration of the role of anger, aggression, and other negative affects in OCPD; the contribution of comorbid conditions in emotional functioning in OCPD; the use of emotional avoidance as a compensatory strategy for underlying emotion difficulties in OCPD; and the potential role of rumination in OCPD. REFERENCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Ansell, E. B., Pinto, A., Crosby, R. D., Becker, D. F., Añez, L. M., Paris, M., & Grilo, C. M. (2010). The prevalence and structure of obsessive-­compulsive personality disorder in Hispanic psychiatric outpatients. Journal of Behavior Therapy and Experimental Psychiatry, 41, 275–281. Battle, C. L., Shea, M. T., Johnson, D. M., Yen, S., Zlotnick, C. Zanarini, M. C., . . . Morey, L. C. (2004). Childhood maltreatment associated with adult personality disorders: Findings from the Collaborative Longitudinal Personality Disorders Study. Journal of Personality Disorders, 18, 193–211. Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893–897. doi: 10.1037/0022-­006X.56.6.893

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