Development of personality disorders in children and adolescents with obsessive-compulsive disorder A 6- to 22-year follow-up study

Forty-seven people with admissions in childhood for obsessive-compulsive disorder (OCD) and 49 child psychiatric controls were followed up in young adulthood and assessed for DSM-III-R personality disorders with the Structured Clinical Interview for DSM-III-R Personality Disorders. The number of personality disorders in OCD patients did not differ significantly from the number in controls. The most common personality disorder was avoidant personality disorder (significantly more frequent than in controls), whereas obsessive-compulsive personality disorder (OCPD) was not found more often in the OCD group. Subjects with OCD in adulthood seemed to have OCPD more often than childhood OCD patients with no OCD at follow-up. In the whole group, histrionic personality disorders were more common in women than in men and OCPD more common in men than in women, whereas borderline personality disorder was most common among women in the OCD group. The presence of a personality disorder in adulthood could not be correlated with such childhood factors as social background, symptoms or age of onset of OCD.     

Trauma and posttraumatic stress disorder in treatment-resistant obsessive-compulsive disorder

Prior research has indicated a seemingly unique relation between obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) that appears to relate to negative treatment outcome for OCD. However, to date, the prevalence of trauma and PTSD in individuals seeking treatment for OCD is unclear. To begin to address this gap, this study assessed history of traumatic experiences and current PTSD in individuals seeking treatment for treatment-resistant OCD. Trauma predictors of PTSD severity also were examined in this sample. Participants included 104 individuals diagnosed with treatment-resistant OCD who sought treatment over the course of 1 year from OCD specialty treatment facilities. Data were collected via naturalistic retrospective chart reviews of pre-treatment clinical intake files. Findings revealed that 82% of participants reported a history of trauma. Over 39% of the overall sample met criteria for PTSD, whereas almost 50% of individuals with a trauma history met criteria for PTSD. Interpersonal traumas and greater frequency of traumas were most predictive of PTSD severity, and individuals diagnosed with OCD and additional major depressive disorder (MDD) or borderline personality disorder (BPD) appeared at particular risk for a comorbid PTSD diagnosis. PTSD may be relatively common in individuals diagnosed with treatment-resistant OCD; and interpersonal traumas, MDD, and BPD may play a relatively strong predictive role in PTSD diagnosis and severity in such OCD patients.     

Obsessive-compulsive disorder and axis II

The relationship between obsessive-compulsive disorder (OCD) and personality traits and characteristics has been of great interest to psychiatrists and researchers. Psychoanalysts have long believed that obsessive-compulsive personality traits (e.g. rigidity, over-conscientiousness, resistance to change) stemmed from a fixation at the anal stage of character development and were the precursor to OCD. Research tended to support this view, as early studies showed these traits to be common in patients with OCD and in their first-degree relatives. However, more recent work using standardized assessments has shown that while 33% to 88% of patients with OCD meet criteria for a personality disorder (most commonly from cluster C), and many patients have obsessive-compulsive personality traits, only a few actually meet criteria for obsessive-compulsive personality disorder. Recent work has also shown that OCD patients with a personality disorder are more symptomatic than patients without a personality disorder, and are also more likely to respond poorly to medication, especially those with cluster A disorders (e.g. schizotypal, paranoid personality). Schizotypal personality specifically may predict response to augmentation of an anti-obsessional agent with an antipsychotic. Interestingly, many abnormal personality traits tend to improve once the patient with OCD has been successfully treated. The relationship between OCD and personality disorder continues to be debated. Some of the remaining issues include determining the true prevalence of personality disorder in unselected samples of OCD patients; determining whether personality disorder is independent and largely unrelated to OCD or develops as a consequence of having OCD; learning how personality disorders interfere with treatment response; and, finally, what happens to personality disorders in OCD patients over time. Long-term follow-up studies will be needed to help clarify these issues.     

EEG-vigilance differences between patients with borderline personality disorder,patients with obsessive-compulsive disorder and healthy controls

The regulation of brain activation, as assessed with the EEG, is a state modulated trait. A decline to lowered EEG-vigilance states has been found to be associated with emotional instability in older studies, but has not been systematically studied in patients with borderline personality disorder (BPD). Twenty unmedicated BPD patients were compared to 20 unmedicated patients with obsessive-compulsive disorder (OCD) as well as 20 healthy controls concerning their EEG-vigilance regulation over a 5-min period assessed with an algorithm classifying every artefact-free 2-s EEG segment into the EEG-vigilance state (A1–A3, B (=non-A)). If the alpha power was posterior more than 55% of the whole alpha power (anterior + posterior) in the artefact-free EEG-segments, that segment was marked as A1, if it was anterior more than 55% of the whole alpha power, as A3. For A2 the following rule was defined: Posterior or anterior alpha between 50 and 55% of the whole alpha power. BPD patients showed significantly lower rates of EEG-vigilance state A compared to OCD patients, indicating a lowered EEG-vigilance. All three groups showed a decrease in the rate of EEG-vigilance state A over the 5 min recording period in line with a lowering of vigilance. The study provides evidence for a less stable regulation of EEG-vigilance in BPD compared to OCD patients and is in line with concepts postulating that the behavioural pattern with sensation seeking and impulsivity in BPD has a compensatory and autoregulatory function to stabilize activation of the CNS.     

Uncomplicated and comorbid obsessive-compulsive disorder in an epidemiologic sample

This study investigated lifetime prevalence rates, demographic characteristics, childhood conduct disorder and adult antisocial features, suicide attempts, and cognitive impairment in individuals with obsessive-compulsive disorder (OCD) uncomplicated by or comorbid with any other psychiatric disorder. The data are from the NIMH Epidemiologic Catchment Area (ECA) study, and the current analyses compared subjects with uncomplicated OCD (no history of any other lifetime psychiatric disorder), comorbid OCD (with any other lifetime disorder), other lifetime psychiatric disorders, and no lifetime psychiatric disorders across these variables. OCD in its uncomplicated and comorbid form had significantly higher rates of childhood conduct symptoms, adult antisocial personality disorder problems, and of suicide attempts than did no or other disorders. Comorbid OCD subjects had higher rates of mild cognitive impairment on the Mini-Mental Status Exam than did subjects with other disorders. These findings suggest that a subgroup of OCD patients may have impulsive features, including childhood conduct disorder symptoms and an increased rate of suicide attempts; wider clinical attention to these outcomes is needed. Depression and Anxiety 4:111–119, 1996/1997.© 1997 Wiley-Liss, Inc.     

瑞典大学人格量表在强迫症患者中的应用

目的采用瑞典大学人格量表（SSP）探讨强迫症患者的人格特质及其与不同临床特征的关系。方法收集33例符合DSM-IV诊断标准的强迫症患者及31例健康对照,采用瑞典大学人格量表（SSP）评估两组样本的人格特质,采用Yale-Brown强迫量表（Y-BOCS）、汉密尔顿焦虑量表（HA-MA）和汉密尔顿抑郁量表（HAMD）评估强迫症患者临床特征。结果强迫症组躯体性焦虑、精神性焦虑、应激敏感性、怨恨、兴奋性和不信任分量表分别为57.70±11.64、63.19±10.41、66.77±10.31、61.14±7.56、54.09±9.13、57.15±11.57,健康对照组分别为46.18±8.30、52.08±8.42、55.79±7.69、56.37±7.92、48.03±7.69、51.59±9.97,强迫症组高于对照组,差异有统计学意义。其余分量表的差异无统计学意义。强迫症患者SSP社交愿望分与Y-BOCS总分呈正相关（r=0.349,P〈0.05）;躯体性焦虑、精神性焦虑和应激敏感性分与HAMA、HAMD总分呈正相关;社交愿望分与HAMA呈正相关;怨恨分与HAMD呈正相关。结论强迫症患者具有神经质和攻击性人格特质;强迫症患者的人格特质与强迫、焦虑和抑郁症状之间可能存在一定的相关性。     

Axis II comorbidity of borderline personality disorder: description of 6-year course and prediction to time-to-remission

OBJECTIVE: The purpose of this study was to compare the axis II comorbidity of 202 patients whose borderline personality disorder (BPD) remitted over 6 years of prospective follow-up to that of 88 whose BPD never remitted. METHOD: The axis II comorbidity of 290 patients meeting both DIB-R and DSM-III-R criteria for BPD was assessed at baseline using a semistructured interview of demonstrated reliability. Over 96% of surviving patients were reinterviewed about their co-occurring axis II disorders blind to all previously collected information at three distinct follow-up waves: 2-, 4-, and 6-year follow-up. RESULTS: Both remitted and non-remitted borderline patients experienced declining rates of most types of axis II disorders over time. However, the rates of avoidant, dependent, and self-defeating personality disorders remained high among non-remitted borderline patients. Additionally, the absence of these three disorders was found to be significantly correlated with a borderline patient's likelihood-of-remission and time-to-remission; self-defeating personality disorder by a factor of 4, dependent personality disorder by a factor of 3 1/2, and avoidant personality disorder by a factor of almost 2. CONCLUSION: The results of this study suggest that axis II disorders co-occur less commonly with BPD over time, particularly for remitted borderline patients. They also suggest that anxious cluster disorders are the axis II disorders which most impede symptomatic remission from BPD.     

Clinical characteristics of schizotypal-related obsessive-compulsive disorder

In this study we compared 15 patients with DSM-IV obsessive-compulsive disorder (OCD) and schizotypal personality disorder (SPD) and 31 non-SPD OCD patients. OCD-SPD patients had poorer insight, more negative symptoms, lower functioning, more antipsychotic augmentation and more first-degree relatives with schizophrenia-spectrum disorders. A distinct clinical phenotype of OCD associated with SPD should be considered when investigating etiopathogenetic mechanisms.     

Gender differences in social and interpersonal features and personality disorders among Japanese patients with obsessive-compulsive disorder

This study sought to elucidate the differential effect of gender on clinical features in 40 males and 54 females who met both DSM-III-R and DSM-IV criteria for obsessive-compulsive disorder (OCD). Males had a lower rate of marriage, and a higher rate of major impairment in social or occupational functioning, whereas females were significantly more likely to involve others in their OCD symptoms, such as reassurance-seeking. Although no significant differences were detected in the distribution of OCD symptoms, cluster A personality disorders (PDs), especially schizotypal PD, were more frequently diagnosed in males, and borderline and dependent PDs tended to be more prevalent in females. Thus, gender differences in OCD subjects were prominently observed in social or interpersonal features, which might be consistent with the differential PD pathology between males and females.     

The serotonin transporter gene polymorphism (5-HTTLPR) and affective symptoms among women diagnosed with borderline personality disorder

Gene variants of the serotonin transporter have been associated with vulnerability to affective disorders. In particular, the presence of one or two copies of the short (s) allele of the 5-HTTLPR polymorphism has been associated with reduced serotonin transporter expression and function, and vulnerability to affective disorders. To test for an association between variants of the serotonin transporter gene polymorphism (5-HTTLPR) and relevant clinical features of borderline personality disorder (BPD), a psychiatric disorder with symptoms characteristic for serotonin dysfunction, 77 women with BPD were genotyped in the 5-HTTLPR polymorphism. They rated their subjective experience of borderline-specific, depressive, anxious and obsessive-compulsive symptoms, and were interviewed about lifetime incidence of suicide attempts and self-harming acts. Carriers of two s alleles of the 5-HTTLPR reported more symptoms of borderline, depression, anxiety and obsessive-compulsive behaviours, but not of suicidal and self-injury behaviour, compared to carriers of a long (l) allele. This indicates that the 5-HTTLPR ss homozygous genotype might influence serotonin function affecting susceptibility to both borderline-specific, depressive, anxious and obsessive-compulsive symptoms in BPD, and leading to a more severe symptomatology related to these clinical features. Further, this suggests that 5-HTT gene variants may not be as influential on suicidal and self-injury behaviour in BPD.     

Borderline personality disorder and depression severity predict suicidal outcomes: A six-month prospective cohort study of depression,bipolar depression,and borderline personality disorder

Background

Suicide risk is high in patients with major depressive disorder (MDD), bipolar disorder (BD) and borderline personality disorder (BPD). Whether risk levels of and risk factors for suicidal ideation (SI) and suicide attempts (SA) are similar or different in these disorders remains unclear, as few directly comparative studies exist. The relationship of short-term changes in depression severity and SI is underinvestigated, and might differ across groups, for example, between BPD and non-BPD patients.

Methods

We followed, for 6 months, a cohort of treatment-seeking, major depressive episode (MDE) patients in psychiatric care (original n = 124), stratified into MDE/MDD, MDE/BD and MDE/BPD subcohorts. We examined risks of suicide-related outcomes and their risk factors prospectively. We examined the covariation of SI and depression over time with biweekly online modified Patient Health Questionnaire 9 surveys and analysed this relationship through multi-level modelling.

Results

Risk of SA in BPD (22.2%) was higher than non-BPD (4.23%) patients. In regression models, BPD severity was correlated with risk of SA and clinically significant SI. During follow-up, mean depression severity and changes in depression symptoms were associated with SI risk regardless of diagnosis.

Conclusions

Concurrent BPD in depression seems predictive for high risk of SA. Severity of BPD features is relevant for assessing risk of SA and SI in MDE. Changes in depressive symptoms indicate concurrent changes in risk of SI. BPD status at intake can index risk for future SA, whereas depressive symptoms appear a useful continuously monitored risk index.     

Longitudinal outcome in patients with bipolar disorder assessed by life-charting is influenced by DSM-IV personality disorder symptoms

Objectives:  Few studies have examined the question of how personality features impact outcome in bipolar disorder (BD), though results from extant work and studies in major depressive disorder suggest that personality features are important in predicting outcome. The primary purpose of this paper was to examine the impact of DSM-IV personality disorder symptoms on long-term clinical outcome in BD.
Methods:  The study used a 'life-charting' approach in which 87 BD patients were followed regularly and treated according to published guidelines. Outcome was determined by examining symptoms over the most recent year of follow-up and personality symptoms were assessed with the Structured Clinical Interview for DSM-IV (SCID-II) instrument at entry into the life-charting study.
Results:  Patients with better outcomes had fewer personality disorder symptoms in seven out of 10 disorder categories and Cluster A personality disorder symptoms best distinguished euthymic and symptomatic patients.
Conclusions:  These results raise important questions about the mechanisms linking personality pathology and outcome in BD, and argue that conceptual models concerning personality pathology and BD need to be further developed. Treatment implications of our results, such as need for psychosocial interventions and treatment algorithms, are also described.     

Dexamethasone suppression test in borderline personality disorder: impact of PTSD symptoms

The purpose of the present study was to investigate the impact of post-traumatic stress disorder (PTSD) symptoms on hypothalamic-pituitary-adrenal axis feedback regulation in 18 female patients with borderline personality disorder (BPD) and 21 healthy controls. Reduced feedback sensitivity was found in BPD patients with a low number of PTSD symptoms, while findings in the BPD group with a high number of PTSD symptoms did not differ from those in controls. The results suggest a hypo-suppression in the dexamethasone suppression test in BPD with few PTSD symptoms.     

Childhood obsessive compulsive disorder: a two-year prospective follow-up of a community sample

A 2-year prospective follow-up of a community-based sample of adolescents previously diagnosed as having obsessive compulsive disorder (OCD) or "obsessive compulsive spectrum" disorder and a control sample was completed by clinicians experienced with OCD but blind to prior diagnosis. An initial diagnosis of OCD or "other psychiatric disorder with OC features" was most likely to predict a diagnosis of OCD at follow-up. Subclinical OCD at baseline did not strongly predict continuing psychopathology. A prior diagnosis of obsessive-compulsive personality predicted continued obsessive-compulsive symptoms but its relationship to OCD remains obscure.     

Comparison of Attachment Styles in Borderline Personality Disorder and Obsessive-Compulsive Personality Disorder

The intense, unstable interpersonal relationships characteristic of patients with borderline personality disorder (BPD) are thought to represent insecure attachment. The Reciprocal Attachment Questionnaire was used to compare the attachment styles of patients with BPD to the styles of patients with a contrasting personality disorder, obsessive-compulsive personality disorder (OCPD). The results showed that patients with BPD were more likely to exhibit angry withdrawal and compulsive care-seeking attachment patterns. Patients with BPD also scored higher on the dimensions of lack of availability of the attachment figure, feared loss of the attachment figure, lack of use of the attachment figure, and separation protest. The findings may be relevant for understanding the core interpersonal psychopathology of BPD and for managing therapeutic relationships with these patients.     

Characteristics of psychosis in borderline personality disorder

Comparing a sample of 88 inpatients with borderline personality disorder (BPD) to inpatients with borderline traits, this paper addresses four hypotheses regarding the association between BPD and psychotic symptoms: (1) narrowly defined psychotic symptoms are rare in BPD; (2) broadly defined psychotic symptoms are often reported in BPD; (3) narrowly defined psychotic symptoms are due to concomitant disorders, and (4) psychotic symptoms may be factitious. Consecutive admissions to acute inpatient services were screened for borderline features and patients were examined using the Diagnostic Interview for Borderlines and the Schedule for Affective Disorders and Schizophrenia. The results generally supported the proposed explanations for the association between BPD and psychotic symptoms. Factitious psychotic symptoms were found in only 13% of the BPD sample.     

Personality disorders in patients with obsessive-compulsive disorder in Japan

A total of 75 patients with obsessive-compulsive disorder (OCD) were studied in order to investigate the characteristics of OCD symptoms and the comorbidity of personality disorders (PD). Contamination obsessions and checking compulsions were most commonly found in patients, of whom 53% met the criteria for at least one PD. Among comorbid PD, the anxious-fearful (cluster C) PDs, such as avoidant, obsessive-compulsive and dependent PD, were most prevalent, followed by the odd-eccentric (cluster A) PDs, such as paranoid and schizotypal PD. The patients with PD had more severe social maladaptation and concurrent depressive and anxious symptoms than the patients without any PD, despite the similar severity of OCD symptoms. These results are consistent with those reported in the Western world, and are considered to be relatively stable cross-culturally.     

Dissociative symptoms in patients with obsessive-compulsive disorder.

To clarify the relationship between dissociative symptoms and obsessive-compulsive disorder (OCD), 100 patients with OCD were assessed with standardized instruments measuring symptoms of OCD, dissociation, and depression. Diagnoses of personality disorders and dissociative disorders were made using structured interviews. Compared with a previous study, OCD patients had dissociation scores slightly higher than normal controls and comparable to patients with other anxiety disorders. Patients with elevated dissociation scores had more severe OCD symptoms, were more depressed, and were more likely to have a personality disorder than patients with low dissociation scores. Although dissociative symptoms were frequently reported by OCD patients, symptoms of OCD may also mimic dissociation in some patients.     

A family study of obsessive-compulsive disorder

BACKGROUND: The causes of obsessive-compulsive disorder (OCD) are as yet unknown. Evidence of familial aggregation is one approach for investigating the role of genetics in the etiology of this condition. The current study was conducted to determine ifOCD is familial and to investigate possible familial subtypes. METHODS: Eighty case probands were identified in 5 specialty OCD clinics and 73 community control probands were identified by random-digit dialing. These probands and their first-degree relatives (343 case and 300 control relatives) were blinded to group and evaluated by psychiatrists and doctoral-level clinical psychologists using semistructured instruments. Final diagnoses were assigned by a blinded-consensus procedure. The results were analyzed using logistic regression by the method of generalized estimating equations. RESULTS: The lifetime prevalence of OCD was significantly higher in case compared with control relatives (11.7% vs 2.7%) (P<.001). Case relatives had higher rates of both obsessions and compulsions; however, this finding is more robust for obsessions. Age at onset of obsessive-compulsive symptoms in the case proband was strongly related to familiality (odds ratio, 0.92; confidence interval, 0.85-0.99) (P = .05); no case of OCD symptoms was detected in the relatives of probands whose age at onset of symptoms was 18 years or older. Probands with tics or obsessive-compulsive personality disorder were not more likely to have relatives with OCD than those without these features. CONCLUSIONS: Obsessive-compulsive disorder is a familial disorder. Obsessions are more specific to the phenotype than are compulsions. Age at onset of OCD is valuable in characterizing a familial subtype.     

Personality traits and smoking in patients with obsessive-compulsive disorder.

As opposed to other psychiatric populations, subjects with obsessive-compulsive disorder (OCD) smoke less than the general population. The present study aims at further investigating the relationship between smoking in OCD subjects and personality traits. Sixty-four subjects with OCD were interviewed concerning their smoking habits. Personality traits were evaluated using the Karolinska Scales of Personality, and specific obsessive-compulsive personality traits were elicited through self-report questionnaires. Non-smokers were more easily fatigued, more inclined to worry, more remorseful, less self-confident, less impulsive and became uneasy more frequently when urged to speed up, than smokers with OCD. Additionally, non-smokers fulfilled significantly more obsessive-compulsive personality disorder criteria as compared to the smokers (P < 0.001). We propose a clinical subtype of OCD related to non-smoking, psychasthenia, anxiety, and pronounced obsessive-compulsive personality disorder traits.