Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD
Gerontology Research Center, National Institute on Aging, Baltimore, MD
Department of Psychiatry and Behavioral Sciences and Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD
Department of Biostatistics, The Johns Hopkins School of Public Health, Baltimore, MD
Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
Correspondence: Dr Jack Samuels, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins Hospital, Meyer 4-181, 600 N. Wolfe Street, Baltimore, MD 21287, USA
Declaration of interest Supported by National Institutes of Health grants R01MH50214 and NIH/NCRR/OPDGCRC RR00052.
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ABSTRACT |
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Aims To determine whether specific personality characteristics are part of a familial spectrum of OCD.
Method Clinicians evaluated personality disorders in 72 OCD case and 72 control probands and 198 case and 207 control first-degree relatives. The selfcompleted Revised NEO Personality Inventory was used for assessment of normal personality dimensions. The prevalence of personality disorders and scores on normal personality dimensions were compared between case and control probands and between case and control relatives.
Results Case probands and case relatives had a high prevalence of obsessivecompulsive personality disorder (OCPD) and high neuroticism scores. Neuroticism was associated with OCPD in case but not control relatives.
Conclusions Neuroticism and OCPD may share a common familial aetiology with OCD.
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INTRODUCTION |
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METHOD |
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Diagnostic procedures
After obtaining informed written consent, clinicians (psychiatrists or
PhD-level clinical psychologists) examined subjects using the fourth revision
of the Schedule for Affective Disorders and Schizophrenia - Lifetime Anxiety
(Mannuzza et al,
1986), which was adapted to include sections on tic disorders and
impulse control disorders; the OCD section was also elaborated to include the
Y-BOCS (Goodman et al,
1989) and additional material on course of symptoms. In addition
to conducting direct interviews, the clinicians contacted a knowledgeable
informant for each subject to obtain collateral information for diagnostic
evaluation. The interviewers were blinded as to whether the subjects were
probands or relatives or were from case or control families. All probands were
interviewed in person. Approximately 30% of the relatives were not available
for direct interview because they were deceased, refused to participate or the
proband refused contact; these relatives were older than direct participants
(mean age=53.3 v. 43.5 years, t(641 d.f.)=6.20,
P<0.001) and a greater proportion were males (60% v. 44%,
2 (1 d.f.)=14.5, P<0.001). For these subjects,
informant interviews were conducted with two individuals who were familiar
with the subject, using an adapted version of the Family Informant Schedule
and Criteria (Mannuzza et al,
1985). For every subject, a DSM-IV Diagnostic Assignment Form was
completed; this form was designed to record the presence of all necessary
diagnostic criteria and guide the assignment of diagnoses according to DSM-IV
criteria.
All available diagnostic materials (evaluation by the clinical examiner, informant interview, clinical case summary, medical records and audiotapes) were reviewed independently by two expert psychiatrists. The diagnosticians were blinded as to whether the subject was a proband or relative or from a case or control family. All psychiatric diagnoses were made according to strict DSM-IV criteria.
The Revised Structured Instrument for the Diagnosis of Personality Disorders (SIDP-R; Pfohl et al, 1989) was used for the assessment of all DSM-IV personality disorders in all subjects over the age of 15 years who were examined directly; this instrument was also used to collect collateral information about directly examined subjects from informants. Subjects for whom only informant interviews were obtained were assessed using only the obsessive-compulsive personality disorder (OCPD) items from this instrument, and this information was used in the relevant analyses.
The Revised NEO Personality Inventory (NEO PI-R; Costa & McCrae, 1992), paper-and-pencil form, was self-completed by subjects who were interviewed directly and this was used for the assessment of the five domains of normal personality as construed by the Five-Factor Model: neuroticism, extraversion, openness, agreeableness and conscientiousness. Each domain is represented by six specific scales that measure facets of the domain. Neuroticism facets are anxiety, angry hostility, depression, self-consciousness, impulsiveness and vulnerability. Extraversion facets are warmth, gregariousness, assertiveness, activity, excitement-seeking and positive emotions. Openness facets are fantasy, aesthetics, feelings, actions, ideas and values. Agreeableness facets are trust, straightforwardness, altruism, compliance, modesty and tender-mindedness. Conscientiousness facets are competence, order, dutifulness, achievement-striving, self-discipline and deliberation. The t-scores for the five domains and 30 facets were calculated according to the method of Costa & McCrae (1992), which uses different reference means and standard deviations for men and women. These distributions have a mean of 50 and a standard deviation of 10. The t-scores are considered average in the range 45-55. Scores less than 45 are considered low, those in the range 56-65 are considered high and those greater than 65 are considered very high.
Statistical analysis
The prevalence of personality disorders was compared in case and control
probands and case and control relatives using Fisher's exact test. The domain
and facet scores were compared in case and control probands and case and
control relatives using Student's t-test. To evaluate the
relation-ship between neuroticism and OCPD in relatives, the prevalence of
OCPD across neuroticism score categories was compared using the
2 test for trend. In addition, the association between
neuroticism (as a continuous dimension) and OCPD was evaluated using logistic
regression. Given the exploratory nature of this study, each test was
two-sided with
=0.05.
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RESULTS |
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As shown in Table 1, nearly 45% of case probands had a personality disorder, which is over four times greater than the 10% prevalence in controls (Fisher's exact test, P<0.001). Avoidant personality disorder was more prevalent in case than in control probands (15.3 v. 1.4%, P=0.004), as was OCPD (32.4 v. 5.6%, P<0.001). Case probands also had a higher prevalence of narcissistic personality disorder, but the difference was not statistically significant.
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As shown in Table 2, case probands scored much higher on neuroticism than did control probands (64.0 v. 49.8; t(135 d.f.)=7.1, P<0.001). In addition, case probands scored significantly lower on extraversion (47.4 v. 52.0; t(135 d.f.)=2.4, P=0.02) and significantly higher on agreeableness domains (48.9 v. 43.8; t(135 d.f.)=2.5, P=0.01), although their mean scores were close to the population means for these scales. Mean openness and conscientiousness scores were not significantly different between the two groups.
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All facets of neuroticism (anxiety, angry hostility, depression, self-consciousness, impulsiveness, and vulnerability) were significantly higher in case probands and above the average range, especially the anxiety facet, with mean scores of 65.5 and 48.7 in the case and control probands, respectively (t(135 d.f.)=9.68, P<0.001). Case probands were also high on two openness facets: they were more open to fantasy (mean score of 56.1 and 52.6 in case and control probands, respectively; t(135 d.f.)=2.14, P=0.035) and more open to feelings (mean scores of 55.5 and 51.2 in case and control probands, respectively; t(135 d.f.)=2.53, P=0.01). In addition, case probands scored below the average range on two conscientiousness facets: they scored lower on competence (43.5 v. 51.0; t(135 d.f.)=3.43, P=0.001) and self-discipline (36.9 v. 46.8; t(135 d.f.)=4.16, P<0.001) than control probands. Case probands also scored significantly lower on assertiveness and openness to actions and significantly higher on straightforwardness, modesty and tender-mindedness than did control probands; however, scores for these facets were within the normal range.
Relatives
To assess personality disorders, 198 relatives of case probands and 207
relatives of control probands were evaluated directly using the SIDP-R. The
OCPD assessments (from direct interviews or informant-only interviews) were
available for 296 case relatives and 242 control relatives. The relatives
differed somewhat with respect to gender and age distributions: 51.4% of the
case relatives, compared to 42.6% of the control relatives, were female
(2 (1 d.f.)=4.1, P=0.04) and the mean ages at
interview were 48.9 and 45.6 years in case and control relatives, respectively
(t(536 d.f.)=2.26, P=0.02). However, controlling for gender
and age in subsequent analyses did not substantially affect the results (data
not shown).
As shown in Table 3, 21% of case relatives had a personality disorder, which is nearly twice the prevalence of 10.7% in the control relatives (Fisher's exact test, P=0.005). Obsessive-compulsive personality disorder was twice as prevalent in case compared to control relatives (11.5% v. 5.8%, P=0.02).
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As shown in Table 4, case relatives scored significantly higher than control relatives on neuroticism. At the neuroticism facet level, case relatives scored significantly higher on anxiety (mean scores of 53.6 and 49.1 in case and control relatives, respectively; t(350 d.f.)=3.80, P<0.001), significantly higher on self-consciousness (51.5 v. 48.5; t(350 d.f.)=2.65, P=0.01) and significantly higher on vulnerability to stress (51.2 v. 48.6; t(350 d.f.)=2.23, P=0.03).
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Scores on other personality domains were not different between the two groups. At the facet level, case relatives scored significantly lower on excitement-seeking (46.6 v. 50.3 in case and control relatives, respectively; t(350 d.f.)=3.33, P=0.001), significantly lower on openness to actions (47.8 v. 51.2; t(350 d.f.)=2.78, P=0.006) and significantly higher on order (48.2 v. 45.4; t(350 d.f.)=2.36, P=0.02).
As shown in Table 5, in
control relatives the prevalence of OCPD was similar across neuroticism
categories. In contrast, in case relatives, the prevalence of OCPD increased
from lowest to successively higher categories of neuroticism
(2 trend (1 d.f.)=6.40, P=0.01). Similarly, when
evaluated as a continuous dimension, neuroticism was associated with OCPD in
case relatives (odds ratio per unit increase in neuroticism=1.06, 95% CI
1.02-1.10, P=0.004) but not in control relatives; however, the
interaction term (neuroticism x relative group) was not statistically
significant (P=0.30). In case relatives, the relationship between
neuroticism and OCPD did not change appreciably after controlling in the
logistic model for the presence of OCD or when the analysis was restricted to
relatives without OCD.
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DISCUSSION |
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Case probands scored substantially higher on the neuroticism domain and all its facets. In addition, two openness facets were markedly higher in case probands (openness to fantasy and openness to feelings), whereas two conscientiousness facets were markedly lower in case probands (competence and self-discipline). The mean scores in case probands were very different from both control and the population means. This profile presents a coherent description of some individuals with OCD as highly neurotic, tenderminded people who lack the ability to carry tasks to completion.
Given the long-standing clinical impression that conscientiousness is characteristic of individuals with OCPD (Janet, 1903; Freud, 1953; Pitman, 1987), it may seem surprising that OCD case probands did not score higher than controls on the conscientiousness domain and, in fact, scored significantly lower on competence and self-discipline facets. Perhaps individuals with OCD judge that they are not performing at the level required by their own high standards; alternatively, worry and doubt may interfere with their productivity. It also is interesting that case probands score higher on impulsiveness (a facet of neuroticism) and openness to fantasy, which may reflect their difficulty in resisting intrusive thoughts. It should be noted that the majority of OCD case probands did not have OCPD and may differ on normal personality dimensions from probands with OCPD.
There have been few previous studies of normal personality features in individuals with OCD. Pfohl et al (1990) found that, compared with non-ill controls, patients with OCD scored very high on harm avoidance, high on reward dependence and low on novelty-seeking dimensions of the Tridimensional Personality Questionnaire (Cloninger, 1986). Bejerot et al (1998) found that, compared with healthy controls, patients with OCD scored significantly higher on harm avoidance and significantly lower on self-directedness and cooperativeness dimensions of the Temperament and Character Inventory (Cloninger et al, 1993). Further research on the comparability of different personality instruments is needed before we can evaluate the consistency between these findings and the results of the current study.
Relatives
The first-degree relatives of OCD probands and controls differed with
respect to specific aspects of disordered and normal personality.
Obsessive-compulsive personality disorder was twice as common in the case
relatives; in contrast, occurrence of other personality disorders was not
significantly different between the two groups of relatives. Case relatives
also scored significantly higher on neuroticism, but not other domains. Case
relatives scored significantly lower on excitement-seeking and openness to
actions and significantly higher on order, a constellation of traits
consistent with obsessionality (Kringlen,
1965).
To our knowledge, this is the first family study to demonstrate that high neuroticism and OCPD are more common in relatives of OCD cases compared with relatives of controls. These personality characteristics may share a common familial aetiology with OCD. Neuroticism, OCPD and OCD may be alternative expressions of the same underlying vulnerability. Each of these phenotypes may represent a different level of severity along a continuum, or additional factors may be necessary for differentiation into the specific clinical phenomena. Alternatively, these three phenotypes may be distinct entities, one a direct expression of the vulnerability and the other(s) emerging secondarily. This is supported by the finding of a relationship between neuroticism and OCPD only in the relatives of OCD cases; however, the interaction term was not statistically significant and this relationship needs to be explored in larger samples. It may be that neuroticism is transmitted in these families, as has been proposed by others (Andrews et al, 1990), but that in order for OCPD to emerge, additional genetic or environmental factors are required. It should be noted that OCD may be aetiologically heterogeneous and that the relationship to neuroticism and OCPD is important only in a subgroup of individuals. Of course, although the current study focused on OCD, high neuroticism may predispose to a variety of other anxiety disorders as well (Trull & Sher, 1994).
Limitations
The major limitation of the current study is that information on normal
personality and personality disorders other than OCPD was unavailable for the
36% of case relatives and 23% of control relatives who were not interviewed
directly. Most of these subjects were deceased; on average, they were older
and a greater proportion were men. The estimated odds of OCPD in case versus
control relatives did not change appreciably after controlling for type of
interview (direct or informant only) in a logistic model, and the relationship
between relative group and neuroticism did not change after controlling for
age and gender of the relative in a linear model (data not shown).
Nevertheless, we do not know if the personality features of relatives who were
not interviewed directly differ from those of participants, or if the
different proportion of non-participation in case and control relatives
introduced a bias in estimation of the prevalence of personality disorders and
distribution of normal personality dimensions. In future family studies, it
would be useful to collect informant information about all personality
disorders; an observer-report version of the NEO (NEO PI-R) is available for
the assessment of normal personality features
(Costa & McCrae, 1992).
Another potential limitation of the study is the problem of state-trait confounding: that is, the assessment of personality features by subjects and their informants might be influenced by current symptoms (Reich et al, 1986). It should be noted that probands were not selected, or scheduled for interview, on the basis of being in active treatment or currently ill. Furthermore, the examining clinician attempted to elicit enduring personality features over the subject's entire life span.
Others have proposed that obsessional personality features precede the development of obsessive-compulsive symptoms (Sandler & Hazari, 1960) and that neuroticism increases the vulnerability to development of several psychiatric disorders (McHugh & Slavney, 1986). In this retrospective study, we evaluated the reported age at onset of obsessive-compulsive symptoms but not obsessive-compulsive personality features. Therefore, the results cannot inform as to whether the development of OCPD precedes or follows the development of OCD. Longitudinal studies are required to elucidate the temporal relationship between neuroticism, OCPD, OCD and other anxiety disorders.
Clinical implications
Despite these limitations, the results emphasise the clinical importance of
temperamental features in individuals with OCD. Patients with OCD who have
personality disorders may have poorer response to treatment
(Baer et al, 1992),
and symptom reduction may not resolve all the difficulties that these patients
experience. Moreover, it is important for clinicians to recognise that
temperamental difficulties are common in the relatives of these patients and
may influence the course of treatment. Finally, the findings suggest that
personality characteristics are important in understanding OCD, and further
investigation of neuroticism and obsessive-compulsive personality traits in
families may help to elucidate the pathogenesis of the disorder
(Lyons et al,
1997).
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication January 17, 2000. Revision received June 9, 2000. Accepted for publication June 9, 2000.
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