Comorbidity of obsessive–compulsive disorder with obsessive–compulsive personality disorder: Does it imply a specific subtype of obsessive–compulsive disorder?
Introduction
The relationship between obsessive–compulsive disorder (OCD) and obsessive–compulsive personality disorder (OCPD) has been the subject of considerable interest during the last 100 years. Pierre Janet was the first to argue that personality pathology was causally related to the development of OCD (Janet, 1906). His work influenced Freud who proposed the construct of anal character marked by parsimony, orderliness and obstinacy. In the Freudian view, anal character or obsessional personality had been seen as predisposing feature of obsessional neurosis with the two conditions sharing a common developmental basis and existing side by side along a continuum. The neurosis represents a failure of repression, the regression to the anal-sadistic level of libidinal organization and the use of defenses against hostility (Rosenberg, 1967). In congruence with the above theoretical framework, earlier clinical studies, in the ‘60s and ‘70s, found extremely high rates of OCPD (53%–72%) in patients with OCD (Pollitt, 1957, Kringlen, 1965, Rosenberg, 1967). With the introduction of DSM-III, the majority of relevant studies using DSM-III criteria estimated much lower prevalence of OCPD, ranging from 0% to 6% and supported that other personality disorders such as avoidant, dependant, passive-aggressive or borderline are more frequently comorbid with OCD than OCPD (Joffe et al., 1988, Black et al., 1989, Baer et al., 1990, Mavissakalian et al., 1990, Black et al., 1993). In contrast, the great majority of recent studies, using DSM-III-R or DSM-IV criteria, reported considerably higher rates of OCPD in OCD subjects, ranging from 23% to 36% (Stanley et al., 1990, Diaferia et al., 1997, Bejerot et al., 1998, Eisen et al., 1999, Samuels et al., 2000, Tenney et al., 2003, Albert et al., 2004, Pinto et al., 2006, Coles et al., 2008). These discrepancies are mainly due to the differences between DSM-III and DSM-III-R/IV criteria for OCPD. As Baer et al. (1990) pointed out the difference in prevalence of OCPD between DSM-III and DSM-III-R may be due to raising the number of criteria provided to make the diagnosis from four of five in DSM-III to five of nine in DSM-III-R. That means that according to DSM-III 80% of the provided criteria are required for an OCPD diagnosis, while according to DSM-III-R only 56%. Therefore, studies using the more lenient DSM-III-R criteria found higher rates of OCPD than studies using the stringent DSM-III criteria (Mancebo et al., 2005). An alternative explanation for the increased prevalence with DSM-III-R is that the addition of new criteria moves the personality disorder somewhat closer to the traditional psychodynamic entity of obsessional character (Baer et al., 1990). It is noticeable that, in the Baer et al. (1990) study, if DSM-III-R criteria were used, the comorbidity rate of OCPD in OCD patients would be raised to 25% from 6% according to the DSM-III criteria.
In addition there are data suggesting that OCPD occur more frequently in patients with OCD than in individuals with panic disorder (Skodol et al., 1995, Okasha et al., 1996, Diaferia et al., 1997), social phobia or major depression (Diaferia et al., 1997), although other studies based on community (Torres et al., 2006a) or clinical samples (Albert et al., 2004) do not support this view. Family studies also report a link between OCD and OCPD. In an earlier study, Lenane et al. (1990) found increased frequencies of obsessive compulsive personality in the parents –mainly fathers- of children with OCD. More recently, Samuels et al. (2000) reported that OCPD was twice more common in the relatives of OCD patients than in the relatives of control probands. Furthermore, in a study examining the source of overlap between OCD and OCPD, it was found that three out of eight OCPD criteria i.e. perfectionism, hoarding and preoccupation with details, were significantly more frequent in patients with OCPD comorbid with OCD than in OCPD individuals without OCD comorbidity (Eisen et al., 2006). On the other hand, Baer (1994) reported that within OCD, a symptom factor characterized by symmetry and hoarding was significantly related to OCPD, while Mataix-Cols et al. (2000) claimed that the Y-BOCS score on the hoarding dimension was strongly positively correlated to the presence of OCPD, but also to the presence of avoidant personality disorder.
Considering that studies evaluating the comorbidity of OCD + OCDP have shown variability in prevalence rates which could be related to different ethnic and cultural background (Coles et al., 2008) the aim of the present study was to examine this comorbidity in an outpatient population of a Community Mental Health Center in Greece. According to our knowledge there are no published studies evaluating this comorbidity in Greek OCD patients. Therefore, in the present study was investigated: 1) the rate of OCPD in patients with OCD, 2) whether patients with OCD + OCPD differ in various sociodemographic and clinical variables from OCD individuals without comorbid OCPD, thus suggesting that OCD + OCPD constitutes a distinct subtype of OCD.
Section snippets
Methods
The study sample consisted of consecutive outpatients who attended the Community Mental Health Center of the North-Western District of Thessaloniki in Greece and received a diagnosis of OCD according to DSM-IV criteria. All patients were provided with an informed consent before participating in the study. Axis I diagnoses were determined by administering the Mini International Neuropsychiatric Interview (M.I.N.I.) 5.0.0/DSM-IV, while for the Axis II diagnoses the International Personality
Results
The total sample consisted of 146 OCD patients, 45 (31%) with and 101 (69%) without comorbid OCPD. The comparison of the two sub-samples on demographic and clinical characteristics is presented on Table 1, Table 2, respectively. There were no statistically significant differences between the groups with regard to their demographic characteristics. The OCD + OCPD subjects had an earlier age at onset of first OC symptoms, an earlier age at onset of full DSM-IV OCD, more obsessions and compulsions
Discussion
According to the present study, 31 % (N = 45) of 146 patients with OCD also had a comorbid diagnosis of OCPD. This rate is within the range of prevalence (23%–36%) reported by previous studies that used DSM-III-R/DSM-IV criteria (Diaferia et al., 1997, Bejerot et al., 1998, Eisen et al., 1999, Samuels et al., 2000, Tenney et al., 2003, Albert et al., 2004, Pinto et al., 2006, Coles et al., 2008). The great majority of these studies also found, alongside to the present study, that OCPD is the most
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