35th International Congress of SPR 16-19 June 2004 Roma - Italy Clinical features of obsessive symptoms in Borderline Personality Disorders and Obsessive Compulsive Disorders: Differences and overlapping aspects in an inpatient sample Fabrizio Didonna, Paolo Zordan, Elena Prunetti, Denise Rigoni, Marzia Zorzi, Marco Bateni Unit for Anxiety and Mood Disorders Unit for Personality Disorders Department of Psychiatry - Casa di Cura Villa Margherita Arcugnano - Vicenza - Italy
Obsessive symptoms are a common clinical feature in several psychiatric syndromes Obsessive-Compulsive Disorder (OCD, 2-3% population) and Borderline Personality Disorder (BPD, 2% population) denote the endpoints on a spectrum of compulsive and impulsive disorders. One endpoint (OCD) marks compulsive behaviors characterized by overestimation of the probability of future harm. The other endpoint (BPD) designates impulsive actions characterized by the lack of consideration of the negative results of such behavior (Hollander, 1999) In Borderline Personality Disorder (BPD) the obsessive aspects (with or without compulsions) seem to be a frequent feature associated with this syndrome
In OCD 5-24% meet the criteria of BPD (Rasmussen & Eisen, 1992) BPD Ss. (differently from OCD) often shift from impulsive to compulsive behaviours (Steketee, 1993) In BPD obsessions and compulsions are usually more ego-syntonic (poorer insight) than in OCD (Hayashi, 1996) In BPD obsessive symptoms are more resistant to treatment than in OCD (Fals-Stewart, Lucente, 1993)
Verify differences and/or overlapping aspects between an OCD sample and a BPD sample in particular regarding obsessive symptoms Investigated and compared the clinical features of two inpatients samples: 1. 58 Borderline Personality Disorder patients with obsessive symptoms admitted in a Unit for Personality Disorders 2. 31 Obsessive-Compulsive Disorders patients (non- Borderline) admitted in a Unit for Anxiety Disorders All patients were admitted to an Inpatient Cognitive- Behavioural treatment (mean duration 30 days) that included: 1. Cognitive Group Therapy (twice a week) 2. Individual Cognitive Therapy (twice a week) 3. Pharmacotherapy
Characteristics of the OCD (non Total Males Females n 31 6 (19,4%) 25 (80,6%) Age: mean (SD) 35,16 (11.7) 25.83 (7.78) 37.40 (10.65) range 14-55 17-36 14-55 Marital status (n, %) (n, %): non-borderline) ) sample Not-married 17 (54.8%) 4 ( 66,7%) 13 (52%) Married 14 (45.2%) 2 (33,3%) 12 (48%) Education (n, %) (n, %): University 0 High School 11 (35.5%) 3 (50.0) 8 (33.3%) Less 20 (64.5%) 3 (50.0) 17 (66.6%) Employment (n, %): Student 3 (10 %) 2 (33.3%) 1 (4 %) Employed 10 (32 %) 2 (33.3%) 8 (32 %) Unemployed 18 (58 %) 2 (33.3%) 16 (64 %)
Characteristics of the Borderline-obsessiveobsessive sample Total Males Females n 58 9 (15,5%) 49 (84,5%) Age: mean (SD) 30.21 (8.18) 26.44 (6.54) 30.90 (8.31) range 18-51 18-40 18-51 Marital status (n, %) (n, %): Not-married 35 (60%) 8 (89%) 27 (55%) Married 11 (19%) 0 11 (22.5%) Separated 12 (21%) 1 (11%) 11 (22.5%) Education (n, %) (n, %): University 3 (5%) 0 3 (6%) High School 33 (57%) 6 (66.6) 27 (55%) Less 22 (38%) 3 (33.3) 19 (39%) Employment (n, %): Student 7 (12%) 2 (22%) 5 (10%) Employed 12 (21%) 2 (22%) 10 (20 %) Unemployed 39 (67%) 5 (56%) 34 (70%)
Measures Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) Y-BOCS Symptom Checklist Padua Inventory (PI) Beck Depression Inventory (BDI) State Trait Anxiety Inventory-Y (STAI-Y) Symptom Check List-90 (SCL-90) SCID II Interview (Personality disorders) Evaluation by and clinical interview with two experienced psychiatrists
OCD vs. BPD-Obsessive samples: Comorbidity in Axis I (DSM IV) 60% OCD non-bpd BPD OBSESSIVE PATIENTS 50% 48% 48% 52,3% 40% 30% 20% 10% 0% 18% 11% 11,4% 4% 2,3% 2,3% 2,3% No comorbidity Mood Disorders Anxiety Disorders No comorbidity Mood Disorders Substance Abuse Hypocondriasis Eating Disorders Impulsive Control Disor. Body Dismorphic Dis.
OCD vs. BPD-obsessive: comorbidity in Axis II (DSM IV) 45% No Personality Disorder 41% Dependent 40% 35% 30% 25% 20% 15% 10% 5% 0% 14% 27% 5% 9% 5%5% 15% 13% 0% 17% 29% 13% 4% 6% OCD non-borderline Borderline-Obsessive Obsessive-Compulsive Histrionic Avoidant Passive-Aggressive NAS Self-frustrating Schizotypal Paranoid
Differences in BDI scores 60 50 40 30 20 OCD non- Borderline Borderline- Obsessive 10 0 Admission Discharge
Psycoticism SCL-90 scores 4 3 2 OCD non- Borderline Borderline- Obsessive 1 0 Admission Discharge
Time spent on compulsions (Y-BOCS) 4 3 2,6 2 1,9 1 0 OCD non- Borderline Borderline- Obsessive
Interference from compulsions (Y-BOCS) 4 3 2,4 2 1,8 1 0 OCD non- Borderline Borderline- Obsessive
Resistance to compulsions (Y-BOCS) 4 3 2,8 2 1,8 1 0 OCD non- Borderline Borderline- Obsessive
Compulsions subtotal (Y-BOCS) 20 18 16 14 12 10 8 6 4 2 0 13,0 OCD non- Borderline 9,4 Borderline- Obsessive
Y-BOCS Total 40 35 30 25 20 15 10 5 0 26,9 OCD non- Borderline 20,7 Borderline- Obsessive
Indecisiveness (Y-BOCS) 4 3,9 3 2 1,8 1 0 OCD non- Borderline Borderline- Obsessive
Worries of losing control over motor behaviours (Padua Inventory) 1 Z - SCORES 1 0,5 0-1 -0,3 OCD non- Borderline Borderline- Obsessive
% 100 90 80 70 60 50 40 30 20 10 0 Types of obsessions Y-BOCS Symptom Checklist Aggressive 86 77 77 Contamination 57 53 50 62 Sexual Hoarding/sa... 41 Religious 53 47 45 Symmetry 26 Miscellaneous 88 93 OCD non- Borderline Borderline- Obsessive
% 100 90 80 70 60 50 40 30 20 10 0 Types of Compulsions YBOCS Symptom Checklist 77 77 79 76 Cleaning 38 Checking Repeating 45 47 Counting 65 31 33 Ordering 30 19 Hoarding 88 Miscellaneous 71 OCD non- Borderline Borderline- Obsessive
What is significant? Comorbidity Axis I: 52% OCD vs. 82% Borderline had comorbidity in Axis I Higher rate of Mood Disorders (Depression) in OCD (48%) Higher rate of Eating Disorders (Bulimia) in Borderline- Obsessive (52%) Comorbidity Axis II: higher rate of OCPD in OCD (27%) higher rate of Passive-Aggressive Personality Disorders in Borderline-Obsessive (29%)
OCD had a lower levels of Depression (BDI) and Psychoticism (SCL-90 90) than BPD-Obsessive at discharge after a CBT inpatient treatment Y-BOCS: OCD more time spent on compulsions than BPD OCD more severe compulsions (not obsessions) than BPD OCD more interference from compulsions than BPD OCD more resistance to compulsions than BPD OCD more indecisiveness about symptoms than BPD BPD more worries of losing control over motor behaviours than OCD
In BPD, obsessive symptoms appear more ego-syntonic (less indecisiveness, interference and resistance to symptoms) and less severe (compulsions) than in OCD BPD patients: understand the metacognitive meanings of the obsessive symptoms in the complex organization of the disorder. These symptoms seem to help to give order and stability in the general discontrol and disregulation of emotions and cognitions (more worries of losing control). Impulsive symptoms represent that discontrol (higher rate of Passive- Aggressive Personality Disorder in BPD) In OCD, obsessive symptoms are aimed at preventing damage for him/herself or others (more indecisiveness and resistance to symptoms). This aim doesn t appear to be, in general, the focus in BPD-obsessive subjects
Clinical observation shows us that obsessive symptoms in Borderline subjects often tend to stop very quickly (independently from the therapy) and are often relationship and/or environment dependent (no diagnosis of OCD in Axis I in BPD sample). On the other hand, in OCD these symptoms are usually persistent and resistant to change. OCD and Borderline patients both can have a Disorganized Attachment System (Liotti, 2001). OCD subjects are able during childhood to organize their disorganized system around the obsessive symptoms. Borderline subjects fail to do so. In fact, impulsive and compulsive behaviour in BPD appear to be strictly dependent on interpersonal interactions (attachment system activation) while in OCD they do not. Further experimental investigations are required in order to better understand the complex connections and differences between these two severe disorders and in particular regarding the obsessive phenomena.