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Personality Profiles in Young Adults with Subclinical Obsessive-Compulsive Symptoms: Not just
obsessionality
Patrick Raynal, Tiffany Melioli, Henri Chabrol
To cite this version:
Patrick Raynal, Tiffany Melioli, Henri Chabrol. Personality Profiles in Young Adults with Subclinical Obsessive-Compulsive Symptoms: Not just obsessionality. Bulletin of the Menninger Clinic, Guilford Press, 2019. �hal-03191814�
Running head: PERSONALITY AND OBSESSIVE-COMPULSIVE SYMPTOMS
Personality Profiles in Young Adults with Subclinical Obsessive-Compulsive Symptoms: Not just obsessionality
Patrick Raynala*, Tiffany Meliolia, Henri Chabrola
a Centre d’Etudes et de Recherches en Psychopathologie et Psychologie de la Santé Université de Toulouse, UT2J, France
* Corresponding author: Patrick Raynal, Centre d'Etudes et de Recherches en Psychopathologie et Psychologie de la Santé, Université de Toulouse-Jean Jaurès, 5 allées Antonio Machado, 31058 Toulouse, France; Phone number : 33 561 50 35 59; Fax number : 33 561 25 70 93; E- mail address: patrick.raynal@inserm.fr
Abstract
Research is scarce regarding the personality profiles of individuals with subclinical obsessive- compulsive symptoms. Cluster analysis based on personality disorders (obsessional, schizotypal, borderline) and autism-spectrum features was conducted on 118 students scoring above cutoff for the Obsessive Compulsive Inventory-Revised. This identified 4 groups (O, L, S and A). One third of the sample was represented by individuals with obsessional traits (O) while another third was composed of individuals with low traits (L); the last two profiles corresponded to a cluster with autistic traits (A) and a group with schizotypal and borderline features (S), both clusters representing altogether the remaining third. Significant differences were observed between groups, both on personality traits and on psychopathological symptoms. The S cluster displayed the highest scores of suicidality, depression or obsessive-compulsive symptoms, suggesting that these individuals should require attention from clinicians. This study thus identified distinct and meaningful personality profiles of individuals with subclinical obsessive-compulsive symptoms.
Keywords: Personality traits; Schizotypy; Borderline; Autism-spectrum; Cluster analysis.
1. Introduction
Obsessive-compulsive disorder (OCD) is a debilitating and chronic illness with an estimated lifetime prevalence of 1.2-2.5%. It is a symptomatically heterogeneous condition in which different kinds of compulsions and obsessions exist, including checking compulsions, symmetry obsessions, washing rituals or repugnant obsessions (e.g., sex, violence…) (Abramowitz, Taylor,
& McKay, 2009; Ruscio, Stein, Chiu, & Kessler, 2010). Research has suggested the existence of possible subtypes of OCD, based on the variety of symptom presentations and on different responses to existing treatments (McKay et al., 2004; Steketee et al., 2011; Farris, McLean, Van Meter, Simpson, & Foa, 2013; McKay et al., 2015), as well as on variations in
neuropsychological functioning (Glahn, Prell, Grosskreutz, Peschel, & Müller-Vahl, 2015).
Heterogeneity was also reported when studying the motivational dimensions of individuals with OCD, as cluster analyses identified four subgroups with relatively high or low levels of harm avoidance and incompleteness motivations (Bragdon & Coles, 2017).
Whether personality plays a role in OCD heterogenity remains unclear. Most individuals with OCD display a comorbid personality disorder (PD) (Torres et al., 2006; Bejerot, Ekselius,
& Knorring, 1998; Baer & Jenike, 1992). Different types of PD can be associated with OCD, notably obsessive-compulsive PD (OCPD). Clinicians have asserted for decades that a strong relationship existed between OCD and OCPD but in fact there is a wide range (10-60%) of comorbidity rate described in the literature (Wu, Clark, & Watson, 2006; Torres et al., 2006).
This fueled the debate about the nature of the link between OCD and OCPD. Researchers suggested that obsessive-compulsive personality traits and OCD may exist along a continuum (Mathews, Jang, Hami, & Stein, 2004; Pinto, Greene, Storch, & Simpson, 2015; Park, Storch, Pinto, & Lewin, 2016). In contrast, other studies indicated that OCDP comorbidity might be rather considered as a marker of OCD severity (Lochner et al., 2011; Wetterneck et al., 2011), or that the comorbidity of OCD with OCPD could be a specific subtype of OCD (Garyfallos et al., 2010).
Schizotypal personality disorder (SPD) is also a frequent comorbidity in patients with OCD or individuals with OCD living in the community, with comorbidity rates ranging from 5 to 30%
(Torres et al., 2006). In non-clinical samples, obsessive-compulsive symptoms were found to be associated with schizotypy (Roth & Baribeau, 2000; Chmielewski & Watson, 2008; Fonseca- Pedrero, Lemos-Giráldez, Paíno-Piñeiro, Villazón-García, & Muñiz, 2010). Not surprisingly, patients with both OCD and SPD or schizotypal features were found to display poorer insight, lower functioning and increased OCD severity in comparison with patients with OCD alone (Poyurovski et al., 2008; Huang, Hwang, Huang, & Hwu, 2011). However other reports failed to show that individuals with OCD and schizophrenia or high levels of schizotypy had a significant increase in OCD severity (Brakoulias et al., 2014; Doyle, Chorcorain, Griffith, Trimble, &
O’Callaghan, 2014; Solem et al. 2015).
In this study, the occurrence of borderline traits in individuals with subclinical obsessive- compulsive symptoms was explored, considering that borderline PD (BPD) is not a rare comorbidity of OCD (rate range: 3-23%; Melca, Yücel, Mendlowicz, de Oliveira-Souza, &
Fontenelle, 2015; Bulli, Melli, Cavalletti, Stopani, & Carraresi, 2016). In addition our study took into consideration autistic characteristics. Indeed overlaps between features of autism spectrum disorders (ASD) and OCD were reported (Chasson et al., 2011; Wakabayashi, Baron-Cohen, &
Ashwin, 2012) and the prevalence of OCD in youth with ASD is not uncommon (Lewin, Wood, Gunderson, Murphy, & Storch, 2011).
Research is scarce regarding the typology of individuals with subclinical obsessive- compulsive difficulties. Yet having obsessions and compulsions is a matter of substantial suffering and disability, as these subjects, even though they are not diagnosed with OCD, may display similar consequences to patients with full-blown OCD (De Bruijn, Beun, De Graaf, Ten Have, & Denys, 2010).
The present study had two objectives: a) to explore the typology of a nonclinical sample of young adults with subclinical obsessive-compulsive symptoms based on schizotypal, obsessional, borderline and autistic features and b) to examine the validity of clusters by comparing them across variables potentially allowing to distinguish clusters (i.e., depressive symptoms, frequency of cannabis use, academic performance). We hypothesized that clusters will differ on both personality traits and psychopathological symptoms. This could allow to identify relatively more homogeneous subgroups from a markedly heterogeneous sample of individuals with subclinical obsessive-compulsive symptoms.
2. Methods 2.1. Participants
Potential participants (students in France universities) were informed about the study via social networks and official website of several French universities. Informed consent was obtained from all participants by ticking a box on the Internet website before completing the study.
Potential participants were provided with information regarding the study aims and were informed that answers to the questionnaires would remain strictly confidential and be analyzed according to scientific aims. No compensation was offered to participate in the study, following a standard procedure of the institution. The participants were provided with the possibility to contact the principal investigator (PR) via email for further information or to receive referral.
The questionnaires were anonymous. The study followed the ethical guidelines of the Helsinki Declaration and its procedures were approved by the ethics committee of the research ward.
Inclusion criteria were also being aged over 18 years and having completed all the scales.
Personal information (age, gender, level of academic degree and academic results during the past semester) was gathered. The initial sample was composed of 476 students (95 males; 381
females) aged between 18 and 25 (mean age of males = 21 ± 2.3; mean age of females = 20.7 ± 1.9; p = 0.32).
2.2. Measures
2.2.1. Obsessive-compulsive symptoms
Obsessive-compulsive symptoms were assessed using the French version of the Obsessive Compulsive Inventory-Revised (OCI-R; Foa et al., 2002; Zermatten, Van der Linden, Jermann, &
Ceschl, 2006). It contained 18 items (e.g., "I check things more often than necessary") scored from 0 ("Not at all") to 4 ("Extremely"). A cutoff score of 25 was chosen to identify individuals with subclinical obsessive-compulsive symptoms as it provides high specificity (Foa et al., 2002). Cronbach's α range was 0.81-0.93 in Foa et al.'s report.
2.2.2. Obsessional personality traits
Obsessional traits were measured using the French version of the Obsessional personality disorder scale of the Personality Diagnostic Questionnaire-4 (Bouvard, 2002; Hyler, Rieder, Williams, Spitzer, & Lyons, 1988). This scale contained 8 items (e.g., "I feel that my standards and ethics are higher than those of my peers") scored 0 (false) or 1 (true). Cronbach's α range was 0.46-0.66 in former studies (Hyler et al., 1988; Bouvard 2002).
2.2.3. Schizotypal traits
Schizotypal traits were assessed using the Schizotypal Personality Questionnaire-Brief (SPQ-B;
Raine & Benishay, 1995), a self-administered scale including 22 dichotomous items. We used a French version of SPQ-B already described in previous studies (Raynal, Goutaudier, Nidetch, &
Chabrol, 2016; Raynal, Melioli, & Chabrol, 2016). Each item (e.g., "People sometimes find me aloof and distant") was scored 0/1 (no/yes). Cronbach's α was 0.81 in a previous report (Fonseca- Pedrero, Paino-Pineiro, Lemos-Giraldez, Villazon-Garcia, & Muniz, 2009).
2.2.4. Borderline personality traits
Borderline PD traits were assessed using the nine relevant items of the Personality Diagnostic Questionnaire-4 under its French version (Bouvard, 2002; Hyler, Rieder, Williams, Spitzer, &
Lyons, 1988). Items (e.g., " I often question my personal identity and frequently change my
opinion of who I am") were scored from 1 (totally false) to 7 (totally true). Cronbach's α range was 0.69 in a former study (Chabrol, Valls, van Leeuwen, & Bui, 2012)
2.2.5. Autism-spectrum characteristics
Autism-spectrum characteristics were measured using the Autism spectrum Quotient (AQ) (Baron-Cohen, Wheelwright, Skinner, Martin, & Clubley, 2001) under its 10-item version. A French version of AQ-10 was adapted from the French version of AQ by selecting the 10 relevant items that have been selected in AQ-10, as previously described (Booth et al., 2013;
Raynal, Goutaudier, Nidetch, & Chabrol, 2016). Items (e.g., "When I am reading a story, I find it difficult to work out the characters intentions") were scored 0 (no) or 1 (yes), except for items 2- 6 and 9 that were scored inversely. Cronbach’s α was 0.85 in Tchanturia et al.’s study (2013).
2.2.6. Depression symptoms and suicidal ideations
Depression was evaluated using The Centre for Epidemiological Studies-Depression scale (CES- D; Radloff, 1977) under its 10-item version (e.g., "My sleep has not been good"). The French version of this questionnaire was used (Fuhrer & Rouillon, 1989). Responses were made on a 4- point Likert scale, ranging from 0 to 3. Cronbach's α was 0.70 in Radloff's report (1977).
The suicidal ideation was assessed using the 3-item scale ("I felt life was not worth living";
"I felt like hurting myself"; "I felt like killing myself") proposed by Garrison, Addy, Jackson, McKeown, & Waller (1991). A French version of this scale was already described (Chabrol, Rodgers, & Rousseau, 2007). Responses to these items were made on the same scale as the CES- D items. A suicidal ideation score (range 0–9) was calculated by summing responses on these three items. Cronbach's α was 0.85 in an earlier report (Chabrol et al., 2007).
2.2.7. Cannabis use
Cannabis use was measured with the Cannabis Use Disorder Identification Test-Revised (CUDIT-R; Adamson et al., 2010). The French version of this questionnaire was
found in Annaheim, Rehm, & Gmel (2008). Cronbach's α range was 0.84 in Adamson et al.'s study.
2.3. Statistical analysis
A cluster analysis was performed on individuals displaying a score above the cut-off for the OCI-R. This analysis was based on scores obtained on the following dimensions: obsessional, schizotypal, borderline and autistic. This was achieved by standardizing as z-scores the participants scores for each dimension. A hierarchical cluster analysis was then conducted
(Ward’s method with Euclidean distance). The dendrogram and the agglomeration schedule were used to identify the number of clusters. Then, K-means clustering was used to assign each
individual to the identified clusters. Missing data was replaced with the item mean. Because the distribution of scores on cannabis use and on suicidal ideations were positively skewed, a square root transformation was used to reduce skewness. Statistical analyses were performed using Statistica 10.
3. Results
3.1. Descriptive statistics
In the initial sample of 476 students, the mean score for the OCI-R was 18.23 (SD = 11.08).
SPQ-B and CES-D-10 mean scores were 8.46 (SD = 4.42) and 12.79 (SD = 4.07), respectively.
Table 1 displays Cronbach's α and score ranges. The obsessional and the autism scales showed suboptimal Cronbach's α in the 0.5 range.
3.2. Comparison of participants with obsessive-compulsive symptoms with a control group The participants scoring above cutoff on the OCI-R were considered as composing the group with a significant level of obsessive-compulsive symptoms (OC; n = 112, 77.7% female, 22.3%
male). This group was compared to the rest of participants (control group; n = 364, 80.8%
female, 19.2% male). The proportion of male was not higher in the OC group compared with the control group (p = 0.278, Fisher's exact test). The OC group had higher scores on all personality traits and psychopathological symptoms (Table 1). Cohen’s d indicated large size effects except
control group had slightly higher academic degrees but academic performance was virtually identical between the two groups.
3.3. Cluster analysis
A cluster analysis was performed on the participants from the OC group. This analysis was conducted in two steps based on scores on the following dimensions: obsessional, schizotypal, borderline and autistic. Absence of multicollinearity was evaluated through an analysis of the correlations between the variables selected for the cluster analysis (all variables had tolerance values > .60). In the first step, a hierarchical cluster analysis was conducted (Ward’s method with Euclidean distance). Based on the dendrogram and the aggregation curve, a four-cluster solution was identified. In the second step, K-means clustering was used to assign individuals to one of the identified clusters. A discriminant analysis showed clear differences between clusters (Wilks’ λ = 0.116, p < 0.001) with 94.6% of cases correctly classified. Data revealed a first group with a score of obsessional traits higher than other clusters by more than one SD, while the scores of this cluster regarding the other variables were close to the mean of the sample
(Figure 1; Table 1). This cluster was thus termed "Obsessional" (O, n = 39, [34.8%]). A second cluster displayed scores on both schizotypal and borderline traits higher than other clusters by at least one SD. It was thus named "Schizotypal-borderline" (S, n = 15 [13.4%]). A third group was characterized with autistic traits higher than the other clusters by nearly one and a half SD and was thus called "Autistic" (A, n = 19 [17%]). A fourth group, called "Low traits" (L, n = 39 [34.8%]) was characterized with scores below the sample mean for all dimensions.
Cluster group differences in levels of PD traits, depression symptoms, suicidality, cannabis use and academic results were tested using an analysis of variance (ANOVA; Table 2). Firstly, ANOVA showed that significant differences between clusters existed on all variables except cannabis use and academic degree (column "F"). Tukey post-hoc test further confirmed the importance of differences between clusters (column "Significant comparisons"). Indeed S was more elevated than all other clusters when considering schizotypy and borderline traits. O scored
higher than the other groups regarding obsessionality. A was more elevated than all other clusters for the autistic dimension. Further confirming this classification, significant differences were also observed between clusters when analyzing depression symptoms, suicidal ideation and academic results of past semester. Indeed S was more elevated than the other clusters on suicidal ideas and it scored higher than O and L regarding depression symptoms. In addition, S displayed higher obsessive-compulsive symptoms in comparison to L, and lesser academic results during past semester, when compared with 0 or L. Of note, A scored higher than L on suicidality and depression. Taken together these data allowed to identify four distinct profiles of individuals with subclinical obsessive-compulsive symptoms.
4. Discussion
Regarding the validity of this study, our sample appeared to be very similar to other non clinical samples described in the literature. For instance, in our initial sample of 476 participants, 112 individuals (24.4%) displayed a score suggesting obsessive-compulsive symptoms, which is close to the rate of 28.2% of US adults reporting similar symptoms (Ruscio, Stein, Chiu, &
Kessler, 2010). Similarly, the mean OCI-R score of this study was 18.23, that is almost identical to values reported earlier: 18.82 in Foa et al. (2002); 18.91 in Hajcak, Huppert, Simons, & Foa (2004). On the same theme, the mean scores for SPQ-B and CES-D-10 in our whole sample were 8.46 and 12.79 respectively, close to 9.6 and 12.9 reported in the general population (Raine
& Benishay, 1995; Radloff, 1977).
In this study we performed a cluster analysis based on PD traits and the autistic dimension on individuals with subclinical obsessive-compulsive symptoms. To our knowledge, this is the first study to propose a personality-based typology of individuals with this type of symptoms.
This resulted in 4 distinct profiles: one third of the sample was represented by individuals with obsessional traits as core feature (O group), while another third was composed of individuals with low traits (L); the last two profiles corresponded to a group of individuals with autistic traits
(A) and a group with schizotypal and borderline features (S), both groups representing altogether the remaining third of the sample.
A noticeable finding provided by this study is that a significant heterogeneity prevails in the personality profiles of individuals with subclinical obsessive-compulsive difficulties. Firstly students with obsessional traits represented one third of these individuals, which is very close to the prevalence rate of OCPD in individuals with OCD described in recent reports (33-34%;
Garyfallos et al., 2010; Lochner et al., 2011). The remaining two thirds of individuals with obsessive-compulsive symptoms was thus composed of persons who did not display
obsessionality features. Hence it seems difficult to envision that obsessionality and subclinical obsessive-compulsive symptoms are necessarily on the same continuum.
Those two thirds were constituted of 3 distinct profiles: A, S and a Low-trait group. The A group is composed of individuals featuring an association between subclinical obsessive- compulsive problems and autism-spectrum traits. Although OCD and ASD seem to be highly disparate at first sight, links between these disorders have been recently established in terms of shared social competence impairment (Chasson et al., 2011), and ASD symptoms were already reported in OCD children (Arildskov et al., 2016). In support of this association, the same polymorphism producing a gain-of-function of the serotonin transporter gene was identified in individuals with OCD and ASD (Wendland et al., 2008). Further supporting this link, our data indicates that, even when considering obsessive-compulsive symptoms at a subclinical level, autistic features are not uncommon, reinforcing the notion that ASD comorbidity can be significantly associated with OCD.
The S group was composed of individuals with high schizotypy and borderline traits, which may reflect the high comorbidity between SPD and BPD (Pulay et al., 2009). This S group appeared to share characteristics with patients displaying OCD and SPD or BPD comorbidity (Melca, Yücel, Mendlowicz, de Oliveira-Souza, & Fontenelle, 2015). However the prevalence of this association seems to be lower in individuals with subclinical obsessive-compulsive
symptoms than in those with full-blown OCD. Indeed individuals with SPD or BPD represented altogether ≈34% of patients with OCD (Melca et al., 2015), while the S group constituted only 13.4% of individuals with subclinical obsessive-compulsive difficulties.
The individuals with the S group profile seem to require the most attention from clinicians, with significant degradations when compared to other clusters. Indeed this group displayed the highest scores of suicidality, depression or obsessive-compulsive symptoms. In agreement with these observations, previous studies on patients with OCD and with SPD or BPD showed that these individuals had the highest rates of several comorbid psychiatric disorders in comparison with other types of patients with OCD (Melca, Yücel, Mendlowicz, de Oliveira-Souza, &
Fontenelle, 2015). Similarly other reports found that patients with OCD with the highest load of schizotypal symptoms had increased general psychopathology, including greater depressive symptomatology (Poyurovsky et al., 2008; Solem et al., 2015).
The S group also showed the highest score for cannabis use, even though large SD impaired the significance of this difference. In addition this group displayed the lowest scores on academic functioning, even though with a non significant difference for the variable "academic degree".
Former studies in patients with full-blown OCD and schizotypal features also reported a lower functioning in these individuals in comparison with non-schizotypal patients with OCD (Huang, Hwang, Huang, & Hwu, 2011; Brakoulias et al., 2014).
Therefore schizotypal and borderline traits appeared to be a detrimental element for
individuals with subclinical obsessive-compulsive symptoms, requiring particular attention from clinicians, as these personality traits may aggravate the outcome of these symptoms, notably through increasing depression and suicidality.
This study is not exempt from limitations. Firstly, the small sample size and the low proportion of men may restrict the generalizability of the present findings, even though OCD appears to be somewhat more frequent in women (Bebbington, 1998). In addition, the cross- sectional nature of data collection and the use of self-report measures impaired the assessment of
causality in the results and can induce common bias in this type of study. Furthermore scales showed suboptimal Cronbach's α in the 0.5 range, although this can be considered as an acceptable level of consistency (Schmitt, 1996).
In conclusion this study identified four distinct personality profiles of individuals with subclinical obsessive-compulsive difficulties, among which those with significant obsessionality represented no more than one third of the sample. This clearly emphasizes the importance of other personality traits, notably schizotypal, borderline and autistic features. Further studies are now required to explore how these profiles may influence the progression of obsessive-
compulsive symptoms.
Acknowledgements: We thank V. Loir and V. Nidetch for help in study design and data collection.
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Figure 1. Four-cluster solution based on the four dimensions indicated on the x-axis.
Cluster names: Obsessional (O); Autistic (A); Schizotypal-borderline (S); Low traits (L).
O
S Mean
(z-scores)
L Obsessional Autistic
Schizotypy Borderline
Cluster:
A 0.5 -
1 -
0 - -0.5 - -1 - 1.5 -
Table 1
Cronbach's α and score ranges for the whole sample, and t-test comparison of the control group
Control OC
n = 364 n = 112
Variables α Range M (SD) M (SD) t Cohen's d
Obsess.-comp. symptoms 0.83 0-64 13.35 (6.89) 33.75 (7.1) 27.19* 2.49
Schizotypy 0.74 0-22 7.34 (3.85) 11.98 (4.31) 10.82* 0.99
Autistic traits 0.53 0-10 2.93 (1.56) 3.69 (1.71) 4.35* 0.4
Borderline traits 0.79 10-70 28.46 (9.81) 40.76 (11.64) 11.08* 1.02 Obsessional traits 0.58 0-8 3.34 (1.47) 4.69 (1.37) 8.62* 0.79 Depression symptoms 0.59 0-36 12.55 (3.95) 15.9 (4.61) 7.52* 0.69
Suicidal ideas 0.82 0-9 0.55 (1.31) 1.89 (2.31) 7.71* 0.71
Cannabis use 0.92 0-32 1.9 (4.45) 3.38 (6.85) 2.69* 0.25
Academic degree n.a. 1-6 2.67 (1.34) 2.34 (1.12) -2.34* -0.21 Academic results n.a. 1-5 3.04 (1.04) 3.02 (1.13) -0.2 -0.02
* p < 0.05; n.a., not applicable
with the group of individuals with obsessive-compulsive symptoms (OC).
Table 2
Typology of individuals with subclinical obsessive-compulsive symptoms;
Cluster comparison using ANOVA and Tukey post-hoc test.
Cluster M (SD)
O S A L F Significant
Variables n=39 34.8 % n=15 13.4% n=19 17% n=39 34.8 % comparisons Schizotypy 12.51 (3.14) 16.33 (2.19) 14.47 (3.31) 8.56 (3.82) 26.24* S>O,L O,A>L Autistic traits 3.38 (1.25) 3.67 (0.72) 6.05 (0.71) 2.85 (1.73) 26.24* A>O,S,L Borderline traits 43.1 (7.43) 56.2 (6.34) 42.26 (9.44) 31.74 (9.97) 31.34* S>O,A>L Obsessional traits 5.95 (0.83) 3.8 (0.68) 4.63 (1.07) 3.79 (1.15) 36.66* O>S,A,L Depression 16.1 (3.86) 20.27 (3.92) 17.79 (4.48) 13.1 (3.81) 14.04* O,S,A>L S>O Suicidal ideation 1.74 (2.07) 5.07 (2.46) 2.11 (2.16) 0.72 (1.19) 19.27* S>O,A,L A>L Cannabis use 2.9 (5.78) 6.93 (10.71) 3.95 (7.28) 2.23 (5.44) 1.86
Obs-comp sympt. 34.69 (7.31) 36.93 (8.51) 34.26 (6.71) 31.33 (5.89) 2.91* S>L Academic degree 2.62 (1.51) 2.07 (1.39) 2.21 (1.23) 2.23 (1.18) 0.89
Academic results 3.23 (1.11) 2.27 (1.1) 2.89 (1.2) 3.15 (1.04) 3.1* O,L>S
* p < 0.05
