Ossessioni e compulsioni in pazienti con disturbo borderline di personalità: caratteristiche cliniche e insight

Objectives Thought abnormalities in borderline personality disorder (BPD) include psychotic transient or psychotic-like symptoms and obsessive- compulsive symptoms. Psychodynamic theories and clinical investigations indicated that psychotic or psychotic-like symptoms represent a core feature of this Axis II disorder. Therefore, DSMIV- TR defined “transient stress-related paranoid ideation or severe dissociative symptoms” as one of diagnostic criteria for BPD. Obsessive-compulsive symptoms are also considered intrinsically related to borderline psychopathology. These symptoms are severe and are characterized in BPD patients by poor insight and resistance and obsessive control evident in personal relationships. Such psychopathological features of obsessive thoughts and compulsive behaviors are the expression of a deficient sense of self and reality and lack of coping abilities. The first aim of the present study is to compare demographic and clinical characteristics between a subgroup of patients with a single diagnosis of obsessive-compulsive disorder (OCD) and a subgroup with a codiagnosis of obsessive-compulsive disorder and borderline personality disorder. The second aim is to investigate which clinical factors are significantly related to the level of insight in the subgroup of patients with concomitant OCD and BPD. Methods 149 consecutive outpatients (79 males and 70 females; mean age 33.19 ± 13.81) who received a DSM-IV-TR diagnosis of obsessive-compulsive disorder were recruited for the study. The age of included patients ranged between 18 and 60 years. Exclusion criteria were lifetime diagnosis of dementia or other cognitive disorders, schizophrenia or other psychotic disorders, and/ or bipolar disorders. Concomitant Axis I or II disorders were also excluded. All participants were tested with: a semistrictured interview for demographic and clinical variables, the Structured Clinical Interview for DSM-IV Axis I and II Disorders (SCID-I and SCID-II), the Clinical Global Impression-Severity Item (CGI-S), the Hamilton Scales for Depression and Anxiety (HAM-D and HAM-A), the Social and Occupational Functioning Assessment Scales (SOFAS), the Borderline Personality Disorder Severity Index (BPDSI), the Yale Brown Obsessive-Compulsive Scale (YBOCS), and the Overvalued Idea Scale (OVIS). Student’s t test and c2 test were used for statistical analysis. Significant variables were included in a multiple regression model, with the OVIS score (level of insight) as dependant variables. The level of significance was set at p ≤ 0.05. Results The continous variables that showed a significant difference between the two subgroups were the CGI-S, the HAM-A, the SOFAS, the Y-BOCS, and the OVIS. Patients with concomitant OCD and BPD scored higher on all these scales (Table I). Comparison of categorical variables showed significant differences between groups for gender and course of illness. There were more women in the group with codiagnosis of OCD and BPD, a group that also showed a higher frequency of episodic course of OCD (Table II). The type of obsessive and compulsive symptoms significantly differed between the two groups: patients with OCD only had a higher frequency of obsessions of doubt and cleaning/washing compulsions, while patients with concomitant OCD and BPD showed more frequently aggressive obsessions and hoarding, and control compulsions (Figs. 1, 2). Multiple regression analysis found the level of insight in the group with OCD and BPD to correlate positively with total BPDSI scores (p = 0.0005) and Y-BOCS scores (p = 0.002), and inversely with CGI-S (p = 0.023) and HAM-A (p = 0.003) scores (Table III). Conclusions The occurrence of BDP in comorbidity with OCD determines noticeable differences in clinical picture. In fact, this group of patients with Axis II codiagnosis is characterized by higher frequencies of female gender and episodic course of OCD. In addition, they have a higher level of global symptomatology and anxiety, a more severe functional impairment, and more severe obsessive symptoms with poorer insight. These results are mainly in accordance with previous findings, suggesting that the concomitance of a serious personality disorder worsens the psychopathology and the clinical picture of mental disorders. The main finding of our study is that patients with BPD have a decreased level of insight into the absurdity of their obsessive ideas, are unable to cope with their thoughts and do not recognize the abnormality of their compulsive behaviors. In addition, our results suggest that insight into obsessive ideas is negatively influenced by the severity of obsessions and borderline personality symptoms. On the contrary, a good level of insight is typical of patients with serious global pathology and high level of anxiety. A possible explanation of this finding is that the lack of insight may play a protective role and reduce emotional distress. Our results are not sufficient to draw final conclusions on the complex relationship involving obsessions and compulsions, borderline pathology, and level of insight, but they contribute to stimulate the interest for oncoming investigations on this psychopathological issue and its clinical and therapeutic implications.