Hysterical and Obsessive-Compulsive Symptom Patterns

Abstract

The recently published Psychodynamic Diagnostic Manual (PDM; PDM Task Force 2006) proposes a diagnostic system with three axes: an S-axis with phenomenological descriptions of symptom patterns; a P-axis with different personality types underlain by the anaclitic and introjective personality dimensions; and an M-axis with descriptions of different profiles of mental functioning. This poster focuses on the interconnected-ness of the P- and the S-axis. More specifically, the hypothesis is tested that the anaclitic interpersonal dimension is associated with hysterical symptom patterns (somatoform disorders and phobias on the S-axis) and that the introjective interpersonal dimension is associated with obsessive-compulsive symptom patterns (see Figure 1, based on the PDM, pp. 544–545). Recently, Desmet et al. (2008) correlated scores on the Inventory of Interpersonal Problems (IIP-64; Horowitz et al. 2000) with clinical ratings on the anaclitic and introjective personality styles, and specified an anaclitic and an introjective IIP profile. The anaclitic profile was marked by high scores on the nonassertive, overly accommodating, and self-sacrificing IIP scales; the introjective profile by high scores on the vindictive and cold IIP scales. Yet when the authors then tested whether these IIP profiles were associated with the predicted symptom patterns, their findings did not confirm the hypotheses.

Figure 1.

Theoretical associations between partial drives, interpersonal orientations, and neurotic symptoms (operationalizations in parentheses)

This study presents an alternative test of these hypotheses. In the earlier study, Desmet and colleagues used the Symptom Check List (SCL-90-R; Derogatis 1992) to measure hysterical and obsessional symptom patterns. But because psychometric research has shown this questionnaire to be inadequate in distinguishing different types of symptoms (Vassend and Skrondal 1999), the present study assesses patients’ symptom patterns thus: first we used structured diagnostic interviews to select small groups of patients with either a purely hysterical or a purely obsessive-compulsive symptom pattern; we then tested whether or not the theoretically predicted interpersonal profiles were observed in the two groups.

Method

Participants and procedure. Westen’s Clinical Diagnostic Interview (CDI) and the SCID-I (appropriate since the PDM’s S-axis matches axis I of DSM-IV) were used to screen at intake the symptom patterns of outpatients of a private psychotherapy practice. The first four patients (2 women, 2 men) with purely hysterical symptom patterns and the first four patients (2 women, 2 men) with purely obsessive-compulsive symptom patterns were selected.

Materials. The IIP-64 is a 64-item self-report questionnaire designed to assess interpersonal problems using 0 to 4 Likert scales. Eight subscales are correlated as a circumplex: domineering, vindictive, cold, socially inhibited, nonassertive, overly accommodating, self-sacrificing, and intrusive.

Results

Table 1.

Descriptions of hysterical symptom patterns (left column) and IIP scores and profiles (right column) in four patients

PATIENTS WITH HYSTERICAL SYMPTOMS
Patient 1
Clinical Description of Symptom Patterns	IIP scores		IIP Circumplex Profile
Female, 20 years old; severe diarrhea, started 6 months ago after her mother was diagnosed with cancer; doesn’t leave the house (of her mother) anymore for fear she would be unable to find a toilet; moderate depressive affectivity (BDI-II score of 19); PDM diagnosis on S-axis is Somatization Disorder (code S305.1)	Dom	−10.25
	Vin	−7.25
	Cold	−4.25
	Soci	5.75
	Non	7.75
	Ovac	1.75
	Sesa	7.75
	Intr	−3.25
Patient 2
Clinical Description of Symptom Patterns	IIP scores		IIP Circumplex Profile
Female, 39 years old; sudden anesthesia in right side of body after death of father; medically unexplained paralysis of right leg, cannot walk anymore; speaks very slowly; severe depressive affectivity (BDI-II score of 40); PDM diagnosis on S-axis is Conversion Disorder (code S305.3).	Dom	−4.06
	Vin	−9.06
	Cold	−4.06
	Soci	9.94
	Non	2.94
	Ovac	5.94
	Sesa	8.94
	Intr	−4.06
Patient 3
Clinical Description of Symptom Patterns	IIP scores		IIP Circumplex Profile
Male, 23 years old; attacks of breathlessness, feelings of suffocating; several phobias (e.g., for airplanes) that keep him from realizing dreams and ambitions (e.g., moving to US); severe depressive affectivity (BDI-II score of 32); PDM diagnosis on S-axis is Panic Disorder without Agoraphobia (code S302.1) and Specific Phobias (code S302.2).	Dom	−13.88
	Vin	−11.88
	Cold	−9.88
	Soci	12.13
	Non	11.13
	Ovac	12.13
	Sesa	11.13
	Intr	−13.91
Patient 4
Clinical Description of Symptom Patterns	IIP scores		IIP Circumplex Profile
Male, 37 years old; inability to write because of sudden and uncontrollable shaking of right hand; symptoms started when writing a letter to his wife after discovering her adultery; previously suffered from medically unexplained convulsive attacks and paralysis of right leg; moderate depressive affectivity (BDI-II score of 24); PDM diagnosis on the S-axis is Conversion Disorder (code S305.3)	Dom	−1.13
	Vin	0.88
	Cold	−7.13
	Soci	−1.13
	Non	3.88
	Ovac	−0.13
	Sesa	1.88
	Intr	1.88

Table 2.

Descriptions of obsessive-compulsive symptom patterns (left column) and IIP scores and profiles (right column) in four patients

PATIENTS WITH OBSESSIVE-COMPULSIVE SYMPTOMS
Patient 5
Clinical Description of Symptom Patterns	IIP scores		IIP Circumplex Profile
Female, 34 years old; numerous compulsive symptoms: several rooms in her house are filled with newspapers because she can’t throw them away; several hours of ritualized cleaning and washing a day; moderate depressive affectivity (BDI-II score of 16); PDM diagnosis on S-axis is Obsessive Compulsive Disorder (code S302.3).	Dom	−2.63
	Vin	−10.63
	Cold	1.38
	Soci	2.38
	Non	6.38
	Ovac	6.38
	Sesa	3.38
	Intr	−5.63
Patient 6
Clinical Description of Symptom Patterns	IIP scores		IIP Circumplex Profile
Female, 70 years old; withdrawn from all social interaction because she is afraid “to say or do something wrong”; compulsive controlling whether or not she said something wrong, did not cause an accident, etc.; moderate depressive affectivity (BDI-II score of 25); PDM diagnosis on S-axis is Obsessive Compulsive Disorder (code S302.3).	Dom	−5.25
	Vin	−1.25
	Cold	1.75
	Soci	5.75
	Non	−3.25
	Ovac	3.75
	Sesa	3.75
	Intr	−8.25
Patient 7
Clinical Description of Symptom Patterns	IIP scores		IIP Circumplex Profile
Male, 27 years old; doubting mania; unable to make decisions, like buying things, where to live, etc.; several other compulsive symptoms, such as ordering and counting all kinds of things; severe depressive affect (BDI-II score of 34); PDM diagnosis on S-axis is Obsessive Compulsive Disorder (code S302.3).	Dom	1.13
	Vin	8.13
	Cold	4.13
	Soci	−1.88
	Non	−1.88
	Ovac	−0.88
	Sesa	−7.88
	Intr	0.13
Patient 8
Clinical Description of Symptom Patterns	IIP scores		IIP Circumplex Profile
Male, 30 years old; obsessive fears of serious disease like cancer; frequently checking his body for signs of illness; frequently consulting physicians for reassurance; performing mental rituals every time he reads about death or dying; mild depressive affect (BDI-II score of 13); PDM diagnosis on S-axis is Obsessive Compulsive Disorder (code S302.3).	Dom	−3.88
	Vin	−3.88
	Cold	1.13
	Soci	8.13
	Non	9.13
	Ovac	−0.88
	Sesa	−3.88
	Intr	−5.88

In line with our hypotheses, Table 3 shows that patients with hysterical symptom patterns scored higher on the nonassertive, overly accommodating, and self-sacrificing IIP scales; patients with obsessional symptom patterns scored higher on the vindictive and cold IIP scales. However, the difference between hysterical and obsessive-compulsive patients reached significance only on the self-sacrificing and the cold scales. No differences were found between the IIP scores of men and women.

Table 3.

Comparison of scores on the IIP-64 scales of hysterical and obsessive-compulsive patients and female and male patients

IIP-64 scale	Comparison IIP-64 scores of Hysterical and Obsessive-compulsive patients			Comparison IIP-64 scores of Female and Male Patients
	Mean Hyst.	Mean Obs.	t (p value)	Mean Fem.	Mean Male	t (p value)
Dom	−6.66	−2.66	1.15 (.295)	−4.88	−4.44	0.11 (.913)
Vin	−6.66	−1.91	1.00 (.354)	−6.87	−1.68	1.11 (.307)
Cold	−7.16	2.09	6.90 (.000)	−2.13	−2.94	0.20 (.845)
Soci	5.84	3.59	0.65 (.542)	5.13	4.31	0.22 (.828)
Non	7.10	2.59	1.32 (.236)	4.13	5.56	0.37 (.721)
Ovac	4.09	2.09	0.61 (.564)	3.63	2.56	0.32 (.761)
Sesa	7.60	−1.16	2.51 (.046)	6.13	0.31	1.32 (.234)
Intr	5.16	−4.92	0.07 (.950)	−5.63	−4.44	0.32 (.759)

Conclusion

Our results confirm the hypothesized associations between the anaclitic and introjective interpersonal dimensions (P-axis) and hysterical and obsessive-compulsive symptom patterns (S-axis), respectively, put forward in the PDM. At the methodological level, this study confirms the validity of the IIP-64 as a measure of anaclitic and introjective interpersonal dimensions and the necessity of extensive clinical interviewing over and above the use of self-report questionnaires to map the symptom patterns of patients. Shortcomings of the present study are associated with the more clinical approach of selecting patients with pure symptom patterns, which almost inevitably entails smaller samples. For this reason, future research should try to replicate our findings in larger samples before firm conclusions are drawn.

References

Desmet

Van Hoorde

Verhaeghe

Meganck

Vanheule

Van den Abeele

(2008). Interpersonal profiles and neurotic symptoms: Are they associated with each other? Psychoanalytic Psychology 25:342–355.

Horowitz

L.M.

Alden

L.E.

Wiggins

J.S.

Pincus

A.L.

(2000). Inventory of Interpersonal Problems. London: The Psychological Corporation.

PDM Task Force (2006). Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations.

Vassend

Skrondal

(1999). The problem of structural indeterminacy in multidimensional symptom report instruments: The case of SCL-90-R. Behaviour Research & Therapy 37:685–701.