Psychopathology and Alexithymia in Personality Disorders

Personality disorders has been a neglected subset of all psychiatric disorders. Borderline Personality Disorder (BPD) and Antisocial Personality Disorder (ASPD) are the two most complex disorders of personality noted. There is a dearth of Indian literature on the same. This study aims at comparing the psychopathology in BPD and ASPD while studying alexithymia in these populations. A wide variety of psychopathology was noted in both these disorders. Anger hostility was more common in ASPD, while somatization and obsessive compulsiveness with anxiety was commoner in the BPD group. Both groups showed an equal amount of interpersonal stressors. Substance abuse was seen in all patients with ASPD while depression was more common in the BPD group. This study though limited in its subjects highlights the need to explore and research this neglected psychiatric population in diverse settings and longitudinally across time. KEY WORD Borderline, Antisocial. Personality disorder. Introduction The term 'personality disorder' is an abstraction that is built upon several tenuous theories. It is an untidy concept but it carries immense clinical importance and usefulness. Acute and detailed observation of the characteristics of personality is a useful clinical skill that has regrettably been neglected for many years (Sims 1983). Borderline Personality Disorder (BPD) has been over the years described as the most controversial of all personality disorders and is best understood as a helerogenous syndrome manifested with ego syntonic affective instability and impulsivity. It also has the propensity to move towards cognitive perceptual distortions in the context of chronic unstable interpersonal relationships (Carrasco & LecicTosveki 2000). BPD is a concept associated with fuzzy boundaries and unfounded clinical speculations. Due to its high level of morbidity it has often been regarded as a m e mental illness lying on the 'border' between psychosis, affective disorders and personality trait variations (Livesley 2000). Antisocial Personality Disorder (ASPD) is a personality disorder of the Cluster B group that has evoked considerable interest among psychiatric researchers. ASPD often starts in early childhood with conduct disorder, aggressive and imtable behavior along with impulsivity that often wrecks havoc on the family members for many years to come (Zocolillo et al., 1992). ASPD and BPD have a number of similarities though. Once the behavioral manifestations influenced by gender are taken into account i.e. criminality and substance abuse in men versus suicide attempts in women, their pictures often look similar. BPD and ASPD often have common family histories along with childhood precursors (Zanarini 1983, Links et.al. 1998). The phenomenological difference reflects the underlying traits with ASPD having pure impulsivity and BPD having a combination of impulsivity and affective instability (Siever & Davis 1991). BPD patients commonly report family dysfunction. serious parental psychopathology and experiences 01 childhood abuse and neglect (Paris 1994). This parallels the risk factors in the prospective studies on ASPD where parental sociopathy and family dysfunction with inconsistent discipline being the positive risk factors (Rutter 1989). Multifactorial models have been suggested in the etiology of BPD and ASPD. Admixtures of Innate temperament, difficul~ childhoods, neurological soft signs along witf biochemical dysfunctions all play a role and the list Indian Journal of Psychological Medicine of etiologic factors grows over time (Paris & Frank 6989, Zweig Frank & Paris 1995). Progress in conquering medical and psychiatric disorders comes from understanding their course and clearly defining what is meant by recovery. With pultiple symptom domain cognitive, affective, impulsive and interpersonal, the disorders both BPD and ASPD have a varied course and profound effects on the life of the patients. Suicide attempts, comorbid '; depression, alcohol and drug abuse along with violence all affect the prognosis in these patients (Coccarro & Seiver 1995, Soloff et.al. 1994. Soloff et.al. 1991). Many decades and voluminous literature has been spent on personality disorders worldwide. There is however a dearth of Indian literature in this regard. hbates between competing philosophies on various issues in BPD and ASPD have been acrimonious due to the heterogeneity of symptom profiles making controlled studies impossible to a large extent. The present study looks at a subset of the BPD and ASPD population studying the psychopathology and quality of life while trying to decipher variables influencing the same. Aims of the study To compare the psychopathology in patients with BPD and ASPD. Material & Methods 40 patients each with BPD and ASPD were chosen for the study. All patients were receiving treatment i t h e psychiatry department at Masina Hospital on an out patient basis, They were chosen on the basis of the following inclusion criteria 1. Age between 25-45 years. 2. Diagnosed by a psychiatrist as having BPD or ASPD at least a year prior to the start of the study. 3. At the time of the start of the study, the patients met the DSM-IV diagnostic criteria for BPD and ASPD. 4. Last in patient admission more than 6 months ago. 5. No psychiatric emergency of any type in the last 6 months. 6 . Absence of physical deformities, medical and surgical illness. 7. Absence of epilepsy and clinically significant head injury. 8. Same place of residence for the last 5 years. 9. No electroconvulsive therapy received in the last 6 months. 10. Patient on the same pharmacological treatment since the last 3 months. 11. Not more than one co-morbid psychiatric diagnosis. A proforrna was designed for the collection of data in the form of a semi-structured interview with socio-demographic data along with variables related to the study being collected. The following scales were used in the study 1. Toronto Alexithymia Scale (TAS) self report scale that assesses alexithymia with 26 items. Scores of 11 or over confirm alexithymia while those of less than 1 1 rule it out. It has been used in a wide variety of settings and cultures and is the only scale used widely in the Asian population. (Bagby et.al. 1988. Taylor et.al. 2003) 2. The Symptom Checklist 90 (SCL -90) This is a self report scale that has been widely used in the normal as well as distressed populations. 90 items are divided into 9 subscales that include Somatization, Obsessive Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Anger-Hostility, Phobia, Paranoia and Psychoticism. The scales have a lickert type scale of distress from 0 to 4. Scores are defined as General Symptom Index (GSI) with higher scores representing more psychopathology. Scores on each scale from 0 to 0.99 are normal while scores over 1 represent psychopathology (Derogatis et.al. 1970). Written informed valid consent was taken from the patients and their relatives prior to the study. Statistical Analysis The entire data was analyzed and tabulated. The analysis was done by a qualified biostatistician. Student t test and chi square test was used in the analysis wherever appropriate and two tailed p values were obtained. Results & Discussion On assessing the socio demographic data (Table I ) it was observed that in both groups majority of patients belonged to the younger age group. Female preponderance was common in BPD with 95% subjects being female while the ASPD group had 90% of its subjects as males. More patients in the ASPD group (75%) were unemployed compared to the BPD group (55%). Patients in the ASPD group were poorly educated compared to the BPD groups. It has been noted that school drop outs, conduct disorder and oppositional defiant disorder are common childhood precursors of ASPDand the fact that many of them remain unemployed for long periods in their life (Robins 1966, Tremblay et.al. 1994). Borderline patients have been known to remain employed and maintain themselves despite their disorder (Stone 1990). Table-1