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Article history: Elevated levels of Neuroticism and lower levels of Extraversion have been reliably shown in patients with
Received 27 February 2014 anxiety and depressive disorders and some studies have demonstrated these patterns amongst patients
Received in revised form 20 July 2014 diagnosed with Obsessive–Compulsive Disorder (OCD). However, because comorbid anxiety and depres-
Accepted 24 July 2014
sion is common in OCD, it is unclear whether the previously observed relationships are due to comorbid
Available online 21 August 2014
anxiety and depression or are more specifically related to the presence of OCD. This study sought to dis-
entangle the relationship between personality and OCD by investigating the relationship between Extra-
Keywords:
version, Neuroticism and OCD symptom severity and illness duration. Additionally, we explored the
Obsessive–Compulsive Disorder
Longitudinal
relationship between these variables and the additional variable of depression. Specifically, we tested
Personality whether depression mediated these relationships amongst a sample of 322 outpatients diagnosed with
Chronicity OCD. We found that depression fully mediated the relationship between personality and OCD symptom
severity but not duration. Indeed, neither personality nor depression could explain illness duration. The
results suggest that depression is an important variable to consider when understanding OCD symptom
severity and trumps personality variables in terms of its explanatory power. The results also suggest that
further work is needed to identify the variables that best explain illness duration in OCD.
Ó 2014 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.paid.2014.07.025
0191-8869/Ó 2014 Elsevier Ltd. All rights reserved.
C.S. Rees et al. / Personality and Individual Differences 71 (2014) 92–97 93
influence of depression. They argued that because the finding of The following hypotheses were proposed:
elevated Neuroticism and low Extraversion has been identified as
a non-specific vulnerability to anxiety and depressive disorders, H1. Participants will have significantly lower scores on Emotional
controlling for depression could help to elucidate the unique rela- Stability as compared to a normative sample (note: Emotional
tionship between OCD and these personality traits. They compared Stability is equivalent to Neuroticism, thus low Emotional Stabil-
98 patients diagnosed with primary OCD to 98 patients diagnosed ity = high Neuroticism).
with primary Major Depressive Disorder (MDD). Using the Revised
NEO Personality Inventory (NEO PI-R, Costa & McCrae, 1992) they
found that although both clinical groups had the expected pattern H2. Participants will have significantly lower scores on Extraver-
of high Neuroticism and low Extraversion, the MDD group had sig- sion as compared to a normative sample.
nificantly higher scores on Neuroticism and significantly lower
scores on Extraversion than the OCD group. This finding suggests
H3. Scores on Emotional Stability will be significantly correlated
that the high Neuroticism and low Extraversion personality profile,
with OCD symptom severity and illness duration.
regarded as a non-specific vulnerability to all anxiety and depres-
sive disorders, may in fact vary between specific disorder groups
and that depression is an important variable to consider. The asso- H4. Scores on Extraversion will be significantly correlated with
ciation between personality and depression was also demonstrated OCD symptom severity and illness duration.
in another study that utilised a categorical approach to examining
the relationship between OCD and personality. Tallis, Rosen, and
H5. Depression will fully mediate the relationship between per-
Shafran (1996) examined comorbidity between OCD and personal-
sonality factors (Emotional Stability and Extraversion) and OCD
ity disorder diagnosis. They found that when depressive symptom-
symptom severity.
atology was controlled, the number of OCD patients with comorbid
personality disorder diagnoses reduced significantly. The results of
these studies suggest that high Neuroticism and low Extraversion H6. After controlling for age, depression will fully mediate the
may be a vulnerability to depression, but not necessarily to OCD. relationship between personality factors (Emotional Stability and
Depression is a highly important variable to consider in its own Extraversion) and OCD duration (see Figs. 1 and 2).
right when studying OCD because up to 50% of patients present
with an additional diagnosis of major depression (MDD) (Crino &
2. Method
Andrews, 1996). OCD patients with comorbid depression who do
not respond to treatment have been found to have higher OCD
2.1. Study design
symptom severity than those without the additional diagnosis
(Abramowitz & Foa, 1998). It is important to acknowledge the
This study is part of a large multicentre longitudinal study car-
influence of affective temperaments and their potential pathoplas-
ried out by the Netherlands Obsessive Compulsive Disorder Associ-
tic role in the etiology and clinical characteristics of OCD. Work by
ation (NOCDA). The NOCDA study aims to investigate the
Hantouche and Demonfaucon (2008) revealed a constellation of
biological, psychological and social determinants of chronicity in
unstable affective temperaments (cyclothymic, irritable and
OCD by studying patients over a 6-year period (for a full descrip-
depressive) being associated with treatment-resistant OCD. Stud-
tion of the NOCDA study see Schuurmans et al., 2012).
ies investigating the temporal relationship between OCD and
All patients diagnosed with OCD who were referred to one of
MDD show that OCD symptoms precede symptoms of depression
the participating mental health care centres were asked permis-
(Bellodi, Scioto, Diaferia, Ronchi, & Smiraldi, 1992; Demal, Lenz,
sion to be contacted for research purposes during the intake proce-
Mayrhofer, Zapotoczky, & Zitterl, 1993). Bartz and Hollander
dure. All patients who consented were contacted and invited to
(2006) draw from this the conclusion that it is unlikely that OCD
participate in the study, irrespective of the stage of the disorder,
and depression share an etiological relationship.
the OCD subtype, the presence of co-morbidity and the stage of
Whilst extant studies reveal that a diagnosis of OCD is associ-
chronicity. Personality, depression and OCD were assessed at
ated with elevated Neuroticism and low Extraversion, no studies
base-line. Specially trained clinical research staff conducted the
have investigated the relationship between these personality traits
baseline interview including the SCID and received a two-day
and OCD symptom severity or illness duration. It may be that those
course and regular follow-up one-day training sessions by the
patients with more severe and/or chronic OCD have a different per-
fieldwork coordinator. All interviews were constantly monitored
sonality profile. Furthermore, it is necessary to conduct such an
by randomly checking at least 10% of all taped interviews.
investigation with a large sample of currently diagnosed patients
to have sufficient power for the analysis and to improve upon
the generalizability of findings. Also, given the interrelationship
between OCD and depression it is imperative to further investigate
this particularly with regard to how it relates to personality fea- Extraversion
tures, symptom severity and course of illness. There is no doubt
that the presence of depression in addition to OCD is associated
with greater occupational and functional disability (Markarian
et al., 2010).
Depression Symptom
Important questions emerging from the current literature is: Severity
Does depression mediate the relationship between personality
and OCD? Can depression account for the previously observed dif-
ferences in levels of Neuroticism and Extraversion? If depression Emotional
does account for the differences in Neuroticism and Extraversion Stability
between OCD patients and non-OCD patients it would suggest that
a diagnosis of OCD is not uniquely related to particular personality Fig. 1. Proposed model with depression mediating the relationship between
vulnerabilities. personality factors and OCD symptom severity.
94 C.S. Rees et al. / Personality and Individual Differences 71 (2014) 92–97
1996). Total scores range from 0 to 63. The reliability of the BDI-
Extraversion
II within the Dutch community has previously been demonstrated
through high internal consistency of items (a = 95, N = 7500;
Roelofs et al., 2013).
Depression OCD
Duration 4. Results
symptoms) to 4 (extreme symptoms) (total range 0–40). The scale Measure Mean SD Range
has excellent inter-rater reliability and high internal consistency Y-BOCS
(Goodman, Price, Rasmussen, Mazure, Fleischmann, et al., 1989) Severity obsessions 10.43 3.99 0–20
as well as good convergent and discriminative validity Severity compulsions 10.67 4.34 0–20
(Goodman, Price, Rasmussen, Mazure, Delgado, et al., 1989) Severity total score 21.11 7.07 7–40
Beck Depression Inventory 15.94 10.02 0–51
Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996).
The BDI-II is a 21-item multiple-choice self-report inventory and it FFPI
Extraversion .10 1.29 3.39 to 3.03
is one of the most widely used instruments for measuring the
Emotional Stability .81 1.16 4.24 to 2.46
severity of depression and clinical improvements (Beck et al.,
C.S. Rees et al. / Personality and Individual Differences 71 (2014) 92–97 95
Table 2 r = .24, p < .001; small to medium effect size), but not with illness
FFPI scores by presence/absence of current major depressive disorder (N = 322). duration (r = .11, p = .06), partially supporting hypothesis 3.
No current major Current major Total Extraversion was significantly negatively correlated with both
depressive depressive symptom severity (r = .20, p < .001; small to medium effect size)
disorder disorder and illness duration (r = .21, p < .001; small to medium effect
N = 264 N = 58
size) supporting hypothesis four.
Extraversion .01 (1.28) .61 (1.20) .10 (1.29) In order to test mediation, a number of assumptions need to be
Emotional Stability .62 (1.11) 1.66 (.97) .81 (1.16)
met (Baron & Kenny, 1986). The independent, mediator and depen-
dent variables must be significantly associated. As displayed in
Table 5, both independent variables (Extraversion and Emotional
Table 3
Severity categories on Y-BOCS and Beck Depression Inventory (N = 322). Stability) were significantly negatively correlated with the media-
tor variable (depression scores) and one dependent variable (sever-
Category Frequency Percent
ity of symptoms). The mediator was also associated with both
a
Y-BOCS dependent variables. However, as previously noted Emotional Sta-
Subclinical 5 1.6
bility was not significantly associated with the second dependent
Mild 72 22.4
Moderate 118 36.6
variable (duration).
Severe 102 31.7 One standard and one hierarchical multiple regression analysis
Extreme 25 7.8 was conducted to test hypothesis five (see Table 6). The results
BDIb from the standard hierarchical regression demonstrate that in
Normal 96 29.8
combination, the two personality variables, Extraversion and Emo-
Mild to moderate 114 35.4
Moderate to severe 79 24.5 tional Stability, accounted for 52% of the variance in the proposed
Severe 33 10.2 mediator, BDI total depression scores, R2 = .52, F(2, 319) = 173.11,
a p < .001. On step one of the hierarchical multiple regression the
Categories from Goodman, Price, Rasmussen, Mazure, Fleischmann, et al.
(1989). two personality variables accounted for 7.9% of the variance in
b
Categories from Beck et al. (1996). OCD symptom severity scores R2 = .08, F(2, 319) = 13.72, p < .001.
Both Extraversion and Emotional Stability contributed significant
unique variance. On step two of the hierarchical multiple regres-
Table 4 sion BDI depression scores were entered and accounted for a fur-
Percentage of participants taking doctor prescribed med- ther 16.1% of the variance in symptom severity, DR2 = .09, F(1,
ications in previous two weeks by medication type.
318) = 34.40, p < .001. In total, the three predictor variables
Medication type % accounted for 16.9% of the variance in symptom severity,
Psychotropic 67.1 R2 = .17, F(3, 318) = 21.57, p < .001. Depression was a significant
Antipsychotic 17.7 predictor of symptom severity, but neither Extraversion nor Emo-
Antidepressant 62.4 tional Stability contributed significant unique variance any longer,
Benzodiazepines 16.8
indicating depression mediated the relationship between personal-
ity and OCD symptom severity. Sobel test-statistics confirm that
depression significantly mediated the relationship between Extra-
sample, a one-sample t-test was conducted. Participants in this version and symptom severity (t = 5.22, p < .001) and Emotional
OCD sample scored significantly lower (M = .10, SD = 1.29) than Stability and symptom severity (t = 5.94, p < .001). To further
the adult normative sample score (M = 0.39, SD = 1, Hendriks clarify the relationships, path analysis was conducted using LISREL
et al., 1999a, 2011): t(321) = 6.81, p < .001, d = 0.38, small-to- (version 8.8). The path model (see Fig. 3) clearly demonstrates that
medium effect. Table 2 provides a breakdown of FFPI Extraversion the impact of the personality variables on symptom severity is
and Emotional Stability scores by whether or not the participant fully mediated by depression.
had a current major depressive disorder at the time of inclusion As age was significantly correlated with OCD duration (see
in the study. Participants with a current major depressive order Table 4), partial correlations between variables, controlling for
scored significantly lower than those who did not on both age were conducted. The results are presented in Table 7. As Extra-
Extraversion (t(320) = 3.36, p = .001) and Emotional Stability version and depression are no longer significantly correlated with
(t(320 = 6.61, p < .001). OCD duration when partialling out age, hypothesis six cannot be
To test hypotheses three and four, that scores on Emotional Sta- supported. After controlling for age, there is no significant relation-
bility and Extraversion were significantly correlated with OCD ship between Extraversion, depression and OCD duration.
symptom severity and illness duration, a correlation matrix was To further investigate the role of depression, the data file was
produced (Table 5). Emotional Stability was significantly nega- split into participants with minimal/normal symptom levels on
tively correlated with symptom severity (Y-BOCS total score; the BDI (<13 n = 96) and levels indicating depression (>13
Table 5
Correlation matrix of key variables (N = 322).
Age Extraversion Emotional Stability BDI total Y-BOCS total OCD duration
Age 1
Extraversion .23** 1
Emotional Stability .09 .19** 1
BDI total .14* .54** .57** 1
Y-BOCS total .04 .20** .24** .41** 1
OCD duration .68** .21** .11 .14* .06 1
*
Significance level of p < .05.
**
Significance level of p < .01.
96 C.S. Rees et al. / Personality and Individual Differences 71 (2014) 92–97
Acknowledgments
5. Discussion
The research infrastructure needed to complete the baseline
As expected, our large sample of participants with a current measurements (including personnel and materials) was financed
diagnosis of OCD showed the typical personality pattern of high almost exclusively by the participating organizations: Academic
Neuroticism (low Emotional Stability) and Introversion (low Extra- department VU Medical Centre/GGZ inGeest, Amsterdam, The
version). However, as depression is highly comorbid with OCD and Netherlands; Innova Research Centre, Mental Health Care Institute
because previous studies had found an influence of depression on GGZ Centraal, Marinade Wolf Anxiety Research Centre, Ermelo, The
observed personality outcomes, we sought to further explore the Netherlands; Center for Anxiety Disorders ‘‘Overwaal’’, Lent, The
relationship between personality, depression and OCD. Our Netherlands; Dimence, GGZ Overijssel; Department of Psychiatry,
hypothesis, that depression would mediate the relationship Leiden University Medical Centre, Leiden, The Netherlands; ‘Vin-
between Extraversion, Neuroticism and OCD symptom severity cent van Gogh institute’ Mental Health Care Centre Noorden Mid-
was supported. This indicates that simply concluding that high den-Limburg, Venray, The Netherlands; Academic Anxiety Center,
Neuroticism and low Extraversion is significantly associated with PsyQ Maastricht University, Division Mental Health and Neurosci-
OCD does not provide an accurate picture. Instead of simply ence, Maastricht, The Netherlands, except for the fieldwork coordi-
C.S. Rees et al. / Personality and Individual Differences 71 (2014) 92–97 97
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disorder (ROC): Clinical picture, protective factors and influence of affective
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