Journal of Affective Disorders 217 (2017) 1–7

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Journal of Affective Disorders

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Research paper

Gender differences in automatic thoughts and cortisol and alpha-amylase MARK

responses to acute psychosocial stress in patients with obsessive-compulsive
personality disorder
Masayuki Kanehisaa, Chiwa Kawashimaa, Mari Nakanishia, Kana Okamotoa, Harumi Oshitab,
Koji Masudaa, Fuku Takitaa, Toshihiko Izumia, Ayako Inouea, Yoshinobu Ishitobia,
⁎
Haruka Higumaa, Taiga Ninomiyaa, Jotaro Akiyoshia,
a
Department of Neuropsychiatry, Oita University Faculty of Medicine, Hasama-Machi, Oita 879-5593, Japan
b
Department of Applied Linguistics, Oita University Faculty of Medicine, Hasama-Machi, Oita 879-5593, Japan

A R T I C L E I N F O A BS T RAC T

Keywords: Introduction: Obsessive-compulsive personality disorder (OCPD) has a pervasive pattern of preoccupation
Obsessive-compulsive personality disorder with orderliness, perfection, and mental and interpersonal control at the expense of flexibility, openness, and
Stress efficiency. The aims of the present study were to explore the relationship between OCPD and psychological
Cortisol stress and psychological tests.
Alpha-amylase
Methods: We evaluated 63 OCPD patients and 107 healthy controls (HCs). We collected saliva samples from
Childhood abuse
patients and controls before and after a social stress procedure, the Trier Social Stress Test (TSST), to measure
Cognition
the concentrations of salivary alpha-amylase (sAA) and salivary cortisol. The Childhood Trauma Questionnaire
(CTQ), Profile of Mood State (POMS), State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI),
Social Adaptation Self-Evaluation Scale (SASS), and Depression and Anxiety Cognition Scale (DACS) were
administered to patients and HCs.
Results: Following TSST exposure, the salivary amylase and cortisol levels were significantly decreased in male
patients compared with controls. Additionally, OCPD patients had higher CTQ, POMS, STAI, and BDI scores
than HCs and exhibited significantly higher anxiety and depressive states. OCPD patients scored higher on
future denial and threat prediction as per the DACS tool. According to a stepwise regression analysis, STAI,
POMS, and salivary cortisol responses were independent predictors of OCPD.
Conclusions: Our results suggested that attenuated sympathetic and parasympathetic reactivity in male OCPD
patients occurs along with attenuated salivary amylase and cortisol responses to the TSST. In addition, there
was a significant difference between OCPD patients and HCs in child trauma, mood, anxiety, and cognition. The
finding support the modeling role of cortisol (20 min) on the relationships between STAI trait and depression
among OCPD.

1. Introduction whereas another found no such association (Garyfallos et al., 2010;

Obsessive-compulsive personality disorder (OCPD) is characterized
by a prevalent pattern of maladaptive behaviors (American Psychiatric
Association, 2013). Individuals with OCPD often exhibit the need for
mental and interpersonal control, over-conscientiousness, difficulty
abandoning items, rigidity, uniformity, and perfectionism.
Assessments of the influence of OCPD on OCD (obsessive-compulsive
disorder) symptoms have produced discrepant findings regarding the
relationship between OCPD and OCD. As an example, one study noted
that OCPD was associated with excessive OCD severity and incapacity,
Lochner et al., 2011).
Variation in personality traits was associated with the neurological
response to mental stress (Yamano et al., 2015). This stress reaction is
mainly regulated by an axial system consisting of two neuroendocrine
systems: the hypothalamic–pituitary–adrenocortical (HPA) axis and the
sympathetic adrenomedullary (SAM) system. A treatment regimen com-
bining virtual reality exposure therapy and the administration of yohim-
bine hydrochloride led to a significant reduction in anxiety compared to
pre-treatment, which induced significantly higher levels of salivary
amylase (sAA) in the treated group (Meyerbroeker et al., 2012).

⁎
Corresponding author.
E-mail address: akiyoshi@oita-u.ac.jp (J. Akiyoshi).

http://dx.doi.org/10.1016/j.jad.2017.03.057
Received 16 September 2016; Received in revised form 6 March 2017; Accepted 26 March 2017
Available online 28 March 2017
0165-0327/ © 2017 Elsevier B.V. All rights reserved.
M. Kanehisa et al. Journal of Affective Disorders 217 (2017) 1–7

Table 1
Demographic characteristics.

Female Male

Control (n=41) OCPD (N=19) Statistics Control (n=66) OCPD (n=44) Statistics

Age 24.9 ± 3.8 23.0 ± 0.9 p=0.11 25.4 ± 18.0 24.9 ± 9.5 p=0.55
BMI 24.2 ± 3.5 23.3 ± 3.7 p=0.75 23.2 ± 3.6 23.8 ± 3.3 p=0.75

Smoking (no. cig)

< 10/day 38 17 56 35
> 10/day 3 2 p=0.65 10 9 p=0.67
Education (years) 12.0 ± 2.5 13.2 ± 2.4 p=0.65 12.3 ± 2.5 13.0 ± 2.2 p=0.58

CTQ
Emotional Abuse 5.8 ± 1.7 6.4 ± 1.6 p < 0.001 5.4 ± 0.9 6.6 ± 3.4 p < 0.001
Physical Abuse 5.4 ± 1.1 5.3 ± 0.8 p=0.70 5.4 ± 1.1 5.6 ± 1.6 p=0.32
Sexual Abuse 5.5 ± 1.0 5.6 ± 1.1 p=0.62 5.3 ± 0.7 5.6 ± 1.1 p=0.17
Emotional Neglect 11.0 ± 2.8 11.6 ± 2.5 p < 0.001 11.8 ± 3.3 13.4 ± 4.1 p < 0.001
Physical Neglect 6.2 ± 2.1 6.4 ± 1.9 p=0.24 6.3 ± 2.0 6.8 ± 2.3 p < 0.003

OCPD=Obsessive-compulsive personality disorder, BMI=Body Mass Index.

CTQ=Childhood trauma Questionnaire.

We previously reported the association between OCD, sAA, and salivary
cortisol (Kawano et al., 2013). The sAA levels in male and female OCD
patients were significantly elevated comparted to healthy controls both
before and after electrical stimulation. However, there were no marked
differences in the salivary cortisol levels between OCD patients and
controls. We also reported the association between avoidant personality
disorder (OCPD), sAA, and salivary cortisol (Tanaka et al., 2016). Following
electrical stimulation, the salivary cortisol levels in female OCPD patients
were significantly decreased compared to healthy female controls, but there
was no significant difference in the salivary cortisol levels between male
OCPD patients and healthy male controls. Additionally, the sAA levels were
not significantly different among male and female OCPD patients and male
and female controls. Following exposure to a social stress procedure known
as the Trier Social Stress Test (TSST), the sAA levels remained nonsigni-
ficantly different among male and female OCPD patients and healthy
controls, and the salivary cortisol levels were also not markedly different
between male and female OCPD patients and controls. We also reported
the association between borderline personality disorder (BPD) and sAA and
salivary cortisol levels (Inoue et al., 2015).
Physical/sexual abuse and emotional abuse/neglect have been shown to
be associated with heightened symptoms of all three personality disorder
clusters (Tyrka et al., 2009). Enhanced symptoms of several specific
personality disorders have also been observed, including paranoid, border-
line, avoidant, dependent, obsessive-compulsive, and depressive personality
disorders.
Cognitive models of OCD suggest that changes in obsessive beliefs
are mechanistically important for treatment (Diedrich et al., 2016).
Extensive evidence also supports the effectiveness of cognitive beha-
vioral therapy (CBT), with exposure and response prevention as the
standard psychotherapeutic intervention for OCD (Skapinakis et al.,
2016). Short-term cognitive therapy has been shown to effectively treat
patients with cluster C personality disorders (including OCPD, OCPD,
and dependent personality disorder) (Johansen et al., 2011; Renner
et al., 2013). In this study, we examined the relationship among sAA
and salivary cortisol levels before and after the TSST, childhood abuse,
and cognitive vulnerability in OCPD patients and healthy controls
(HCs).
We examined the relationship between psychopathological assess-
ments and endocrine responses to an empirical stress test.
2. Methods
2.1. Patients and healthy controls
Sixty-three Japanese patients meeting the Diagnostic and Statistical
Manual of Mental Disorders (DSM)-IV-TR criteria for OCPD and 107
Japanese HCs participated in the study. OCPD patients were recruited
via advertisement and screened by interviews. In particular, OCPD
patients who met the DSM-IV-TR criteria and who did not have axis I
disorders were selected for the study. An OCPD diagnosis was
determined using the Structured Clinical Interview of DSM-IV-TR for
Personality Disorders (SCID-II) (First et al., 1997). The diagnoses of
current axis I disorders were made by a trained psychiatrist (JA) using
the Mini International Neuropsychiatry Interview (MINI), a standar-
dized psychiatric examination validated in the general population
(Sheehan et al., 1998) as per the DSM-IV-TR criteria (Ritchie et al.,
2004). We excluded 12 OCPD patients with axis I disorders (8 with
major depressive disorder [MDD], 3 with panic disorder, and 1 with
bipolar disorder). HCs were enrolled via advertising and confirmed to
be free of any axis I or II disorders (as determined by MINI and SCID-
II). All participants were free of major illnesses according to their
medical history and a physical examination and did not show any
substance or alcohol abuse or dependence within 12 months prior to
the study.
Demographic information (age, body mass index [BMI], smoking,
and education) was collected from all participants (Table 1). The
participants were instructed to avoid strenuous physical activity for
48 h as well as any form of physical exercise and alcohol consumption
24 h prior to the study. Caffeine, tea, and smoking were not permitted
within 3 h prior to the study, and tooth brushing and/or eating was to
be avoided 2 h before the study. To diminish the influence of circadian
rhythms on physiological variables, all experiments were performed in
the afternoon (between 1 and 5 p.m.). All female subjects participated
in the experiment during their late luteal phase to reduce the impact of
hormonal variations through the menstrual cycle. After receiving a
comprehensive explanation of the study, all participants offered their
written informed consent. The study was approved by the ethics
committee of the Oita University Faculty of Medicine.
2.2. Stimuli and procedures
2.2.1. TSST stress challenge
All participants were TSST stress challenged to reduce the effect of
habituation and relaxation in the experimental environment. The
participants were divided into small groups consisting of four to five
people. All participants were invited to our laboratory on a weekday
afternoon between 1 and 5 p.m. After a 30-min resting period intended
to minimize the impact of physical activity, prior stress, and emotions
as well as to allow the participants to fill out questionnaires, the
participants were exposed to the TSST (Kirschbaum et al., 1993). The

2
M. Kanehisa et al.
TSST consisted of a 3-min preparation period; a 5-min speech task,
during which the participants had to discuss their personal character-
istics; and a 5-min mental arithmetic task. All tasks were performed in
front of an audience. After the test, the participants remained in our
laboratory for another 20 min for a collection of saliva samples during
recovery.
2.3. Psychological measures
The Childhood Trauma Questionnaire (CTQ) (Bernstein et al.,
1994), Profile of Mood State (POMS) (McNair et al., 1992), State-
Trait Anxiety Inventory (STAI) (Spielberger et al., 1973), Beck
Depression Inventory (BDI) (Beck et al., 1961), Social Adaptation
Self-Evaluation Scale (SASS) (Bosc et al., 1997), and Depression and
Anxiety Cognition Scale (DACS) were administered (Fukui, 1998;
Ishitobi et al., 2014). The POMS and STAI were administered once
more after the TSST.
The CTQ is the most commonly used test for assessing childhood
maltreatment. The POMS provides a rapid, economical method of
assessing transient, fluctuating active mood states. It is an ideal
instrument for measuring and monitoring treatment change in clinical,
medical, and addiction counseling centers. The STAI clearly differenti-
ates between the temporary condition of “state anxiety” and the more
general and long-standing quality of “trait anxiety” and helps profes-
sionals distinguish between a client's feelings of anxiety and depres-
sion. The BDI is a well-established measure of depression. The SASS is
a scale developed for the evaluation of patients’ social functioning. The
DACS is a questionnaire used to measure automatic thoughts that
cause depression and anxiety.
2.4. Physiological measures
We measured the sAA and salivary cortisol levels before, immedi-
ately after, and 20 min after TSST as per previous reports (Ishitobi
et al., 2010; Tanaka et al., 2012a, 2012b, 2013; Maruyama et al., 2012;
Kawano et al., 2013; Tamura et al., 2013). To control for circadian
variations in the sAA and cortisol levels, the exposure to psychological
stressors and collection of saliva were both performed between 1 and
5 p.m.
The sAA levels were measured using the Dry Chemistry System
(Nipro Corp., Tokyo, Japan) in accordance with the manufacturer’s
protocol. Saliva was sampled by holding a saliva-sampling strip under
the tongue for 30 s. The strip was immediately placed in an automatic
saliva transfer system, and saliva was transferred to the alpha-amylase
test paper on the reverse side of the strip sleeve by compression. The
alpha-amylase test paper contained the substrate 2-chloro-4-nitrophe-
nyl-4-O-β-D-galactopyranosylmaltoside. The enzymatic reaction was
started upon transfer by compression, and the level of free 2-chloro-
4-nitrophenyl was optically measured after 20 s. The alpha-amylase
activity that reduced sugars equivalent to 1 µmol/min of maltose was
defined as 1 unit (Robles et al., 2011).
The concentration of salivary cortisol (μg/dl) was analyzed by an
enzyme-linked immunosorbent assay (ELISA), with intra-assay and
inter-assay coefficients of variation of 3% and 10%, respectively. The
samples were stored in a freezer at −20 °C until they were thawed for
the analysis.
We also measured the HRV immediately after the TSST. Low-
frequency (LF; 0.04–0.15 Hz) and high-frequency (HF; 0.15–0.4 Hz)
fluctuations in the HR on R-R intervals were calculated using an APG
Heart-Rater SA-3000P (Tokyo Iken Co., Ltd., Tokyo, Japan). LF
fluctuation has frequently been used in the past as a measure of the
sympathetic nervous system activity, but recent pharmacological
research has repeatedly questioned its validity, indicating this variable
is not a measure of the cardiac sympathetic tone but may instead be a
measure of the modulation of cardiac autonomic outflows by barore-
flexes (Goldstein et al., 2011). In particular, HF fluctuations (also
3
Journal of Affective Disorders 217 (2017) 1–7
referred to as respiratory sinus arrhythmia) are highly sensitive to
confounding influences, such as respiratory parameters (tidal volume)
and other factors (participant’s level of fitness, medication, and
position at assessment). Without the assessment of these confounders,
it was not possible to perform valid HF calculations.
2.5. Statistical analyses
The data are presented as the mean ± standard deviation (S.D.) and
reliability coefficients (Cronbach’s alpha) of the individual values from
each test. We performed analyses using the SPSS 19 software program
(IBM Corporation, Armonk, NY, USA). We used the χ2 test, Mann–
Whitney U test, and Spearman’s rank correlation coefficient for sample
characterization. A repeated measures analysis of variance (ANOVA)
was used to compare the sAA or cortisol response level means between
the patients and controls, followed by Scheffé’s method significant
difference tests. The results were analyzed via structural equation
modeling (SEM) using SPSS AMOS 21.0. Statistical significance was set
at p < 0.05.
3. Results
3.1. Psychological assessment
We adjusted all analyses to match ages, and 107 HCs were selected
to provide close matches to the 63 patients with respect to age and
gender. There was no marked differences between the OCPD and
healthy participant groups with regard to gender, age, smoking history,
and education level (Table 1). The CTQ profiles of emotional abuse and
neglect were significantly increased in OCPD female patients compared
with HCs (p < 0.01), while those of emotional abuse and neglect and
physical neglect were significantly increased in OCPD male patients
compared with HCs (p < 0.001) (Table 1). Regarding the post-POMS
testing, OCPD female patients scored significantly higher across three
categories (depression–dejection, anger–hostility, and fatigue) than
HCs (p < 0.05) (Table 2). There were no marked differences in other
categories between the OCPD female patients and the controls pre-
POMS. Furthermore, there were no marked differences in the cate-
gories between the OCPD male patients and the controls either pre- or
post-POMS. Regarding pre- and post-STAI testing, OCPD female
patients scored significantly higher for trait anxiety than HCs (p <
0.01) in the pre-STAI (Table 3). There were no marked differences in
the state anxiety between the OCPD male patients and HCs in pre- and
post-STAI. Regarding the BDI, OCPD male patients scored significantly
higher than HCs (p < 0.05) (Table 3). There were no marked differences
in the BDI scores between OCPD female patients and the HCs.
Regarding the HRV, there were no differences in the LF, HF, and
LF/HF scores between OCPD patients and HCs (Table 3). Regarding
the SASS scores, there were also no marked differences (Table 4).
Regarding the DACS, the OCPD female patients scored significantly
higher for future denial than HCs (p < 0.01), and OCPD male patients
scored significantly higher for threat prediction than HCs (p < 0.05)
(Table 4). There were no marked differences in other scores between
the OCPD patients and the HCs.
3.2. Physiological assessment
After TSST exposure, the salivary cortisol levels in male OCPD
patients were significantly lower than in male HCs (F (2, 91)=3.98, p <
0.01, Fig. 1B). In contrast, the salivary cortisol levels were not
markedly different between female OCPD patients and HCs (F (2,
50)=0.46, p=0.51, Fig. 1A). The sAA levels in OCPD males were
significantly decreased compared to those in male HCs (F (2,
91)=6.31, p < 0.01, Fig. 2B) but were not markedly different between
female OCPD patients and HCs (F (2, 50)=0.48, p=0.49, Fig. 2A). There
were no marked differences in the LF, HF, and LF/HF values between
M. Kanehisa et al. Journal of Affective Disorders 217 (2017) 1–7

Table 2
Characteristics of OCPD and Control.

Female Male

Control (n=41) OCPD (N=19) p Control (n=66) OCPD (n=44) p

Min-max Mean ± SD Min-max Mean ± SD Min-max Mean ± SD Min-max Mean ± SD

Pre-POMS
Tension-Anxiety 33–73 40.5 ± 8.2 34–59 44.4 ± 8.1 p=0.09 34–75 41.0 ± 8.6 33–65 41.8 ± 8.6 p=0.63
Depression-Dejection 40–59 43.0 ± 6.6 39–68 45.5 ± 7.4 p=0.19 39–66 43.1 ± 7.9 39–72 43.6 ± 5.8 p=0.72
Anger-Hostility 37–61 40.2 ± 5.6 37–60 41.7 ± 6.6 p=0.36 37–60 39.8 ± 5.3 35–64 42.0 ± 7.3 p=0.07
Vigor 27–75 48.1 ± 8.9 30–77 48.3 ± 13.5 p=0.95 32–65 47.3 ± 10.9 27–70 48.6 ± 11.9 p=0.57
Fatigue 36–74 40.7 ± 6.3 34–65 44.2 ± 9.3 p=0.09 35–59 42.7 ± 6.5 35–68 43.5 ± 8.3 p=0.56
Confusion 32–71 44.8 ± 8.0 33–60 45.9 ± 8.5 p=0.60 33–75 43.1 ± 7.7 32–71 44.0 ± 7.2 p=0.58

Post-POMS
Tension-Anxiety 33–75 43.8 ± 9.7 34–75 48.1 ± 10.5 p=0.13 32–70 43.9 ± 9.4 34–75 44.6 ± 10.2 p = 0.70
Depression-Dejection 40–72 42.7 ± 6.4 39–75 47.2 ± 10.6 p < 0.05 39–78 44.3 ± 7.8 39–68 43.8 ± 6.5 p = 0.71
Anger-Hostility 37–56 38.6 ± 4.2 37–65 42.1 ± 7.6 p < 0.05 36–85 40.8 ± 7.3 37–60 40.2 ± 5.4 p=0.63
Vigor 27–73 40.8 ± 10.4 30–67 40.5 ± 9.5 p=0.91 27–70 40.3 ± 10.2 30–77 40.0 ± 13.4 p=0.90
Fatigue 36–78 43.4 ± 9.1 35–68 48.9 ± 9.9 p < 0.05 36–72 46.7 ± 8.9 35–75 46.5 ± 10.8 p=0.91
Confusion 32–85 49.4 ± 10.5 36–85 53.7 ± 12.9 p=0.17 35–71 48.4 ± 9.2 33–78 48.2 ± 11.8 p=0.94

OCPD=Obsessive-compulsive personality disorder.

OCPD patients and the HCs (Table 3). As shown in Table 5, according
to the stepwise regression analysis of OCPD, three variables were
determined as independent predictors of response: trait anxiety (STAI),
depression-dejection (Pre-POMS), and salivary cortisol responses
(20 min). A structural equation model was run in AMOS to examine
the path diagram. The fit statistics for the structural model are shown
in Fig. 3. The finding support the modeling role of cortisol (20 min) on
the relationships between STAI trait and depression among OCPD.
4. Discussion
Decreased parasympathetic reactivity in male OCPD patients
occurred with attenuated sAA upon administration of the TSST. The
sAA levels were not markedly different between female OCPD patients
and HCs. Decreased sympathetic reactivity in OCPD males also
occurred with attenuated salivary cortisol levels in response to the
TSST, but the salivary cortisol levels were not markedly different
between OCPD females and HCs. Both the sympathetic and parasym-
pathetic responses and endocrine responsivity were low in the male
OCPDs. This profile may be related to the low penetration of the tests in
males with OCPD.
We previously reported that sAA levels in both male and female
OCD patients were significantly elevated relative to the values in
controls both before and after electrical stimulation. In contrast, there
were no marked differences in the salivary cortisol levels between OCD
patients and the HCs. The elevated secretion of sAA before and after
electrical stimulation may suggest an increased responsiveness to novel
and uncontrollable situations in patients with OCD (Kawano et al.,
2013). Our present results did not corroborate these previous findings.
This may be due to different mechanisms of stress between the studies:
electrical stimulation and the TSST. Another possible explanation for
the differences might be the pathophysiological states of OCPD and
OCD. The duration of stress in OCPD might be longer than that in OCD
(Cullen et al., 2008). This longer stress state might suppress the
autonomic response.
Male OCPD patients exhibited significant sAA and salivary cortisol
responses, but female OCPD patients did not show similar sAA or
salivary cortisol profiles. Previous studies assessing gender differences
have yielded conflicting results, with one study reporting equal rates for
men and women (Grant et al., 2012) while other studies have indicated
higher frequency rates in men than in women (Coid et al., 2006; Light
et al., 2006). Additionally, other studies have consistently shown that
OCD patients and comorbid OCPD patients did not differ significantly
with respect to gender (Lochner et al., 2011; Gordon et al., 2013; Pinto
et al., 2011). Kawano et al. (2013) reported that the sAA levels in male
and female OCD patients were significantly higher than in controls

Table 3
Characteristics of OCPD and Control.

Female Male

Control (n=41) OCPD (N=19) p Control (n=66) OCPD (n=44) p

Min-max Mean ± SD Min-max Mean ± SD Min-max Mean ± SD Min-max Mean ± SD

Pre-STAI
Trait Anxiety 21–68 35.5 ± 9.4 27–64 46.3 ± 10.5 p < 0.01 22–57 37.7 ± 8.5 23–70 40.1 ± 9.4 p=0.17
State Anxiety 20–73 35.8 ± 9.6 22–62 41.1 ± 10.7 p=0.06 26–62 36.6 ± 7.4 22–73 38.0 ± 9.7 p=0.39

Post-STAI
State Anxiety 20–63 42.5 ± 10.5 34–74 48.5 ± 9.5 p < 0.05 24–63 43.2 ± 9.3 24–69 44.1 ± 10.8 p=0.63
BDI 0–12 2.7 ± 7.2 0–14 4.8 ± 5.2 p=0.28 0–13 2.5 ± 3.2 0–18 4.3 ± 4.7 p < 0.05

HRV
LF 7.4–92.2 52.0 ± 19.4 17.4–86.7 46.5 ± 19.4 p=0.34 34.2–88.5 61.3 ± 16.4 19.0–86.3 59.1 ± 17.4 p=0.51
HF 7.8–83.6 46.4 ± 20.0 13.3–82.6 53.5 ± 19.4 p=0.20 11.5–65.8 38.7 ± 16.4 13.7–81.0 40.9 ± 17.4 p=0.51
LF/HF 0.2–11.8 1.9 ± 2.4 0.2–6.5 1.3 ± 1.5 p=0.32 0.5–7.7 2.3 ± 1.9 0.2–6.3 2.0 ± 1.5 p=0.37

OCPD=Obsessive-compulsive personality disorder, BDI=Beck Depression Inventory, HRV=Heart Rate Variability.

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M. Kanehisa et al. Journal of Affective Disorders 217 (2017) 1–7

Table 4
Characteristics of OCPD and Control.

Female Male

Control (n=41) OCPD (N=19) p Control (n=66) OCPD (n=44) p

Min-max Mean ± SD Min-max Mean ± SD Min-max Mean ± SD Min-max Mean ± SD

SASS 23–47 38.3 ± 6.3 15–56 40.1 ± 8.8 p=0.38 22–52 40.9 ± 6.6 26–56 40.7 ± 5.6 p=0.86

DACS
Future denial 38–58 43.4 ± 6.1 39–74 50.1 ± 10.7 p < 0.01 38–56 41.6 ± 5.0 39–56 43.4 ± 5.4 p=0.09
Threat prediction 16–71 41.3 ± 14.6 28–65 47.4 ± 10.6 p=0.12 17–70 39.0 ± 13.5 20–68 45.3 ± 13.1 p < 0.05
Self-denial 31–66 46.3 ± 10.4 31–72 52.0 ± 11.6 p=0.07 30–65 42.3 ± 9.2 31–75 43.9 ± 11.7 p=0.45
Past denial 30–62 42.8 ± 9.3 32–63 46.1 ± 9.2 p=0.22 28–60 38.8 ± 8.7 30–68 43.0 ± 12.0 p=0.06
Interpersonal threat 11–61 42.5 ± 13.0 25–62 48.9 ± 10.5 p=0.07 11–65 40.1 ± 15.0 11–65 44.3 ± 13.4 p=0.16

OCPD=Obsessive-compulsive personality disorder, DACS=Depression and Anxiety Cognition Scale.

before and after electrical stimulation. In contrast, there were no
differences in the salivary cortisol levels between male and female OCD
patients and controls. The elevated secretion of sAA before and after
electrical stimulation may suggest an increased responsiveness to new
and uncontrollable situations in OCD patients, and an increase in the
sAA might be a distinctive aspect of OCD. However, our results
obtained in the present study show that OCPD and OCD have distinct
pathophysiologies.
The CTQ (emotional abuse, emotional neglect) scores were sig-
nificantly increased in OCPD female patients compared with controls.
Similarly, the CTQ (emotional abuse, emotional neglect, and physical
neglect) scores were also significantly increased in OCPD male patients
compared with controls. As stated previously, physical/sexual abuse
and emotional abuse/neglect have been shown to be associated with
elevated symptoms of all three personality disorder clusters, including
OCPD (Tyrka et al., 2009). Another study reported that physical and
emotional abuse were more likely to manifest subclinical symptoms of
paranoid, narcissistic, borderline, antisocial, OCPD, passive-aggressive,
and depressive personality disorders (Grover et al., 2007). A significant
relationship was noted between obsessive-compulsive symptoms and
childhood trauma, specifically emotional abuse and physical neglect, all
of which were due to co-occurring anxiety symptoms (Mathews et al.,
2008). These results suggest that child trauma is likely associated with
OCPD.
In our study, there was a significant difference between OCPD
patients and HCs in mood. Specifically, the BDI in male OCPD patients
was higher than in HCs. However, the BDI level was just shy of the cut-
off point for depression (10). This indicates minimal depression and
excludes moderate and severe depression. The most common comor-
bidities were major depression, generalized anxiety, and social anxiety
disorder. (Miguel et al., 2008). Patients with first-episode depression
were screened using the BDI scale, with a cut-off point of > 9. One-
third of the participants had OCPD. It is important to identify
comorbid OCPD when evaluating persons of employable age suffering
from depression (Raiskila et al., 2013). Interestingly, a study dissecting
OCPD and depression noted a relationship between obsessive-compul-
sive traits and a genetic variation in the dopamine D3 receptor in
patients with major depressive disorder (Light et al., 2006). Thus,
OCPD might be associated with depression.
Regarding the DACS, OCPD female patients scored significantly
higher in future denial than HCs, and OCPD male patients scored
significantly higher in threat prediction than HCs. Dysfunctional beliefs
in OCD patients and disquiet are thought to give rise to vulnerability
and the maintenance of pathological anxiety (Calleo et al., 2010).
Overestimation of threat/responsibility and intolerance of uncertainty
were significantly correlated with obsession and worry severity. The
compulsive style is susceptible to dysfunctional cognition (Blasczyk-
Schiep et al., 2016). There is a relationship between obsessive–

Fig. 1. Salivary cortisol responses to the Trier Social Stress Test (TSST) in patients with obsessive-compulsive personality disorder and healthy matched control subjects. (A) Female, (B)
male. After TSST exposure, the salivary cortisol levels in male OCPD patients were significantly lower than in male HCs. In contrast, the salivary cortisol levels were not markedly
different between female OCPD patients and female HCs. The values are presented as the mean ± standard deviation.

5
M. Kanehisa et al. Journal of Affective Disorders 217 (2017) 1–7

Fig. 2. Salivary alpha‐amylase (sAA) responses to the Trier Social Stress Test in patients with obsessive-compulsive personality disorder and healthy matched control subjects. (A)
Female, (B) male. After TSST exposure, the sAA levels in OCPD males were significantly lower than in male HCs. In contrast, the sAA levels were not markedly different between female
OCPD patients and female HCs. The values are presented as the mean ± standard deviation.

Table 5 shown that the sAA and salivary cortisol levels can differ according to
The multiple regression analysis of OCPD. the length of time that a participant spends in the hospital (Balodis
et al., 2010). Lastly, our findings cannot be generalized to other ethnic
β Significance
groups. Thus, it will be necessary to conduct further studies in larger
STAI and more diverse populations to confirm the reproducibility of our
Trait Anxiety −0.227 0.036 data.
In conclusion, our findings suggested that attenuated sympathetic
Post-POMS
and parasympathetic reactivity in male OCPD patients occurs with
Depression-Dejection 0.221 0.063
attenuated sAA and cortisol responses to the TSST. Additionally, there
Salivary Cortisol were significant differences between the OCPD patients and HCs in
20 min 0.222 0.065 child trauma, mood, anxiety, and cognition. The finding support the
R2 < 0.00001
modeling role of cortisol (20 min) on the relationships between STAI
OCPD=Obsessive-compulsive personality disorder, STAI=State-Trait Anxiety Inventory;
trait and depression among OCPD.
POMS=Profile of Modd State.
Role of funding sources

The study was supported by a Grant-in-Aid for Scientific Research

(C: 23591719) from the Ministry of Health and Welfare.

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