Original Article Psychoanalysis 2011;22:9-18 ISSN 1226-7503 Copyright c 2011 Korean Association of Psychoanalysis Gender Difference in Clinical and Psychological Characteristics in Patients with Borderline Personality Disorder at a University Hospital Bo-Young Mun 1, Jin-Young Jeong 1, Hye-Rim Lee 1, Shin-Ho Song 2, Jun-Yeob Lee 3 and Bon-Hoon Koo 1 1 Department of Psychiatry, College of Medicine, Yeungnam University, Daegu, Korea 2 Department of Psychiatry, Pohang Saint Mary s Hospital, Pohang, Korea 3 Department of Psychiatry, CHA Gumi Medical Center, Gumi, Korea 일대학병원을방문한경계성인격장애환자의성별에따른임상양상, 심리특성및방어기제의차이 문보영 1 정진영 1 이혜림 1 송신호 2 이준엽 3 구본훈 1 영남대학교의과대학정신과학교실, 1 포항성모병원정신과, 2 CHA 의과학대학교정신과학교실 3 Objectives: Previous studies on gender differences of patients with borderline personality disorder (BPD) were mainly to estimate prevalence rates and comorbidities in epidemiology. This study evaluated clinical and psychological characteristics, including defense mechanisms, between male and female patients with BPD in a clinical setting. Methods: We recruited 30 male and 35 female patients with BPD according to the Diagnostic and Statistical Manual of Mental Disorder, 4th edition diagnostic criteria. We investigated the gender difference of Axis I comorbidities and characteristics of suicidal attempts, and retrospectively assessed psychological characteristics of patients with BPD using the Symptom Checklist-90-Revised, the Minnesota Multiphasic Personality Inventory, the Personality Disorder Questionnaire-4+, and the Defense Style Questionnaire. Results: Male patients showed amoreparanoid, socially introverted, and antisocial tendency compared to female patients. Female patients used splitting more frequently as the primary defense mechanism than male patients. Conclusion: This study suggests that the core psychopathologies of BPD are very similar between male and female patients in spite of some gender differences in clinical characteristics of BPD. Female patients are more likely to show a typical prototype of BPD than male. Psychoanalysis 2011;22:9-18 KEY WORDS: Borderline personality disorder Sex difference Defense mechanisms. Received: February 23, 2011 Revised: March 13, 2011 Accepted: March 24, 2011 Address for correspondence: Bon-Hoon Koo, MD, PhD Department of Psychiatry, Yeungnam University College of Medicine, 317-1 Daemyeong 5-dong, Nam-gu, Daegu 705-717, Korea Tel: +82-53-620-3343, Fax: +82-53-629-0256, E-mail: vijnana@chol.com 서론 경계성인격장애 (boderline personality disorder) 는정신과임상에서접할수있는인격장애중가장흔하지만충동성, 공격성과함께분리 (splitting), 투사적동일시 (projective identification), 부정 (denial) 등과같은원시적방어기제의사용, 자해및자살시도등의특징으로인해진단및치료적접근이어려운질환이다 (Zanarini 등 2001; Bender 등 2001; Skodol 등 2002). 지역사회인구를대상으로한외국의연구들에서경계성인격장애의유병률은 0.4~1.8% 로 보고되었으며 (Maier 등 1992; Swartz 등 1990; Torgensen 등 2001), 임상현장에서는 10~25% 의유병률이보고되고있다 (APA 1994; Gunderson 등 1987). 과거정신분석적패러다임이정신과를지배하고있을때정신역동이론에서는경계성인격장애를정신증과신경증의경계에있다고보았다 (Gunderson 2009). 이후정신질환의진단에있어서기술적접근방법을사용하게됨에따라최근정신장애진단통계편람제4판 (Diagnostic and Statistical Manual of Mental Disorder, 4th edition, DSM-IV) 에서는경계성인격장애의진단기준으로주체성결여, 충동성, www.freud.or.kr 9
Gender Difference in Patients with Borderline Personality Disorder 유기불안, 정동과대인관계에서의불안정성, 만성적공허감, 반복적자살시도, 스트레스와연관된일시적해리또는정신병적증상, 분리등의미성숙한방어기제의사용등을들고있다. 현재이러한경계성인격장애의진단기준을널리사용하고있지만실제임상에서는경계성인격장애가이질적인환자의집합일수있다는연구도있었다 (Clarkin 등 1992; Giesen-Bloo 등 2006). 따라서경계성인격장애의여러특성에따라경계성인격장애의하위유형을분류하려는다양한시도가있었다 (Choi 2009). Gabbard(2005) 는경계성인격장애환자를정신병리나중증도에따라네가지군으로나누었으며, Gunderson(2009) 은대인관계문제의유형에따라경계성인격장애환자를구분하였다. 이러한경계성인격장애환자자체의이질적성향이치료에어려움을주는한가지요소가될수있다. 또한, 다른정신질환이나인격장애에도마찬가지로경계성인격장애환자의나이나성별등과같은인자에의해서도경계성인격장애의임상양상이나심리적특성에차이가있을것으로생각된다. 그동안경계성인격장애에대한연구는주로생물학적원인이나약물치료및정신치료와관련된연구들이많았다 (Mauchnik 등 2010; Stoffers 등 2010; Paris 2010). 그러나경계성인격장애의성별에따른임상양상에대해시행된연구는거의없었고, 우리나라에서도아직이루어지지않았다. 특히, 기존의경계성인격장애환자의성별차이에대한연구에서는주로지역사회인구를대상으로남녀별유병률및공존질환의차이를알아본연구는있었으나 (Johnson 등 2003; McCormick 등 2007) 실제임상환자를대상으로성별에따른심리적특성의차이를비교한연구는없었다. 따라서본연구에서는일대학병원에방문한실제임상현장의경계성인격장애환자를대상으로성별에따른임상양상, 심리적특성및방어기제의차이를알아보고자하였다. 방법 대상 2006년 10월부터 2009년 6월까지광역시소재의일대학병원정신과병동에입원하거나외래를방문한 18~65세의환자중본연구에필요한심리검사를시행한환자들을대상으로하였다. 이중정신과전문의에의해 DSM-IV 의경계성인격장애진단기준에따라진단된경계성인격장애환자 65명 ( 남자 30명, 여자 35명 ) 을선정하였다. 경계성인격장애외에추가로다른인격장애가동반되어있는경우, 지적장애등의다른축 II의진단이동반한경우에는제외하였고, 또한, 심각한내과, 외과적질환등을동반한경우도연 구대상에서제외하였다. 또한, 시행한심리검사중미네소타다면적인성검사 (Minnesota Multiphasic Personality Inventory, MMPI) 에서 Bagby(2005) 가제안하는방법에따라부정왜곡혹은꾀병을가장하는프로파일을가진검사신뢰도및타당도에의심이되는환자들도대상에서제외하였다. 방법연구대상자의병록지를근거로자료를수집한후향적연구방법을사용하였으며, 사전에준비한자료조사표에는대상환자들의기초적인인구학적자료, 자살시도횟수및방법, 공존질환조사등의병력및본연구를수행하는데필요한제반임상적자료등이포함되도록하였다. 도구간이정신진단검사 -90- 개정판 (The Symptom Checklist-90-Revised) The Symptom Checklist-90-Revised(SCL-90-R) 은 Derogatis 등 (1973) 에의해개발된자기보고식다차원증상목록검사로환자의주관적인경험을제공해주고전문적인도움을필요로하는사람을선별하여주는일차적인도구로사용될수있으며, 검사시행과채점이간편하고환자의전반적인증상을포괄할수있다는장점이있다 (Kim 등 1984). SCL-90-R 은채점되지않는부가적문항을포함한 90개문항으로구성되어있으며, 신체화 (somatization), 강박증 (obsessive-compulsive), 대인민감성 (interpersonal sensitivity), 우울 (depression), 불안 (anxiety), 적대감 (hostility), 공포불안 (phobic anxiety), 편집증 (paranoid ideation), 정신증 (psychotism) 등의 9개증상차원이있다. 그리고전체지표 (global index) 는각문항에서 1점이상에평정한점수의합계를총문항수로나눈점수로, 현재의장애의수준혹은정도를나타내는전체심도지수 (global severity index, GSI), 증상의수, 즉 1점이상에평정된문항수인표출증상합계 (positive symptom total, PST) 그리고각문항에서 1점이상에평정한점수의합계를 1점이상에평정한문항수로나눈점수인표출증상심도지수 (positive symptom distress index, PSDI) 가있다. 미네소타다면적인성검사 (The Minnesota Multiphasic Personality Inventory) MMPI는 1943년미국미네소타대학의 Hathaway 와 Mckinley(1943) 에의해비정상적인행동을객관적으로측정 10 Psychoanalysis 2011;22:9-18
BY Mun, et al. 하기위해만들어진검사로일차적인목적은정신과적진단분류를위한측정이었다. 현재임상장면에서가장널리사용되는심리평가도구로써정신병리및성격차원의평가등에사용된다. MMPI는 566문항으로일반적표준척도로타당도척도 3개 [ 부인 (Lie; L), 비전형 (Infrequency; F), 교정 (Correction; K)] 와임상척도 10개 [ 건강염려증 (Hypochondriasis; Hs), 우울증 (Depression; D), 히스테리 (Hysteria; Hy), 반사회성 (Psychopathic Deviate; Pd), 남성-여성특성 (Masculinity-Femininity; Mf), 편집증 (Paranoia; Pa), 강박증 (Psychasthenia; Pt), 정신분열증 (Schizophrenia; Sc), 경조증 (Hypomania; Ma), 사회적내향성 (Social Introversion; Si)] 로구성되어있다 (Kim 등 2007). 우리나라에서는 Kim 등 (1989) 에의해재표준화되어사용되고있다. 한국판인격장애검사 (The Personality Disorder Questionnaire-4+) The Personality Disorder Questionnaire-4+(PDQ- 4+) 는 DSM-IV의진단기준에맞게개발되어 10개의성격장애를평가할수있는자기보고형검사로 Hyler(1998) 가새롭게개발한 PDQ-4+ 를 Kim 등 (2000) 이표준화한검사이다. PDQ-4+ 는 10가지인격장애와함께 DSM-IV 의부록에포함된부정적또는수동-공격성인격장애, 우울성인격장애를추가적으로진단할수있는총 99문항으로이루어진진위형검사이다. 자신의문제를축소해서기록하는것을막기위해 4개의질문이환자가느끼지못하도록포함되어있으며, 거짓말을하거나이질문지에성의있게대답하지않은것을알아낼수있도록 2개의질문이포함되어있다. 채점방법은 너무좋음 (4문항) 과 응답이의심스러움 (2 문항 ) 을제외한 93문항을총점으로 1문항당 1점씩계산을하고총점이 30점이상이면인격장애가있다는것을의미한다. 정상인들은대개 20점이하로, 총점이높을수록전반적인인격장애를의미하며, 각각의장애에따라서최소한 3점내지 5점이상일때그항목에서의인격장애를의미한다 ( 김소영등 2003). 방어유형설문지 (The Defense Style Questionnaire) The Defense Style Questionnaire(DSQ) 는 Bond 등 (1986) 에의해제작된자기보고식방어기제검사도구로서다양한방어기제의의식적파생물을기술하는 78개문항과 11개의허위성문항으로구성되어있다. 방어유형은여러개의방어기제들로구성되며, 각각의방어기제는다시그방어기제를나타내는개별문항들에의해측정될수있다. 검사문항에대한응답방식은피검자자신과일치하는정도 에따라 1 부터 9 까지의숫자가운데하나로평가하도록되 어있다 ( 정명원등 1993). DSQ 는적절한타당도와재검사 신뢰도를보유하며, 역동적성격이론의연구에광범위하게 사용되고있다. 이는방어의성숙도에따라서배열된 4 가지 방어기제의양상 ; 비적응형 (maladaptive), 표상왜곡형 (image-distorting), 희생형 (self-sacrificing), 적응형 (adaptive) 방어양상 (defense style) 을측정한다. 통계분석 병록지조사를통해얻어진자료는 Statistical Package for the Social Sciences(SPSS) version 17.0 을이용하여 처리하였고, 통계분석에는카이제곱검정 (chi-square test), 스튜던트 t 검정 (student t-test) 을사용하였으며, p 값이 0.05 미만인경우에유의성이있는것으로판단하였다. 인구학적특성 결 과 연구대상자는총 65 명으로남성이 30 명 (46.2%), 여성이 35 명 (53.8%) 이었으며, 연령에있어서남성이 25.03±8.66 세, 여성이 28.77±7.18 세로남성에비해여성이비교적나 이가많았으나통계적으로유의한차이는없었다 (Table 1). 결혼상태에서전체연구대상자중미혼이 45 명 (69.2%) 로 가장많았으며, 기혼 12 명 (18.5%), 무응답 5 명 (7.7%), 이혼 및사별 3 명 (4.6%) 순으로나타났고, 집단간분포의차이 는없었다. Table 1. Demographic data of male and female patients with borderline personality disorder Male (n=30) Female (n=35) Total (n=65) Age (Mean±SD) 25.03±8.66 28.77±7.18 27.05±8.06 Marital status Married 03 (10.0) 09 (25.7) 12 (18.5) Unmarried 24 (80.0) 21 (60.0) 45 (69.2) Divorce, Separation 0 (0.0) 3 (8.6) 3 (4.6) Non-respondents 03 (10.0) 2 (5.7) 5 (7.7) Academic background Middle school 04 (13.3) 0 (0.0) 04 High school 19 (63.3) 06 (17.1) 25 University 1 (3.3) 3 (8.6) 04 Non-respondents 06 (20.0) 26 (74.3) 32 n: numbers of patients, SD: standard deviation www.freud.or.kr 11
Gender Difference in Patients with Borderline Personality Disorder Table 2. Comorbid Axis I psychiatric disorders, attempt of suicide and suicidal methods in male and female patients with borderline personality disorder Psychiatric disorders Attention deficit/ hyperactivity disorder Male (n=30) Female (n=35) 축 I 공존질환과입원유무및자살시도양상 Total (n=65) 1 (3.3)0 2 (5.7)0 3 (3.6)0 Adjustment disorder 5 (16.7) 5 (14.3) 10 (12.0) Anxiety disorder 6 (20.0) 2 (5.7)0 8 (9.6)0 Bipolar disorder 1 (3.3)0 5 (14.3) 6 (7.2)0 Conversion disorder (-) 3 (8.6)0 3 (3.6)0 Depressive disorder 13 (43.3) 14 (40.0) 27 (32.5) Impulse control disorder 2 (6.7)0 (-) 2 (2.4)0 Psychotic disorder 2 (6.7)0 2 (5.7)0 4 (4.8)0 Sexual identity disorder 2 (6.7)0 (-) 2 (2.4)0 Substance use disorder 2 (6.7)0 5 (14.3) 7 (8.4)0 Eating disorder (-) 2 (5.7)0 2 (2.4)0 No Axis I diagnosis 5 (16.7) 4 (11.4) 9 (10.8) Hospitalization Yes 7 (23.3) 13 (37.1) 20 (30.8) No 23 (76.7) 22 (62.9) 45 (69.2) Attempt of suicide* Yes 3 (10.0) 16 (45.7) 19 (29.2) No 27 (90.0) 19 (54.3) 46 (70.8) Methods of suicide attempt Ingestion (-) 5 (25.0) 5 (21.7) Jumping down (-) 2 (10.0) 2 (8.7)0 Hanging (-) 4 (20.0) 4 (17.4) Weapons (Knife) 2 (66.7) 8 (40.0) 10 (43.5) Others 1 (33.3) 1 (5.0)0 2 (8.7)0 *significant difference at p<0.05. n: numbers of patients 전체경계성인격장애환자의축 I 공존질환중우울장애 가 27 명 (32.5%) 으로가장많았으며, 다음으로적응장애 10 명 (12.0%), 불안장애 8 명 (9.6%), 알코올의존 7 명 (8.4%), 양극성장애 6 명이었고 (7.2%), 공존질환이없는경우는 9 명 (10.8%) 이었다 (Table 2). 남성의경우우울장애가 13 명 (43.3%) 으로가장많았고, 그다음이불안장애 6 명 (20.0%), 적응장애 5 명 (16.7%), 축 I 공존질환이없는경우는 5 명 (16.7%) 이었다. 여성의경우에도우울장애가 14 명 (40.0%) 으로가장많았고, 적응장애, 양극성장애, 알코올의존, 적응 장애가각각 5 명 (14.3%), 축 I 공존질환이없는경우는 4 명 (11.4%) 이었다. 입원유무에있어서는전체경계성인격장 애환자에서입원을한경우는 20명 (30.8%) 이었는데, 남성의경우에는 7명 (23.3%), 여자의경우에는 13명 (37.1%) 으로집단간에유의한분포차이는없었다. 자살시도의유무에있어서는전체환자에서자살시도를한경우가 19명 (29.2%) 이었으며, 남성의경우에는 3명 (10.0%), 여성의경우에는 16명 (45.7%) 이자살시도를한적이있는것으로나타나여자환자에게서자살시도가유의하게많았다 (p<0.05). 자살시도방법에있어서는여자환자가음독, 투신, 목매달기, 과도나칼과같은무기등다양한방법을사용하였고, 남자환자는주로칼등의무기를사용하였다. 정신병리적특성 SCL-90-R 점수비교공포불안척도에서성별간에유의한차이가있었으며 (p< 0.05), 남성이 1.51±1.30 으로, 여성 0.93±0.72 에비해유의하게높았다 (Table 3). 편집증척도에서도남성이 1.92± 1.14으로여성 1.40±0.90에비해유의하게높았다 (p< 0.05). 그외증상차원에서는성별간에유의한차이가없었으며, 전체심도지수, 표출증상합계, 표출증상심도지수와같은전체지표에서도성별간에유의한차이가없었다. MMPI 점수비교타당도척도중 F척도에서남성이 67.40±17.79 으로여성 58.51±11.44 에비해유의하게높았다 (p<0.05)(table 4). 임상척도에서성별간에유의한차이가있는척도의점수는모두남자환자가여자환자에비해높았는데우울증척도에서남성이 69.13±6.86 으로여성 60.74±14.23 보다높았고 (p<0.05), 남성성- 여성성 (Mf) 척도에서남성이 54.43 ±13.21, 여성은 48.54±8.98이었고 (p<0.05), 강박증척도에서남성이 70.47±16.91, 여성은 61.97±12.38 이었으며 (p<0.05), 정신분열증척도에서도남성이 68.77±15.90 으로여성 61.37±13.07 에비해유의하게높았다 (p<0.05). 그리고, 사회적내향성척도에서도남성이 67.63±16.41 로, 여성의 56.14±14.26 에비해유의하게높았다 (p<0.01). Fig. 1은 MMPI 점수의성별에따른차이를나타낸것이다. MMPI 프로파일의경향을보면사회적내향성척도를제외하고는남녀간에비슷한경향을보였다. PDQ-4+ 점수비교인격장애별소척도점수에서반사회성인격장애척도에서만남성이 3.57±2.13 로여성 2.24±1.67 보다유의하게높았고 (p<0.01), 이외인격장애에서는성별간에유의한 12 Psychoanalysis 2011;22:9-18
BY Mun, et al. Table 3. Comparison of the results of SCL-90-R in male and female patients with borderline personality disorder Subscale scores Male (n=30) Female (n=35) t p Somatization 1.64±1.11 1.57±1.11 0.262 0.794 Obsessive-compulsive 2.25±0.98 1.96±0.86 1.248 0.217 Interpersonal sensitivity 1.29±1.12 1.66±0.95 1.675 0.099 Depression 2.18±1.09 2.13±0.03 0.185 0.854 Anxiety 1.92±1.14 1.64±0.97 1.088 0.281 Hostility 2.41±1.20 1.86±1.11 1.901 0.062 Phobic anxiety 1.51±1.30 0.93±0.72 2.266 0.027* Paranoid ideation 1.92±1.14 1.40±0.90 2.029 0.047* Psychoticism 1.67±1.12 1.35±0.80 1.304 0.197 General index scores General symptomatic index 1.95±1.04 1.66±0.82 1.287 0.203 Positive symptom total 68.20±21.19 64.67±19.94 0.694 0.490 Positive symptom distress level 2.41±0.77 2.18±0.98 1.260 0.212 Values are expressed as mean±sd. *p<0.05. n: numbers of patients, SD: standard deviation, SCL-90-R: Symptom Checklist-90- Revised Table 4. Comparison of the results of MMPI in male and female patients with borderline personality disorder Validity scales Male (n=30) Female (n=35) t p Lie (L) 40.60±8.010 43.11±7.420 1.313 0.194 Infrequency (F) 67.40±17.79 58.51±11.44 2.428 0.018* Correction (K) 37.80±7.070 38.60±6.860 0.462 0.646 Clinical scales Hypochondriasis 60.80±12.75 57.34±11.70 1.139 0.259 Depression 69.13±6.860 60.74±14.23 2.176 0.033* Hysteria 59.47±10.10 57.09±9.230 0.993 0.325 Psychopathic deviate 65.67±12.65 61.86±11.65 1.263 0.211 Masculinity-femininity 54.43±13.21 48.54±8.980 2.127 0.037* Paranoia 69.60±20.70 63.31±11.08 1.557 0.125 Psychasthenia 70.47±16.91 61.97±12.38 2.333 0.023* Schizophrenia 68.77±15.90 61.37±13.07 2.059 0.044* Hypomania 57.03±12.04 59.09±11.76 0.694 0.490 Social introversion 67.63±16.41 56.14±14.26 3.021 0.004 Values are expressed as mean±sd. *p<0.05, p<0.01. n: numbers of patients, SD: standard deviation, MMPI: Minnesota Multiphasic Personality Inventory 차이가없었다 (Table 5). 한편인격장애별소척도의절단점수 (cut-off) 에따라진단하여그분포를비교한결과, 반사회성인격장애척도의분포와경계선인격장애척도의분포에서성별간에유의한차이가있었고 (p<0.05) 그외인격장애척도의분포에서는성별간에유의한차이가없었다. DSQ 점수비교네가지방어양식에서는성별간에유의한차이가없었다 (Table 6). 개별방어기제중분리 (splitting) 에서성별간에유의한차이가있었으며 (p<0.05), 남성이 3.24±2.61로여성 5.06±2.93 에비해낮았다. 한편전능화 / 평가절하에서도성별간에유의한차이가있었으며 (p<0.01), 남성이 5.84±2.32 로여성 3.80±2.40 에비해높았다. 그리고친화에서도성별간에유의한차이가있었으며 (p<0.05), 남성이 6.76±3.03 으로여성 4.97±3.67 에비해높았다. www.freud.or.kr 13
Gender Difference in Patients with Borderline Personality Disorder 100 90 80 70 60 50 40 30 20 10 0 * * L F K Hs D Hy Pd Mf Pa Pt Sc Ma Si Figure 1. Mean profiles of MMPI in male and female patients with borderline personality disorder. *p<0.05, p<0.01. MMPI: Minnesota Multiphasic Personality Inventory, L: Lie, F: Infrequency, K: Correction, Hs: Hypochodriasis, D: Depression, Hy: Hysteria, Pd: Psychopathic deviate, Mf: Masculinity-Femininity, Pa: Paranoia, Pt: Psychasthenia, Sc: Schizophrenia, Ma: Hypomania, Si: Social introversion. * * * Male Female 고찰 본연구는일대학병원에방문한경계성인격장애환자를대상으로남녀별임상양상및심리특성을알아보고자하였다. 경계성인격장애의공존정신과적장애의경우전체적으로볼때남녀모두에서우울증의빈도가가장높았는데이는기존의연구결과와일치하는것으로볼수있다 (Gunderson 등 1987; Derogatis 등 1973; Johnson 등 2003; Zlotnick 등 2002). Johnson 등 (2003) 은경계성인격장애환자의공존질환을알아본연구에서여성에서호발하는우울증이경계성인격장애환자에서는남녀에서성별차이가없는점에대해경계성인격장애의정신병리가일반적인성별의차이점을약화시키는우세한성격화경향으로설명하 Table 5. Comparison of the results of PDQ-4+ in male and female patients with borderline personality disorder Male (n=30) Female (n=35) Total (n=65) t (Chi) PNPD 4.50±1.89 4.29±1.59 4.39±1.72 0.474 0.367 CRES 22 (73.3) 24 (70.6) 46 (71.9) (0.059) 0.807 SZPD 3.33±2.02 3.50±1.50 3.42±1.72 0.377 0.707 CRES 14 (46.7) 16 (47.1) 30 (46.9) (0.001) 0.975 STPD 4.63±2.44 3.97±1.91 4.28±2.19 1.215 0.229 CRES 17 (56.7) 13 (38.2) 30 (46.9) (2.174) 0.140 ASPD 3.57±2.13 2.24±1.67 2.86±2.00 2.800 0.007* CRES 22 (73.3) 16 (47.1) 38 (59.4) (4.561) 0.033 BDPD 5.70±1.44 5.03±1.75 5.34±1.64 1.660 0.102 CRES 26 (86.7) 20 (58.8) 46 (71.9) (6.112) 0.013 HSPD 4.23±1.79 3.62±1.65 3.91±1.73 1.429 0.158 CRES 11 (36.7) 10 (29.4) 21 (32.8) (0.381) 0.537 NSPD 3.90±1.97 3.38±2.34 3.62±2.17 0.951 0.345 CRES 11 (36.7) 11 (32.4) 22 (34.4) (0.131) 0.717 ADPD 4.50±2.39 3.74±2.12 4.09±2.27 1.356 0.180 CRES 21 (70.0) 19 (55.9) 40 (62.5) (1.355) 0.244 DDPD 4.57±2.08 3.91±2.17 4.22±2.13 1.230 0.223 CRES 15 (50.0) 15 (44.1) 30 (46.9) (0.221) 0.638 OCPD 3.97±1.67 3.94±1.32 3.95±1.48 0.068 0.946 CRES 16 (53.3) 19 (55.9) 35 (54.7) (0.042) 0.838 DSPD 4.50±1.72 4.09±1.51 4.28±1.61 1.023 0.311 CRES 17 (56.7) 14 (41.2) 31 (48.4) (1.531) 0.216 NTPD 4.30±2.21 3.68±1.55 3.97±1.90 1.316 0.193 CRES 18 (60.0) 17 (50.0) 35 (54.7) (0.643) 0.423 Values are expressed as mean±sd. *p<0.01 at student t-test, p<0.05 at Chi-square test. PDQ-4+: Personality Disorder Questionnaire-4+, n: numbers of patients, SD: standard deviation, CRES: correspondence, PNPD: paranoid personality disorder, SZPD: schizoid personality disorder, STPD: schizotypal personality disorder, ASPD: antisocial personality disorder, BDPD: borderline personality disorder, HSPD: histrionic personality disorder, NSPD: narcissistic personality disorder, ADPD: avoidant personality disorder, DDPD: dependent personality disorder, OCPD: obsessive-compulsive personality disorder, DSPD: depressive personality disorder, NTPD: negativistic personality disorder p 14 Psychoanalysis 2011;22:9-18
BY Mun, et al. Table 6. Comparison of the results of DSQ in male and female patients with borderline personality disorder Cluster score Male (n=30) Female (n=35) t p Maladaptive action 5.45±1.31 4.87±0.97 2.003 0.050 Image-distorting 4.52±1.06 4.31±1.04 0.785 0.436 Self-sacrificing 3.50±1.31 3.98±1.42 1.381 0.172 Adaptive 4.15±1.19 4.81±1.61 1.808 0.076 Defense mechanism Neurotic denial 4.02±1.81 3.55±2.13 0.919 0.362 Nondelusional projection 4.85±1.67 4.36±1.65 1.158 0.251 Passive aggression 7.83±1.83 7.13±2.55 1.224 0.226 Acting out 7.37±1.52 6.90±1.89 1.051 0.297 Splitting of other s image 3.24±2.61 5.06±2.93 2.552 0.013* Projective identification 4.14±2.95 5.28±2.67 1.590 0.117 Omnipotense 5.84±2.32 3.80±2.40 3.380 0.001 Undoing 3.52±2.46 4.38±2.51 1.346 0.184 Affiliation 6.76±3.03 4.97±3.67 2.065 0.043* Somatization 5.10±2.85 4.63±3.20 0.614 0.541 Hypochondriasis 2.65±1.20 2.51±1.27 0.438 0.663 Values are expressed as mean±sd. *p<0.05, p<0.01. n: numbers of patients, SD: standard deviation, DSQ: the Defense Style Questionnaire 였다. 각각의성별에따른공존질환을살펴보면집단의대상수가적어서통계적유의성은알수없으나남자에서는우울증다음으로불안장애, 적응장애순이었으며, 여자에서는우울증다음으로적응장애, 양극성장애, 물질사용장애의빈도가동일하게나타났다. 기존외국연구 (Gunderson 등 1987; Derogatis 등 1973; Johnson 등 2003; Zlotnick 등 2002) 에서는우울증다음으로남자의경우물질사용장애가여자에비해많았고, 여자의경우에는섭식장애, 외상후스트레스장애가많은것으로보고되었다. 본연구에서물질사용장애의경우기존의연구와는차이가있는데이전연구의경우에는알코올사용관련장애이외의마약, 마리화나등의다양한물질관련장애를모두포함한것이고, 국내의경우알코올관련장애만포함시켰고연구대상수가적어서직접적으로그결과를비교하기는어려울것으로생각된다. 본연구에서섭식장애는여자환자 2명에게만동반되어있었으며대상수가적은제한점이있지만이는이전연구결과와일치하는점으로보인다 (McCormick 등 2007; Zlotnick 등 2002). 남녀의자살시도양상의경우여자가남자에비해자살시도횟수가유의하게더많았고더다양한방법을사용하는것으로나타났다. 기존의연구결과에서여자가남자보다자살시도가많고, 남자의경우보다치명적인방법을사용하는것으로보고되었는데 (Bogdanovica 등 2010), 본연구 에서는여자환자에게서자살시도가많은점은이전연구결과와일치하지만, 여자환자가다양한방법을사용한점과남자환자는과도나칼과같은무기만사용한것으로나타났으며남자환자의수가적어서직접적인비교는어려운것으로생각된다. 한편으로는경계성인격장애환자의과거자살경력과자해행동의횟수가성별로유사하다는연구도있었다 (McCormick 등 2007). SCL-90R에서는남자의경우대체로강박증척도, 우울척도, 불안척도, 적대감척도, 편집증척도가높은경향을보였고, 여자의경우강박증척도, 대인민감성척도, 우울척도, 불안척도, 적대감척도등이높은경향을나타내었다. 경계성인격장애환자의기술적진단에초점을맞추었던 Grinker 등 (1968) 은경계성증후군모두에서공통으로나타나는네가지주된임상양상으로분노가유일한감정, 대인관계의결함, 일관된자기정체성의결여, 전반적인우울등을제시하였고, 경계성인격장애환자를정신역동적으로조명한 Kernberg 등 (1975) 은경계성인격구성 (borderline personality organization) 으로인해경계성인격장애환자들은막연한불안감, 강박증상, 다중공포, 해리반응, 전환증상, 건강염려증적집착, 편집증적경향, 그리고다양한성도착증적행위및약물남용의증상을보인다고하였다. 본연구에서 SCL-90R 의점수경향을볼때남녀모두에게서강박증척도, 우울및불안척도, 적대감척도가공통적으로높 www.freud.or.kr 15
Gender Difference in Patients with Borderline Personality Disorder 아 Grinker 등 (1968) 과 Kernberg 등 (1975) 이언급한바와같이경계성인격장애환자에서분노, 우울경향, 불안, 강박증상등이같이동반되어있는것으로생각된다. SCL-90R 의척도중특히, 공포불안척도와편집증척도가남자에서여자보다유의하게높게나타났다. 이것은남자환자가대인관계상황에서좀더예민하고편집증적경향을보일수있고이로인해대인관계를회피하는양상을보이는것으로추정된다. 실제임상에서도남자환자의경우, 쉽게타인으로부터무시당한다는느낌을받거나비난이나평가를받는다는관계사고적인경향을보이는경우가자주있으며, 이로인해대인관계없이지내는경우가많이있다. 경계성인격장애환자의축 II 공존질환을알아본기존의연구에서반사회적인격장애와함께편집성인격장애가여자보다남자에서높은것으로보고하였는데 (Johnson 등 2003) 본연구에서 SCL-90R의결과편집증척도가남자에서더높은것도이와연관된것으로추정해볼수있다. MMPI의전체적인프로파일을살펴보면남녀모두공통적으로타당도척도에서는비전형 (F) 척도, 임상척도에서는우울증 (D), 반사회성 (Pd), 편집증 (Pa), 강박증 (Pt), 정신분열증 (Sc) 척도의상승을보였고, 남자환자에서사회적내향성 (Si) 척도의상승을제외하고는성별간에유사한프로파일을보였다. 비전형 (F) 척도가높게나온것은경계성인격장애환자가다른인격장애에비해스스로고통을받는경우가많기때문에치료를더많이받으러오게되는것과도연관이있다. 그리고, 남녀모두에서상승을보인임상척도의프로파일양상을살펴보면경계성인격장애환자는 Grinker 등 (1968) 과 Kernberg 등 (1975) 이보고한정신병리와마찬가지로쉽게우울해지고, 충동적이거나행동화하려는경향이강하고, 대인관계에서예민하며, 강박증상과같이여러가지걱정이나생각이많으며, 이로인해위축되는양상을보이는것으로추정된다. 한편남녀성별차이가유의한척도는비전형 (F) 척도와임상척도중우울증 (D), 남성-여성특성 (Mf), 강박증 (Pt), 정신분열증 (Sc), 사회적내향성 (Si) 척도였다. 본연구에서는경계성인격장애를가진남자환자가여자환자보다전반적으로심리적고통을더많이경험하고있다는것으로추정해볼수있으며, 한편으로는그중사회적내향성 (Si) 이가장많이차이가나는점으로볼때남자가여자보다대인관계에서더회피적인양상을보인다고추정해볼수있다. 또한, 본연구의결과로는대체로남자가여자보다증상이더심한것으로나타났는데, 본연구에서남자환자의경우군문제가동반된환자들이연구대상에일부포함되어있어서이차적이득의문제로인해증상을더심하게표현했을가능성도배제할수없다. 하지만연구대상선정시꾀병또는부정왜곡이의심되는환자는제외하였고, 이시기남자경계성인격장애환자에게는군문제가명백한스트레스요인으로작용하여기존의경계성성격병리를더악화시켰을수도있을것으로생각해볼수있다. 경계성인격장애환자의기능장애측면에서삶의질, 사회적응척도, 그리고정신과진료이용과관계된일수등을조사한기존의연구에서는증상으로인한전반적인기능저하문제가여성에서더심하다고보고한연구도있었고 (McCormick 등 2007), 남녀간에기능장애의차이는없다고보고한연구도있었다 (Zlotnick 등 2002). 향후이에대해자살문제와더불어좀더직접적으로기능장애를비교할수있는연구가필요할것으로생각된다. 또한남자환자에서사회적내향성 (Si) 이높은것은 SCL-90R 에서남자환자가편집증척도와공포불안척도가높은것과관계되어대인관계에서예민하고불안해하는점으로인해위축되는경향을보이는것으로추정해볼수있다. PDQ-4+ 에서는반사회성인격장애척도가남자에서여자보다유의하게높게나타났다. 반사회성인격장애는일반인구표본에서도여자보다남자에게서더많으며, 경계성인격장애환자군에서도남자가여자보다동반이환되는경우가많다는점이다른연구를통하여알려져있다 (McCormick 등 2007; Johnson 등 2003; Zlotnick 등 2002). 즉, 본연구의경우축 II의다른인격장애를가진환자를제외하여반사회성인격장애의진단을배제하더라도남자의경우여자보다좀더반사회적경향이나타나는것으로볼수있다. 반면에이연구에서여자환자의동반질환에서알코올과같은물질남용장애나섭식장애가더많이동반된것으로보아여자의경우사회적으로용인되는행동을하는것으로추정해볼수있다. 이러한측면으로볼때남자경계성인격장애환자와여자경계성인격장애환자가자신의내적갈등을표출하는방법이질적으로다르다는점을추정해볼수있으나추후많은환자를대상으로한연구가필요할것으로생각된다. DSQ에서남자는비적응형 (maladptive) 방어양상, 표상왜곡형 (image-distorting) 방어양상이높은경향을보였고개별방어기제로는수동공격성 (passive aggression), 행동화 (acting out), 전능화 (omnipotence), 친화 (affiliation), 그리고신체화 (somatization) 가높은경향을보였다. 여자의경우, 방어양상으로는비적응형방어양상과적응적 (adaptive) 방어양상이높은경향을보였고개별방어기제로는수동공격성, 행동화, 분리 (splitting), 투사적동일시 (projective identification) 등이높은경향을보였다. 전체적으로 16 Psychoanalysis 2011;22:9-18
BY Mun, et al. 볼때 Kernberg(1975) 가말한경계성인격구성 (borderline personality organization) 에포함되어있는원초적인방어기제는여자경계성인격장애에서더전형적으로사용되는것으로추정해볼수있다. 이러한점에대해 Gabbard (2005) 는여자에게서경계성인격장애의유병률이더높으며여자환자들이남자에비해더자주경계성인격장애의원형을보인다고하였다. DSQ에서성별에따른차이를보면여자환자에게서는분리를, 남자환자에게서는전능화와친화를유의하게더많이사용하는것으로나타났다. 여자환자가남자보다심리적갈등을처리하기위해분리를더많이사용한다는것은자신이나타인에대해감정을통합하지못하고분리하여대인관계에서나자신에대해쉽게평가절하나이상화를할수있는것으로추정된다. 남자의경우자신의심리적어려움을전지전능한환상등을통해보상을하려고하며, 동시에타인에대한내적친화력을가지려고하나실제생활에서는위축되고고립되어게임등의혼자만의세계에빠질수있는경향이많을것으로추정해볼수있다. 요약하면경계성인격장애환자에서성별에따라축 I의공존질환이나자살시도와같은임상양상과 SCL-90R과 MMPI에서보이는정신병리, 그리고 PDQ-4+ 와 DSQ에서보이는인격경향및방어기제등의차이를알아본결과남자경계성인격장애의경우좀더편집적이고대인관계에서위축된상태로내적환상을통해보상하려는경향과반사회적경향을보이는반면, 여자경계성인격장애의경우주요방어기제로서분리를더많이사용하는경향이있는것으로나타났다. 따라서치료에이러한점들을고려하여남자환자에게는경계성인격장애에대한일반적인치료전략외에편집적경향과위축경향에대한치료적접근이필요할것으로생각된다. 그러나공존질환과정신병리측면등을포함하여경계성인격장애핵심병리측면에서는대부분남녀간에차이보다는유사점이많은것으로생각되고, 특히여자환자가좀더경계성인격장애의원형에가까운특성을가지고있는것으로추정해볼수있다. 경계성인격장애환자의성별공존질환, 진단기준, 소아기학대병력, 기능장애, 그리고성격및기질특성을연구한기존의연구에서도결론적으로경계성인격장애환자에서성별간에차이점보다는유사점이더많은것으로보고하였다 (Johnson 등 2003). 본연구의제한점으로는집단의수가적다는점과후향적연구라는점을들수있다. 향후좀더많은환자를대상으로성별뿐만아니라나이, 소아기학대병력을포함한정신적외상경력등의여러가지다양한인자들을고려하여 이질적인경계성인격장애환자의임상아형을알아보는전 향적연구가필요할것으로사료된다. Acknowledgments 이논문은 2009 년도재단법인천마의학연구재단지원에의하여이루어졌음. Conflicts of Interest The authors have no financial conflicts of interest. REFERENCES American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: APA;1994. Bagby RM. Detecting overreporting on the MMPI-2. Workshop presented at the 40th Annual MMPI-2/MMPI-A Workshops. Fort LAuderdale, FL;2005. Bender DS, Dolan RT, Skodol AE, Sanislow CA, Dyck IR, Mc- Glashan TH, et al. Treatment utilization by patients with personality disorders. Am J Psychiatry 2001;158:295-302. Bogdanovica I, Jiang GX, Löhr C, Schmidtke A, Mittendorfer-Rutz E. Changes in rates, methods and characteristics of suicide attempters over a 15-year period: comparison between Stockholm, Sweden, and Würzburg, Germany. Soc Psychiatry Psychiatr Epidemiol 2010. Bond MP, Vaillant JS. An empirical study of the relationship between diagnosis and defense style. Arch Gen Psychiatry 1986;43:285-288. Choi YK. Childhood sexual abuse and impulsivity among subtypes of borderline personality. Kor J Psychopathol 2009;28:639-650. Clarkin JF, Marziali E, Munroe-Blum H. Boderline personality disorder: clinical and empirical perspectives. New York: Guilford;1992. Derogatis LR, Lipman RS, Covi L. SCL-90: an outpatient psychiatric rating scale--preliminary report. Psychopharmacol Bull 1973;9:13-28. Gabbard GO. Psychodynamic psychiatry in clinical practice. American Psychiatric Publishing Inc;2005. Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, et al. Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry 2006;63:649-658. Grinker RR Jr, Werble B, Drye RC. The borderline syndrome: abehavioral study of ego-functions. New York: Basic Books;1968. Gunderson JG. Borderline personality disorder: ontogeny of a diagnosis. Am J Psychiatry 2009;166:530-539. Gunderson JG, Zanarini MC. Current overview of the borderline diagnosis. J Clin Psychiatry 1987;48 Suppl:5-14. Hathaway SR, McKinley JC. The minnesota multiphasic personality inventory. Minneapolis: University of Minnesota Press;1943. Hyler SE. Personality diagnostic questionnaire-iv. New York: New York State Psychiatric Institute;1994. Johnson DM, Shea MT, Yen S, Battle CL, Zlotnick C, Sanislow CA, et al. Gender differences in borderline personality disorder: findings from the Collaborative Longitudinal Personality Disorders Study. Compr Psychiatry 2003;44:284-292. Jung MW, Kim SH, Park SH. A Preliminary study for the development of a Defense Style Questionnaire adapted for Koreans. J Korean Neuropsychiatr Assoc 1993;32:707-716. Kernberg OF. Borderline conditions and pathological narcissism. New York: Jason Aronson;1975. Kim D, Kim JH, Chung SA, Nam JH, Bae H, Chang HJ. The MMPI profile of adult schizophrenia with childhood physical or sexual abuse. J Korean Neuropsychiatr Assoc 2007;46:223-228. Kim DI, Choi MR, Cho EC. The preliminary study of reliability and validity on the korean version of personality disorder questionnaire-4+ (PDQ-4+). J Korean Neuropsychiatr Assoc 2000;39:525-538. www.freud.or.kr 17
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