Anxiety and Mood Vol 14, No 2 / pissn / eissn ORIGINAL ARTICLE 범법조현병환자에서한국형성격장애척도를이용

Anxiety and Mood Vol 14, No 2 / pissn 2586-0151 / eissn 2586-0046 https://doi.org/10.24986/anxmod.2018.14.2.120 ORIGINAL ARTICLE 범법조현병환자에서한국형성격장애척도를이용한성격장애평가 충남대학교병원정신건강의학과, 1 보훈공단대전보훈병원정신건강의학과, 2 충남대학교의과대학정신건강의학과교실, 3 충남대학교뇌과학연구소 4 강지욱 1. 이미지 1. 권지현 2. 지익성 1,3,4 Use of the Korean Inventory of Interpersonal Problem Personality Disorder Scales to Assess Personality Disorder in a Criminal Schizophrenic Patient Sample JiWook Kang, MD 1, MiJi Lee, MD 1, JeeHyun Kwon, MD 2 and Ik-Seung Chee, MD, PhD 1,3 Department of Psychiatry 1, Chungnam National University Hospital, Daejeon, Department of Psychiatry 2, VHS Medical Center, Daejeon, School of Medicine 3, Chungnam National University, Daejeon, Institute of Brain Research 4, Chungnam National University, Daejeon, Korea ABSTRACT Objective : Psychopathy has been suggested as one of the important cause of violence in patients with schizophrenia. The purpose of this study was to evaluate the personality disorder in criminal schizophrenia. Methods : A total of 187 criminal schizophrenia participated in this study. All participants filled out the Korean Inventory of Interpersonal Problem Personality Disorder Scales (K-IIP-PD), Psychopathic Personality Inventory-Revised (PPI-R), Personality Assessment Inventory (PAI). Using the correlations between the scales, we investigated whether K-IIP-PD could be used to evaluate personality disorder in criminal schizophrenia. Moreover, participants were divided into two groups of psychopathic and nonpsychopathic schizophrenics, and scores of K-IIP-PD were compared between the two subgroups. Results : The overall correlation between the scales was very high. In particular, sum of 3 item scores (interprsonal sensitivity+interpersonal ambivalence+aggression) and aggression of K-IIP-PD were highly correlated with PPI-R and PAI. Total score of personality disorder scale and subscales were higher in psychopathic schizophrenic group compared to nonpsychopathic schizophrenic group. Conclusion : The K-IIP-PD could be used to assess the antisocial and aggressive nature of criminal schizophrenia. Further studies in various clinical groups including the general population are required. (Anxiety and Mood 2018;14(2):120-126) KEY WORDS : Psychopathy Criminal schizophrenia Personality disorder scale. 서 론 대부분의조현병환자들은폭력적이지않으나다른정신 질환과비교하면폭력의비율은상대적으로높으며일반인에 Received : May 8, 2018 / Revised : July 20, 2018 Accepted : July 20, 2018 Address for correspondence Ik-Seung Chee, M.D., Ph.D., Department of Psychiatry, School of Medicine, Chungnam National University, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea Tel : +82-42-280-8291, Fax : +82-42-280-7886 E-mail : ischee@cnu.ac.kr 본논문은 2015년도충남대학교학술연구비의지원에의하여연구되었음. 비해서도 3~5배높은것으로보고되고있고, 1,2 특히물질남용이동반된경우는폭력을행사할가능성이더높은것으로알려져있다. 3 조현병에서폭력은대체로 3가지요인에의하여발생하는데정신병적양성증상, 충동성, 그리고동반된정신병질적성격이중요하고, 4 최근 Bo 등 5 은조현병환자의폭력적행동을추적연구를통해서알아본결과급격하게발생한양성증상에따른폭력과성격 (personality), 특히정신병질적인성향과관련있는폭력으로구별하였다. 정신병질 (psychopathy) 혹은정신병질적성격 (psychopathic personality) 은감정적, 대인관계, 행동적인면에서독특한특색을보인다. 즉피상적인매력과높은지능, 병적인자기중 120 Anxiety and Mood Volume 14, No 2 October, 2018

강지욱등 심성, 비진실성과위선, 교묘한속임수, 연민이나죄책감결여, 빈약한감정, 동정심결여, 신뢰감저하, 비인격적인성생활, 보편적인삶의추구실패, 충동성, 반사회적행동, 판단력결여, 망상및신경증적증상의부재, 매우낮은자살가능성, 공감능력결여등으로나타난다. 6 심각한폭력을범한조현병환자에서정신병질의동반율이생각보다높고, 7-9 특히조현병환자의범죄중에서재범을하는요인중가장중요하게작용하는것이정신병질이며, 10 치료프로그램에대한순응도가떨어져병원에서도치료결과가좋지않으며범죄위험성이나폭력에대한인식도낮고, 11 정신병이없는정신병질자와유사한정도로감정적정보처리에장애가있고증상학적으로도과대적이고적대적인면이더많을뿐만아니라대인관계에서도호응도가떨어지고충동성과공격성이높다. 12 이러한면에서보면조현병의폭력에서정신병질은망상이나환청같은조현병의증상이호전되어도성격특성 (personality trait) 으로써지속적으로폭력의잠재적인원인으로작용할수있기에정신병적양성증상의호전으로만폭력을근절시킬수있는것은아니기때문에이에대한다양한연구와평가그리고예방과치료가필요하다. 13 저자들은범법조현병환자를대상으로정신병질적성격평가, 14 그리고성격평가질문지 (Personality Assessment Inventroy) 를통하여정신병질적성격평가 15 를할수있는지그리고정신병질성격과대인관계문제 16 에대하여보고한바있다. 본연구는범법조현병환자를대상으로성격적인특성을알아보고자하는일련의연구로또다른연구도구를이용하여성격장애를알아보기위하여시행되었다. 연구대상및방법 연구대상본연구는범법행위로치료감호를선고받고국립법무병원에입원해있는 18세에서 60세사이의정신질환자중 Diagnostic and Statistical Manual of Mental Disorder-IV(DSM-IV) 의조현병의진단기준을만족시키는환자를대상으로하였다. 신경계이상이동반되었거나기질성뇌질환의병력이있는환자, 의사소통에장애가있어평가가어려운환자들은연구에서제외하였다. 본연구는충남대학교병원임상시험심사위원회의승인을받았고, 모든참여자들에게연구의목적과취지에대해충분히설명을한후서면동의서를받았다. 연구방법연구도구한국형성격장애척도 (Korean Inventory of Interpersonal Problem Personality Disorder Scales, K-IIP-PD) 성격장애척도는 Horowitz 등 17 의 64문항으로구성된대인관계문제검사를 Kim 등 18 이개발한한국형대인관계문제검사 (Korean Inventory of Interpersonal Problem, K-IIP) 를이용하였다. 미국의 IIP는 64문항으로구성된원형척도 (IIP- C) 이지만 K-IIP 는 99문항으로구성되어있으며두가지독립적검사인원형척도 (IIP Circumplex Scale, K-IIP-C) 와성격장애척도 (IIP Personality Disorder Scales, K-IIP-PD) 로이루어져있다. 이중 80개문항은 K-IIP-C 로채점이되고, 47 개문항은 K-IIP-PD 에채점되도록되어있고 K-IIP-C 와 K-IIP-PD 간에는 28개의문항이중복되어있다. 본연구에서사용한성격장애검사 (K-IIP-PD) 는대인적과민성 (PD1, 8문항 ), 대인적비수용성 (PD2, 11문항 ), 공격성 (PD3, 9문항 ), 사회적인정욕구 (PD4, 7문항 ), 사회성부족 (PD5, 12문항 ) 등 5개의척도로구성되어있다. 모든척도는 0~4점까지 5점척도로응답하게되며대학생과성인표본을대상으로추정된한국형대인관계문제검사의 Cronbach 내적합치도 (α) 는 0.69~0.93으로높은편이며, 문항간상관평균은 0.24로문항들이독립적인내용들로구성되어있다. 또한표준 T점수의검사-재검사신뢰도는 0.59~0.84로전반적으로높은편이다. 한국판정신병질성격평가검사 -개정판 (Psychopathic Personality Inventory-Revised, PPI-R) 이는정신병질의특성들을측정하기위해 Lilienfeld와 Andrews 19 가개발한 Psychopathic Personality Inventory 를 Lilienfeld 와 Widow 20 가개정한것으로, 본연구에서는 Lee 와 Park 21 이한국판으로표준화한것을사용하였다. PPI-R 은 8개의내용척도와 4개의타당도척도로구성되어있다. 내용척도는 [ 권모술수적이기주의 (Machiavellian Egocentricity, ME), 반항적인비협조 (Rebellious Nonconformity, RN), 비난의외재화 (Blame Externalization, BE), 무책임한비계획성 (Carefree Nonplanfulness, CN), 사회적영향력 (Social Influences, SOI), 대담성 (Fearlessness, F), 스트레스면역 (Stress Immunity, STI), 냉담함 (Coldheartedness, C)] 이고, 타당도척도는 [ 도덕적반응 (Virtuous Responding, VR), 비정상적반응 (Deviant Responding, DR), 모순된반응 15(Inconsistent Responding 15, IR15), 모순된반응 40(Inconsistent Responding 40, IR40)] 으로구성되어있다. Anxiety and Mood Volume 14, No 2 October, 2018 121

범법조현병환자의성격장애평가 PPI-R 의총점이높을수록정신병질적성격의전형, 예를들어무책임함, 충동성, 부정직함, 교활함, 공감능력및죄책감의부재등의특징들을많이갖추고있다는의미로해석할수있다. 19 PPI-R 의신뢰도연구결과수용자집단에서총점과내용척도의내적합치도계수 (Cronbach α) 가 0.70 이상으로수용가능한수준이었으며, PPI-R 의총점과내용척도, 요인들에대한반복측정신뢰도는 0.82~0.95 로본검사가시간안정성을갖춘도구임이증명되었다. 21 한국판성격평가질문지 (Personality Assessment Inventory, PAI) 이는 Morey 22 가성격에대한종합평가를위하여개발한것으로, 본연구에서는 Kim 등 23 이한국판으로표준화한것을사용하였다. PAI는 4개의타당도척도 [ 비일관성척도 (Inconsistency, ICN), 저빈도척도 (Infrequency, INF), 부정적인상척도 (Negative Impression, NIM), 긍정적인상척도 (Positive Impression, PIM)] 과 11개의임상척도 [ 신체적호소 (Somatic Complaints, SOM), 불안척도 (Anxiety, ANX), 불안관련장애척도 (Anxiety-Related Disorder, ARD), 우울척도 (Depression, DEP), 조증척도 (Mania, MAN), 편집증척도 (Paranoia, PAR), 조현병척도 (Schizophrenia, SCZ), 경계선적특징척도 (Borderline Features, BOR), 반사회적특징척도 (Antisocial Features, ANT), 알코올문제척도 (Alcohol Problems, ALC), 약물문제척도 (Drug Problems, DRG)] 와 5개의치료척도 [ 공격성척도 (Aggression, AGG), 자살관념척도 (Suicide Ideation, SUI), 스트레스척도 (Stress, STR), 비지지척도 (Nonsupport, NON), 치료거부척도 (Treatment Rejection, TXR)] 그리고 2개의대인관계척도 [ 지배성척도 (Dominance, DOM), 온정성척도 (Warmth, WRM)] 로구성되어있다. 이중 10개의척도는복잡한임상적구성개념을측정하고해석하기위한하위척도를포함하고있다. 한국판성격평가질문지검사의내적합치도는비일관성척도와저빈도척도를제외한나머지척도에서 0.68~0.88 였으며, 전체 22개척도의중앙치는대학생과성인의경우각각 0.77, 0.76 이었고, 반복측정신뢰도는비일관성척도와저빈도척도를제외하고 0.77~0.91 로비교적양호한편이었다. 24 dominance ; FD=SOI+F+STI) 과반사회적행동측면을평가하는 PPI-R-2 요인인자기중심적충동성요인 (self-centered impulsivity ; SCI=ME+RN+BE+CN)) 으로구별한 2-요인척도 25 로구별하여 K-IIP-PD 의척도와의상관관계를구하였다. 정신병질군과비정신병질군의구분은 PPI-R 에서는전통적으로의미있는차이를보이는 T점수 65점을정신병질자의구분기준으로구별하기때문에 21 본연구에서도 65점을기준으로정신병질군 (65점이상 ) 과비정신병질군 (64점이하 ) 으로분류하여 K-IIP-PD 에서차이가있는지 t-test로비교하였다. 정규분포는 Kolmogorov-Smirnov test 통하여확인하였다. 통계처리는 SPSS Version 17.0을사용하였고, 유의수준은 p<0.05 로정하였다. 결과 사회인구학적변인연구에참여한 187명이 K-IIP-PD, PPI-R, PAI를완료하였다. 이중 PPI-R 평가하여정신병질로평가된환자수는 27명이었다. 성별에따른정신병질의빈도차이는없었다 (Fisher's exact test : χ 2 =0.801, p=0.58). 전체참가자들의평균연령은 41.72±9.29 세, 평균교육연한은 11.16±2.90 년이었다. 전체참여자의 K-IIP-DP 점수와척도간의상관관계및정신병질적조현병군과비정신병질적조현병군의비교전체참여자의점수를일반인군 21) 과단순비교한결과범법조현병군에서높은경향을보였고, 전체참여자를정신병질적조현병군과비정신병질적조현병군으로나누어전체점수와각척도점수를비교한결과정신병질적조현병군에서 K- IIP-PD 의총점과하위척도모두에서의미있게더높았으며 (PD1 ; 18.70±5.89 vs. 12.80±6.88, p=0.001, PD2 ; 25.41± 7.32 vs. 17.80±9.32, p=0.001, PD3 ; 18.44±6.98 vs. 9.11± 7.24, p=0.001, PDT ; 62.56±16.42 vs. 39.71±20.49, p=0.001, PD4 ; 15.00±6.36 vs. 11.86±6.49, p=0.021, PD5 ; 25.22± 10.05, p=0.007, Total PD ; 102.78±29.98 vs. 70.37±35.56, p=0.001)(table 1), K-IIP-PD 의각척도간의상관관계는매우높았다 (p<0.01)(table 2). 분석방법피어슨상관계수를이용하여 K-IIP-PD 의각척도간상관관계와 K-IIP-PD 의총점과내용척도와 PPI-R 의총점과내용척도, PAI의내용척도의점수간의상관관계를알아보았다. 또한 PPI-R 의 8개내용척도를정신병질의대인관계측면을평가하는 PPI-R-1 요인인대담성의우세요인 (fearless K-IIP-PD와 PPI-R 및 PPI-R 2요인과의상관관계 K-IIP-PD 와 PPI-R 의상관관계를분석한결과는 Table 3 과같다. 우선 K-IIP-PD 의총점과 PPI-R 의총점사이의상관관계는매우높은정적인상관관계를보였다 (r=0.463, p<0.01). PPI-R 의하위척도중 (r range=0.233~0.463), 특히비난의 122 Anxiety and Mood Volume 14, No 2 October, 2018

강지욱등 Table 1. Total score of K-IIP-PD in all participants and comparison score between psychopathic group and nonpsychopathic group Scales Psychopathic (N=27) Nonpsychopathic (N=160) Statistics (t, df, p-value) Total score Normal population 21 PD1 18.70±5.89 12.80±6.88-4.205, 185, 0.001 13.65±7.04 13.80±4.18 PD2 25.41±7.32 17.80±9.32-4.035, 185, 0.001 18.89±9.43 15.09±5.22 PD3 18.44±6.98 9.11±7.24-6.231, 185, 0.001 10.45±7.90 9.66±5.18 PDT 62.56±16.42 39.71±20.49-5.501, 185, 0.001 43.01±21.48 38.42±11.42 PD4 15.00±6.36 11.86±6.49-2.332, 185, 0.021 12.31±6.54 13.09±4.20 PD5 25.22±10.05 18.80±11.50-2.732, 185, 0.007 19.73±11.50 16.28±7.17 Total PD 102.78±29.98 70.37±35.56-4.473, 185, 0.001 75.05±36.56 67.87±18.99 K-IIP-PD : Korean Inventory of Interpersonal Problem-Personality Disorder Scales, Statistics : Comparison score between psychopathic group and nonpsychopathic group, PD1 : Interpersonal Sensitivity, PD2 : Interpersonal Ambivalence, PD3 : Aggression, PD4 : Need for Social Approval, PD5 : Lack of Sociability, PDT : PD1+PD2+PD3 Table 2. Correlation between subscales of K-IIP-PD Scales PD1 PD2 PD3 PDT PD4 PD5 Total PD PD1 1 0.696* 0.678* 0.883* 0.765* 0.692* 0.873* PD2 0.696* 1 0.621* 0.895* 0.594* 0.822* 0.891* PD3 0.678* 0.621* 1 0.863* 0.545* 0.587* 0.789* PDT 0.883* 0.895* 0.863* 1 0.712* 0.803* 0.967* PD4 0.765* 0.594* 0.545* 0.712* 1 0.689* 0.814* PD5 0.692* 0.822* 0.587* 0.803* 0.689* 1 0.910* Total PD 0.873* 0.891* 0.789* 0.967* 0.814* 0.910* 1 * : p<0.01. K-IIP-PD : Korean Inventory of Interpersonal Problem-Personality Disorder Scales, PD1 : Interpersonal Sensitivity, PD2 : Interpersonal Ambivalence, PD3 : Aggression, PD4 : Need for Social Approval, PD5 : Lack of Sociability, PDT: PD1+PD2+PD3 Table 3. Correlation of K-IIP-PD and PPI-R K-IIP-PD PPI-R total score PPI-R subscalesa PPI-R 2- factorsb ME RN BE CN SOI F STI C SCI FD PD1 0.396** 0.552** 0.549** 0.609** 0.037-0.176* 0.289** -0.127-0.291** 0.595** -0.156* PD2 0.432** 0.549** 0.534** 0.684** 0.239** -0.344** 0.066-0.184* -0.087 0.683** -0.341** PD3 0.615** 0.562** 0.638** 0.586** 0.271** -0.135 0.340** -0.187* 0.039 0.705** -0.099 PDT 0.546** 0.629** 0.649** 0.716** 0.217** -0.258** 0.249** -0.191-0.119** 0.755** 0.237** PD4 0.233** 0.378** 0.444** 0.520** -0.019-0.173* 0.165* -0.155* -0.340** 0.450** -0.183* PD5 0.289** 0.426** 0.459** 0.647** 0.243** -0.408** 0.018-0.169* -0.186* 0.605** -0.426** Total PD 0.463** 0.571** 0.605** 0.717** 0.200** -0.311** 0.181* -0193** -0.189** 0.714** -0.306** * : p<0.05, ** : p<0.01. K-IIP-PD : Korean Inventory of Interpersonal Problem-Personality Disorder Scales, PD1 : Interpersonal Sensitivity, PD2 : Interpersonal Ambivalence, PD3 : Aggression, PD4 : Need for Social Approval, PD5 : Lack of Sociability, PDT : PD1+PD2+PD3, PPI-R : Psychopathic Personality Inventory-Revised, ME : Machiavellian Egocentricity, RN : Rebellious Nonconfromity, BE : Blame Externalization, CN : Carefree Nonplanfulness, SOI : Social Influence, F : Fearlessness, STI : Stress Immunity, C : Coldheartedness. bcorresponding PPI-R 2 factors labels : SCI : Self-Centered Impulsivity, FD : Fearlessness Dominance 외재화 (BE ; r range=0.520~0.717, p<0.01), 반항적비협조 (RN ; r range=0.444~0.638, p<0.01), 그리고권모술수적이기주의 (ME ; r range=0.378~0.571, p<0.01) 와강한정적상관관계를보였다. 또한 K-IIP-PD 와 PPI-R 의사회적영향력과의상관관계에서 PD3를제외한나머지척도에서의미있는부적상관관계를보였고 (SOI ; r range -0.135~-0.408, p< 0.05~p<0.01), 스트레스면역과의상관관계도 PD1, PDT를제외한적도에서의미있는부적상관관계를보였고 (STI ; r range=-0.127~-0.193, p<0.05~p<0.01), 냉담함에서도 PD2, PD3를제외한척도에서의미있는부적상관관계를보였다 (C ; r range=0.039~-0.340, p<0.05~p<0.01). K-IIP-P의전체점수와 PPI-R 의 2 척도요인과의상관관계는 SCI와의상관계수는매우높은정적인관계를보였고 (r range=0.714, p<0.01), FD와는부적상관관계를보였다 (r range=-0.306, p<0.05). K-IIP-PD 의모든하위척도에서도 SCI와강한정적상관관계 (r range=0.450~0.705, p<0.01) 를보였고, FD와는 PD3를제외하곤부적상관관계 (r range=-0.099~-0.426, p< 0.05~p<0.01) 를보였다. Anxiety and Mood Volume 14, No 2 October, 2018 123

범법조현병환자의성격장애평가 Table 4. Correlation of K-IIP-PD and PAI PAI subscales K-IIP-PD SOM ANX DEP MAN PAR SCZ BOR ANT ALC DRG AGG SUI STR NON TXR DOM WRM PD1 0.487** 0.526** 0.365** 0.473** 0.402** 0.471** 0.519** 0.474** 0.253** 0.222** 0.434** 0.375** 0.338** 0.161* -0.435** -0.042-0.014 PD2 0.487** 0.584** 0.565** 0.379** 0.500** 0.604** 0.572** 0.463** 0.300** 0.252** 0.371** 0.400** 0.373** 0.346** -0.385** -0.255** -0.235** PD3 0.501** 0.508** 0.423** 0.483** 0.485** 0.573** 0.635** 0.606** 0.425** 0.432** 0.585** 0.438** 0.208** 0.306** -0.284** -0.123-0.170* PDT 0.556** 0.614** 0.523** 0.498** 0.529** 0.629** 0.654** 0.580** 0.371** 0.342** 0.520** 0.459** 0.350** 0.317** -0.415** -0.171* -0.170* PD4 0.444** 0.486** 0.385** 0.391** 0.399** 0.437** 0.419** 0.329** 0.256** 0.156** 0.257** 0.272** 0.319** 0.199** -0.409** -0.114-0.004 PD5 0.510** 0.637** 0.620** 0.264** 0.488** 0.583** 0.519** 0.379** 0.330** 0.217** 0.274** 0.419** 0.394** 0.386** -0.452** -0.415** -0.222** Total PD 0.567** 0.648** 0.571** 0.446** 0.536** 0.631** 0.623** 0.519** 0.367** 0.297** 0.438** 0.450** 0.387** 0.343** -0.459** -0.251** -0.171** * : p<0.05, ** : p<0.01. K-IIP-PD : Korean Inventory of Interpersonal Problem-Personality Disorder Scales, PD1 : Interpersonal Sensitivity, PD2 : Interpersonal Ambivalence, PD3 : Aggression, PD4 : Need for Social Approval, PD5: Lack of Sociability, PDT : PD1+PD2+PD3, PAI : Personality Assessment Inventory, SOM : Somatic Complaints, ANX : Anxiety, ARD : Anxiety-Related Disorders, DEP : Depression, MAN : Manic, PAR : Paranoia, SCZ : Schizophrenia, BOR : Borderline Features, ANT : Antisocial Features, ALC : Alcohol Problems, DRG : Drug Problems, AGG : Aggression, SUI : Suicide Idea, STR : Stress, NON : Nonsuppor t, TXR : Treatment Rejection, DOM : Dominance, WRM : Warmth K-IIP-PD와 PAI와의상관관계 K-IIP-PD 의총점과각하위척도와 PAI 대부분의하위척도간에정적인상관관계를보였고 (p<0.05), TXR과는모든척도와의미있는부적상관관계를보였고 (r range=-0.284~ -0.459, p<0.01), DOM과는 PD2(p<0.01), PDT(p<0.05, PD5(p<0.01) 에서 Total PD(p<0.01) 와의미있는부적상관관계 (r range=-0.042~-0.415) 를보였으며, WRM과에서도 PD1, PD4을제외한다른척도에서모두의미있는부적인상관관계를보였다 (r range=-0.004~-0.235, p<0.05~p<0.01) (Table 4). 고찰 저자등은범법조현병환자를대상으로한국형성격장애척도 (K-IIP-PD) 를이용하여범법조현병환자의성격특성을알아보고 K-IIP-PD 가정신병질적조현병과비정신별질적조현병사이에차이가있는지알아보고자하였다. 본연구에서사용된성격장애척도는 Pilkonis 등 26 이 Inventory of Interpersonal Problems 에서 47개의문항을추출하여성격장애환자를선별할수있는척도 (IIP Personality disorder Scales, IIP-PD) 로만든것으로대인적과민성 (PD1), 대인적비수용성 (PD2), 공격성 (PD3), 사회적인정욕구 (PD4), 사회성부족 (PD5) 등 5개의하위척도로구성되어있다. 5개의하위척도는성격장애와성격장애가아닌환자를구분하는대인적과민성 (PD1), 대인적비수용성 (PD2), 공격성척도 (PD3) 와군집 C 성격 (Cluster C) 장애와다른환자를구분하는데유용한사회적인정욕구 (PD4) 와사회성부족 (PD5) 으로구성되어있다. 한국형대인관계문제검사 (Korean Inventory of Interpersonal Problem, K-IIP) 18 에서의성격장애평가에서도 5개의척도로구성되어있는데, Lim 등 27 이임상표본을대상으로확인적요인분석을시행한결과에서도 5개의하위척도가가장적합한모형이라고하였다. 우선 K-IIP-PD 의각척도의특성을살펴보면대인적과민성 (PD1) 은대인관계에서경계의부족을평가할수있는것으로대인관계에서다른사람의비판을지나치게민감하게받아들이고충고나비판을무시하기가매우어렵고다른사람을자주시기하고질투하는경향이높다. 대인적인비수용성 (PD2) 은타인과협조적이지못하고타인의입장을수용하고공감하는능력의부족과관련이있다. 공격성 (PD3) 은타인에대한태도가지나치게비판적이고공격적이면상대방에게분노나복수심을느낄때가많고쉽게짜증을내고자주싸우고는경향이높다. 사회적인정욕구 (PD4) 는타인의평가에대하여만성적인불안을나타낸다. 사회성부족 (PD5) 은다른사람들과같이있다는것 124 Anxiety and Mood Volume 14, No 2 October, 2018

강지욱등 을매우불편하게여기고쉽게긴장하며자신감을갖지못하는경향이있다. 18 전체참여자의 K-IIP-PD 의전체점수와각척도간의점수를 Kim 등 18 의연구결과중성인표준화표준점수에서전체참여자의평균점수와단순비교해해보면성격장애유무를판별할수있는대인적과민성 (PD1)+ 대인적비수용성 (PD2)+ 공격성 (PD3) 의합이나군집 C의성격특성을판별하는사회적인정욕구 (PD4)+ 사회성부족 (PD5) 의합에서도범법조현병군에서높아서범법조현병군에서성격장애가동반될가능성을시사하지만단순히간접비교만으로는전체조현병환자군에서성격장애가동반되어있다고단언하기는어렵다. 또한 Cho 등 28 이보고한정신병과신경증환자들의대인관계문제에서정신병의전체점수 (73.250±30.67) 와유사하여범법조현병군에서더높다고단정하기는어려웠다. 조현병군을정신병질적조현병군과비정신병질적조현병군으로구별하여비교하였을때는정신병질적조현병군에서모든척도의점수가통계적으로의미있게높았다. 대인적과민성 (PD1)+ 대인적비수용성 (PD2)+ 공격성 (PD3) 의합의점수가높아성격장애가동반되어있을가능성이높고사회적인정욕구 (PD4) 와사회성부족 (PD5) 의점수또한높아서군집 C 의성격특성을보일가능성도높다고할수있겠다. 또한 Cho 등 28 의일반정신병군보다본연구의정신병질적조현병군에서훨씬높아일반정신병군보다는성격장애의문제가더많을가능성을간접적으로알수있었다. K-IIP-PD 의척도간의상관관계에서도상당히각척도간의상관이매우높은것으로나타나는데 Kim 등 18 의대학생과성인표본의상관과유사한패턴을보였으나더높은수치의상관관계를보인다. 특히대인적과민성 (PD1) 과사회적인정욕구 (PD4), 사회성부족 (PD5) 간의상관관계가높고, 대인적비수용성 (PD2) 또한대인적과민성 (PD1) 과사회성부족 (PD5) 과상관관계가높아서타인으로부터인정받고자하는욕구가강하나사회적기술이부족하여타인의반응이나행동에신경을많이쓰고예민함을반영하고있다. 공격성척도는대인적과민성및대인적비수용성척도와는높은반면사회적인정욕구와사회적부족척도와는낮아서사회기술이부족하고타인에게인정받고자하는사회적상황에서반응이결여되어있을것으로여겨진다. K-IIP-PD 와 PPI-R 의상관관계에서전체총점사이에서매우높은상관관계를보였고, 특히공격성척도 (PD3) 가 PPI-R 의전체점수와가장높은상관관계를보였고, 대인적과민성 (PD1)+ 대인적비수용성 (PD2)+ 공격성 (PD3) 의합이전체적으로 PPI-R 하위척도중 BE, RN, ME와강한상관관계를보였고사회적인정욕구 (PD4), 사회성부족 (PD5) 는그보다낮 은상관을보였다. 따라서 K-IIP-PD 의공격성척도 (PD3) 가 범법조현병환자들의공격성을평가하는데좋은척도가될 수있고대인적과민성 (PD1)+ 대인적비수용성 (PD2)+ 공격성 (PD3) 의합이범법조현병환자들에동반된성격장애의폭력 성이나공격적성향을평가하는데에도도움이되리라고생 각된다. PAI 와의상관관계도 K-IIP-PD 전체점수뿐만아니라각 척도들도높은상관관계를보였다. 특히공격성 (PD3) 와과민 성 (PD1)+ 대인적비수용성 (PD2)+ 공격성 (PD3) 의합이전반적 으로 PAI 의각척도와상관관계가높았는데특히조현병척도 (SCZ), 경계선적특징척도 (BOR), 반사회적인특징척도 (ANT) 그리고불안척도 (ANX) 등의척도와높은상관을보이고치 료거부척도 (TXR), 대인관계척도인지배성척도 (DOM) 와온 정적척도 (WRM) 와는부적인상관을보여 K-IIP-PD 가범 법조현병환자들의정신병적특성과반사회적이고공격적인 면을평가하는데도움이될수있을것으로평가된다. 본연구결과 K-IIP-PD 가폭력을범한조현병환자를대 상으로동반된성격장애의공격성이나폭력성의경향을파악 하는데도움이될수있을것으로여겨진다. 그러나비범법 조현병환자와일반인등을대상으로직접적인비교를할수 없어서단정하기는어렵고향후다양한임상군을포함한추 후연구를통해확인할필요가있다. 중심단어 : 정신병질 범법 조현병 성격장애평가. REFERENCES 1. Joyal CC, Dubreucq JL, Gendron C, Millaud F. Major mental disorders and violence: a critical update. Curr Psychiatry Rev 2007;3:33-50. 2. Kooyman I, Dean K, Harvey S, Walsh E. Outcomes of public concern in schizophrenia. Br J Psychiatry 2007;191(Suppl 50):29-36. 3. Swanson HW, Holzer CE, Ganju VK, Jono RT. Violence and psychiatric disorder in the community: evidence from the epidemiologic catchment area survey. Hosp Commun Psychiatry 1990;41:61-770. 4. Volavka J, Citrome L. Heterogeneity of violence in schizophrenia and implications for long-term treatment. Int J Clin Prac 2008;62: 1237-1245. 5. Bo S, Abu-Akel A, Kongerslev M, Haah U, Simonsen E. Risk factors for violence among patients with schizophrenia. Clin Psychol Rev 2011;31:711-726. 6. Cleckley H. The mask of sanity. St Lous, MO. Mosby;1941. 7. Nolan KA, Volavka J, Mohr P, Czobor P. Psychopathy and violent behavior among patients with schizophrenia or schizoaffective disorder. Psychiatr Serv 1999;50:787-792. 8. Abushua leh K, Abu-Akel A. Association of psychopathic traits and symptomatology with violence in patients with schizophrenia. Psychiatry Res 2006;143:205-211. 9. Rasmussen K, Levander S. Symptoms and personality characteristics of patients in a maximum security psychiatric unit. Int J Law Psychiatry 1996;19:27-37. 10. Tengström A, Grann M, Långström N, Kullgren G. Psychopathy (PCL-R) as a predictor of violent recidivism among criminal offenders with schizophrenia. Law Hum Behav 2000;24:45-58. 11. Dolan M, Davies G. Psychopathy and institutional outcome in pa- Anxiety and Mood Volume 14, No 2 October, 2018 125

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