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Chapter: Psychiatric Mental Health Nursing : Personality Disorders

Obsessive-Compulsive Personality Disorder

Obsessive–compulsive personality disorder is character-ized by a pervasive pattern of preoccupation with perfec-tionism, mental and interpersonal control, and orderliness at the expense of flexibility, openness, and efficiency.



Clinical Picture


Obsessive–compulsive personality disorder is character-ized by a pervasive pattern of preoccupation with perfec-tionism, mental and interpersonal control, and orderliness at the expense of flexibility, openness, and efficiency. It occurs in about 1% to 2% of the population, affecting twice as many men as women. This increases to 3% to 10% in clients in mental health settings. Incidence is increased in oldest children and people in professions involving facts, figures, or methodical focus on detail. These people often seek treatment because they recognize that their life is pleasureless or they are experiencing problems with work or relationships. Clients frequently benefit from individual therapy (APA, 2000).


The demeanor of these clients is formal and serious, and they answer questions with precision and much detail. They often report feeling the need to be perfect beginning in childhood. They were expected to be good and to do the right thing to win parental approval. Expressing emotions or asserting independence was probably met with harsh disapproval and emotional consequences. Emotional range is usually quite constricted. They have difficulty express-ing emotions, and any emotions they do express are rigid, stiff, and formal, lacking spontaneity. Clients can be very stubborn and reluctant to relinquish control, which makes it difficult for them to be vulnerable to others by express-ing feelings. Affect is also restricted: they usually appear anxious and fretful or stiff and reluctant to reveal underly-ing emotions.


Clients are preoccupied with orderliness and try to maintain it in all areas of life. They strive for perfection as though it were attainable and are preoccupied with details, rules, lists, and schedules to the point of often missing “the big picture.” They become absorbed in their own perspective, believe they are right, and do not listen care-fully to others because they have already dismissed what is being said. Clients check and recheck the details of any project or activity; often, they never complete the project because of “trying to get it right.” They have problems with judgment and decision-making—specifically actu-ally reaching a decision. They consider and reconsider alternatives, and the desire for perfection prevents reach-ing a decision. Clients interpret rules or guidelines liter-ally and cannot be flexible or modify decisions based on circumstances. They prefer written rules for each and every activity at work. Insight is limited, and they are often oblivious that their behavior annoys or frustrates others. If confronted with this annoyance, these clients are stunned, unable to believe others “don’t want me to do a good job.”


These clients have low self-esteem and are always harsh, critical, and judgmental of themselves; they believe that they “could have done better” regardless of how well the job has been done. Praise and reassurance do not change this belief. Clients are burdened by extremely high and unattainable standards and expectations. Although no one could live up to these expectations, they feel guilty and worthless for being unable to achieve them. They tend to evaluate self and others solely on deeds or actions without regard for personal qualities.


These clients have much difficulty in relationships, few friends, and little social life. They do not express warm or tender feelings to others; attempts to do so are very stiff and formal and may sound insincere. For example, if a significant other expresses love and affection, a client’s response might be “The feeling is mutual.”


Marital and parent–child relationships are often dif-ficult because these clients can be harsh and unrelent-ing. For example, most clients are frugal, do not give gifts or want to discard old items, and insist that those around them do the same. Shopping for something new to wear may seem frivolous and wasteful. Clients can-not tolerate lack of control and hence may organize family outings to the point that no one enjoys them. These behaviors can cause daily strife and discord in family life.


At work, clients may experience some success, particu-larly in fields when precision and attention to detail are desirable. They may miss deadlines, however, while trying to achieve perfection or may fail to make needed decisions while searching for more data. They fail to make timely decisions because of continually striving for perfection. They have difficulty working collaboratively, preferring to “do it myself” so it is done correctly. If clients do accept help from others, they may give such detailed instructions and watch the other person so closely that coworkers are insulted, annoyed, and refuse to work with them. Given this excessive need for routine and control, new situations and compromise are also difficult.



Nursing Interventions


Nurses may be able to help clients to view decision-making and completion of projects from a different per-spective. Rather than striving for the goal of perfection, clients can set a goal of completing the project or making the decision by a specified deadline. Helping clients to accept or to tolerate less-than-perfect work or decisions made on time may alleviate some difficulties at work or home. Clients may benefit from cognitive restructuring techniques. The nurse can ask, “What is the worst that could happen?” or “How might your boss (or your wife) see this situation?” These questions may challenge some rigid and inflexible thinking.


Encouraging clients to take risks, such as letting some-one else plan a family activity, may improve relationships. Practicing negotiation with family or friends also may help clients to relinquish some of their need for control.

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