Obsessive–Compulsive Personality Disorder

Obsessive–Compulsive Personality Disorder

Definition

Obsessive–compulsive PD (OCPD) includes a preoccupation with orderliness, perfectionism, and mental and interpersonal control (American Psychiatric Association, 2000). OCPD is in-dicated by the presence of four or more of the eight diagnostic criteria presented in DSM criteria for OCPD.

Etiology and Pathology

A variety of studies have indicated heritability for the trait of ob-sessionality. OCPD may also relate to the adult personality trait of conscientiousness–constraint and the childhood temperament of attentional self-regulation, both of which have demonstrated substantial heritability.

Early psychoanalytic theories regarding OCPD concerned issues of unconscious guilt or shame (Gunderson and Gabbard, 2000). A variety of underlying conflicts have since been pro-posed, including a need to maintain an illusion of infallibility to defend against feelings of insecurity, an identification with authoritarian parents, or an excessive, rigid control of feelings and impulses (Gabbard, 2000; Oldham and Frosch, 1991; Stone, 1993). Any one or more of these conflicts might be relevant for a particular person with OCPD but there is quite limited empirical support for these particular models of etiology and pathology. OCPD includes personality traits that are highly valued within most cultures (e.g., conscientiousness) and some instances of OCPD may reflect exaggerated or excessive responses to the expectations of or pressures by parental figures.

Differential Diagnosis

Devotion to work and productivity will vary substantially across cultural groups. One should be careful not to confuse normal cultural variation in conscientiousness with the presence of this personality disorder. A diagnosis of OCPD requires that the devotion to work be maladaptive or to the exclusion of leisure activities and friendships (American Psychiatric Association, 2000).

OCPD resembles to some extent the obsessive–compulsive anxiety disorder (OCAD). However, many persons with OCPD fail to develop OCAD, and vice versa. OCAD involves intrusive obsessions or circumscribed and repetitively performed rituals whose purpose is to reduce or control feelings of anxiety (Ameri-can Psychiatric Association, 2000). OCPD, in contrast, involves rigid, inhibited and authoritarian behavior patterns that are more egosyntonic. If both behavior patterns are present, both diagno-ses should be given as these disorders are sufficiently distinct that it is likely that in such cases two different disorders are in fact present.

OCPD may at times resemble narcissistic PD, as both disorders can involve assertiveness, domination, achievement and a professed perfectionism. However, the emphasis in OCPD will be on work for its own sake whereas narcissistic persons will work only to achieve status and recognition. Persons with OCPD will also be troubled by doubts, worries and self-criti-cism, whereas the narcissistic person will tend to be overly self-assured..

Epidemiology and Comorbidity

Conscientiousness is one of the fundamental dimensions of per-sonality characterized by the tendency to emphasize duty, order, deliberation, discipline, competence and achievement (Costa and McCrae, 1992). Persons who are excessively organized, ordered, deliberate, dutiful and disciplined would be characterized as hav-ing OCPD (Widiger et al., 2002). Only 1 to 2% of the general community may meet the diagnostic criteria for the disorder but this could be an underestimation (Oldham and Frosch, 1991). Up to 10% of the population has been estimated to be maladaptively stubborn, 4% excessively devoted to work, and 8% excessively perfectionistic. OCPD is one of the less frequently diagnosed personality disorders within inpatient settings, occurring in ap-proximately 3 to 10% of patients (American Psychiatric Associa-tion, 2000) but its prevalence may be much higher within private practice settings. This disorder does appear to occur more often in males than in females but exceptions to this finding have been reported.

Course

As children, some persons with OCPD may have appeared to be relatively well-behaved, responsible and conscientious. However, they may have also been overly serious, rigid and constrained. As adults, many will obtain good to excellent success within a job or career. They can be excellent workers to the point of excess, sacrificing their social and leisure activities, marriage and family for their job (Oldham and Frosch, 1991; Stone, 1993). Relation-ships with spouse and children are likely to be strained due to their tendency to be detached and uninvolved, yet authoritarian and domineering with respect to decisions. A spouse may com-plain of a lack of affection, tenderness and warmth. Relationships with colleagues at work may be equally strained by the excessive perfectionism, domination, indecision, worrying and anger. Jobs that require flexibility, openness, creativity, or diplomacy may be particularly difficult. Persons with OCPD may be prone to various anxiety and physical disorders that are secondary to their worrying, indecision and stress. Those with concomitant traits of angry hostility and competitiveness may be prone to cardiovas-cular disorders. Mood disorders may not develop until the person recognizes the sacrifices that have been made by their devotion to work and productivity, which may at times not occur until middle-age. However, most will experience early employment or career difficulties or even failures that may result in depression.

Treatment

Persons with OCPD may fail to seek treatment for the OCPD symptomatology. They may seek treatment instead for disorders and problems that are secondary to their OCPD traits, includ-ing anxiety disorders, health problems (e.g., cardiovascular dis-orders), and problems within various relationships (e.g., marital, familial and occupational). Treatment will be complicated by their inability to appreciate the contribution of their personality to these problems and disorders. It is not unusual for persons with OCPD to perceive themselves as being simply conscientious, dutiful, moral and responsible, rather than perfectionistic, stub-born, rigid, domineering and unavailable. Their understanding is complicated further by the contribution of their traits to vari-ous achievements and successes (e.g., career advancement) and to the control of negative affect (e.g., ability to control feelings of dysphoria during a crisis). The OCPD traits are not invariably or always maladaptive, and persons with this disorder may notappreciate the disorder’s cost to their physical health, psychologi-cal well-being and personal relationships.

Cognitive–behavioral techniques that address the irra-tionality of excessive conscientiousness, moralism, perfection-ism, devotion to work and stubborness can be effective in the treatment of OCPD (Beck and Freeman, 1990). Persons with OCPD may in fact appreciate the rational approach to treatment provided by cognitive–behavioral therapy. A common difficulty though is the tendency to drift into lengthy and unproductive ru-minations and intellectualized speculations (Beck and Freeman, 1990). Therapeutic techniques that emphasize the acknowledg-ment, recognition and acceptance of feelings will therefore be useful. Gestalt techniques that focus upon and confront feeling states will often feel threatening to persons with OCPD but pre-cisely for this reason they can also be quite revealing and useful. Persons with OCPD will attempt to control therapeutic sessions, and techniques that encourage uncontrolled, freely expressed associations to explore historical motivations for control, perfec-tionism and workaholism are often helpful.

Persons with OCPD can be problematic in groups. They will tend to be domineering, constricted and judgmental. There is no accepted pharmacologic treatment for OCPD. Some persons with OCPD will benefit from anxiolytic or antidepressant medi-cations, but this will typically reflect the presence of associated features or comorbid disorders. The core traits of OCPD might not be affected by pharmacologic interventions.