Diagnostic Features:
Obsessive-Compulsive Personality Disorder is a condition characterized by a chronic preoccupation with rules, orderliness, and control. This disorder is only diagnosed when these behaviors become persistent and disabling. The individual with this disorder often becomes upset when control is lost. The individual then either emotionally withdraws from these situations, or becomes very angry. The individual usually expresses affection in a highly controlled or stilted fashion and may be very uncomfortable in the presence of others who are emotionally expressive. The person often has difficulty expressing tender feelings, and rarely pays compliments.
Complications:
The individual's chronic preoccupation with rules, orderliness, and control seems to prevent many of the complications (e.g., drug abuse, reckless sex, financial irresponsibility) that are common to some other personality disorders. Occupationally, the individual tends to be a high achiever with an excessive devotion to work. However, inflexibility, perfectionism, preoccupation with detail, and inability to delegate work may seriously interfere with the individual's ability to complete a given task. The individual experiences occupational difficulties when confronted with new situations that demand flexibility and compromise.
Symptoms
There are five primary areas that cause anxiety for OCPD individuals: time, personal and social relationships, cleanliness, tidiness, and money. Time becomes a problem when they dwell for so long on getting something "right" that they stand the chance of not finishing in time. Personal and social relationships are often under serious strain because the OCPD individual insists on being in charge and the only one who knows what is "right". Uncleanliness is, in the eyes of some OCPD individuals, a form of lack of perfection, as is untidiness. They may spend considerable time each day putting everything in precisely the right place in precisely the right manner. Money is of concern because many OCPD sufferers are anxious about the potential for things to go wrong in their lives. They may hoard items for a 'rainy day'. Money, for the same reason, may be hoarded so that as little as possible is spent on daily living. This may look like miserliness or stinginess to other people.
There are few moral 'grey' areas for a person with fully developed OCPD; actions and beliefs are either completely right, or absolutely wrong with the OCPD individual always 'in the right'. As might be expected, interpersonal relationships are difficult because of the excessive demands placed on friends, romantic partners and children. Sometimes frustration with other people not doing what the OCPD individual wants spills over into anger and even violence. This is known as disinhibition. Persons with OCPD often have a negative outlook on life (pessimism) with a low underlying form of depression. This can at times become so serious that suicide is a real risk. Indeed, one study suggests that personality disorders are a significant substrate to psychiatric morbidity. They cause more problems in functioning than does a major depressive episode.
People with OCPD, when anxious or excited, may twitch or grimace, or make odd noises, as in a mild form of Tourette Syndrome or do impulsive and unpredictable things, including risk taking. They may keep their homes perfectly organized, or be anxious about delegating tasks for fear that they won't be completed correctly. They may even insist on taking over a task someone else is doing so that it will be done properly. About one in four OCPD individuals may display rigid and stubborn characteristics, a defining criterion.
Comorbidity:
Obsessive-Compulsive Disorder should not be confused with Obsessive-Compulsive Personality Disorder. The majority of individuals with Obsessive-Compulsive Disorder do not have Obsessive-Compulsive Personality Disorder. Anxiety Disorders (e.g., Generalized Anxiety Disorder and Obsessive-Compulsive Disorder, Social Phobia, Specific Phobias), Mood Disorders, and Eating Disorders often co-occur with this disorder.
Associated Laboratory Findings:
No laboratory test has been found to be diagnostic of this disorder.
Prevalence:
The prevalence of Obsessive-Compulsive Personality Disorder is about 1% of the general population. It is seen in 3%-10% of psychiatric outpatients. It is twice as common in males as females.
Course:
It usually begins in early adulthood, and has a chronic course.
Psychotherapy:
As with most personality disorders, individuals seek treatment for items in their life which have become overwhelming to their existing coping skills. These skills may be somewhat limited, in the first place, because of their disorder. While they may be generally effective enough in most instances to shield the client from stress and emotional difficulties, during times of increased stress, work pressure, family problems, etc. the underlying disorder will become more evident in day-to-day behaviors.
As with most personality disorders, treatment is often focused on short-term symptom relief and the support of existing coping mechanisms while teaching new ones. Long-term or substantive work on personality change is usually beyond most clinician's skill levels, and patient's budgets. Obsessive-compulsive personality disorder is especially resistant to such changes, because of the basic makeup of this disorder.
Short-term therapy will be most likely to be beneficial when the patient's current support system and coping skills are examined. Those skills which are not currently working could be reinforced with additional skill sets. Social relationships can also be examined, reinforcing strong, positive relationships while having the client re-examine negative or harmful relationships. One important aspect is to try and have the individual examine and properly identify their feeling states, rather than just intellectualizing or distancing themselves from their emotions. This can be accomplished through a variety of techniques, such as feeling identification (e.g., the "feeling faces") at the onset of every therapy session. Homework might include writing feelings down in a journal, especially as they notice them. Proper identification and realization of feelings can bring about much change in and of itself.
Individuals suffering from obsessive-compulsive personality disorder often are not in touch with their emotional states as much as their thoughts. Leading the client away from describing situations, events, and daily happenings and to talking about how such situations, events and daily happenings made them feel may be helpful. Sometimes the patient may complain he or she doesn't remember or know how he or she felt at the time; the journal becomes a useful tool at this point.
Therapy with people who have this disorder can sometimes be trying, since they can see the world in a very "all-or-nothing" manner. Beck's cognitive therapy doesn't seem to be all that effective in treatment, and cognitive approaches in general probably aren't useful in this case. Clinicians must be willing to undergo verbal attacks on their professionalism and knowledge, as such skepticism about a therapist's treatment approach from the client with this disorder can be expected. Clinicians should also be careful about engaging the client within these verbal attacks or intellectual discussions, as they continue to distance the patient from his or her feelings. And take the focus off of the client and onto unrelated matters (e.g., a therapist's professional training).
Most people who suffer from this personality disorder (and the different, but related, obsessive-compulsive disorder) lead relatively normal lives, may have a family, friends, and work regularly. Clinicians should be careful not to overgeneralize psychopathology and look to change aspects of the patient's personality he or she is not ready or willing to change. This means, in effect, that if the way they relate to others in their environment (which a clinician might characterize as a personality disorder) is working for them, a clinician should not seek to change it 180 degrees without the client's purposeful consent. Therapy will most often be most effective when it focuses on correcting short-term difficulties currently being experienced. It will become increasingly less effective when the goal of therapy is complex, long-term personality change.
Although a group therapy modality may be helpful and an effective treatment option, most people who suffer from this disorder will not be able to withstand the minimum social contact necessary to gain a healthy group dynamic. They may quickly become ostracized by the group for pointing out other people's deficits and "wrong-headed" ways of doing things.
Hospitalization:
Hospitalization is rarely needed for people who suffer from this disorder, unless an extreme or severe stressor or stressful life event occurs which increases the compulsive behaviors to an extent where regular daily activites are halted or present possible risks of harm to the patient. Hospitalization may also be needed when the obsessive thoughts do not allow the individual to conduct any usual activities, paralyzing them in bed or with their accompanying compulsive behaviors.
Medications:
In most cases, medication for this disorder is not indictated unless the individuals is also suffering from a clearly delineated Axis I diagnosis as well. However, newer medications such as Prozac, an SRRI, have been approved for the treatment of obsessive-compulsive disorder and may provide some relief to individuals with the personality disorder. Long-term use, though, is rarely indicated, appropriate, or beneficial.
Self-Help:
Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Support groups, though, offer an excellent adjunct to continuing medication check-ups once a month, and a way to gain emotional and social support through the community. These groups also allow others to ensure the client is doing well and promotes the client's independence and stability. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings.
Such support groups are recommended to individuals suffering from this disorder, especially if they have found therapy unhelpful or too expensive.
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