Obsessive-compulsive personality disorder
Definition
Obsessive-compulsive personality disorder (OCPD) is a type of personality disorder marked by rigidity, control, perfectionism, and an overconcern with work at the expense of close interpersonal relationships. Persons with this disorder often have trouble relaxing because they are preoccupied with details, rules, and productivity. They are often perceived by others as stubborn, stingy, self-righteous, and uncooperative.
The mental health professional's handbook, the Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revision (2000), which is also called DSM-IV-TR , groups obsessive-compulsive personality disorder together with the avoidant and dependent personality disorders in Cluster C. The disorders in this cluster are considered to have anxiety and fearfulness as common characteristics. The ICD-10, which is the European counterpart of DSM-IV-TR , refers to OCPD as "anankastic personality disorder."
It is important to distinguish between OCPD and obsessive-compulsive disorder (OCD), which is an anxiety disorder characterized by the presence of intrusive or disturbing thoughts, impulses, images or ideas (obsessions), accompanied by repeated attempts to suppress these thoughts through the performance of irrational and ritualistic behaviors or mental acts (compulsions). It is unusual but possible, however, for a patient to suffer from both disorders, especially in extreme cases of hoarding behavior. In some reported cases of animal hoarding, the people involved appear to have symptoms of both OCD and OCPD.
Description
People suffering from OCPD have careful rules and procedures for conducting many aspects of their everyday lives. While their goal is to accomplish things in a careful, orderly manner, their desire for perfection and insistence on going "by the book" often overrides their ability to complete a task. For example, one patient with OCPD was so preoccupied with finding a mislaid shopping list that he took much more time searching for it than it would have taken him to rewrite the list from memory. This type of inflexibility typically extends to interpersonal relationships. People with OCPD are known for being highly controlling and bossy toward other people, especially subordinates. They will often insist that there is one and only one right way (their way) to fold laundry, cut grass, drive a car, or write a report. In addition, they are so insistent on following rules that they cannot allow for what most people would consider legitimate exceptions. Their attitudes toward their own superiors or supervisors depend on whether they respect these authorities. People with OCPD are often unusually courteous to superiors that they respect, but resistant to or contemptuous of those they do not respect.
While work environments may reward their conscientiousness and attention to detail, people with OCPD do not show much spontaneity or imagination. They may feel paralyzed when immediate action is necessary; they feel overwhelmed by trying to make decisions without concrete guidelines. They expect colleagues to stick to detailed rules and procedures, and often perform poorly in jobs that require flexibility and the ability to compromise. Even when people with OCPD are behind schedule, they are uncomfortable delegating work to others because the others may not do the job "properly." People with OCPD often get so lost in the finer points of a task that they cannot see the larger picture; they are frequently described as "unable to see the forest for the trees." They are often highly anxious in situations without clearly defined rules because such situations arouse their fears of making a mistake and being punished for it. An additional feature of this personality disorder is stinginess or miserliness, frequently combined with an inability to throw out worn-out or useless items. This characteristic has sometimes been described as "pack rat" behavior.
People diagnosed with OCPD come across to others as difficult and demanding. Their rigid expectations of others are also applied to themselves, however; they tend to be intolerant of their own shortcomings. Such persons feel bound to present a consistent facade of propriety and control. They feel uncomfortable with expressions of tender feelings and tend to avoid relatives or colleagues who are more emotionally expressive. This strict and ungenerous approach to life limits their ability to relax; they are seldom if ever able to release their needs for control. Even recreational activities frequently become another form of work. A person with OCPD, for example, may turn a tennis game into an opportunity to perfect his or her backhand rather than simply enjoying the exercise, the weather, or the companionship of the other players. Many OCPD sufferers bring office work along on vacations in order to avoid "wasting time," and feel a sense of relief upon returning to the structure of their work environment. Not surprisingly, this combination of traits strains their interpersonal relationships and can lead to a lonely existence.
Causes and symptoms
Causes
No single specific cause of OCPD has been identified. Since the early days of Freudian psychoanalysis , however, faulty parenting has been viewed as a major factor in the development of personality disorders. Current studies have tended to support the importance of early life experiences, finding that healthy emotional development largely depends on two important variables: parental warmth and appropriate responsiveness to the child's needs. When these qualities are present, the child feels secure and appropriately valued. By contrast, many people with personality disorders did not have parents who were emotionally warm toward them. Patients with OCPD often recall their parents as being emotionally withholding and either overprotective or overcontrolling. One researcher has noted that people with OCPD appear to have been punished by their parents for every transgression of a rule, no matter how minor, and rewarded for almost nothing. As a result, the child is unable to safely develop or express a sense of joy, spontaneity, or independent thought, and begins to develop the symptoms of OCPD as a strategy for avoiding punishment. Children with this type of upbringing are also likely to choke down the anger they feel toward their parents; they may be outwardly obedient and polite to authority figures, but at the same time treat younger children or those they regard as their inferiors harshly.
Genetic contributions to OCPD have not been well documented. Cultural influences may, however, play a part in the development of OCPD. That is, cultures that are highly authoritarian and rule-bound may encourage child-rearing practices that contribute to the development of OCPD. On the other hand, simply because a culture is comparatively strict or has a strong work ethic does not mean it is necessarily unhealthful. In Japanese societies, for example, excessive devotion to work, restricted emotional expression, and moral scrupulosity are highly valued characteristics that are rewarded within that culture. Similarly, certain religions and professions require exactness and careful attention to rules in their members; the military is one example. OCPD is not diagnosed in persons who are simply behaving in accordance with such outside expectations as military regulations or the rule of a religious order. Appropriate evaluation of persons from other cultures requires close examination in order to differentiate people who are merely following culturally prescribed patterns from people whose behaviors are excessive even by the standards of their own culture.
Symptoms
The symptoms of OCPD include a pervasive overconcern with mental, emotional, and behavioral control of the self and others. Excessive conscientiousness means that people with this disorder are generally poor problem-solvers and have trouble making decisions; as a result, they are frequently highly inefficient. Their need for control is easily upset by schedule changes or minor unexpected events. While many people have some of the following characteristics, a person who meets the DSMIV-TR criteria for OCPD must display at least four of them:
- Preoccupation with details, rules, lists, order, organization, or schedules to the point at which the major goal of the activity is lost.
- Excessive concern for perfection in small details that interferes with the completion of projects.
- Dedication to work and productivity that shuts out friendships and leisure-time activities, when the long hours of work cannot be explained by financial necessity.
- Excessive moral rigidity and inflexibility in matters of ethics and values that cannot be accounted for by the standards of the person's religion or culture.
- Hoarding things, or saving worn-out or useless objects even when they have no sentimental or likely monetary value.
- Insistence that tasks be completed according to one's personal preferences.
- Stinginess with the self and others.
- Excessive rigidity and obstinacy.
Demographics
Obsessive-compulsive personality disorder is estimated to occur in about 1% of the population, although rates of 3%–10% are reported among psychiatric outpatients. The disorder is usually diagnosed in late adolescence or young adulthood. In the United States, OCPD occurs almost twice as often in men as in women. Some researchers attribute this disproportion to gender stereotyping, in that men have greater permission from general Western culture to act in stubborn, withholding, and controlling ways.
Diagnosis
It is relatively unusual for OCPD to be diagnosed as the patient's primary reason for making an appointment with their doctor. In many cases the person with OCPD is unaware of the discomfort that his or her stubbornness and rigidity cause other people, precisely because these traits usually enable them to get their way with others. They are more likely to enter therapy because of such other issues as anxiety disorders, serious relationship difficulties, or stress-related medical problems. Diagnosis of OCPD depends on careful observation and appropriate assessment of the individual's behavior; the person must not only give evidence of the attitudes and behaviors associated with OCPD, but these must be severe enough to interfere with their occupational and interpersonal functioning.
The differential diagnosis will include distinguishing between obsessive-compulsive disorder (OCD) and OCPD. A person who has obsessions and compulsions that they experience as alien and irrational is more likely to be suffering from OCD, whereas the person who feels perfectly comfortable with self-imposed systems of extensive rules and procedures for mopping the kitchen floor probably has OCPD. In addition, the thoughts and behaviors that are found in OCD are seldom relevant to real-life problems; by contrast, people with OCPD are preoccupied primarily with managing (however inefficiently) the various tasks they encounter in their daily lives.
Some features of OCPD may occur in other personality disorders. For example, a person with a narcissistic personality disorder may be preoccupied with perfection and be critical and stingy toward others; narcissists are usually generous with themselves, however, while people with OCPD are self-critical and reluctant to spend money even on themselves. Likewise, a person with schizoid personality disorder , who lacks a fundamental capacity for intimacy, may resemble someone with OCPD in being formal and detached in dealing with others. The difference here is that a person with OCPD, while awkward in emotional situations, is able to experience caring and may long for close relationships. Certain medical conditions may also mimic OCPD, but are distinct in that the onset of the symptoms is directly related to the illness. Certain behaviors related to substance abuse may also be mistaken for symptoms of OCPD, especially if the substance problem is unrecognized.
As described earlier, diagnosis may also be complicated by the fact that behaviors similar to OCPD may be normal variants within a given culture, occupation, or religion; however, in order to fulfill criteria for the personality disorder, the behaviors must be sufficiently severe as to impair the patient's functioning.
Treatments
Psychotherapy
Psychotherapeutic approaches to the treatment of OCPD have found insight-oriented psychodynamic techniques and cognitive behavioral therapy to be helpful for many patients. This choice of effective approaches stands in contrast to the limitations of traditional forms of psychotherapy with most patients diagnosed with OCD. Learning to find satisfaction in life through close relationships and recreational outlets, instead of only through work-related activities, can greatly enrich the OCPD patient's quality of life. Specific training in relaxation techniques may help patients diagnosed with OCPD who have the so-called "Type A" characteristics of competitiveness and time urgency as well as preoccupation with work.
It is difficult, however, for a psychotherapist to develop a therapeutic alliance with a person with OCPD. The patient comes into therapy with a powerful need to control the situation and the therapist; a reluctance to trust others; and a tendency to doubt or question almost everything about the therapy situation. The therapist must be alert to the patient's defenses against genuine change and work to gain a level of commitment to the therapeutic process. Without this commitment, the therapist may be fooled into thinking that therapy has been successful when, in fact, the patient is simply being superficially compliant.
Medications
For many years, medications for OCPD and other personality disorders were thought to be ineffective since they did not affect the underlying causes of the disorder. More recent studies, however, indicate that treatment with specific drugs may be a useful adjunct (help) to psychotherapy. In particular, the medications known as selective serotonin reuptake inhibitors (SSRIs) appear to help the OCPD patient with his or her rigidity and compulsiveness, even when the patient did not show signs of pre-existing depression. Medication can also help the patient to think more clearly and make decisions better and faster without being so distracted by minor details. While symptom control may not "cure" the underlying personality disorder, medication does enable some OCPD patients to function with less distress.
Prognosis
Individuals with OCPD often experience a moderate level of professional success, but relationships with a spouse or children may be strained due to their combination of emotional detachment and controlling behaviors. In addition, people with OCPD often do not attain the level of professional achievement that might be predicted for their talents and abilities because their rigidity and stubbornness make them poor "team players" or supervisors. Although there are few large-scale outcome studies of treatments for OCPD, existing reports suggest that these patients do benefit from psychotherapy to help them understand the emotional issues underlying their controlling behaviors and to teach them how to relax. Since OCPD sufferers, unlike people with OCD, usually view their compulsive behaviors as voluntary, they are better able to consider change, especially as they come to fully recognize the personal and interpersonal costs of their disorder.
Prevention
Most theories attribute the development of OCPD to early life experiences, including a lack of parental warmth; parental overcontrol and rigidity, and few rewards for spontaneous emotional expression. Little work has been done, however, in identifying preventive strategies.
See also Gender issues in mental health
Resources
BOOKS
Alarcon, Renato D., Edward F. Foulks, and Mark Vakkur. Personality Disorders and Culture. New York: John Wiley and Sons, 1998.
Baer, Lee. "Personality Disorders in Obsessive-Compulsive Disorder." In Obsessive-Compulsive Disorders: Practical Management. 3rd edition. Edited by Michael Jenike and others. St. Louis: Mosby, 1998.
Jenike, Michael. "Psychotherapy of Obsessive-Compulsive Personality." In Obsessive-Compulsive Personality Disorders: Practical Management. 3rd edition. Edited by Michael Jenike and others. St. Louis: Mosby, 1998.
Kay, Jerald, Allen Tasman, and Jeffery Liberman. "Obsessive-Compulsive Disorder." In Psychiatry: Behavioral Science and Clinical Essentials, edited by Michael Jenike, Lee Baer, and William Minichiello. Philadelphia: W. B. Saunders, 2000.
Millon, Theodore. Personality-Guided Therapy. New York: John Wiley and Sons, 1999.
World Health Organization (WHO). The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO, 1992.
PERIODICALS
Barber, Jacques P., Connolly, Mary B., Crits-Christoph, Lynn G., and Siqueland, Lynne. "Alliance Predicts Patients' Outcome Beyond In-Treatment change in Symptoms." Journal of Consulting and Clinical Psychology 68 (2000); 1027-1032.
Nordahl, Hans M. and Tore C. Stiles. "Perceptions of Parental Bonding in Patients with Various Personality Disorders, Lifetime Depressive Disorders, and Healthy Controls." Journal of Personality Disorders 11 (1997): 457-462.
Samuels, Jack, and others. "Personality Disorders and Normal Personality Dimensions in Obsessive-Compulsive Disorder." British Journal of Psychiatry 177 (2000) 457-462.
Zaider, Talia, Jeffrey G. Johnson, Sarah J. Cockell. "Psychiatric Comorbidity Associated with Eating Disorder Symptomatology Among Adolescents in the Community." International Journal of Eating Disorders 28 (2000): 58-67.
ORGANIZATIONS
Anxiety Disorders Association of America (ADAA). 11900 Parklawn Drive, Suite 100, Rockville, MD 20852-2624. (301) 231-9350. <www.adaa.org> .
Freedom From Fear. 308 Seaview Avenue, Staten Island, NY 10305. (718) 351-1717. <www.freedomfromfear.com> .
Jane A. Fitzgerald, Ph.D.
Granted... Everyone is different, but in my case, I have two children. One is extremely affected by OCPD, the other shows no signs of it at all. My son is a completely typical kid and was raised no differently than his sister was. If anything, he may have received less attention because he was the second child, though I tried not to let this happen.
My daughter displayed traights of severe OCPD from the time she was 2 months old. She didn't like sitting on anyone's lap. When she was teething, if you touched her, she would cry 200 times louder. All we could do was be in the room and keep talking to her. She was also WAY more upset by her teething than most kids. She would get almost violent in her fits.
Family friends who spent any time with us could tell already that she was a bit different, but no one could quite put their finger on why. I didn't put a lot of stock in it since she was my first, so I didn't worry about it and just continued to be the best mom I could.
She didn't stand until she was 15 months old. She didn't walk until she was 2 and she NEVER fell down. She didn't talk until she was 4, and when she did she started with counting to 10, then skipped straight to full sentences with 3 syllable words within a month. From the time she was born she waited until she was SURE she could do something correctly before she would even attempt it.
When she was 1 1/2, she would always put stickers on sheets in a perfectly straight line and get raging violent if she accidently put a sticker on a sheet crooked. When she was 4, rather than watching her cousin open birthday presents, she spent her time gathering and organizing juice boxes into a straight line on one of the tables, then threw a fit when her uncle moved one of them.
So you tell me... Exactly what could I have possibly done wrong (with her and not her brother) in the first few weeks of her life to cause her to have this disorder.
Continued in next comment...
Today, she is able to cope when there is a change in plans, try new experiences and manage when things don't go according to "her" plan. The ONLY reason she is able to do this is because her mother was able to reach her and figure out the best way to teach this little girl how to cope with life and it's irregularities.
I see in your article that there aren't a lot of treatments that have proven effective. Perhaps the 'professionals' need to learn from parents of children with the disorder, rather than blame them.
As far as whether or not children learn the behavior from their upbringing or if it is inherited, I believe that there is some of both involved. At the time my husband was diagnosed, the psychologist in reviewing the details of his life came to the conclusion that his mother had Obsessive Compulsive Disorder (in her case, hoarding), which I believe came originally from the Personality Disorder. In watching his family, I also see signs of it in most of his siblings to one degree or another. Also, my husband has an uncle on his father's side who clearly struggles with the same behavior. So in my mind, there is clear evidence to believe that it may be hereditary. Also, in reading articles and such, there seems to be some thought that physical problems can make the problem worse. In my husband's case, he was thrown out of a ride at an amusement park at the age of nine causing severe damage to his head, which may have played a part?
As far as the upbringing goes, when talking to a psychologist about how to deal with my husband's behaviors, he asked me how much of it I may have picked up. Which brought to my mind that by living with my husband, I may have taken some of his attitudes and ways of doing things as the way they needed to be done. I think that in raising our children, my husband's way of seeing and doing things may have become the way things are done at our home to some extent and by that, our children may have gotten some of it themselves. So I am sure that by our very example we do contribute to the problem as well. My way of dealing with this, and I'm not sure it's the best, is to talk with my children about why whenever we are shaking our heads at things their father does and to try and understand with them that it's the problem and not him. I also hope that by us discussing the behaviors, we can keep watch for the same impulses in them. With 6 children, I am definitely seeing some of it to various degrees in them as well. So far none as strongly as their father.
To the woman who's 12 year old daughter has struggled with the problem for years, I admire you for being able to work with her and help her through. From everything that I've seen, the problem tends to increase over the years and I would imagine that it's going to get more difficult. It's good that you are able to get her help now. My husband tried medication at one point, but did not like it. Technically he knows that he has the problem but does not believe that it is causing problems in his life, so we are left to try and deal with him the best we can.
I would like to hear more from people who are dealing with these problems as it helps those of us who deal with it in our lives.
Yes OCD and other mental disorders can be genetic and also enforced by the parents to some degree and that is because people can be born to an OCD or OCPD parent. It is a thorny problem. One has to fight for their own personality and not be dominated and ruined by the person with the bad juju going on in that persons head. People have not mentioned that these people can be so manipulative, loud and painful to be with. They also are very stingy with affection of any type. Emotions seem empty except for anger or rage and panic. The best solution is a very good diet, vitamins, allergy testing, faith that God is real and forgiving (they obsess about perfection and think on one hand they are perfect and others terribly imperfect, so they dislike most people and are cold. Teaching them they are and will ALWAYS be imperfect only God is perfect, helps them forgive themselves and others for imperfection, then they become less fearful,angry and cold). Antidepressants of the right kind can work wonders for OCD or OCPD also. I watched one young man go from stalker to normal when I told his parents which antidepressant helps best with his problem. It was like a miracle, they thanked me for the advice and for helping them get their son back after being a problem for so long. His therapist was very happy too. To the lady who's husband didn't like his antidepressant tell him he has to switch around to find one that works best because your mind and the children's are getting crapped on by him because he refuses treatment. It is like any sickness he must be treated. He is addicted to his obsessions in a way, they control him and he wants them to control you too. Don't let it ruin your life or set the kids up to let someone come along and control them in unreasonable ways. Insist on treatment and get yourselves free.
There have been years we've gone without sex because I would not initiate or do things the way he wanted me to, therefore ruining his "mood". He has taken suitcases back from our car into the house before a long trip we had planned for months because the lamp in our family room did not have a timer to switch on in our absence! He was in such a rage he threw the lamp and told us we were cancelling the trip. I just went along with it, and after he had calmed down, he repacked the suitcases and we were finally on our way.
I try to talk to our daughter and she has also done research online trying to find solutions to his problems. We both know and reassure each other that "it's not me, it's his OCPD" but we can only do that so many times. There have been times when I just couldn't take it any longer and ironically I am now the one on anti depressants because I don't think I could cope with him otherwise.
My daughter and I are both too afraid to approach him and tell him that he has a problem and needs help. Do you think he knows there is something wrong with his behavior? It doesn't appear that he does. Whenever we have gone an vacation which is always work related, he is usually ok for the first 3 - 4 days, but after that he becomes very agitated and before you know it the whole trip is in ruins. Sometimes I talk back to him, and that really infuriates him.He constantly complains that I don't go on walks with him when I honestly dread those walks. They always turn into an opportunity for him to educate stupid me about the "right way" to do things. He has a monologue the whole time we're walking, with me nodding my head and keeping my mouth shut.
His evening thing is to rearrange the dishwasher since I don't do it right - with him commenting the whole time about how many times he has told me to do it properly and I'm still not getting it. Until I read more about this disorder I was seriously considering leaving him and just disappearing so can never find me and continue to torment me. Now I just want to help him - I am really the only person he has. I know from what he has told me that this behavior started in childhood. He didn't speak un til he was 3 yrs old and then just spoke like everyone else, as though he had been withholding speech to torment his parents. He would throw unimaginable fits when didn't get his way and the poor parents tried to indulge him as much as they could. I believe that they have suspected that there was something not right with their son. In the culture where he was raised it is notaccepted to have any kind of sickness since it would be considered bad karma.
What can I do? I am very afraid of his outbursts and try to ride the wave of his regret he has after such an event for as long as possible. Those times are really the only times that I can call "good" in our home. Does anyone have an answer?
He made life hell for our family. About 8 years before he died I figured out that he was a narcissist and perhaps had NPD. That information helped me immensely. I did not learn about OCPD until after his death. This category so clearly fits his behavior. My entire adult life I spoke of him as being rule bound. I don't recall ever having a conversation with him. He did all of the talking and furthermore even in my 50s he demanded that I look at him while he spoke, if I dared drop my eyes or glance away his wrath was invoked. As I child I did notice that he conversed with people whom he liked. But that was it.
Of course as he aged it all grew worse. If I had it all to do over again and I knew what I know now I would have left home as soon as possible and never looked back.
Originally I jthought my husband was just a "control freak." Also noticed it was impossible to have any kind of conversation with him. He was busy all the time with unnecessary work. Always exhausted. He insists on doing all the grocery shopping. I washed the windows while he was gone one nice sunny day and he threw a fit. Got out a bucket and did them all over again his way. Then other behaviors gave me great concern: drives around and around a parking lot and can't pick out a space. The car is old, scratched and has its share of dents and his difficulty in picking out a space has nothing to do with the normal reasons we are careful where we park. In a completely empty lot he took forever to finally park. As we reached the door of the store he turned and looked at the car and said he'd be back, he didn't like the spot he had chosen, and went back and moved the car. He drove one car until it literally rusted off its frame; fortunately we were in a parking lot driving slowly when it happened. We are financially secure and can afford a car but he won't even buy a box of popscicles if they aren't on sale.
On our daily walks he complains about each house, the way the landscaping is done, the idiot who keeps his trash cans on the side of the house, etc. Same conversation every day even though I request a nice pleasant walk and ignoring those things. We walked along the road's edge one winter day because the sidewalks were covered with snow. When a car was approaching from some distance he said to cross over to the other side which I did as we briskly walked and I was told I did not cross the street efficiently. An hour later as we were almost home and crossing a side street he put his weight on my shoulders in the middle of the street to keep me from taking another step. I told him he was hurting my knees and he said if I would just listen to him he wouldn't have to do that. I should cross the street at a 90-degree angle which is more efficient and safer. Silly me waited for an apology or some concern about my knees. I knew this was an instance I had to set boundaries so I said don't ever do that again.
There are endless situations I could describe. I no longer will go into a store with him because it ends up in an argument with someone. He doesn't understand why people get impatient with him after 15 minutes of questions: "how will I know I can get 2000 hours out of this lightbulb. Do I have to keep track?" The clerk remarks "oh for goodness sake, it's a $5 light bulb." My husband blows up, the manager comes running over and I drag my husband out the door. He sits in a chair at the shoe store for 3 hours to decide if he should buy these shoes that feel so comfortable, and usually leaves the store without them. Then complains for another 2 years that his feet get wet from the holes in the soles of his old shoes. Once asked if there was a company rep available for a brand of tennis shoes he wanted to buy so he could ask how they were constructed.
The more we talk and share the more power we'll have to survive and understand the ramifications of living with a loved one with mental illness. I appreciate articles like this one. Just knowing professionals are studying mental illness is comforting.