208 Obsessive-Compulsive Personality Disorder

DSM-IV-TR Criteria

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

1. is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
2. shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)
3. is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)
4. is over conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)
5. is unable to discard worn-out or worthless objects even when they have no sentimental value
6. is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things
7. adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes
8. shows rigidity and stubbornness

Associated Features

Obsessive compulsive personality disorder (OCPD) is a disorder in which the subject suffers from an obsession with control and rules and becomes so fixated on following these rules or rituals that it becomes detrimental to their day to day lives. They believe that these rules and rituals keep them from harm. This harm is something they perceive out of their own warped perspective. People with OCPD experience things such as rigidity, indecisiveness, and depressed demeanor.

Relationships are hard to maintain due to their volatility. This volatility surfaces when this person is put in a situation where they have lost control. Some resort to aggressive behavior while others may simply withdraw from the situation completely. The subject generally does not express emotion very well. People who suffer from this disease tend to excel at school or work because of their devotion to rules. Though beneficial in some situations this dedication to rules often leads to failure because of their lack of flexibility when unexpected change occurs.

These individuals are preoccupied with maintaining control mentally and in their interpersonal relationships. They make sure they do not make a mistake, and often check for the presence of mistakes. Much attention to detail is observed, and this often causes homework to not get completed because of perfectionist qualities. They tend to be workaholics and are not involved in many leisure activities; there may be problems in relaxing or having any type of fun.

They demand everything be done their way and posses stubborn qualities. Individuals are usually serious, rigid, formal, inflexible, and tend to be extremely moral. They tend to be stingy and want to save useless stuff of no value. Basically, those that cannot let loose, are cold, and stiff with anal tendencies most likely retentive. The OCPD is different from obsessive-compulsive disorder (OCD) in that the personality disorder does not include the obsessions and compulsions that define OCD. These disorders are contrary to popular belief that they are related on the same spectrum

• Co-morbidity is often seen with Dependent Personality Disorder, and Avoidant Personality Disorder.
• The most common types of obsessions in persons with OCD in Western countries are:
  • fear of contamination (impurity, pollution, badness)
  • doubts (worrying about whether one has omitted to do something)
  • an intense need to have or put things in a particular order
  • aggressive or frightening impulses
  • recurrent sexual thoughts or image
• The most common types of compulsions in persons with OCD in Western countries are:
  • washing/cleaning
  • counting
  • hoarding
  • checking
  • putting objects in a certain order
  • repeated “confessing” or asking others for assurance
  • repeated actions
  • making lists

Child vs. Adult Presentation

Once this disorder begins to manifest itself in early adulthood, there is no child presentation to compare with the adult presentation.

Unusual behaviors in children that may be signs of OCD include:

• Avoidance of scissors or other sharp objects. A child may be obsessed with fears of hurting herself or others.
• Chronic lateness or dawdling. The child may be per forming checking rituals (repeatedly making sure all her school supplies are in her book bag, for example).
• Daydreaming or preoccupation. The child may be counting or performing balancing rituals mentally.
• Spending long periods of time in the bathroom. The child may have a hand washing compulsion.
• Schoolwork handed in late or papers with holes erased in them. The child may be repeatedly checking and correcting her work.

Gender and Cultural Differences in Presentation

Men are twice as likely to suffer from this disorder as women. Some researchers theorize that the cause of the gender difference is due to the Western culture allowing men to act more controlling and stubborn.

Epidemiology

This disorder appears to only be present in approximately 1% of the United States population. It also seems to affect men more often than women. There is prevalence between 2% and 8% in the general population, and between 8% and 9% in outpatient psychiatric settings. And anywhere from 3% to 10% of individuals in mental health clinics have Obsessive-Compulsive Personality Disorder. There are no significant familial problems.

Etiology

The causes of OCPD are not well-known. Research leads us to believe that most sufferers are genetically predisposed. Another assumption is that OCPD is caused by things such as rigid parenting with young children. Children that are punished too harshly and receive little or no positive reinforcement for their good behavior are likely to develop this disorder. In most cases the children who develop OCPD are the oldest children in their families. Individuals were often punished for failing to be perfect and received no rewards for success. Affection and emotions were expected to be controlled or remain unexpressed.

These individuals do not generally present themselves voluntarily to treatment settings, thus making these disorders more difficult to properly research. Those that do come in are in a debilitated state, and it becomes difficult to specify the causal factors because we have to go back and piece together the etiological pieces of the puzzle. The most critical problem is that many of the Personality Disorders are co-morbid with each other, making it very difficult to separate out which factors are unique to each disorder.

Individuals with OCPD expect others to judge and criticize them in the same way that caregivers did during their development. Therefore, individuals with OCPD judge others by the same strict standards and self-criticize in the same manner as the caregivers who once criticized them.

Psychosocial causes:

In the early part of the century, Sigmund Freud theorized that OCD symptoms were caused by punitive, rigid toilet-training practices that led to internalized conflicts. Other theorists thought that OCD was influenced by such wider cultural attitudes as insistence on cleanliness and neatness, as well as by the attitudes and parenting style of the patient’s parents. Cross-cultural studies of OCD indicate that, while the incidence of OCD seems to be about the same in most countries around the world, the symptoms are often shaped by the patient’s culture of origin

Biological causes:

There is considerable evidence that OCD has a biological component. Some researchers have noted that OCD is more common in patients who have suffered head trauma or have been diagnosed with Tourette’s syndrome. Recent studies using positron emission tomography (PET) scanning indicate that OCD patients have patterns of brain activity that differ from those of people without mental illness or with some other mental illness. Other studies using magnetic resonance imaging(MRI) found that patients diagnosed with OCD had significantly less white matter in their brains than did normal control subjects. This finding suggests that there is a widely distributed brain abnormality in OCD. Some researchers have reported abnormalities in the metabolism of serotonin, an important neurotransmitter, in patients diagnosed with OCD. Serotonin affects the efficiency of communication between the front part of the brain (the cortex) and structures that lie deeper in the brain known as the basal ganglia. Dysfunction in the serotonergic system occurs in certain other mental illnesses, including major depression. OCD appears to have a number of features in common with the so-called obsessive-compulsive spectrum disorders, which include Tourette’s syndrome; Sydenham’s chorea; eating disorders; trichotillomania ; and delusional disorders. There appear to be genetic factors involved in OCD. The families of persons who are diagnosed with the disorder have a greater risk of OCD and tic disorders than does the general population. Childhood-onset OCD appears to run in families more than adult-onset OCD, and is more likely to be associated with tic disorders. Twin studies indicate that monozygotic, or identical twins, are more likely to share the disorder than dizygotic, or fraternal twins (www.minddisorders).

Empirically Supported Treatments

• Treatment for this disease is mostly limited to psychotherapy and self help treatments. Generally very difficult to treat, Cluster C seems most promising to treat and Cluster A least so.
• Medicine seems to only alleviate some depressive symptoms but doesn’t seem to improve symptoms in the long term sense. Obsessions can be influenced with selective serotonin re-uptake inhibitors or mono amine oxidase inhibitors.
• In extreme cases electro-convulsive therapy (ECT) or neurosurgery are used.
• Prevention is also almost impossible. As stated earlier most cases are people who are genetically predisposed. Early detection and treatment offers the best results.
• Therapy for this disorder can be quite difficult. Because of patients obsession with rules and doing things their own way it is difficult to teach them a new concept.

Medications

According to the encyclopedia of Menatal Disorders, the most useful medications for the treatment of OCD are the selective serotonin reuptake inhibitors (SSRIs), which affect the body’s reabsorption of serotonin, a chemical in the brain that helps to transmit nerve impulses across the very small gaps between nerve cells. These drugs, specifically **clomipramine** (Anafranil), **fluoxetine** (Prozac), fluvoxamine (Luvox), **sertraline** (Zoloft), and **paroxetine** (Paxil) have been found to relieve OCD symptoms in over half of the patients studied. It is not always possible for the doctor to predict which of the SSRIs will work best for a specific patient. Lack of response to one SSRI does not mean that other drugs within the same family will not work. Treatment of OCD often proceeds slowly, with various medications being tried before the most effective one is found. While studies report that about half of those treated with SSRIs show definite improvement, relapse rates may be as high as 90% when medications are discontinued.

Portrayed in Popular Culture

• Jerry from Seinfeld
  • He is characterized by rigid conformity to rules, moral codes, and excessive orderliness
• Monk from Monk
• Sheldon Cooper from Big Bang Theory
• Harvey Dent Two-Face from Batman
  • Has a preoccupation with coin-flipping
• Mr. Edward Nygma (The Riddler) from Batman
  • He has to leave riddles behind
  • In a 1999 issue of Gotham Adventures, he tries to commit a crime without leaving a riddle, but fails
• Dolores Umbridge from Harry Potter
  • The temporary Headmistress and Inquisitor of Hogwarts upon Dumbledore’s disappearance is the perfect picture of obsessiveness and rigidity.
  • She has to maintain order at all times

DSM-V Changes

• Reformulated as the Obsessive-Compulsive Type
• Individuals who match this personality disorder type are ruled by their need for order, precision, and perfection.
• Activities are conducted in super-methodical and overly detailed ways. They have intense concerns with time, punctuality, schedules, and rules.
• Affected individuals exhibit an overdeveloped sense of duty and obligation, and a need to try to complete all tasks thoroughly and meticulously.
• The need to try to do things perfectly may result in a paralysis of indecision, as the pros and cons of alternatives are weighed, such that important tasks may not ever be completed.
• Tasks, problems, and people are approached rigidly, and there is limited capacity to adapt to changing demands or circumstances.
• For the most part, strong emotions – both positive (e.g., love) and negative (e.g., anger) – are not consciously experienced or expressed.
• At times, however, the individual may show significant insecurity, lack of self confidence, and anxiety subsequent to guilt or shame over real or perceived deficiencies or failures.
• Additionally, individuals with this type are controlling of others, competitive with them, and critical of them.
• They are conflicted about authority (e.g., they may feel they must submit to it or rebel against it), prone to get into power struggles either overtly or covertly, and act self-righteous or moralistic.
• They are unable to appreciate or understand the ideas, emotions, and behaviors of other people.
• Instructions

(APA, 2010)

https://youtu.be/kBA6ACBFNqg

An example of how Obsessive-Compulsive Personality Disorder is portrayed in pop culture. In the television show Big Bang Theory, Sheldon Cooper, a theoretical physicist who shows signs of Asperger Syndrome and Obsessive-Compulsive Personality Disorder, has a compulsive need to knock three times, say the persons name three times, and repeat for a total of three times.