Obsessive-compulsive personality disorder is marked by perfectionism, rigidity, poor time management, and poor emotional expression. It is not a temporary condition, but it is an ongoing and relatively permanent condition that causes a significant amount of pain and suffering for the individuals that have it. The purpose of this paper is to discuss the general features of the obsessive-compulsive personality disorder, its etiology, comorbidity and differential diagnosis, and gender and cultural issues in regard to prevalence. A general overview of treatment options indicates that individuals with obsessive-compulsive disorder are difficult to treat, but that successful treatment can result in greater self-awareness and an ability to develop skills that will enable them to have more productive and less painful lives. Description of Obsessive-Compulsive Personality Disorder
There are 10 personality disorders which are organized according to clusters A, B, and C. Personality disorders are Axis II disorders in the Diagnostic and Statistical Manual (DSM-IV-TR) (APA, 2000). Any personality disorder is considered enduring and stable over time and is marked by patterns of behaviors and inner experiences that are not consistent with a person’s cultural expectations; they are ongoing patterns of thinking, feeling, and behaving. People who have a personality disorder are usually not flexible and their behavioral patterns generally create disturbances and impairment in many areas of functioning. Onset of a personality disorder typically occurs in adolescence or early adulthood and persists throughout the remainder of the individual’s lifespan.
Cluster A includes paranoid, schizoid, and schizotypal personality disorders, which are marked by odd and eccentric behaviors. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders, which are marked by erratic behaviors, extreme emotionality, and a dramatic presentation. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders, which are marked by anxiety and fearfulness (Serin & Marshall, 2003). The focus of this paper is the obsessive-compulsive personality disorder (OCPD).
People who have been diagnosed with OCPD are generally seen as perfectionists, preoccupied with orderliness; they are inflexible, and typically “see trees before the forest” (Yovel, Revelle, & Mineka, 2005, p. 123). They also have an extensive need to be in control of their mental processes as well as their interpersonal relationships. Eight diagnostic features of OCPD that are present in many different contexts are (APA, 2000):
- When a job needs to be done, or a task completed, people with OCPD become so preoccupied with the planning that they often forget or lose track of the main goal. They maintain a sense of control by making exhaustive lists and schedules, and by outlining details and procedures that most people around them can not follow. The self-imposed high standards of a person with OCPD usually become counter productive, cause distress for them and for people who are trying to work with them.
- The person with OCPD can not use time efficiently and their excessively careful and cautious personality results in repetition and incomplete tasks, projects, and work in general. For example, if the task is planning a party for a 10 year old, the person with OCPD would go to such lengths to control all aspects of the event (to make everything perfect), that they may not have covered the basics needed, such as inviting the guests or ordering enough food, that at the last minute someone else may need to finish the plans or actually give the party.
- People with OCPD are usually consumed by work. They value work above all other things and they are driven by internal motives that often have little or nothing to do with financial gain. They would rather work than develop friendships or spend time doing leisure activities.
- Individuals with OCPD are extremely conscientious and follow rules without making any exceptions. They have a strict moral and ethical framework that is completely and totally inflexible. When they make mistakes, they are harsh judges of their own behaviors, and they also judge others harshly. To them rules need to be followed and authority usually obeyed without exception. They are ridged and consistent. Their moral and ethical organization is internally driven and can not be accounted for by their religion or culture.
- A person with OCPD usually holds on to all possessions and is unable to get rid of things that are no longer useful. They are unable to throw things in the garbage even when an object is broken and has no sentimental value. They seem to be unable to physically and psychologically purge. They like to hold on to things because of the remote possibility that some day a worthless object might become useful again.
- Individuals with OCPD need to be in control and are extremely reluctant to delegate tasks or responsibilities to others. They would rather struggle by themselves for as long as it takes rather than ask for help or tell someone else to do it. They generally believe that they are the only ones who can do it correctly, and they allow others to help only if they submit completely to doing something exactly the way they were told to do it by the individual with OCPD.
- People who have OCPD are usually very frugal and do not spend money on anything but what is absolutely necessary. According to them, money is to be horded so that it can be used in case of an emergency or an unforeseen disaster.
- Individuals who have OCPD are rigid, compulsive, and stubborn. They don’t change their routines or their minds. They believe that they are righteous and they know how to do things correctly. They often sacrifice efficiency and cooperative interpersonal relationships for a sense of control and orderliness.
In order to be diagnosed with OCPD, a person has to meet four or more of the criteria noted above (APA, 2000). In addition to the eight criteria described, individuals who have OCPD have a difficult time emotionally. According to Seligman (1998) they are emotionally restricted because any kind of an emotion represents a state that is out of control; to have emotions is threatening. People with OCPD want to present themselves as being highly proficient and good. This creates a significant amount of anxiety and fear. Their fear is believed to arise from the notion that others will see them as inadequate or imperfect. These types of emotional difficulties are believed to develop as a result of the care and attention they received early in life.
Generally, individuals with OCPD do not tolerate their own imperfections or the imperfections of others. Their relationships are usually serious in tone and they are very uncomfortable when other people express their emotions. They control their feelings of affection and have difficulty being tender and loving. They are difficult to work with and to live with because of their strict adherence to rules and to small details, and because of their stubbornness. People with OCPD are usually not able to respond appropriately or flexibly when they are confronted with new situations and with a need to compromise (APA, 2000).
People who have OCPD are often considered to be workaholics. They may display a Type A personality that is characterized by their preoccupation with work. They work diligently and tirelessly. They may be competitive, and they also experience stress due to time constraints and time urgency, which leaves them vulnerable to heart disease, such as, myocardial infarction. People with OCPD often sabotage their own efforts because they have a tendency to get caught up in small and irrelevant details, which results in falling behind and not meeting deadlines. The stress and anxiety associated with demands that are difficult or impossible for them to meet usually causes a person with OCPD to suffer emotionally and to seek professional help (Eskedal & Demetri, 2006).
Early work with personality disorders was primarily psychoanalytical, as was the language used to describe the development of the disorders and their treatment. Currently, according to Esckedal and Demetri (2006) there is no empirical evidence that supports the existence of a biological predisposition to personality disorders. The primary causes for them are still considered environmental, and specifically the early home environment and the relationship between the child and the primary caregiver. Personality disorders are believed to stem from less than ideal care-giving and an insecure attachment type as outlined by the attachment theory. Attachment theory suggests that the early bonds between a child and his caregiver become a working model for all other relationships (Ainsworth, Blehar, Waters, & Wall, 1978: Bowlby, 1969). Secure and insecure attachment styles (attachment framework) develop early in life and help to shape perceptions of self and others.
John Bowlby (1969) developed the original attachment theory and pointed out that the attachment between infant and his caregiver is a matter of an innate behavioral system (an adaptive behavioral system), which insures that the child will be cared-for and will survive. The development of attachment is a function of the proximity and availability of the caregiver. The early experiences that result in the attachment of the infant to his caregiver also function to regulate emotions. Current research suggests that the attachment framework is a way for us to understand how affects are regulated, in other words, it is the framework for the affect regulation system (Mikulincer, Shaver, & Pereg, 2003).
Contemporary research is beginning to think in terms of dimensions of attachment; attachment security, attachment avoidance, and attachment anxiety (Brennan, Clark, & Shaver, 1998; Mikulincer, Shaver, & Pereg, 2003). When an infant is feeling ill, hungry, or cold, he experiences anxiety and other negative feelings. If his needs are met in such a way that they alleviate negative emotions, he is likely to develop attachment security. If his needs are not met adequately, or at all, he might develop attachment avoidance or attachment anxiety. These early emotional experiences are internalized and used to understand self and others throughout the life span. Additionally, the attachment framework shapes behavioral functioning in relationships and during times of stress and loss.
People who develop OCPD are believed to have been anxiously attached because their parents were over-controlling and responded with severe disciplinary actions when the child misbehaved. In early childhood, and then throughout the life-span, anxiously attached people try to do things perfectly, which creates a great deal of more anxiety. When perfection is not accomplished then there are further negative feelings such as guilt. People with OCPD have unrealistic goals that they try to meet, which results in repetitive and compulsive behaviors, and in obsessions on small details. In the effort to control their mental processes and their environment and to reduce anxiety, people with anxious attachment styles are unable to let go of their need for perfection. In addition their irrational sense of right and wrong creates difficulties in many areas of life, such as in intimate relationships, family and professional life (Eskedal & Demetri, 2006; Serin, & Marshall, 2003).
From the psychoanalytic perspective, OCPD is directly linked to the anal stage of psychosexual development. When the child is being toilet trained, harsh, rigid, impatient, and overly demanding parents may cause that child to develop a fixation at the anal stage. These children may develop a superego that is harsh and condemning, and are later on in life considered to be anal-retentive individuals (Benjamin, 2003; Chessick, 2001).
Yovel, Revelle, and Mineka (2005) discussed the cognitive approach to psychopathology and researched the obsessive-compulsive cognitive style. They noted that people respond differently to the same objective stimuli because of differences in cognitive processing on both lower-level and higher-level mental representation. For example, a schemata is a higher-level broad mental representation of self and the world. Each person has a characteristic way of perceiving and thinking, which “mediate their cognitive, emotional, and social functioning” (p. 123). Yovel, Revelle, and Mineka (2005) reported that an obsessive-compulsive cognitive style is marked by excessive visual attention to small and irrelevant details, which prevents the individual from perceiving global information (forest for the trees). The discussion on cognitive style and OCPD did not include information on how maladaptive schemata’s or faulty cognitive processing develop and result in OCPD.
Grilo et al. (2004) conducted a large scale study to evaluate diagnostic efficiencies of the OCPD criteria. They did not discuss etiology of OCPD, but evaluated what they called cognitive-interpersonal OCPD criteria. They found that three such criteria have consistently predictive utility. They are “‘preoccupied with details’, rigid and stubborn,’ and ‘reluctant to delegate'” (p. 64). Grilo et al. (2004) noted that in the past 20 years or so little empirical research has been dedicated to OCPD. Literature review conducted for this paper indicates that modern psychological language is being used when discussing OCPD, but research and discussions on the etiology are limited and continue to refer to attachment theory as a primary source of the disorder.
Gender and Cultural Issues
Serin and Marshall (2003) discuss the difficulties inherently present in establishing a diagnosis of a personality disorder, which includes real concerns about possible cultural and gender biases in diagnostic practices. In the DSM-IV-TR (APA, 2000) it is documented that some personality disorders are more frequently diagnosed in men and others in women and that OCPD is diagnosed twice as often in men than in women. The DSM-IV-TR (APA, 2000) notes that the differences in the prevalence of personality disorders reflects real gender differences and they warn clinicians not to overdiagnose or underdiagnose because of social stereotypes that include typical gender roles and behaviors. This sounds like the American Psychiatric Association is trying to say that the reasons for the prevalence of some disorders among men and others among women are caused by real factors and are not due to biases when making a diagnosis.
Eskedal & Demetri (2006) noted that gender biases in diagnosing personality disorders are historic and not current. Boggs et al. (2005) conducted a large scale study to investigate sex biases in the diagnostic criteria for four personality disorders (borderline, schizotypal, avoidant, and OCPD) and this seemed to reach the same conclusion. Their results suggested that there might be some sex bias in the borderline personality diagnosis, but the other personality disorders under study displayed no sex bias at all. Therefore using the current criteria for diagnosing OCPD, the 2:1 ratio between men and women appears to be an accurate representation of the occurrence of the disease in people seeking help due to psychological problems. According to the DSM-IV-TR (APA, 2000) OCPD is diagnosed in about 1% of community samples and from 3% to 10% in the mental health clinic population. At the current time there is no research supporting unequal distributions of OCPD across cultures. Lewin, Slade, Andres, Carr, and Hornabrook (2005) discussing a national mental health survey in Australia, noted that nationally there is an estimated prevalence of 6.5% of personality disorders. They suggested that the International Personality Disorder Examination Questionnaire be used in future mental health surveys because it would provide useful and more accurate information about the prevalence of personality disorders in the general population.
Comorbidity and Differential Diagnosis
A large scale Collaborative Longitudinal Personality Disorders Study conducted by Shea et al. (2004) examined associations between the schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders and generally believed co-occurring Axis I disorders. In the DSM-IV-TR (APA, 2000) it is noted that individuals with several types of anxiety disorders, such as social phobia and obsessive-compulsive disorder, have an increased chance of having OCPD. Although it was noted that the majority of people who have been diagnosed with obsessive-compulsive disorder do not have OCPD, there continues to be an association between the two disorders and a suggested comorbidity. The work of Shea et al. concluded that there was little or no association between OCPD and Axis I disorders.
It is important to note that some obsessive-compulsive characteristics are valued in many cultures, such as dedication to work, a need to make things as perfect as possible, controlled emotional expression, and prudence with money. A person may have many obsessive-compulsive personality characteristics without meeting the criterion for a diagnosis. When behaviors become maladaptive and a person experiences pain and suffering because of disruption to professional and personal life, then following an evaluation, it could be determined that they have met the criterion for OCPD. Generally this disorder does not appear to be comorbid with many other Axis I disorders, although it was stated in the DSM-IV-TR (APA, 2000) that there was an association between OCPD and mood and eating disorders. Research reviewed did not support this assumption.
Obsessive-compulsive disorder is an anxiety disorder that might at times be confused with OCPD. The two disorders are easily distinguishable because people with the anxiety disorders have true compulsions and obsessions. For example, they are the ones who may wash their hands 100 times per day and be consumed by worries about germs and cleanliness. People with OCPD have a personality type that pursues perfectionism and their behaviors are motivated by inner constructs and not by anxious reactions and odd obsessions. One relatively simple way to distinguish the obsessive-compulsive anxiety disorder from OCPD is that people with the anxiety disorder become extreme in their hoarding; the material that they accumulate may obstruct hallways and create unlivable conditions, as well as a fire hazard.
Many of the 10 personality disorders may have shared characteristic features. Distinguishing one from the other requires a careful look at the behaviors, thoughts, emotions, and the underlying motivations of the person being evaluated. For example, people with a Narcissistic Personality Disorder may seem to be perfectionist, but unlike an individual with OCPD they believe that they are already perfect. Individuals with Antisocial Personality Disorder, just like people with OCPD, are not generous and do not
lavish others in their lives with gifts. However, the individuals with OCPD are not generous with themselves or others because they are frugal with money, whereas the person with Antisocial Personally Disorder will be very generous with self and will indulge in whatever they find desirable. Differentiating OCPD from other mental disorders requires an extensive knowledge of other personality disorders and of the DSM-IV-TR diagnostic code in general.
There is a current trend to evaluate mental illness based on biological, psychological, and social factors. Schotte, VanDenBossche, DeDoncker, Claes, and Cosyns (2006) notes that biological factors include genetic factors, temperamental predispositions and gender; psychological factors include early and recent trauma, maladaptive schemas and coping styles, intergenerational factors, and gender; social factors include environmental factors, Western societies instability and insecurity and gender. They also included a fourth somatic risk factor, which includes somatic diseases, substance misuse, and gender. Schotte et al. (2006) discussed biological vulnerability and psychological vulnerability as well as protective factors, such as good physical health and material prosperity in regard to depression and not to personality disorders. As it was mentioned earlier, in the last 20 years there has been very little research conducted regarding the causes of personality disorders and a biopsychosocial model of OCPD is unavailable (Critchfield& Benjamin, 2006; Grilo et al., 2004; Serin, & Marshall, 2003). Alternatively, Kinderman (2005) argues that the biopsychosocial model, which appears to have been embraced by many, falls short of the truth about mental disorders, and notes that biological, social, and circumstantial factors work together to disrupt psychological processes which in turn result in a mental disorder.
The information gathered for this paper, suggests that psychological and social factors are the primary contributors to OCPD. Early home environment, demanding and emotionally unavailable parents, difficulty during the anal stage of psychosocial development, and the subsequent expectations of the self and others, appear to contribute to the development of a personality that meets the criterion for OCPD.
It has been well document that it is difficult to treat people with personality disorders and that it continues to remain a developing area of psychological work and research (Critchfield& Benjamin, 2006; Eskedal & Demetri, 2006; Serin, & Marshall, 2003; Stauss, et al., 2006). There are several factors that influence treatment effectiveness and evaluation that includes the very nature of personality disorders and the tendency of people suffering with them not to seek treatment or to drop out of treatment shortly after starting it. Eskedal and Demetri (2006) noted that when treating people with OCPD, the therapist needs to focus on two primary goals. The first goals include an effort to help the client to develop realistic goals about self and others; to drop impossible expectations of perfection, and to help them to realize that becoming more flexible and less rigid will; give up false sense of control, will enable them to be more productive. The second goal revolves around superego modification which may require long term treatment that would ultimately result in a change in the individual’s character structure. Critchfield and Benjamin (2006) reviewed the APA’s Division 12 Task Force summary of psychosocial treatment of personality disorders. They noted that regardless of the theoretical background of the therapist, treatment needs to be comprehensive and the therapist patient, emphatic, and flexible.
Cognitive Behavioral Treatment
Seligman (1998) and Beck, Freeman, and Davis (2003) suggested that cognitive-behavioral therapy (CBT) for OCPD is well documented and effective in treating this disorder. CBT generally focuses on the present situation; is a problem oriented therapy with treatment plans that are structured and well organized, and it requires limited emotionally on the part of the client and the therapist. All of these factors are helpful to a person with OCPD, who looks for structure and boundaries. Additionally, CBP would explore why the client developed maladaptive schemas, which include perfectionism and their need for control. Through a collaborative effort and CBT techniques of guided observation and a re-enactment of situations where faulty schemas were developed, the therapist would assist the client in developing self awareness. Sperry (1999) notes that individuals with OCPD need to develop the ability to express emotions and to recognize and be able to cope with the emotions of others. Thus, the goals of CBT would include a development of self-awareness and empathy, as well as reducing ruminative thinking. Empathy, social skills, and extinction training would all be included in the comprehensive CBT treatment of individuals with OCPD.
Strauss et al. (2006) studied the importance of the therapeutic relationship between the client with OCPD or avoidant personality disorder and the cognitive behavioral therapist. Their study included 30 adult clients who completed 52 weekly sessions of therapy. Strauss et al. (2006) concluded that two relationship factors predicted a greater reduction of symptoms, which included early alliance as indicated by a rating of the therapeutic alliance by the client. The second factor was called rapture-repair alliance, which was a problem or a disruption in the therapeutic relationship. When disruptions in alliance occurred, the client had an opportunity to have, what Strauss et al. (2006) called, a corrective experience. The methods used in CBT are important, as is the relationship between the client and therapist, which facilitates self-awareness and positive change.
According to the psychoanalytic view, a patient who has OCPD experienced difficulties in the anal stage of development, which resulted in general uncertainty and insecurity in life and a need to control ones emotions, mental processes, and the environment (Chessick, 2001). Individuals with OCPD require structure and predictability in their therapeutic environment, as well as clear directives which reduce their anxiety and enable them to plan. The methods used in traditional psychoanalysis, such as free association, are difficult for a client with OCPD; therefore psychoanalytic treatment is usually modified for these clients. However, free associations are conducted, but the client is stopped from excessive focus on irrelevant details and encouraged to think about present life circumstances. Psychodynamic psychotherapy enables the client to work though early trauma or negative associations with parental figures. Transference and countertransference is useful in developing new frameworks of self and others. Although there is a general lack of empirical research, there is some evidence that suggests shorter goal oriented psychodynamic psychotherapy for OCPD may be more beneficial than on-going long term traditional psychoanalysis (Eskedal & Demetri, 2006).
Group therapy and overview of treatment
Individuals with OCPD have a difficult time adjusting to group therapy. They generally tend to monopolize the sessions because of their need to control the situation. Also, they lack empathy which may be difficult for other group members to deal with. Clients with OCPD are recommended to attend individual counseling until they develop a degree of self-awareness and empathy. Sperry (1999) suggests that a heterogeneous group of people might be the best group therapy environment for those with OCPD. In a heterogeneous group, the atmosphere with many different personality types might provide opportunities for multiple transferences and help the OCPD client to have “corrective family experiences as well as engaging in reality testing (Eskedal & Demetri, 2006, p. 12).
Critchfield and Benjamin (2006) noted that in order to provide the most beneficial treatment to people who have a personality disorder there needs to be consideration of the extent of the client’s pending problems and level of dysfunction. Issues of severity, chronicity, and comorbidity need to be evaluated and determined and then the therapist needs to develop a treatment plan that matches the level of the impairment. Critchfield and Benjamin (2006) outlined six factors concerning the client that must be considered in order to have a positive therapeutic outcome. They are: the client’s willingness and ability to engage in treatment, history of attachment and trauma, resistance to treatment and the treatment type, client’s positive expectations that the treatment will succeed, client’s stage of readiness for change, and the client’s social class. In order to have positive therapeutic outcomes the therapist’s personal characteristics also need to be evaluated. Is a therapist able to successfully treat a person with a personality disorder may depend on the following factors: is the therapist comfortable with and able to maintain a long-term, emotionally intense relationship with a client, patience, tolerance for feelings that might arise regarding the client and the treatment process, did the therapist receive specialized training, and is the therapist open-minded, flexible, and creative (Critchfield & Benjamin, 2006).
Personality connotes something that develops over time and is enduring; with or without mental disorders people may experience some difficulties in life because of their personality type of style. Based on the literature review conducted for this paper, individuals who have an Axis II personality disorder do not always go for help, and when they do it might be difficult for them to stay in therapy, or to commit to creating a positive change in their lives. Most treatment is therapeutic and not pharmacological. Medication might be prescribed if a person has comorbid anxiety or other Axis I disorders, but otherwise it is a matter of developing greater self-awareness and actively attending the type of therapy that is beneficial to the individual; that helps them to function more productively and increases satisfaction and happiness in life. Conclusion
OCPD is one of the 10 personality disorders identified in the DSM-IV-TR (APA, 2000). Personality disorders are defined in terms of enduring patterns of thinking, feeling, and behaving that are maladaptive and create considerable disruption and impairment in personal relationships, social and professional functioning. OCPD is a cluster C disorder, which are generally marked by anxiety and fearfulness. In order to be diagnosed, an individual has to meet four or more of the eight diagnosis criteria. The features of OCPD include perfectionism, rigidity, inflexibility, stubbornness, inability to express emotions or to show empathy, a strong need for control of mental process and the environment, an inability to delegate, time urgency, and a focus on small and irrelevant details. Many people with OCPD seek professional help when they are unable to meet daily demands are suffering and in distress (Eskedal & Demetri, 2006).
Research on the causes of most personality disorders is limited. However, there is significant amount of literature which suggests that OCPD develops as a result of early childhood experiences with the primary caregiver and an anxious attachment framework. These children are believed to experience controlling and demanding primary caregivers who are emotionally unavailable. In adulthood anxiously attachment people tend to be extremely critical of themselves and of others. They strive to be perfect and are not flexible in any area of their life (Brennan, Clark, & Shaver, 1998; Mikulincer, Shaver, & Pereg, 2003). From the psychoanalytical framework, OCPD might be an anal retentive problem which developed in the second psychosexual stage of development (Benjamin, 2003; Chessick, 2001). Cognitive psychologists suggest that OCPD is caused by faulty schemas of self and others (Seligman, 1998; Beck, Freeman, & Davis, 2003).
OCPD is twice as prevalent in men as it is women. Research conducted on diagnosing criteria and gender bias indicated that there is no gender bias, and that the discrepancy of the disorder between men and women is an accurate reflection of real gender differences (Boggs et al., 2005). At the present time there is no empirical research supporting different distributions of OCPD across cultures.
Most personality disorders are difficult to treat because clients are resident and usually don’t complete a treatment program. CBT, psychodynamic psychotherapy, and group therapy have been shown to reduce symptoms and to promote healthier functioning. However, in order to maximize success and have a positive treatment outcome the OCPD client must be willing to stay for the duration of the treatment, and the therapist needs to be flexible so that adjustments are made that promote the likelihood of compliance. Primary goals when treating people with OCPD are to: 1) develop self-awareness and empathy and to reduce rigidity, and to 2) help the client to modify their superego so that a permanent change in functioning could be achieved (Eskedal & Demetri, 2006).References
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