Obsessive–compulsive personality disorder

"OCPD" redirects here. Not to be confused with Obsessive-compulsive disorder. For other uses, see OCPD (disambiguation).

Obsessive-compulsive personality disorder
Other names	Anankastic personality disorder
One of the symptoms of OCPD is a great attention to detail
Specialty	Psychiatry
Symptoms	Obsession with rules and order; perfectionism; excessive devotion to productivity; inability to delegate tasks; zealotry on matters of morality; rigidity and stubbornness
Usual onset	Adolescence to early adulthood
Risk factors	Negative life experiences, genetics
Differential diagnosis	Obsessive-compulsive disorder, personality disorders, substance use disorder, personality disorder due to another medical condition
Treatment	Psychotherapy
Frequency	3% to 8% prevalence in the general population

Obsessive–compulsive personality disorder (OCPD) is a cluster C personality disorder marked by an excessive need for orderliness, neatness, and perfectionism. Symptoms are usually present by the time a person reaches adulthood, and are visible in a variety of situations.

The cause of OCPD is thought to involve a combination of genetic and environmental factors, namely problems with attachment.

This is a distinct disorder from obsessive-compulsive disorder (OCD), and the relation between the two is contentious. Some studies have found high comorbidity rates between the two disorders but others have shown little comorbidity. Both disorders may share outside similarities; rigid and ritual-like behaviors, for example. Attitudes toward these behaviors differ between people affected with either of the disorders: for people with OCD, these behaviors are egodystonic; unwanted and involuntary, being the product of anxiety-inducing and involuntary thoughts. On the other hand, for people with OCPD, they are egosyntonic; the person perceives them as rational and wanted, being the result of, for example, strong adherence to routines, a desire for control, or a need for perfection. OCPD is highly comorbid with other personality disorders, Asperger's syndrome, eating disorders, anxiety, mood disorders, and substance use disorders.

The disorder is the most common personality disorder in the United States, and is diagnosed twice as often in males as in females, however, there is evidence to suggest the prevalence between men and women is equal.

Signs and symptoms

(OCPD) is a cluster C personality disorder marked by an excessive obsession with rules, lists, schedules, and order; a need for perfectionism that interferes with efficiency and the ability to complete tasks; a devotion to productivity that hinders interpersonal relationships and leisure time; rigidity and zealousness on matters of morality and ethics; an inability to delegate responsibilities or work to others; restricted functioning in interpersonal relationships; restricted expression of emotion and affect; and a need for control over one's environment and self.

Signs and symptoms of OCPD

Some of OCPD's symptoms are persistent and stable, whilst others are unstable. The obsession with perfectionism, reluctance to delegate tasks to others, and the rigidity and stubbornness are stable. On the other hand, the symptoms that were most likely to change over time were the miserly spending style and the excessive devotion to productivity. This discrepancy in the stability of symptoms may lead to mixed results in terms of the course of the disorder, with some studies showing a remission rate of 58% after a 12 month period, whilst others suggesting that the symptoms are stable and may worsen with age.

Attention to order and perfection

People with OCPD tend to be obsessed with controlling their environments; to satisfy this need for control, they become preoccupied with trivial details, lists, procedures, rules, and schedules. They lose sight of the main objective of a task due to the obsessions. For example, a person with OCPD may devise a schedule for cleaning up the house, then decide that they should complete the more time-consuming tasks first, then they might decide to sort the tasks in alphabetical order. Next, they may decide to plan how they will complete each task down to the meticulous detail, and so on, until they have dedicated such a large portion of time to perfecting the schedule that they do not have enough time to clean the house.

This preoccupation with details and rules makes the person unable to delegate tasks and responsibilities to other people unless they submit to their exact way of completing a task because they believe that there is only one correct way of doing something. They stubbornly insist that a task or job must be completed their way, and only their way, and may micromanage people when they are assigned a group task. They are frustrated when other people suggest alternative methods. A person with this disorder may reject help even when they desperately need it as they believe that only they can do something correctly.

People with OCPD are obsessed with maintaining perfection. The perfectionism and the extremely high standards that they establish are to their detriment and may cause delays and failures to complete objectives and tasks. Every mistake is thought of as a major catastrophe that will soil their reputation for life. For example, a person may write an essay for a college, and then believe that it fell short of "perfection", so they continue rewriting it until they miss the deadline. They may never complete the essay due to the self-imposed high standards. They are unaware that other people may become frustrated and annoyed by the repeated delays and hassles that this behavior causes. Work relationships may then become a source of tension.

Devotion to productivity is an observed symptom of OCPD

Devotion to productivity

Individuals with OCPD devote themselves to work and productivity at the expense of interpersonal relationships and recreation. Economic necessity, such as poverty, cannot account for this behavior. They may believe that they do not have sufficient time to relax because they have to prioritize their work above all. They may refuse to spend time with friends and family because of that. They may find it difficult to go on a vacation, and even if they book a vacation, they may keep postponing it until it never happens. They may feel uncomfortable when they do go on a vacation and will take something along with them so they can work. They choose hobbies that are organized and structured, and they approach them as a serious task requiring work to perfect. The devotion to productivity in OCPD, however, is distinct from work addiction. OCPD is controlled and ego-syntonic, whereas work addiction is uncontrolled and ego-dystonic, and the person afflicted may display signs of withdrawal.

Rigidity

Individuals with OCPD are overconscientious, scrupulous, and rigid and inflexible on matters of morality, ethics, and other areas of life. They may force themselves and others to follow rigid moral principles and strict standards of performance. They are self-critical and harsh about their mistakes. These symptoms should not be accounted for or caused by a person's culture or religion. Their view of the world is polarised and dichotomous; there is no grey area between what is right and what is wrong. Whenever this dichotomous view of the world cannot be applied to a situation, this causes internal conflict as the person's perfectionist tendencies are challenged.

People with this disorder are so obsessed with doing everything the "right and correct" way that they have a hard time understanding and appreciating the ideas, beliefs, and values of other people, and are reluctant to change their views, especially on matters of morality and politics.

Restricted emotions and interpersonal functioning

Individuals with this disorder display little affection and warmth; their relationships and speech tend to have a formal and professional approach, and not much affection is expressed even to loved ones, such as greeting or hugging a significant other at an airport or train station.

They are highly careful in their interpersonal interactions. They have little spontaneity when interacting with others, and ensure that their speech follows rigid and austere standards by excessively scrutinising it. They filter their speech for embarrassing or imperfect articulation, and they have a low bar for what they consider to be such. They lower their bar even further when they are communicating with their superiors or with a person of high status. Communication becomes a time-consuming and exhausting effort, and they start avoiding it altogether. Others regard them as cold and detached as a result.

Their need for restricting affect is a defence mechanism used to control their emotions. They may expunge emotions from their memories and organize them as a library of facts and data; the memories are intellectualized and rationalized, not experiences that they can feel. This helps them avoid unexpected emotions and feelings and allows them to remain in control. They view self-exploration as a waste of time and have a patronising attitude towards emotional people.

Millon's subtypes

In his book, Personality Disorders in Modern Life, Theodore Millon describes 5 types of obsessive-compulsive personality disorder, which he shortened to compulsive personality disorder.

The Conscientious Compulsive

Millon described those with conscientious compulsive traits as displaying a dependent form of compulsive personality disorder. Those with conscientious compulsivity view themselves as helpful, co-operative, and compromising. They downplay their achievements and abilities and base their confidence on the opinions and expectations of others; this compensates for their feelings of insecurity and instability. They assume that devotion to work and striving for perfection will lead to them receiving love and reassurance. They believe that making a mistake or not achieving perfection will lead to abandonment and criticism. This mindset causes perpetual feelings of anxiety and an inability to appreciate their work.

The Puritanical Compulsive

The puritanical compulsive is a blend of paranoid and compulsive features. They have strong internal impulses that are countered vociferously through the use of religion. They are constantly battling their impulses and sexual drives, which they view as irrational. They attempt to purify and pacify the urges by adopting a cold and detached lifestyle. They create an enemy which they use to vent their hostility, such as "non-believers", or "lazy people". They are patronizing, bigoted, and zealous in their attitude toward others. Their beliefs are polarized into "good" and "evil".

The Bureaucratic Compulsive

The bureaucratic compulsive displays signs of narcissistic traits alongside the compulsivity. They are champions of tradition, values, and bureaucracy. They cherish organizations that follow hierarchies and feel comforted by definitive roles between subordinates and superiors, and the known expectations and responsibilities. They derive their identity from work and project an image of diligence, reliability, and commitment to their institution. They view work and productivity in a polarized manner; either done or not. They may use their power and status to inflict fear and obedience in their subordinates if they do not strictly follow their rules and procedures, and derive pleasure from the sense of control and power that they acquire by doing so.

The Parsimonious Compulsive

The parsimonious compulsive is hoarding and possessive in nature; they behave in a manner congruent with schizoid traits. They are selfish, miserly, and are suspicious of others' intentions, believing that others may take away their possessions. This attitude may be caused by parents who deprived their child of wants or wishes but provided necessities, causing the child to develop an extreme protective approach to their belongings, often being self-sufficient and distant from others. They use this shielding behavior to prevent having their urges, desires, and imperfections discovered.

The Bedevilled Compulsive

This form of compulsive personality is a mixture of negativistic and compulsive behavior. When faced with dilemmas, they procrastinate and attempt to stall the decision through any means. They are in a constant battle between their desires and will, and may engage in self-defeating behavior and self-torture in order to resolve the internal conflict. Their identity is unstable, and they are indecisive.

Cause

The cause of OCPD is thought to involve a combination of genetic and environmental factors. There is clear evidence to support the theory that OCPD is genetically inherited, however, the relevance and impact of genetic factors varies with studies placing it somewhere between 27% and 78%. Too few studies have dealt with the specific gene involved in the disorder's heritability, and more research is required to ascertain the exact genes.

Other studies have found links between attachment theory and the development of OCPD. According to this hypothesis, those with OCPD have never developed a secure attachment style, had overbearing parents, were shown little care, and were unable to develop empathetically and emotionally.

Diagnosis

DSM-5

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, a widely used manual for diagnosing mental disorders, places obsessive compulsive personality disorder under section II, under the "personality disorders" chapter, and defines it as: "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". A diagnosis of OCPD is only received when four out of the eight criteria are met.

Alternative model for diagnosis

The DSM-5 also includes an alternative set of diagnostic criteria as per the dimensional model of conceptualising personality disorders. Under the proposed set of criteria, a person only receives a diagnosis when there is an impairment in two out of four areas of one's personality functioning, and when there are three out of four pathological traits, one of which must be rigid perfectionism.

The patient must also meet the general criteria C through G for a personality disorder, which state that the traits and symptoms being displayed by the patient must be stable and unchanging over time with an onset of at least adolescence or early adulthood, visible in a variety of situations, not caused by another mental disorder, not caused by a substance or medical condition, and abnormal in comparison to a person's developmental stage and culture/religion.

Differential diagnosis

There are several mental disorders in the DSM-5 that are listed as differential diagnoses for OCPD. They are as follows:

• Obsessive-compulsive disorder. OCD and OCPD may have a similar name which may cause confusion; however, OCD can be easily distinguished from OCPD by the absence of true obsessions or compulsions.
• Hoarding disorder. A diagnosis of hoarding disorder is only considered when the hoarding behavior exhibited is causing severe impairment in the functioning of the person, such as an inability to access rooms in a house due to excessive hoarding.
• Narcissistic personality disorder. Individuals with narcissistic personality disorder may believe that they are perfect and that no one else can be as "perfect" or "right" as them; however, people with narcissistic personality disorder usually believe that they have achieved perfection and cannot get better, whereas those with OCPD do not believe that they have achieved perfection, and are self-critical. Those with NPD tend to be stingy and lack generosity; however, they are usually generous when spending on themselves, unlike those with OCPD who hoard money and are miserly on themselves and others.
• Antisocial personality disorder. Similarly, individuals with anti personality disorder are not generous and miserly around others, although they usually over-indulge themselves and are sometimes reckless in spending.
• Schizoid personality disorder. Schizoid personality disorder and obsessive-compulsive personality disorder may both display restricted affectivity and coldness; however, in OCPD, this is usually due to a controlling attitude, whereas in SPD, it occurs due to a lack of ability to experience emotion and display affection.
• Other personality traits. Obsessive-compulsive personality traits may be particularly useful and helpful, especially in productive environments. Only when these traits become extreme, maladaptive, and cause clinically significant impairment in several aspects of one's life should a diagnosis of OCPD be considered.
• Personality change due to another medical condition. Obsessive–compulsive personality disorder must be differentiated from a personality change due to a medical condition, which affects the central nervous system, and may cause changes in behavior and traits.
• Substance use disorders. Substance use may cause the advent of obsessive-compulsive traits. It is necessary that this is distinguished from underlying and persistent behavior, which must occur when a person is not under influence of a substance.

ICD-10

The World Health Organization's ICD-10 uses the term anankastic personality disorder (F60.5). Anankastic is derived from the Greek word ἀναγκαστικός (Anankastikos: "compulsion"). The criteria for the disorder are generally similar to the DSM-5 criteria, with the largest difference being the absence of hoarding as a criterion for diagnosis. Under this set of criteria person can only receive a diagnosis when four out of the eight prescribed criteria.It is also a requirement of ICD-10 that a diagnosis of any specific personality disorder satisfies a set of general personality disorder criteria.

Comorbidity

Several disorders have been observed to have a higher risk of comorbidity with OCPD, they include: obsessive-compulsive disorder, eating disorders, Asperger's syndrome, and depression.

Obsessive-compulsive disorder

OCPD is often confused with obsessive-compulsive disorder (OCD). Despite the similar names, they are two distinct disorders. Some OCPD individuals do have OCD, and the two can be found in the same family, sometimes along with eating disorders. People with OCPD do not generally feel the need to repeatedly perform ritualistic actions—a common symptom of OCD—and usually find pleasure in perfecting a task, whereas people with OCD are often more distressed after their actions.

There is significant similarity in the symptoms of OCD and OCPD, which can lead to complexity in distinguishing them clinically. For example, perfectionism is an OCPD criterion and a symptom of OCD if it involves the need for tidiness, symmetry, and organization. Hoarding is also considered both a compulsion found in OCD and a criterion for OCPD in the DSM-5. Even though OCD and OCPD are seemingly separate disorders there are obvious redundancies between the two concerning several symptoms.

Regardless of similarities between the OCPD criteria and the obsessions and compulsions found in OCD, there are discrete qualitative dissimilarities between these disorders, predominantly in the functional part of symptoms. Unlike OCPD, OCD is described as invasive, and stressful. Time-consuming obsessions and habits are aimed at reducing the obsession related stress. OCD symptoms are at times regarded as ego-dystonic because they are experienced as alien and repulsive to the person. Therefore, there is a greater mental anxiety associated with OCD.

In contrast, the symptoms seen in OCPD, although repetitive, are not linked with repulsive thoughts, images, or urges. OCPD characteristics and behaviors are known as ego-syntonic, as people with this disorder view them as suitable and correct. On the other hand, the main features of perfectionism and inflexibility can result in considerable suffering in an individual with OCPD as a result of the associated need for control.

Studies using DSM-IV criteria have persistently found high rates of OCPD in persons with OCD, with an approximate range of 23% to 32% in persons with OCD. Data suggest that there may be specificity in the link between OCD and OCPD. OCPD rates are consistently higher in persons with OCD than in healthy population controls using DSM-IV criteria.

Comorbidity between OCD and OCPD has been linked to a more severe presentation of symptoms, more significant impairment in functioning, poorer insight, and higher comorbidity of depression and anxiety. The presence of OCPD also negatively affected the course of treatment.

Asperger's syndrome

There are considerable similarities and overlap between Asperger's syndrome and OCPD, such as list-making, inflexible adherence to rules, and obsessive aspects of Asperger's syndrome, although the latter may be distinguished from OCPD especially regarding affective behaviors, worse social skills, difficulties with Theory of Mind and intense intellectual interests e.g. an ability to recall every aspect of a hobby. A 2009 study involving adult autistic people found that 40% of those diagnosed with Asperger's syndrome met the diagnostic requirements for a comorbid OCPD diagnosis.

Eating disorders

In people with eating disorders, 13% also have OCPD. Divergences between different studies as to the incidence of OCPD among people diagnosed with anorexia nervosa (AN) and bulimia nervosa (BN) have been found, which may in part reflect differences in the methodology chosen in different studies, as well as the difficulties of diagnosing personality disorders.

Regardless of the prevalence of the full-fledged OCPD among eating disordered samples, the presence of this personality disorder and its over-controlled quality has been found to be positively correlated with a range of complications in eating disorders, as opposed to impulsive features—those linked with histrionic personality disorder, for example—which predict a better outcome from treatment. OCPD predicts more severe symptoms of AN, worse remission rates, and the presence of aggravating behaviors such as compulsive exercising. Compulsive exercising in samples with eating disorders, along with smaller lifetime BMI and illness duration among people with AN, also correlates positively and significantly with an important OCPD trait: perfectionism.

Perfectionism has been linked with AN in research for decades. A researcher in 1949 described the behavior of the average “anorexic girl” as being "rigid" and "hyperconscious", observing a tendency to "[n]eatness, meticulosity, and a mulish stubbornness not amenable to reason [which] make her a rank perfectionist".

The obsessive-compulsive personality traits of over-attention to details and inflexibility have been found in cognitive testing of people with anorexia. Over-attention to details among people with anorexia and weak central coherence are linked with a well-known cognitive failure in this group, that of missing "the big picture", a characteristic of the cognitive style of those with OCPD.

Other disorders

A diagnosis of OCPD is common with anxiety disorders, substance use disorders, and mood disorders. OCPD is also highly comorbid with Cluster A personality disorders, especially paranoid and schizotypal personality disorders. OCPD has also been linked to a higher relapse in those who are treated for major depressive disorder, and a higher risk of suicidal behaviour.

OCPD is linked to hypochondriasis, with some studies estimating a rate of co-occurrence as high as 55.7%. This may be due to the similar nature of the condition to OCPD, namely the need for control and the low tolerance for ambiguity and uncertainty in both.

Treatment

Pyschotherapy is a proposed treatment for OCPD

The best validated treatment for OCPD is cognitive therapy (CT) or cognitive behavioral therapy (CBT), with studies showing an improvement in areas of personality impairment, and reduced levels of anxiety and depression. Group CBT is also associated with an increase in extraversion and agreeableness, and a reduced neuroticism. Interpersonal psychotherapy has been linked to even better results when it came to reducing depressive symptoms.

Epidemiology

Estimates for the prevalence of OCPD in the general population range from 3% to 8%, making it the most common personality disorder. Some studies show no gender differences, but others show OCPD more prevalent among men. It is estimated to occur in 8.7% of psychiatric outpatient settings.

History

Sigmund Freud, 1921

In 1908, Sigmund Freud named what is now known as obsessive-compulsive or anankastic personality disorder "anal retentive character". He identified the main strands of the personality type as a preoccupation with orderliness, parsimony (frugality), and obstinacy (rigidity and stubbornness). The concept fits his theory of psychosexual development. Freud believed that the anal retentive character faced difficulties regulating the control of defecation, leading to repercussions by the parents, and it is the latter that would cause the anal retentive character.

OCPD was included in the first edition of the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association. It has since been included in every edition of the manual, including the most recent DSM-5, unlike other personality disorders which have undergone changes to categorisation over time.

The diagnostic criteria for OCPD have gone through considerable changes with each DSM modification. For example, the DSM-IV stopped using two criteria present in the DSM-III-R, constrained expression of affection and indecisiveness, mainly based on reviews of the empirical literature that found these traits did not contain internal consistency.

With DSM-IV, OCPD was classified as a 'Cluster C' personality disorder. There was a dispute about the categorization of OCPD as an Axis II anxiety disorder. Although the DSM-IV attempted to distinguish between OCPD and OCD by focusing on the absence of obsessions and compulsions in OCPD, OC personality traits are easily mistaken for abnormal cognitions or values considered to underpin OCD. The disorder is neglected and understudied area of research and further research is needed to conceptualise this disorder in a more concrete manner.

See also

• Analysis paralysis
• Anal retentiveness
• Authoritarian personality
• Compulsive hoarding
• Germaphobia
• Jobsworth
• Pedantic
• Scrupulosity

Further reading

• Cheeseman, Gwyneth D. (2013). "All You Need To Know About OCPD and Perfectionism". Willows Books Publishing. UK. [1]
• Freud, S. (1959, original work published 1908).Character and Anal Eroticism, in The Standard Edition of the Complete Psychological Works of Sigmund Freud, 9, 170–71. James Strachey, ed. London: Hogarth. ISBN 978-0-7012-0067-1 ISBN 0-7012-0067-7

External links

• MedlinePlus Encyclopedia: Obsessive–compulsive personality disorder