Obsessive–compulsive personality disorder

Not to be confused with Obsessive-compulsive disorder.
"OCPD" redirects here. For other uses, see OCPD (disambiguation).
Obsessive-compulsive personality disorder
Classification and external resources
Specialty Psychiatry
ICD-10 F60.5
ICD-9-CM 301.4
MedlinePlus 000942
MeSH D003193

Obsessive-compulsive personality disorder (OCPD), also called anankastic personality disorder,[1] is a personality disorder characterized by a general pattern of concern with orderliness, perfectionism, excessive attention to details, mental and interpersonal control, and a need for control over one's environment, at the expense of flexibility, openness, and efficiency. Workaholism and miserliness are also seen often in those with this personality disorder.[2]

Rituals are performed to the point of excluding leisure activities and friendships. Persons affected with this disorder may find it hard to relax, always feeling that time is running out for their activities, and that more effort is needed to achieve their goals. They may plan their activities down to the minute—a manifestation of the compulsive tendency to keep control over their environment and to dislike unpredictable things as things they cannot control.[2]

OCPD occurs in about 2–8% of the general population and 8–9% of psychiatric outpatients.[3] The disorder most often occurs in men.[4]

This is a distinct disorder from obsessive–compulsive disorder (OCD), and the relation between the two is contentious. Some (but not all) studies have found high comorbidity rates between the two disorders, and both may share outside similarities – rigid and ritual-like behaviors, for example. Hoarding, orderliness, and a need for symmetry and organization are often seen in people with either disorder.

Attitudes toward these behaviors differ between people affected with either of the disorders: for people with OCD, these behaviors are unwanted and seen as unhealthy, being the product of anxiety-inducing and involuntary thoughts, while for people with OCPD they are experienced as rational and desirable, being the result of, for example, a strong adherence to routines, a natural inclination towards cautiousness, or a desire to achieve perfection.

Signs and symptoms

The main symptoms of OCPD are preoccupation with remembering and paying attention to minute details and facts, following rules and regulations, compulsion to make lists and schedules, and rigidity/inflexibility of beliefs or showing perfectionism that interferes with task completion. Symptoms may cause extreme distress and interfere with a person's occupational and social functioning.[5] Most people spend their early life avoiding symptoms and developing techniques to avoid dealing with these strenuous issues.

Obsessions

Some people with OCPD, but not all, show an obsessive need for cleanliness. This, and an obsessive preoccupation with tidiness, may instead make daily living difficult. Though this kind of obsessive behavior may contribute to a sense of controlling personal anxiety, tension may continue. In the case of a compulsive hoarder, attention to clean the home effectively may be hindered by the amount of clutter that the hoarder resolves to organize later.[6]

Perception of own and others' actions and beliefs tend to be polarised (i.e., "right" or "wrong", with little or no margin between the two) for people with this disorder. As it might be expected, such rigidity places strain on interpersonal relationships, with frustration sometimes turning into anger and even violence. This is known as disinhibition.[7] People with OCPD often tend to general pessimism and/or underlying form(s) of depression.[8][9][10] This can at times become so serious that suicide is a risk.[11] Indeed, one study suggests that personality disorders are a substrate to psychiatric morbidity. They may cause more problems in functioning than a major depressive episode.[12]

Associated conditions

Obsessive–compulsive disorder

OCPD is often confused with obsessive–compulsive disorder (OCD). Despite the similar names, they are two distinct disorders—OCD is an anxiety disorder and OCPD is a personality disorder. Some OCPD individuals do have OCD, and the two are sometimes found in the same family,[13] sometimes along with eating disorders.[14] 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.

Some OCPD features are common in those afflicted with OCD. For example, perfectionism, hoarding, and preoccupation in details (which are three characteristics of OCPD) were found in people with OCD and not in people without OCD, showing a particular relationship between these OCPD traits with OCD.[15] The reverse is also true: certain OCD symptoms appear to have close parallels in OCPD ones. This is particularly the case for checking and ordering and symmetry symptoms. OCPD samples who have OCD are particularly likely to endorse obsessions and compulsions regarding symmetry and organization.[16] Washing symptoms, which are among the most common OCD symptoms, don't appear to have much of a link with OCPD, in contrast.

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-IV. Even though OCD and OCPD are seemingly separate disorders there are obvious redundancies between the two concerning several symptoms.[2]

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, stressful, time-consuming obsessions and habits 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.[2]

In contrast, the symptoms seen in OCPD, though they are repetitive, are not linked with repulsive thoughts, images, or urges. OCPD characteristics and behaviors are known as ego-syntonic, as persons with the 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.[2]

A 2014 study also found a second difference between OCPD and OCD: samples afflicted with OCPD, regardless of the presence of comorbid OCD, are more rigid in behavior and have a greater delayed gratification than either those afflicted with OCD or healthy control samples.[17] Delayed gratification is a measure of self-control — it expresses one's capacity to suppress the impulse to pursue more immediate gratification in order to acquire greater rewards in the future.

Recent 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. Some 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.[2]

Asperger's syndrome

There are considerable similarities and overlap between Asperger's syndrome and OCPD,[18] such as list-making, inflexible adherence to rules, and obsessive aspects of Asperger's syndrome, though the former 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.[19] A 2009 study involving adult autistic people found that 40% of those diagnosed with Asperger's syndrome met the diagnostic requirements for a co-morbid OCPD diagnosis.[20]

Eating disorders

Stiff and rigid personalities have been consistently linked with eating disorders, especially with Anorexia Nervosa.[21][22] Divergences between different studies as to the incidence of OCPD among anorexics and bulimics has been found, which may in part reflect differences in the methodology chosen in different studies, as well as the difficulties of diagnosing personality disorders.[22] In the table below, results are shown for the frequency of OCPD among anorexics (non-specified subtype, AN), restricting anorexics (RAN), binge/purge anorexics as well as anorexics with a history of Bulimia Nervosa (BPAN), and normal-weight bulimics (BN).

Study AN RAN BPAN BN
Arderluh et al. (2009)[23] 71.4% 46.7%—64% 40%
Halmi et al. (2005a)[24] 31% 32% 24%
Halmi et al. (2005b)[22] 6% 11-13% 0%
Anderluh et al. (2003)[23] 61% 46%
Matsunaga et al. (1999)[25] 43.8% 25% 25%

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 better outcome from treatment.[26] OCPD predicts including more severe anorexic symptoms,[27] worse remission rates,[27] and the presence of aggravating behaviors such as compulsive exercising.[28] Compulsive exercising in eating disordered samples, along with smaller lifetime BMI and illness duration among anorexics,[29] also correlates positively and significantly with an important OCPD trait, perfectionism.[30]

Perfectionism has been linked with Anorexia Nervosa in research for decades. Researchers in 1949 described the behavior of the average anorexic girl as being "rigid" and "hyperconscious", observing also a tendency to "[n]eatness, meticulosity, and a mulish stubbornness not amenable to reason [which] make her a rank perfectionist".[21] Perfectionism is a life enduring trait in the biographies of anorexics. It is felt before the onset of the eating disorder, generally in childhood,[23] during the illness, and also, after remission.[31] The incessant striving for thinness among anorexic women is itself a manifestation of this trait, of an insistence upon meeting unattainably high standards of performance.[32] Because of its chronicity, those with eating disorders also display perfectionistic tendencies in other domains of life than dieting and weight control. Over-achievement at school, for example, has been observed among anorexics,[32][33][34] as a result of their over-industrious behavior.[32][35][36]

A Swedish study found that hospitalization for eating disorders was around twice more common among girls who took advanced courses and achieved high average grades than among those who had medium or low grades.[37] The link with over-achievement was particularly high among those hospitalized for AN, which was 3.5 times as common among those with high grades as in those with other grade levels.[37] In some individuals with Bulimia Nervosa, the seemingly conflicting traits of impulsivity and perfectionism are present.[22]

Apart from perfectionism, other OCPD traits have been observed in the childhoods of the eating disordered in much higher frequency than among control samples, including among their unaffected sisters.

Childhood OCPD trait AN[38] RAN[23] BPAN[23] BN[23] OCPD[39] OCPD+OCD[39] OCD (without OCPD)[39] Sisters of anorexics[38] Control samples[23][38][39]
Perfectionism 78% 65.4% 72.2% 50.0% 85.2% 67.9% 42.9% 31% 0—24%
Inflexibility 31% 76.9% 61.1% 25.0% 66.7% 50.0% 32.1% 9% 0—5%
Rule-bound trait 41% 61.5% 77.8% 50.0% 22% 15—17.9%
Doubt and cautiousness 28% 27.3% 46.7% 21.4% 3% 0—5%
Order and symmetry 6% 38.5% 31.3% 10.7% 66.7% 46.4% 17.9% 3% 0—3.6%

Like those afflicted with OCPD, anorexics and bulimics also tend to have a great need for order and symmetry in their activities and surroundings,[31][40] something seen in their relationship with a third disorder, OCD. Eating disorders are largely comorbid with OCD;[41] with some studies showing that OCD symptoms are nearly as severe among anorexics as among a classic OCD sample, and that this remains so even after discounting food- and weight-related obsessions and compulsions.[42]

The eating disordered are less likely, however, to develop the multi-object obsessions and compulsions of classic OCD pacients, who self-report symptoms related to a multitude of themes such as violence, sex, washing, moral taboos etc.. The symptoms of both anorexics[43] and bulimics[44] tend to be more restricted to symmetry and orderliness concerns. The same has been noted in samples afflicted with comorbid OCPD and OCD, who are more likely harbor obsessions and compulsions about symmetry and order than those have OCD only.[16]

At least one paper has made an explicit link between OCPD and the OCD symptoms endorsed by anorexics, noticing that in the samples under study—one with both restrictive anorexia and OCD and another from OCD but no present eating disorder—those with comorbid AN and OCD were more likely to be diagnosed with OCPD than those with OCD only (38.1% vs 8.7%).[25] In a larger sample which included anorexic bingers and bulimics, it was found that all three eating disordered groups were more likely to develop symptoms about order and symmetry than the OCD-only group.[45] Among women recovered from AN, orderliness concerns remain higher than among control samples without an eating disorder history.[31]

The obsessive compulsive personality traits of over-attention to details and inflexibility have also been found in cognitive testing of anorexics;[46] this group, compared to healthy controls, will display average to above average performance in tests requiring accuracy and the avoiding of errors[46] but poorly on tests requiring mental flexibility and central coherence, i.e., the ability to integrate details of information into a bigger narrative.[47] Over-attention to details among anorexics and weak central coherence are linked with a well-known cognitive failure in this group, that of missing "the big picture", a characteristic also of the cognitive style of those with OCPD.[48]

Both anorexics and non-eating disordered OCPD samples have also been found to share the trait of increased self-control, an above average ability to delay gratification in the name of a greater good to be received in the future. Among anorexics specifically, this trait is manifested in their capacity to repress a key natural urge, that of satisfying hunger, in order to be 'rewarded' with weight loss.[49] In a 2012 paper, it was verified this trait exists among anorexics also beyond food and weight themes.[49] The anorexics, especially those of the restricting type, were observed to save money handled to them by researchers more persistently than a control sample of healthy women.[49]

A similar experiment was tested on four non-eating disordered samples—one with OCPD only, another from OCD only, a third afflicted with both OCPD and OCD, and a sample of healthy controls. Delay gratification was found to be pronounced among those with OCPD but not those with OCD only or the control samples, who had similar performances to one another.[17] Delayed gratification, they found, was highly correlated with the severity of OCPD, i.e., the greater the capacity to delay gratification in a person afflicted with OCPD, the more impairing was the disorder.[17] As the authors noticed, while many psychiatric disorders—substance abuse, for example—may be marked by impulse deregulation, OCPD and anorexia nervosa stand out as the only disorders shown to spring forth from the opposite quality: excessive self-control.[17]

Some family studies have also found a close genetic link between OCPD and anorexia. Lilenfeld et al. 1998, compared for a variety of psychiatric diagnoses three sets of women—one suffering from the restricting type of anorexia nervosa, another from bulimia nervosa, and a group of control women without an eating disorder—plus their respective relatives unaffected by eating disorders. They found a much higher incidence of OCPD among anorexics and their relatives (46% and 19%, respectively) than in the control samples and the latter's own relatives (5% and 6%, respectively). What's more, the rates of OCPD among relatives of Anorexics with that personality disorder and those without it were about the same—evidence, in the authors' words, "suggesting shared familial transmission of AN and OCPD".[50]

In this study, bulimics and their relatives were not found to have elevated rates of OCPD (4% and 7%, respectively). Strober et al. 2007, in a similarly intended study, also found much higher incidence of OCPD among relatives of restrictive anorexics than among relatives of a normal control sample (20.7% vs. 7%). Along with diagnoses of OCD and Generalized Anxiety Disorder, OCPD was the one that best distinguished between the two groups.[51]

Cause

Researchers have set forth both genetic and environmental theories for what causes OCPD. Under the genetic theory, people with a form of the DRD3 gene will probably develop OCPD and depression, particularly if they are male.[52][53] But genetic concomitants may lie dormant until triggered by events in the lives of those who are predisposed to OCPD. These events could include trauma faced during childhood, such as physical, emotional, or sexual abuse, or other psychological trauma. Under the environmental theory, OCPD is a learned behavior.

Diagnosis

DSM

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a widely used manual for diagnosing mental disorders, defines obsessive–compulsive personality disorder (in Axis II Cluster C) as an extensive pattern of preoccupation with perfectionism, orderliness, and interpersonal and mental control, at the cost of efficiency, flexibility and openness. Symptoms must appear by early adulthood and in multiple contexts. At least four of the following should be present:[54]

  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 overconscientious, 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.

Criticism

Since the DSM-IV-TR was published in 2000, some studies have found fault with its OCPD coverage. A 2004 study challenged the usefulness of all but three of the criteria: perfectionism, rigidity and stubbornness, and miserliness.[55] A study in 2007[56] found that OCPD is etiologically distinct from avoidant and dependent personality disorders, suggesting it is incorrectly categorized as a Cluster C disorder.

WHO

The World Health Organization's ICD-10 uses the term anankastic personality disorder (F60.5).[57] Anankastic is derived from the Greek word ἀναγκαστικός (Anankastikos: "compulsion").

It is characterized by at least three of the following:

It includes:

Also, it excludes:

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Millon's subtypes

Theodore Millon identified five subtypes of the compulsive personality (2004).[58][59] Any compulsive personality may exhibit one or more of the following:

Subtype Description Compulsive personality traits
Conscientious Including dependent features Rule-bound and duty-bound; earnest, hardworking, meticulous, painstaking; indecisive, inflexible; marked self-doubts; dreads errors and mistakes.
Bureaucratic Including narcissistic features Empowered in formal organizations; rules of group provide identity and security; officious, high-handed, unimaginative, intrusive, nosy, petty-minded, meddlesome, trifling, closed-minded.
Puritanical Including paranoid features Austere, self-righteous, bigoted, dogmatic, zealous, uncompromising, indignant, and judgmental; grim and prudish morality; must control and counteract own repugnant impulses and fantasies.
Parsimonious Including schizoid features. Miserly, tight-fisted, ungiving, hoarding, unsharing; protects self against loss; fears intrusions into vacant inner world; dreads exposure of personal improprieties and contrary impulses.
Bedeviled Including negativistic features Ambivalences unresolved; feels tormented, muddled, indecisive, befuddled; beset by intrapsychic conflicts, confusions, frustrations; obsessions and compulsions condense and control contradictory emotions.

Treatment

Treatment for OCPD includes psychotherapy, cognitive behavioral therapy, behavior therapy or self-help. Medication may be prescribed. In behavior therapy, a patient discusses with a psychotherapist ways of changing compulsions into healthier, productive behaviors. Cognitive analytic therapy is an effective form of behavior therapy.[60][61]

Treatment is complicated if the patient does not accept that they have OCPD, or believes that their thoughts or behaviors are in some sense correct and therefore should not be changed. Medication alone is generally not indicated for this personality disorder, but fluoxetine has been prescribed with success. Selective serotonin reuptake inhibitors (SSRIs) may be useful in addition to psychotherapy by helping the person with OCPD be less bogged down by minor details and to lessen how rigid they are.

People with OCPD are three times more likely to receive individual psychotherapy than people with major depressive disorder.[62][63] There are higher rates of primary care utilization.[64][65] There is no treatment for OCPD that has been thoroughly validated. There are no known properly controlled studies of treatment options for OCPD.[2][66][67] More research is needed to explore better treatment options.[2]

Epidemiology

Estimates for the prevalence of OCPD in the general population range from 2.1% to 7.9%.[54] A large American study found a prevalence rate of 7.9%, making it the most common personality disorder.[68] Men are diagnosed with OCPD about twice as often as women.[54] It may occur in 8–9% of psychiatric outpatients.[3]

A University of Colorado Colorado Springs study comparing personality disorders and Myers-Briggs Type Indicator types found that the disorder had a significant correlation with the Introverted (I), Sensing (S), Thinking (T), and Judging (J) preferences.[69]

History

Psychoanalytic

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.

OCPD was first included in DSM-II, and was largely based on Sigmund Freud's notion of the obsessive personality or anal-erotic character style characterized by orderliness, parsimony, and obstinacy.[2]

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.[2] Since the early 1990s, considerable research continues to characterize OCPD and its core features, including the tendency for it to run in families along with eating disorders[70] and even to appear in childhood.[71]

According to the DSM-IV, OCPD is classified as a 'Cluster C' personality disorder. There was a dispute about the categorization of OCPD as an Axis II anxiety disorder. It has been argued that it is more appropriate for OCPD to appear alongside OC spectrum disorders including OCD, body dysmorphic disorder, compulsive hoarding, trichotillomania, compulsive skin-picking, tic disorders, autistic disorders, and eating disorders.[72]

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. Aspects of self-directed perfectionism, such as believing a perfect solution is commendable, discomfort if things are sensed not to have been done completely, and doubting one's actions were performed correctly, have also been proposed as enduring features of OCD.[73] Moreover, in DSM-IV field trials, a majority of OCD patients reported being unsure whether their OC symptoms really were unreasonable.[74]

See also

References

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