Day # 141: Obsessive-Compulsive Personality Disorder

Today we will continue our current theme of cluster C personality disorders. Today's topic is obsessive-compulsive personality disorder.

Today's Content Level: Beginner and Intermediate

Introduction 1

• Individuals with obsessive-compulsive personality disorder (OCPD) have a long-standing pattern of perfectionism, orderliness, control, and inflexibility.

• They are often successful professionally, but may become overly preoccupied with perfecting unimportant details and find it difficult to complete simple tasks on time.

• Common traits/symptoms may include being -> perfectionistic, controlling, persistent, determined, strict, formal, rule-based, scrupulous, rigid, inflexible, stubborn, indecisive, and frugal.

Diagnostic Criteria 2

• The diagnosis of OCPD requires a pervasive pattern of preoccupation with orderliness, control, and perfectionism at the expense of efficiency and flexibility, beginning by early adulthood and present in a variety of contexts.

• ≥4 of the following must also be present: Mnemonic "SCRIMPER"

• Stubborn - Rigid and stubborn

• Cannot discard - Unable to discard worthless objects even with no sentimental value

• Rules - Preoccupation with details, rules, lists, and organization such that the major point of the activity is lost

• Inflexible morals/ethics/values - Excessive conscientiousness and scrupulousness about morals and ethics

• Miserly - Cheap/stingy spending style

• Perfectionistic - Perfectionism that is detrimental to completion of task

• Employment - Excessive devotion to work and productivity

• Reluctance - Reluctant to delegate tasks unless they agree to their exact way of doing things

Epidemiology/Pathogenesis 3, 4, 5

• Prevalence estimates vary between 2-8% of the general population. A number of studies provide evidence that OCPD is the most prevalent personality disorder in the general population and the second or third most common in the psychiatric population.

• Some studies demonstrate higher rates among men, whereas other studies demonstrate the same prevalence among men and women.

• As with all personality disorders, the dominant theory suggests dependent PD develops from a combination of genetic vulnerability and environmental stressors.

• OCPD occurs more frequently in first-degree biological relatives with OCPD than the general population. OCPD is possibly genetically unrelated to other cluster C PDs. Being the oldest sibling has also been found to be a risk factor. The following parental approaches have also been associated-> harsh discipline methods, authoritarian, and overprotection which reduces the formation of secure attachments.

Clinical Pearls 6, 7, 8

• History: OCDP begins early in life by a pervasive pattern of preoccupation with rules, orderliness, details, and the achievement of "perfection". They insist rules be followed rigidly and find it difficult to be flexible, compromise, and tolerate others. This often leads to a sense of formality, seriousness, a lack of sense of humor, and limited interpersonal skills. They may flourish in their career particularly in positions that are demanding and require methodical or detailed work. They may be eager to please those whom they see as more powerful and carry out their wishes in an authoritarian manner. Their perfectionism and fear of making mistakes may be detrimental to completing tasks or lead to indecisiveness. They may be vulnerable to unexpected changes and can lead to significant anxiety or depressive symptoms. Overall the lifetime course of OCPD is unpredictable and an increasing number of studies show that OCPD (among other personality disorders) are less stable and persistent than originally assumed. One study reported a remission rate of 38% within a 24 month follow up, whereas other data suggests symptoms remain stable or even worsen with age.

• Mental status exam: Patients will often appear stiff and formal in the psychiatric interview. Their affect is not flat or blunted but can be described as constricted. They lack spontaneity and their mood is usually serious. They may answer questions with a significant amount of detail. Common defense mechanisms for these patients are intellectualization, rationalization, reaction formation, and undoing.

• Optional personality questionnaires: Personality Assessment Inventory (PAI), Minnesota Multiphasic Personality Inventory (MMPI).

• Differential diagnosis: Due to the similarity in their names, OCPD should be distinguished from obsessive-compulsive disorder (OCD). OCD is distinguished by intrusive/recurrent obsessions or compulsions which are not present in pure OCPD although comorbid OCD and OCPD can occur. Additionally, patients with OCD are typically aware they have a problem and wish that their thoughts and behaviors would go away (aka ego-dystonic) whereas patients with OCPD may have thoughts and behaviors that are more acceptable/compatible to themselves (aka ego-syntonic). Also consider other personality disorders in the differential diagnosis particularly narcissistic PD as both involve assertiveness, control, and achievement, however patients with OCPD are typically motivated by the work itself rather than the status, recognition, or power. Screen for eating disorders in patients with OCPD since it is estimated that it increases the odds of having an eating disorder by 7 times.

Treatment 9, 10, 11

• General approach to personality disorders: In general, the first-line treatment of all personality disorders is psychotherapy, however, the data is not robust and depending on the personality disorder, patients rarely seek treatment themselves unless they have other comorbid behavioral health conditions. Patients with personality disorders may be highly symptomatic and are often prescribed multiple medications in a manner unsupported by evidence.

• Psychotherapy: Cognitive behavioral therapy (CBT) is effective for cluster C personality disorders including OCPD. This treatment is based on the tenet that maladaptive emotions and behaviors manifest from cognitive biases and core beliefs developed in childhood. Studies have found CBT effective in improving social agreeableness and self esteem and reducing symptom severity including co-morbid depression and anxiety. Interpersonal therapy (IPT) and Schema therapy (ST) have also been proven to be effective with some studies showing a stronger response than CBT for certain symptoms. IPT aims to provide reassurance, improve interpersonal communication, and clarify feelings and has been found particularly effective for depressive symptoms. ST brings together elements from CBT, psychoanalysis, attachment theory, and emotion-focused therapy, among others. Insight-oriented therapies, such as psychodynamic psychotherapy, involves a close examination into certain past relationships in which their strict and controlling behavior was encouraged.

• Pharmacotherapy: There are no FDA approved medications or randomized control trials for OCPD. There are very few studies on this subject and they mostly consist of case studies, uncontrolled longitudinal studies, and/or include individuals suffering from comorbid disorders in addition to OCPD. Some research suggest a reduction in OCPD traits and decreased depression/anxiety in patients treated with citalopram, fluvoxamine, and carbamazepine. Expectations for treatment response should be attenuated and the potentially limited benefits must outweigh the risks associated with medication treatment. Comorbid anxiety, OCD, and depressive disorders should be treated accordingly (see treatment of depression; treatment of OCD; treatment of anxiety).

Conclusion

• Next lesson we will have a review quiz and after that we will move on to our next theme: eating disorders. If you want more learning resources then check out our recommended resources page.

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• Resources for today's post include: First Aid for Psychiatry, Kaplan and Sadock’s Synopsis of Psychiatry, DSM-5, Pocket Psychiatry, and the articles referenced above.