Obsessive–compulsive personality disorder

Obsessive–compulsive personality disorder (OCPD), also called anankastic personality disorder, is a personality disorder characterized by a pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control at the expense of flexibility, openness, and efficiency. In contrast to people with obsessive-compulsive disorder (OCD), behaviors are rational and desirable to people with OCPD.
OCPD is a chronic non-adaptive pattern of extreme perfectionism, preoccupation with neatness and detail, and a need for control or power over one's environment that causes major suffering and stress, especially in areas of personal relationships. Persons with OCPD are usually inflexible and controlling. They may find it hard to relax, and must plan out their activities down to the minute. OCPD occurs in about 1% of the general population. It is seen in 3–10% of psychiatric outpatients. The disorder most often occurs in men.

Diagnosis

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, as well as 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. Most people spend their early life avoiding symptoms and developing techniques to avoid dealing with these strenuous issues.

Obsessions

Some, but not all, people with OCPD show an obsessive need for cleanliness. This OCPD trait is not to be confused with domestic efficiency; over-attention to related details may instead make these (and other) activities of daily living difficult to accomplish. Though obsessive behavior is in part a way to control anxiety, tension often remains. In the case of a hoarder, attention to effectively clean the home may be hindered by the amount of clutter that the hoarder resolves to later organize.

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 might be expected, such rigidity places strain on interpersonal relationships, with frustration sometimes turning into anger and even violence. This is known as disinhibition.

People with OCPD often tend to general pessimism and/or underlying form(s) of depression. This can at times become so serious that suicide is a risk. Indeed, one study suggests that personality disorders are a significant substrate to psychiatric morbidity. They may cause more problems in functioning than a major depressive episode.

DSM

The Diagnostic and Statistical Manual of Mental Disorders fourth edition, (DSM IV-TR = 301.4), a widely used manual for diagnosing mental disorders, defines obsessive–compulsive personality disorder (in Axis II Cluster C) 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, as indicated by four (or more) of the following:

1. is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
2. shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)
3. is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)
4. is 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 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. A study in 2007 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 (F60.5) Anankastic personality disorder.

It is characterized by at least three of the following:

1. feelings of excessive doubt and caution;
2. preoccupation with details, rules, lists, order, organization or schedule;
3. perfectionism that interferes with task completion;
4. excessive conscientiousness, scrupulousness, and undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships;
5. excessive pedantry and adherence to social conventions;
6. rigidity and stubbornness;
7. unreasonable insistence by the individual that others submit exactly to his or her way of doing things, or unreasonable reluctance to allow others to do things;
8. intrusion of insistent and unwelcome thoughts or impulses.

Includes:

• compulsive and obsessional personality (disorder)
• obsessive-compulsive personality disorder

Excludes:

• obsessive-compulsive disorder

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 compulsive (2004). Any individual compulsive may exhibit one or more of the following:

Subtype	Description	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. Resembles Fromm's hoarding orientation	Miserly, tight-fisted, ungiving, hoarding, unsharing; protects self against loss; fears intrusions into vacant inner world; dreads exposure of personal improprietries 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.

Etiology

Researchers 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. 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. People get OCPD by copying others throughout childhood. OCPD comes from constant contact throughout childhood between the child and persons (e.g., parents or teachers) who are inflexible, controlling, and obsess over the children under their watch.

Comorbidity

OCPD and obsessive-compulsive disorder

OCPD is often confused with obsessive–compulsive disorder (OCD). Despite the similar names, they are two distinct disorders, although some OCPD individuals also suffer from OCD, and the two are sometimes 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.
Significantly higher rates of OCPD have been found in subjects with OCD, with estimates ranging from 23 to 32 percent. For example perfectionism, hoarding, and preoccupation in details (3 characteristics of OCPD) were found in people with OCD and not in people without OCD, showing a particular relationship with OCD.

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. 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.

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. 

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.

While there are superficial similarities between the list-making, inflexible guidelines, and obsessive aspects of Asperger's syndrome and OCPD, the former is different from OCPD especially regarding affective behaviors and restricted interests, including (but not limited to) empathy, recalling every aspect of a subject of interest, non-verbal communication, social cognition, as well as both conversational and general social skills.

OCPD and eating disorders

Perfectionist, inflexible, and stiff personality qualities have been identified in people with anorexia nervosa; however, the occurrence of OCPD in people with eating disorders seems low. Perfectionism is a central feature and risk factor for developing an eating disorder. In some individuals with bulimia nervosa, the seemingly conflicting traits of impulsivity and perfectionism are present.

Using the Structured Clinical Interview for DSM-IV, researchers examined the occurrence of OCPD in a variety of eating disorder diagnostic groups. They found that only 9% of 105 patients met the criteria for OCPD. Only 6% of anorectic restrictors met this diagnosis compared with 13% of the binge type anorectics. The same study also identified subthreshold OCPD (the presence of symptoms that did not meet the threshold for diagnosis) in 18% of the anorexia nervosa patients. Furthermore, none of the normal-weight bulimia nervosa patients in this study met the threshold criteria for the diagnosis of OCPD; yet, six met the subthreshold diagnostic criteria. This finding suggests that bulimia nervosa patients may have some, but not all, of the characteristics of obsessive-compulsive personality, along with impulsive behaviors.

In a sample of mixed anorexics and bulimics, 22% met the criteria for the diagnosis of OCPD when assessed for personality disorders using the Structured Interview for DSM Personality Disorders-Revised (SIDP).

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. 

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 in isolation is generally not indicated for this personality disorder, but fluoxetine has been prescribed with success.

Psychotherapy is not always available, therefore people are advised to read as much as possible about the disorder and seek the cooperation of their families and friends to remind them in a non-confrontational manner when they begin engaging in OCPD behaviours. Self-help may be crucial for a swift accommodation to having to deal with people and situations in what may seem an unfamiliar manner. Self-insight is no less significant. Self-help techniques include keeping a diary for noting down anything that is upsetting, anxiety-provoking, or that overwhelms and depresses the OCPD individual. Family members can help by making a note of their observations and sharing them in a non-confrontational manner.

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

History and theoretical models

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 in large based on Sigmund Freud's notion of the obsessive personality or anal-erotic character style characterized by orderliness, parsimony, and obstinacy.

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.

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 and even to appear in childhood. 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 is more appropriately for OCPD alongside OC spectrum disorders including OCD, body dysmorphic disorder, compulsive hoarding, trichotillomania, compulsive skin-picking, tic disorders, autistic disorders, and eating disorders.

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 ones actions were performed correctly, have also been proposed as enduring features of OCD.

Moreover, in DSM-IV field trials, a majority of OCD patients reported being unsure whether their OC symptoms really were unreasonable.

The ADHD-OCPD theory of human behavior

A new theory published in Medical Hypotheses proposes that civilizations arose because of a selective advantage for some OCPD spectrum traits. The theory called the ADHD-OCPD theory argues that in environments where large scale farming was feasible individual farmers could produce a surplus of a specific type of agricultural product therefore farmers began to compete to be the best producer of specific agricultural products. The farmers with more of the OCPD spectrum traits like orderliness, timeliness, perfectionism and paying great attention to detail were more likely to become the most reliable suppliers of the agricultural product beating out their competitors.

Over time more and more farmers had to specialize on one or very few products to beat out competitors at the market resulting in food production becoming very specialized. Being specialization oriented then became advantageous resulting in the population developing more functional OCPD spectrum traits over many generations. Specialization then spread from farming to other fields giving rise to black-smiths, merchants, doctors and teachers and eventually a full blown civilization made up of people with functional obsessive compulsive personality trait (The theory views OCPD as a spectrum with those with too much of the trait being at the extreme end of the spectrum where the trait is maladaptive and is included in the DSM while the mild form does not fit DSM criteria and is postulated to have led to civilizations.) Members of civilizations were free to specialize on specific crafts because they could use their wages(after money is developed) to get a balanced diet from food markets were the products of specialist farmers were sold.

The theory further argues that in environments where large scale farming was not possible like deserts that are far from big rivers, most of Africa and other areas OCPD spectrum traits were not favorable. In these areas being multi-tasking oriented rather than being specialization oriented was likely required in order to achieve a balanced diet for survival. The condition called ADHD best estimates the characteristics of the multi-tasking oriented personality trait. These environments were not conducive for civilizations to arise therefore the absence of civilizations speaks to the nature of the environment and not to the inferiority of the humans descended from those environments as it has long been held.

The ADHD-OCPD theory provides a model for adaptive radiation in human behavior to achieve a balanced diet in various environments. It goes against the long held view that humans from areas without civilizations are inferior because it provides a model of how humans with the same brain could develop different behaviors as dictated by their different environments. It places the success of a human population on how well it achieves a balanced diet therefore the San, the Inuit, the Native American and other groups seen as inferior were as successful as civilized groups because they managed to achieve a balanced diet for thousands of years in their respective environment.

The theory also purports that civilized man has enjoyed rapid technological advancement not because he is more successful at achieving a balanced diet than 'primitive' man but as a side effect of the OCPD spectrum trait of perfectionism selected for by the environment. In this sense all humans are 'children of nature' not just primitive humans. In the theory, if the Kalahari desert had changed to favor large scale farming the San would have developed OCPD spectrum traits over generations and a civilization would have formed. Similarly if Europe had suddenly become a desert, civilizations there would have collapsed as OCPD spectrum traits gradually waned giving rise to more multi-tasking (ADHD spectrum trait) people in this theory. The ADHD-OCPD theory is a greatly revised version of The Hunter-Farmer theory.