Obsessive-compulsive personality disorder: causes, symptoms, diagnosis, therapy, medication

By Cristiano Antonino On Nov 1, 2022

Obsessive-compulsive personality disorder (hence the acronym OCPD) is a personality disorder characterised by: preoccupation with order and rules, difficulty in completing tasks, perfectionism, rigidity on matters of ethics and morality, need for control in work, need for control in interpersonal relationships

As is always the case in psychiatry, since these aspects can also be found in the healthy population, they are considered pathological when they come to interfere with the ability to work and develop social and/or intimate relationships, then it is appropriate to diagnose the presence of obsessive-compulsive personality disorder.

Obsessive-compulsive disorder is included in Cluster C of personality disorders, which encompasses three personality disorders characterised by low self-esteem and/or high anxiety and for which people often appear anxious or fearful.

Cluster C includes, in addition to obsessive-compulsive disorder, also:

avoidant personality disorder: the sufferer tends to avoid social situations altogether for fear of negative judgements from others, thus presenting a marked shyness;
dependent personality disorder: sufferers have a marked need to be looked after and looked after by others, thus delegating all their decisions.
Obsessive-compulsive personality disorder’ is also called ‘obsessive-compulsive personality disorder’: the two names are synonymous.

Causes of obsessive-compulsive personality disorder

The causes are still not entirely clear, but it is thought to be a multifactorial aetiology in which environmental factors, such as upbringing, education and/or stressful or shattering events, are in fact triggered by a genetic predisposition.

An important weight in the onset of this disorder is most likely to be assumed by the parents, who themselves often suffer from obsessive-compulsive personality disorder.

Often it is only one parent who suffers from it, but statistically it is the parent who spends the most time with the children, i.e. the mother.

Here are a number of characteristics present in the parents of these patients that seem to point their children towards the same disorder:

hyper-control by the parents;
use of excessive punishment when the child deviates even slightly from the set standards;
lack of parental emotionality;
inhibition of the expression of emotions and contact with them;
push to make the child autonomous without, however, associating adequate support in the exploration of the outside world;
excessive indulgence during the child’s early years and high moral standards associated with unrealistic demands for maturity and responsibility in later years.

Symptoms and signs of obsessive-compulsive personality disorder

As already mentioned at the beginning of the article, patients who present with obsessive-compulsive personality disorder exhibit certain characteristic behaviours, among which are

strict application of the rules they believe in
scrupulousness of morality and ethics;
rigid organisation of daily life;
excessive dedication to work;
perfectionism;
elaboration of rigid schemes and lists relating to the performance of a task;
accumulation of objects of no value;
accumulation of information of no value;
avarice;
formal, polite and correct interpersonal behaviour;
judgmental, critical, controlling and punitive behaviour towards other people (relatives, friends, partners, colleagues…);
tendency towards order and organisation through the use of lists, schemes, rigid spatial and mental geometries;
complacent behaviour towards figures they consider authoritative;
reluctance to delegate the performance of a task to others, since such a task would certainly be performed worse than if performed autonomously;
lack of cooperation in work groups;
insistence on forcing subordinates to adhere to one’s own working method;
difficulty expressing one’s moods;
difficulty manifesting emotions of warmth and caring towards others;
tendency to restrain one’s aggressive feelings;
stubbornness;
anxiety if something does not go exactly as planned or as it ‘should’;
anxiety if there is no ‘order’;
not accepting that one is wrong or has made mistakes;
anger at people who, according to one’s own yardstick, do not ‘get it right’;
maniacal attention to everything around them;
desire for control over ‘everything’;
having personal rules that are difficult for them to change, even if other people show them that they could be improved or made wrong;
passive-aggressive behaviour;
hoarding money with a view to future catastrophes (the prediction of which is, however, unfounded).

Differences between obsessive-compulsive disorder and obsessive-compulsive personality disorder

Many people, even in health care, confuse obsessive-compulsive disorder with obsessive-compulsive personality disorder.

The differences are relatively blurred, yet they are present, for example, obsessive-compulsive disorder is an anxiety disorder, while obsessive-compulsive personality disorder is a personality disorder.

Obsessive-compulsive personality disorder differs from obsessive-compulsive disorder mainly in two factors:

in personality disorder, there is usually an absence of real obsessions and compulsions (which, on the other hand, are present in obsessive-compulsive disorder and force the person to repeat the same action several times)
Obsessive-compulsive disorder sufferers are tormented by recurrent thoughts with unpleasant content and driven to engage in ritualistic behaviour: this way of life is recognised as problematic by the person himself and he wants to get rid of it (he is ‘egodystonic’); obsessive-compulsive personality disorder sufferers, on the other hand, rarely experience discomfort because of their personality traits and, rather, regard them as highly adaptive and useful for coping with their life, work and relationships (he is ‘egosyntonic’).

Diagnosis

The diagnosis is made by the doctor on the basis of the patient’s anamnesis and characteristics, using the following criteria (the most up-to-date are those of the DSM-5):

Diagnosis according to DSM-IV-TR criteria

The official DSM-IV-TR classification requires the presence of at least four of the following symptoms:

Excessive preoccupation with lists, details and organisation to the detriment of the overall goal
Perfectionism that interferes with getting a job done quickly
Excessive dedication to work (not justified by economic necessity) resulting in reduced time for leisure activities
Inability to throw away old or useless objects, even when they have no emotional value
Inflexibility on ethical and/or moral positions (not justified by political or religious affiliation)
Reluctance to delegate tasks or work in a group
Excessively thrifty lifestyle towards both oneself and others
Rigidity and stubbornness.

Diagnosis according to ICD-10 criteria

The ICD-10 classification (in which the disorder is called Anankastic personality disorder) requires the presence of at least four of the following symptoms:

Excessive indecision and caution
Preoccupation with details, rules, lists, order and organisation to the detriment of the overall purpose of the activity
Perfectionism that interferes with the success of a job
Excessive scrupulosity and responsibility
Dedication to work and productivity resulting in devaluation of leisure activities and interpersonal relationships
Excessive pedantry and adherence to social conventions
Rigidity and obstinacy
Need for constant control and the need for others to act exactly according to the subject’s instructions.

Diagnosis according to DSM-5 criteria

For a diagnosis of obsessive-compulsive personality disorder, patients must have

A persistent pattern of preoccupation with order; perfectionism; and control of self, others and situations

This pattern is evidenced by the presence of ≥ 4 of the following:

Concern for details, rules, schedules, organisation and lists
Striving to do something perfect that interferes with task completion
Excessive devotion to work and productivity (not due to financial need), resulting in abandonment of leisure activities and friends
Excessive conscientiousness, meticulousness and inflexibility regarding ethical and moral issues and values
Lack of willingness to throw away worn-out or worthless objects, even those with no sentimental value
Reluctance to delegate or work with other people unless these people decide to do things exactly as the patients want them to
A stingy approach to spending on themselves and others because they see money as something to be kept for future disasters
Rigidity and stubbornness.

Symptoms must begin in early adulthood.

Differential diagnosis arises with various diseases and conditions, including:

obsessive-compulsive disorder;
avoidant personality disorder;
schizoid personality disorder;
narcissistic personality disorder;
antisocial personality disorder;
post-traumatic stress disorder;
social phobia;
hypochondria;
depression;
Asperger’s syndrome;
narcissistic personality disorder;
panic attacks;
agoraphobia;
similar symptoms caused by drug use.

In some cases obsessive-compulsive personality disorder may occur simultaneously with one or more of the conditions and pathologies listed above, making diagnosis more difficult.

Obsessive-compulsive personality disorder should also not be confused with a simple precision- and order-oriented lifestyle or obsessive-compulsive traits.

Although these symptoms are part of the adult population affected by OCD, the personality disorder – as already stated at the beginning of this article – is only considered as such when it comes to interfering with the subject’s life, thus with the ability to work and develop social and/or intimate relationships.

Obsessive-compulsive personality disorder can be confused with narcissistic personality disorder because they share a tendency towards perfectionism

There are differences: whereas patients with narcissistic personality disorder tend to believe they have achieved absolutely perfect standards – without self-criticism or a tendency to further improvement – on the contrary, patients with obsessive-compulsive personality disorder tend to believe they have not achieved perfection, generally remaining dissatisfied with their achievements and self-critical of themselves.

Obsessive-compulsive personality disorder can be likened to narcissistic personality disorder and antisocial personality disorder in that all three disorders are linked by stinginess, but whereas in obsessive-compulsive personality disorder, one is stingy towards others as well as oneself, in the other two disorders one is stingy only towards others (and NOT towards oneself).

Obsessive-compulsive personality disorder patients present a significant impairment of social, work and affective life.

From a social point of view, the excessive dedication to work and productivity, coupled with avarice, often leads the subjects to exclude leisure activities and alienate friendships.

From a professional point of view, the tendency to perfectionism and detailed organisation of activities – although apparently and in some cases actually effective in working efficiently – may interfere with the ability to complete planned tasks and make decisions.

Other characteristics that may impede the performance, especially of certain types of work, are the reluctance to delegate the performance of tasks to others, the difficulty in fitting into a peer group, and the relationship of excessive control of subordinates.

From an affective point of view, the patient has difficulty accessing and expressing his emotions and moods and this interferes with the formation of long-term intimate relationships.

Contributing to this is the tendency to control one’s partner too much, to have excessive expectations of him or her and to excessively control the home environment and routines.

The treatment of obsessive-compulsive personality disorder includes various types of therapies and instruments, which can also be used synergistically:

psychodynamic psychotherapy
cognitive-behavioural therapy;
narrative medicine;
exposition therapy;
narrative exposure therapy;
drug therapy.

Treatment is usually complicated by the patient’s rigidity, stubbornness, and need for control, which can be frustrating for therapists; let us also remember that this disorder is often egosyntonic, i.e. it is seen by the patient as a good way to cope with work and social life, so it is not seen as a disease to be treated.

Psychodynamic therapy and cognitive-behavioural therapy can help patients with obsessive-compulsive personality disorder; in some cases, drugs belonging to the selective serotonin reuptake inhibitor class can be helpful.

Cognitive-behavioural therapy

Within the framework of cognitive-behavioural therapy for obsessive-compulsive personality disorder, the treatment goals are agreed upon in collaboration between patient and therapist and therefore differ from patient to patient.

The goals of cognitive behavioural therapy are:

to lower pathologically high standards of performance and goals;
to learn strategies for dealing with problematic situations;
encourage acceptance of one’s moods and emotions;
reduce negative states of irritability and anxiety;
reduce the tendency to avoid situations that are outside one’s rigid rules;
promote flexibility in matters of morality and ethics;
increase the ability to relax in leisure activities;
develop the ability to establish more relaxed, informal, and intimate relationships;
abandoning complacent behaviour on the one hand, dominant behaviour on the other;
managing situations where one cannot ‘control everything’.

The method for achieving these goals uses these strategies

identify, question and change basic beliefs about oneself and the world;
identifying and interrupting vicious circles between emotions, thoughts and behaviour;
accepting oneself and one’s limits;
learning relaxation techniques;
exposure to feared situations (e.g. situations the patient cannot control).

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