The Oxford Handbook of Personality Disorders
Chapter 26
Obsessive-compulsive personality disorder

History of a concept

Early psychoanalytical perspectives

Freud hypothesized that orderliness, parsimony and obstinacy were either sublimations of. Or reaction formations against, anal-erotic instincts of childhood. This is without empirical support.

Early psychoanalysts provided rich clinical descriptions of what would later become known as compulsive or obsessive-compulsive personality disorder. Several of the traits were incorporated into later diagnostic criteria.

The diagnostic and statistical manual of mental disorders and revisions

DSM-IV and DSM-IV-TR specified the essential feature of obsessive-compulsive personality disorder as ‘preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. An individual must have at least four of the eight criteria in order to meet the diagnosis.

Obsessive-compulsive personality traits in moderation may be especially adaptive, particularly in situations that reward high performance.

International classification of diseases

The equivalent of obsessive-compulsive personality disorder in the ICD-10, is anankastic personality disorder. Criteria are: 1) preoccupation with details, rules, list, order, organisation or schedule 2) perfectionism that interferes with task completion 3) excessive conscientiousness and scrupulousness 4) undue preoccupation with productivity to the exclusion of pleasure an interpersonal relationships 5) rigidity and stubbornness 6) unreasonable insistence by the individual that others submit to exactly his or her way of doing things 7) feelings of excessive doubt and caution 8) excessive pedantry and adherence to social conventions.

Clinical aspects

Epidemiology

Estimates about the prevalence of obsessive-compulsive personality disorder range from 1.6-2.5%.

The prevalence in men and women is similar. The prevalence s greater in older age groups.

Comorbidity

Anxiety and mood disorders

Patients with OCPD had higher prevalences of anxiety disorder, social phobia, obsessive-complusive anxiety disorder and mood disorder.

Obsessive-compulsive disorder

Neuroticism and OCPD may be alternative expressions of the same underlying vulnerability in at least some families with OCD.

Eating disorders

OCPD has been found to be the most common personality disorder in patients with eating disorders.

Co-occurrence with other personality disorders

There is considerable diagnostic overlap between OCPD and other personality disorders. There are significant correlations with: avoidant PD, dependent PD, paranoid PD and borderline PD.

More than half the patients with OCPD had a co-occurring personality disorder.

Functional impairment

A substantial proportion of patients with OCPD show evidence of functional impairment.

Treatment

The traditional treatment approach is intensive psychoanalyses. It is hoped that the patient will become aware of the defences (s)he marshals to control anxiety and how these interfere with a satisfying interpersonal life.

Cognitive-behavioural therapies aim to identify and change patients’ maladaptive interpretations and meanings that they associate with experience. Behavioural therapy aims to increase adaptive and decrease maladaptive behaviour patterns, by using behavioural techniques such as 1) graded exposure to increase the patient’s rewards and tolerance for novelty 2) increase emotional awareness and expression 3) decrease avoidance tendencies.

Validity of obsessive-compulsive personality disorder criteria

Stability

OCPD has a relatively stable trait structure, but with fluctuation in the severity or amount of features present at each point in time. Over a 2-year period, the most prevalent and least changeable OCPD criteria are rigidity and problems delegating. The least prevalent and most changeable criteria are distress and inflexibility about morality.

Interrater agreement

Studies do not support the convergent validity of the OCPD diagnosis.

Dimensional approaches to obsessive-compulsive personality disorder

The five-factor model

The five factor model proposes that the personality disorders should be described and understood as extreme or maladaptive variants of underlying dimensions of personality structure.

Differentiating extreme form maladaptive variants of general personality traits

Very extreme scores on the taxonomic dimensions of the FFM are likely to be maladaptive. Not every very extreme score is necessary going to express or reflect pathology or maladaptivity or lead to impairment or dysfunction. Situational or contextual factors are powerful determinants of what is a good or bad fit of a trait.

Other facets or traits in the person’s particular personality profile may buffer, constrain, modify, or otherwise influence how the trait is expressed concretely in particular situations.

But, one should not consider ‘OCPD to be simply a disorder of excessive conscientiousness’.