Obsessive–compulsive PD

**Obsessive–compulsive personality disorder** (**OCPD**) is a personality disorder characterized by excessive concern with orderliness, perfectionism, attention to details, mental and interpersonal control, and a need for control over one's environment, which interferes with flexibility, openness to experience, and efficiency, as well as interpersonal relationships. Workaholism and miserliness are also seen often in those with this personality disorder.

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 events as elements beyond their control.

The cause of OCPD is thought to involve a combination of genetic and environmental factors. This is a distinctly different 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 egosyntonic (that is, they are perceived by the subject 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.

The disorder occurs more often in men.

## Signs and symptoms

The main observed symptoms of OCPD are (1) preoccupation with remembering past events, (2) paying attention to minor details, (3) excessive compliance with existing social customs, rules or regulations, (4) unwarranted compulsion to note-taking, or making lists and schedules, and (5) rigidity of one's own beliefs, or (6) showing unreasonable degree of perfectionism that could eventually interfere with completing the task at hand.

OCPD's symptoms may cause varying level of distress for varying length of time (transient, acute, or chronic), and may interfere with the patient's occupational, social, and romantic life.

### Obsessions

Some OCD patients show an obsessive need for cleanliness, usually combined with an obsessive preoccupation for tidiness. This obsessive tendency might make their daily life rather difficult. Although this kind of obsessive behavior can contribute to a sense of "controlling personal anxiety," the tension might continue to exist. On the contrary, OCPD patients might tend not to organize things, and they could become compulsive hoarders. This is due to their efforts in cleaning their surroundings, which can effectively be hindered by the amount of clutter that the person still plans to organize in the future.

In reality, OCPD patients might never obsessively clean or organize, as they become increasingly busy with their workload, and thus their stress turns gradually to what can be described as anxiety. Anxiety is a disorder known for excessive and unexpected worry that negatively impacts an individual's daily life and routines.

### Rigidity

Perception of one's own and others' actions and beliefs tend to be polarised into "right" or "wrong", with little or no margin between the two. For people with this disorder, rigidity could place strain on interpersonal relationships, with occasional frustration turning into anger and even varying degrees of violence. This is known as disinhibition.

### Associated conditions

#### Obsessive-compulsive disorder

OCPD is often confused with obsessive**-**compulsive disorder (OCD). Despite the similar names, they are two distinct disorders. Some OCPD individuals do have 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.

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. 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. 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.

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, although they are repetitive, are not linked with repulsive thoughts, images, or urges. OCPD characteristics and behaviors are known as ego-syntonic, as people with this 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.

In psychoanalysis, **egosyntonic** refers to the behaviors, values, and feelings that are in harmony with or acceptable to the needs and goals of the ego, or consistent with one's ideal self-image. **Egodystonic** (or *ego alien*) is the opposite, referring to thoughts and behaviors (dreams, compulsions, desires, etc.) that are in conflict, or dissonant, with the needs and goals of the ego, or, further, in conflict with a person's ideal self-image.
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. 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.

#### Asperger's syndrome

There are considerable similarities and overlap between Asperger's syndrome and OCPD, such as list-making, inflexible adherence to rules, and obsessive aspects of Asperger's syndrome, though the latter 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. 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.

#### Eating disorders

Stiff and rigid personalities have been consistently linked with eating disorders, especially with anorexia nervosa. Anorexia Nervosa is an eating disorder that is characterized by excessive amounts of restriction regarding food intake in fear of gaining weight. Many people who experience this disorder also experience body dysmorphia. Divergences between different studies as to the incidence of OCPD among anorexics and bulimics have been found, which may in part reflect differences in the methodology chosen in different studies, as well as the difficulties of diagnosing personality disorders. 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).

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. OCPD predicts more severe anorexic symptoms, worse remission rates, and the presence of aggravating behaviors such as compulsive exercising. Compulsive exercising in eating disordered samples, along with smaller lifetime BMI and illness duration among anorexics, also correlates positively and significantly with an important OCPD trait: perfectionism.

Perfectionism has been linked with anorexia nervosa in research for decades. A researcher 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". Perfectionism is a life enduring trait in the biographies of anorexics. It is felt before the onset of the eating disorder, generally in childhood, during the illness, as well as after remission. 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. 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, as a result of their over-industrious behavior.

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. 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. In some individuals with bulimia nervosa, the seemingly conflicting traits of impulsivity and perfectionism are present.

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

Like those afflicted with OCPD, anorexics and bulimics also tend to have a great need for order and symmetry in their activities and surroundings, something seen in their relationship with a third disorder, OCD. Eating disorders are largely comorbid with OCD; 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.

Those with eating disorders are less likely, however, to develop the multi-object obsessions and compulsions of people with classic OCD, who self-report symptoms related to a multitude of themes such as violence, sex, washing, moral taboos etc. The symptoms of both anorexics and bulimics, however, 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 to harbor obsessions and compulsions about symmetry and order than those who have OCD only.

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 with 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%). In a larger sample which included anorexic bingers and normal weight 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. Among women recovered from AN, orderliness concerns remain higher than among control samples without an eating disorder history.

The obsessive compulsive personality traits of over-attention to details and inflexibility have also been found in cognitive testing of anorexics; this group, compared to healthy controls, will display average to above average performance in tests requiring accuracy and the avoiding of errors but poorly on tests requiring mental flexibility and central coherence, i.e., the ability to integrate details of information into a bigger narrative. 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.

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. In a 2012 paper, it was verified that this trait exists among anorexics also beyond food and weight themes. The anorexics, especially those of the restricting type, were observed to save money handed to them by researchers more persistently than a control sample of healthy women.

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. Delayed 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. 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. 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.

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). Additionally, 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".

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.

### Depression

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 substrate to psychiatric morbidity. They may cause more problems in functioning than a major depressive episode.

## Cause

The cause of OCPD is thought to involve a combination of genetic and environmental factors. 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 parenting styles that are over-involved and/or overly protective, as well as trauma faced during childhood. Traumas that could lead to OCPD include physical, emotional, or sexual abuse, or other psychological trauma. Under the environmental theory, OCPD is a learned behavior. Further research is needed to determine the relative importance of genetic and environmental factors.

## Diagnosis

### DSM

The fourth edition of the *Diagnostic and Statistical Manual of Mental Disorders*, 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:

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. 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.

The fifth edition of the *Diagnostic and Statistical Manual of Mental Disorders* (DSM-5), has updated the diagnostic criterion where a person has to meet all of the following conditions for diagnosis:

1. Impairments in **self functioning** (a or b):
a. **Identity**: Sense of self derived predominantly from work or productivity; constricted experience and expression of strong emotions.
b. **Self-direction**: Difficulty completing tasks and realizing goals associated with **rigid** and unreasonably high and inflexible internal standards of behavior; overly conscientious and moralistic attitudes.
AND
2. Impairments in **Interpersonal functioning** (a or b):
a. **Empathy**: Difficulty understanding and appreciating the ideas, feelings, or behaviors of others.
b. **Intimacy**: Relationships seen as secondary to work and productivity; rigidity and stubbornness negatively affect relationships with others.
B. Pathological personality traits in the following domains:
1. **Compulsivity**, characterized by:
a. Rigid perfectionism: Rigid insistence on everything being flawless, perfect, without errors or faults, including one's own and others' performance; sacrificing of timeliness to ensure correctness in every detail; believing that there is only one right way to do things; difficulty changing ideas and/or viewpoint; preoccupation with details, organization, and order.
2. **Negative Affectivity**, characterized by:
a. Perseveration: Persistence at tasks long after the behavior has ceased to be functional or effective; continuance of the same behavior despite repeated failures.
C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual‟s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma). | ”

### WHO

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

It is characterized by at least four of the following:

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.

It includes:

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

Also, it 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 the compulsive personality (2004). Any compulsive personality may exhibit one or more of the following:

 **Bureaucratic compulsive** | Including narcissistic features
 **Puritanical compulsive** | Including paranoid features
 **Parsimonious compulsive** | Including schizoid features
 **Bedeviled compulsive** | Including negativistic features

## Treatment

Treatment for OCPD includes psychotherapy, cognitive behavioral therapy, behavior therapy or self-help. Medication may be prescribed. In behavior therapy, a person with OCPD 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 person 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. 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. There are higher rates of primary care utilization. There are no known properly controlled studies of treatment options for OCPD. More research is needed to explore better treatment options.

## Epidemiology

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

## 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.

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 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.

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