Obsessive-Compulsive Personality: The Overlooked Diagnosis
Originally published by: NJ-ACT
Part 1 – Differential Diagnosis of OCD and OCPD
1.1 Recognizing Obsessive-Compulsive Personality Disorder
When patients with OCPD or OCPD traits enter treatment, they usually do not mention their OCPD. They enter treatment for other problems. These patients do not experience their personality disorder or traits as a problem. Often significant others have pushed OCPD patients into treatment because OCPD patients can be very difficult to live with.
I would recommend listening for and assessing OCPD traits in all patients, especially patients who present with anxiety disorders. The rigidities, perfectionism, and overwork of OCPD patients often create the symptoms of anxiety disorders, especially Generalized Anxiety Disorder such as physical aches and pains. Successful treatment of OCPD or OCPD traits often eliminates anxiety symptoms.
Recognizing OCPD and distinguishing OCPD from Obsessive-Compulsive Disorder is important because these two conditions can look similar, but they require different treatments. The most common treatment for OCD is exposure and response prevention (ERP), a behavioral technique. In OCPD, the key treatment goal is to restructure patients’ values. OCPD patients value organization, accomplishment, and efficiency. The treatment goal for OCPD is to decrease the degree to which to which they value organization, accomplishment and efficiency, and increase the degree to which they value fun, flexibility, relaxation, and spontaneity.
1.2 Description of OCD
Obsessions are recurrent, unwanted thoughts about danger to oneself or others Obsessions are clearly irrational or even bizarre to others, and almost always to OCD patients themselves. Some common obsessions are “What if this headache means that I have a brain tumor,” or “What if I stab my child with a knife.” Everyone would recognize these concerns as irrational or bizarre.” If a patient begins describing a concern with the words “What if…,” that usually means OCD.
Anxiety. Obsessions create anxiety.
Compulsions are behaviors intended to prevent the feared danger and alleviate the anxiety caused by the fear of that danger. Compulsive behaviors are almost always recognized by OCD patients as unnecessary.
1.3 Description of OCPD
The key characteristic of OCPD is rigidity. Also perfectionism, orderliness, over-attention to minor details, difficulty with spontaneity and flexibility, inflexible morality, discomfort with changing plans, being unaware of their own emotions or the emotions of others, a need for control, and valuing accomplishment over fun or interpersonal relationships.
Clinical vignette: Danielle was referred for treatment of her OCD.
Danielle began her initial session by saying, “My previous therapist referred me to you because I have Obsessive-Compulsive Disorder. I understand that you treat OCD, but my previous therapist doesn’t treat OCD.”
“Why don’t you begin by describing your symptoms?” I suggested.
“I obsess about every detail of my life,” Danielle explained. “I compulsively have to do all my chores before I can relax, and I become upset and angry if everything isn’t exactly the way I want it, for example if my husband leaves his dirty clothes on the floor instead of putting them in the hamper.”
Although Danielle had used the words “obsession” and “compulsion” to describe her symptoms, Danielle did not have obsessions, she did not have compulsions, and she did not have OCD. Danielle was suffering from Obsessive-Compulsive Personality Disorder.
1.4 Five criteria for distinguishing OCPD from OCD
OCD patients’ obsessions are about danger. OCPD patients’ concerns are not about danger. Danielle’s wishes for orderliness were not about danger; she did not believe anything dangerous would happen if her house was disorderly.
In OCD the obsessions are irrational or even bizarre. In OCPD, the concerns are exaggerated, but they are not irrational or bizarre. Danielle’s concerns were exaggerated forms of a normal wish for order.
OCD patients’ want to be rid of their obsessions. OCPD patients do not want to be rid of their rigidities, they value and want to live according to their rigidities. Danielle did not experience her thoughts as unwanted. What was unwanted to Danielle was that others, especially her husband, were not as neat and orderly as she believed they should be.
OCD patients’ obsessions are limited to a few circumscribed areas. OCPD patients are rigid in all aspects of their lives. Danielle was rigid in all aspects of her life.
In OCD the obsessions and compulsions come and go, and often change over time. New obsessions and compulsions develop, and old obsessions and compulsions fade away. Sometimes all obsessions and compulsions go into remission, only to return months or years later. OCPD patients’ rigidities are usually constant throughout the day and over many years. Danielle’s rigidities were constant and long-standing. They did not come and go.
Part 2 – Treating Obsessive-Compulsive Disorder
2.1 Behavioral treatment of OCD
Exposure and response prevention, the behavioral treatment for OCD, is based on the theory that obsessions create anxiety and compulsions serve to reduce that anxiety. Exposure for OCD means exposing yourself to the situations that evoke your obsessions and your anxiety. Response prevention for OCD means doing nothing to avoid, escape, or diminish obsessions and the anxiety they create. In other words: experience the obsession – don’t perform the compulsion.
2.2 Cognitive treatment of OCD
Exposure and response prevention is generally considered to be the treatment of choice for OCD. However many studies have found that cognitive therapy is equal to ERP for OCD, and ERP plus cognitive therapy is often superior to exposure alone.
Cognitive treatment of OCD is based on the theory that everyone occasionally has a fleeting thought of danger. OCD sufferers make catastrophic appraisals of these fleeting thoughts of danger and the catastrophic appraisals convert those thoughts into obsessions. Cognitive Therapy for OCD utilizes logic, including disputation and Socratic questioning, to convince OCD sufferers to view their thoughts of danger as normal, just random, meaningless thoughts that pass through the mind, rather than signs of real danger.
In the next part of this article we shall see that the treatment of Obsessive-Compulsive Personality Disorder is very different from either the behavioral or the cognitive treatment for Obsessive-Compulsive Disorder.
Part 3 – Treating Obsessive-Compulsive Personality Disorder
Clinical vignette: Danny was referred for Generalized Anxiety Disorder.
Danny complained to his primary care physician about chest pains. The physician referred Danny for a series of tests and told Danny there was nothing physically wrong with him; he was just suffering from stress and anxiety, and he should consult a psychologist. Danny could have been diagnosed with Generalized Anxiety Disorder because he met the criteria. He constantly worried about his work as an IT trouble shooter for his company, he never turned off his cell phone, and he frequently received calls about computer problems. When he received these calls, he immediately stopped whatever he was doing and rushed to fix these problems. His GAD was secondary to his OCPD. His treatment included no interventions for GAD, but his chest pains remitted when treatment alleviated his OCPD.
3.1 Enjoying life is more important than accomplishment.
Every session, ask OCPD patients what they enjoyed since the last session. OCPD patients often report “nothing,” because they tend to focus on what they have accomplished and forget or not notice what they enjoyed. But it cannot be true that they enjoyed nothing for an entire week. They must have enjoyed something they ate, or something they watched on TV, or a conversation, etc. So ask them detailed questions about what they did. For example, ask them how every course of a recent meal tasted, or ask them if they enjoyed watching a TV show. If you do this every session, pretty soon they will begin asking themselves what they have enjoyed, paying more attention to what they enjoy, and eventually adding more enjoyable activities to their lives.
Replace perfectionism with “good enough.” OCPD patients often go over and over their work to make sure it is perfect. But in every project there comes a point where you could put in a little more time and make the results a little better, but the small improvement is just not worth the extra time and effort. One OCPD patient would spend 15 minutes driving to a gas station where the price of gas was 2 cents cheaper than at a closer station. The gas he used to drive the extra distance probably cost more than the money he saved, not to mention the extra time and effort he invested. But he just couldn’t bear to pay the extra 2 cents per gallon at the closer gas station.
Enjoy remembering past pleasures and looking forward to future pleasures. OCPD patients ruminate on past problems and forget past pleasures. Help them to experience the enjoyment of looking forward to and looking back at enjoyable experiences. Looking at pictures from an enjoyable vacation can increase the pleasure of that vacation.
Enjoy doing, not getting things done. When asked what they have enjoyed, OCPD patients often respond, “I enjoyed getting X done.” But this question refers to enjoying doing, not enjoying getting something done. OCPD patients need to reorient themselves from finishing tasks to enjoying tasks, and paying attention to how they feel when engaging in any activity.
No multitasking. If you are engaging in two activities at once you cannot fully enjoy either activity.
Turn off your cell phone. Many OCPD patients are constantly checking their cell phones, believing they must deal with messages as soon as they come in. Even when no messages come in, some part of their attention is listening for those sounds that signal an incoming message. Turning off their cell phones for periods of time may seem like a trivial intervention, but several patients have told me that turning off their cell phones gives them a feeling of calmness they never realized they were missing.
Don’t set outcome goals. OCPD patients often feel pressure to succeed at any project they undertake. But the outcome of most projects is partially dependent on luck or on the contributions of others. Anyone can handle a job interview perfectly and still not get the job because the interviewer wants to give the job to her nephew. Help OCPD patients to set the goal of making a good enough effort, regardless of the outcome. They can control the effort they put in, but they can’t control the outcome of that effort.
OCPD patients often refuse to participate in anything that they are not very good at. Tell these patients they don’t have to be good to enjoy an activity. In fact, they can be the worst at something and still enjoy it.
Clinical vignette: Walter was the worst bowler in the league.
Walter told me that he was going to quit his bowling league because he had the worst average in the league. This embarrassed him and dragged his team down in the standings. I asked Walter if his teammates were upset about his low average.
Pt: No, they don’t really care. I think for them, bowling is just an excuse to drink beer.
Th: So why should you care?
Pt: Because it is me who is the worst, and this humiliates me.
Th: No, you humiliate yourself because of your low average.
Pt: Well, I’m still quitting.
Th: You know Walter, if everyone felt the way you do, no one would ever bowl in a league.
Pt: That’s not true. Most of the others are very good.
Th: Yes, but if you quit, someone else will become the worst bowler in the league, and then he would quit. And then the next worst would quit, etc. etc., until the best bowler in the league was the only one left, so he would also be the worst, and he would quit as well.
Walter got the humor and eventually decided to remain in the league. And the good news is that by the end of the season, Walter’s bowling had improved; he finished the season as the only second worst bowler in the league.
3.2 Live mindfully in the present.
Mindfulness means being fully and non-judgmentally aware of the present, what you can see, hear, feel, taste, and smell, what you are thinking and feeling, not what you did yesterday or what you plan to do tomorrow. Mindfulness also means just experiencing the present, without evaluating yourself, your thoughts, or your feelings.
Be fully aware of your thoughts and feelings. OCPD patients focus on accomplishing tasks and are often unaware of what they are feeling. At an extreme, they may not even understand what emotions are. An OCPD patient who was an engineer once said to me “When characters on TV seem very emotional, they are just acting, right? Real people don’t experience emotions like that, do they?” This patient was totally unaware of any of his emotional reactions. The first step in his treatment was to teach him the definitions of the English words that describe the various emotions. The next step was to help him experience and correctly label his own emotions.
Be able to clearly and fully articulate your thoughts and feelings. OCPD patients sometimes report that they feel “upset,” failing to distinguish among specific emotions such as hurt, sadness, anger, annoyance, disappointment, disgust, etc. One emotion that OCPD patients often do recognize is anger, although sometimes they deny feeling angry when it is obvious to everyone else that they are very angry. And when OCPD patients do recognize that they feel angry, they are often unaware that they are also feeling hurt. To help these patients, frequently ask them what they are feeling right now and what they were feeling during the events they are describing. Help them to describe their emotions precisely and accurately. Ask them to ask themselves how they are feeling throughout the day.
Drive mindfully. Bring your attention to the cars in front of you, the scenery around you, not what you will do when you arrive at your destination or what happened this morning. Ask patients to describe what they saw while driving -- were the buildings and scenery they passed ugly, pretty, or something in between?
Eat mindfully, not mindlessly. Ask patients to be aware of and describe to you the taste, texture, temperature of each food they are eating. Was the food cold, cool, just right, or too hot? And if something does not suit their taste, encourage them to fix it so they can fully enjoy it. The opposite of eating mindfully is eating mindlessly – looking down at your empty plate and not remembering how anything tasted.
Shower mindfully. Is the water too cool, too hot, or just right? Is the spray too hard, too soft or just right? Adjust the shower to make it more pleasurable.
Be fully aware of your bodily sensations. Are any parts of your body irritated? painful? tense? Are you feeling energetic or lethargic or somewhere in between? Are you feeling hot, cold, does your mind feel alert or dull? Does your stomach feel full? A little appetite? Hungry ? Starving?
Sit on a park bench for 30 minutes and mindfully experience the passing scene. If your mind wanders to something other than what you can see and hear, bring it back without any self-criticism.
If you frequently ask OCPD patients about their emotions, their physical sensations, and what they observe right now, pretty soon they will start asking themselves these questions, and they will be living in the present, fully, mindfully, and non-judgmentally.
“Evaluate every patient for OCPD and OCPD traits.”
3.3 Overcome time urgency.
Rushing is a state of mind. Suppose a man is walking quickly to get to his office on time, and a jogger runs past him. The man is worrying about being late. He is feeling rushed. The jogger is moving more quickly, but is feeling relaxed and enjoying his run. So rushing refers to a state of mind, not moving quickly. But even though rushing is a state of mind, moving quickly can contribute to feeling rushed. So...
Don’t speed, don’t rush, walk leisurely. Walk, drive, and generally go from one place to another as if you have all the time in the world, because in fact you do. Rushing may save a few seconds or a few minutes, but so what? Enjoying getting there is much more valuable than getting there a few seconds or a few minutes earlier.
The more you rush, the longer it takes. When you feel rushed, you make mistakes and then you have to spend time and effort correcting those mistakes. If you perform tasks slowly and mindfully, you will make very few mistakes, the tasks will be completed sooner, and when you are not feeling rushed, you are more likely to have a creative idea that enables you to perform the task more effectively or more efficiently.
Allocate extra time for tasks, especially travel. Everyone underestimates how long it will take to complete tasks. OCPD patients do this more than most people because they usually try to accomplish one more task before they stop work or leave for an appointment. When they have to get somewhere, they leave later than they should, and they do not factor in extra time for unforeseen events like delayed public transportation or slow drivers in front of them. Leaving late for their next appointment, they feel rushed and travel becomes a struggle to arrive on time, rather than a pleasant journey.
There are no deadlines. OCPD patients tend to decide they want to complete certain tasks within a certain time period, for example by lunch, and they start feeling pressure to complete those tasks by the artificial deadline they have imposed on themselves. Sometimes there are real consequences for missing a deadline, but usually no harm occurs if a “deadline” is missed. Even being late with your income tax return will not incur a penalty if you file for an extension.
Suggest that OCPD patients make a “to do” list of the tasks they want to get done, decide which task they will do first, then start working on that task and forget about all the other tasks on their list. When they finish that first task, they can take out their list and decide if they want to start another task or relax for a while. Instead of telling themselves “I have to get this task done today,” they should tell themselves, “I’ll get this done when I get this done.”
It doesn’t hurt you if someone else is inefficient. OCPD patients often become angry if another person does something slowly or inefficiently, particularly if the other person is their spouse or their child, or if the other person’s inefficiency delays them. They become angry and criticize others’ inefficiency or take over the task themselves. This leads to animosity in their interpersonal relationships. Tell them “the other person’s inefficiency may delay you for a couple of minutes, but the anger you create for yourself is much more harmful to you than the few minutes lost. Your impatience can ruin your day and impair your relationships with your family and friends.”
3.4 Move from rigidity to flexibility.
OCPD patients make overly detailed plans, feel they must execute those plans, and feel uncomfortable until the plans are completed. OCPD patients have trouble changing their plans in response to new information. Flexibility means changing plans when new information warrants a change.
The continuum from rigidity to flexibility to spontaneity to impulsivity. Explain to OCPD patients that people vary along a continuum running from rigid to flexible to spontaneous to impulsive. People with OCPD fall toward the rigid end of this continuum. Most people are too impulsive, usually doing what they feel like doing at the moment, and not doing what will achieve their goals in the long run. That is not good, but being too rigid, being inflexible and un-spontaneous is not good either. Rigidity prevents people with OCPD from doing what is best for them at the moment. If an OCPD patient has started housecleaning and the sun comes out unexpectedly, having to finish the housecleaning before taking a walk means that clouds or rain may roll in before the housecleaning is finished. The flexible behavior would be to stop the housecleaning before it is finished, take a walk while the sun is out, and finish the housecleaning later.
Ask patients to do flexibility exercises and self-talk. OCPD patients are initially uncomfortable changing plans or stopping a task before it is completed. Some OCPD patients ruminate about unfinished tasks. Ask them to intentionally stop performing some task before it is finished, or to not do a task they feel they should do, and remind themselves that there is no harm in doing the task later.
OCPD patients often report that leaving a task undone makes them feel uncomfortable or guilty. This is not correct -- they make themselves feel uncomfortable or guilty if they stop performing a task before it is completed. But if they are making themselves feel guilty, they can also make themselves not feel guilty. With enough exposure and enough self-talk, the discomfort with undone tasks will gradually dissipate.
Do what makes sense right now. If the weather is good in the morning and rain is predicted for the afternoon, go for a walk in the morning and put off work for when the weather turns bad. Help OCPD patients overcome the feeling that they have to work before they can play. The choice of what to do right now should also be informed by how they are feeling. If they feel tired, they should either take a break or do a task that does not require concentration or creativity. When they feel alert, they should do something that requires mental sharpness. Of course this requires OCPD patients to be aware of how they are feeling, another aspect of treatment for OCPD.
“A walk in the sun with the dishes half done”
3.5 Move from flexibility to spontaneity.
Spontaneity means doing what you feel like at the moment. Don’t just execute your pre-determined plan, don‘t even do what makes logical sense at the moment -- do what your body and emotions are telling you to do right now. Here are some spontaneity exercises:
Take a walk with no plan or goal in mind. When you get to a corner, look in various directions and ask yourself which direction looks interesting. Then take that route.
Schedule some unscheduled time. Schedule a length of time in which you have nothing to do. When the time comes, ask yourself what you feel like doing right now – and then do it.
What do you feel like eating right now? Instead of planning a meal or part of a meal in advance, ask yourself what you feel like eating right now – and then eat it.
3.6 Interventions for OCPD-Induced anger
Here are some interventions for reducing the anger OCPD patients frequently experience when others do not behave as the OCPD patient believes they should behave:
Reframe the situation. “You become angry if your wife doesn’t have dinner ready when you come home from work because you’re thinking ‘She knows I like dinner as soon as I come home. If she really loved me, she would have it ready.’ But the reason she doesn’t have dinner ready is not that she doesn’t love you. It is that she is not an organized and efficient person. You shouldn’t take this personally. It has nothing to do with you, it has nothing to do with anything you have said or done, and it has nothing to do with how she feels about you. It is just the way she is. She would not have dinner ready regardless of whom she was married to.”
Reappraise the whole person. “I understand that you would like your wife to have dinner ready when you come home, but dinner not being ready is a minor inconvenience. Think of all the things you love about your wife. You have to take the whole package, all of your wife’s characteristics. You can’t have the good unless you also have the bad. You will get less angry if you remind yourself of all her good qualities when you come home and dinner is not ready.
Self-interest. “You know getting angry doesn’t get dinner ready any sooner. You have been doing this for a long time and dinner is still not ready when you come home. So getting angry only hurts you by ruining your evening. And it probably also gets your wife angry so you have to spend the evening with angry person. That can’t be fun for either you or her.”
Road rage: Reframing and self-interest. “If a car cuts you off or drives too slowly in front of you, you take it as a personal affront, but it’s not. The other driver has never met you. He or she is just feeling rushed and driving recklessly. This endangers both of you. The smart thing is for you to stay away from that reckless driver to avoid an accident and arrive at your destination 30 seconds later, but alive. And it would also reduce your anger if you could feel some sympathy for the other driver who probably goes through life feeling rushed and engages in reckless driving that may some day kill him.”
Empathy training. OCPD patients usually have trouble understanding how their critical and controlling behavior affects others. Frequently ask them questions like “How do you think your wife felt when you criticized her for not recording that check she wrote?” It is very difficult for OCPD patients to admit mistakes and apologize. An apology can usually obtain forgiveness for critical and controlling behavior, and can also help OCPD patients understand others’ feelings. Help OCPD patients learn to apologize. Role playing can also help OCPD patients learn to understand others’ feelings.
Clinical vignette: Angela was referred for an eating disorder.
Angela suffered from binging and purging, and she was overly concerned with her shape and weight. She was slender, but she reported that she counted every calorie, she exercised compulsively, and she frequently checked herself in the mirror to determine if any part of her body was flabby or fat. She also had very strict rules about only eating low calorie, low fat, low carbohydrate foods. Angela would exercise more or restrict her calorie intake further if she noticed any imperfection in her body. If she felt she had eaten too much, or too much of the wrong food, she would make herself vomit. These are the classic symptoms of an eating disorder.
But Angela also reported that she worked compulsively and could never leave her office until she had completed every task on her “to do” list. She felt guilty if she postponed accomplishing tasks in order to relax or have fun. It seemed clear that her eating disorder was only one manifestation of her Obsessive-Compulsive Personality Disorder. So I decided to treat Angela’s OCPD rather than her eating disorder.
Angela readily accepted and cooperated with the treatment of her OCPD. At no time during Angela’s treatment did I utilize any intervention targeting her eating disorder. But as her OCPD remitted, her eating disorder remitted as well.
Sometimes eating disorders, temper problems, GAD, and other emotional disorders are but one manifestation of Obsessive-Compulsive Personality Disorder or OCPD traits, and overcoming the OCPD or the OCPD traits will cause these other emotional disorders to remit. I recommend evaluating every patient for Obsessive-Compulsive Personality Disorder and for OCPD traits in those patients who do not meet the OCPD criteria.
References available in original article on NJ-ACT.
