Obsessive-compulsive personality disorder: a current review
Originally published by: National Library of Medicine
Additional Authors: Ulrich Voderholzer
This review provides a current overview on the diagnostics, epidemiology, co-occurrences, aetiology and treatment of obsessive–compulsive personality disorder(OCPD). The diagnostic criteria for OCPD according to the recently published Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) include an official set of criteria for clinical practice and a new, alternative set of criteria for research purposes. OCPD is a personality disorder prevalent in the general population (3–8 %) that is more common in older and less educated individuals. Findings on sex distribution and course of OCPD are inconsistent. OCPD is comorbid with several other medical and psychological conditions. As for causes of OCPD, most empirical evidence provides support for disturbed attachment as well as the heritability of OCPD. So far, cognitive (behavioural) therapy is the best validated treatment of OCPD. Self-esteem variability, stronger early alliances as well as the distress level seem to predict cognitive (behavioural) therapy outcome. Future research is needed to further advance knowledge in OCPD and to resolve inconsistencies.
Introduction
Obsessive–compulsive personality disorder (OCPD) was first described more than 100 years ago. In 1952, with the publication of the first Diagnostic and Statistical Manual for Mental Disorders (DSM), it became a diagnosable mental disorder. Since then, and unlike other personality disorders, it has been included in all revisions of the DSM including the Fifth Edition of the DSM (DSM-5). It is characterized by eight personality traits: preoccupation with details, perfectionism, excessive devotion to work and productivity, over-conscientiousness, inability to discard worthless objects, inability to delegate tasks, miserliness, and rigidity and stubbornness. As the most common personality disorder in the general population, it is associated with at least moderate impairment in psychosocial functioning, reduced quality of life and a considerable economic burden. Despite its importance for public health and economy, research on OCPD is still scant and often inconsistent. Thus, the purpose of the present review is to provide both practitioners and researchers with a summary of significant current theoretical developments as well as empirical findings regarding the diagnostics, epidemiology, course, co-occurrences, aetiology, and treatment of OCPD. Hopefully, this will help in initiating future research on this important but often neglected mental disorder and thus advancing clinical practice in OCPD.
Diagnostics of OCPD
The most important recent development in the classification of OCPD is the inclusion of two sets of diagnostic criteria for OCPD in the DSM-5, namely
the official set of criteria and the so called alternative set of criteria. Whilst the criteria from the official set have remained unchanged from DSM-IV criteria and should be used in clinical practice, the criteria from the “alternative set” represent additional and/or revised criteria and should be used for research purposes.
Changes in the alternative set of the DSM-5 for OCPD evolved as a response to criticisms of the DSM-IV criteria for OCPD. Specifically, DSM-IV criteria had been criticized for not being sensitive enough to correctly identify the percentage of individuals that suffer from OCPD and for not being specific enough to correctly identify the percentage of individuals that do not. Problems of specificity included the presence of polythetic criteria instead of the inclusion of a hallmark feature. These problems resulted in an indistinct diagnostic category that contained a plurality of (partly even incompatible) types of OCPD. These were summarized as one diagnosis in which central traits for OCPD were partly neglected. Problems of sensitivity included the exclusion of elements that had before been identified as important for the diagnosis of OCPD (e.g. future-oriented planning at the cost of present moment pleasure, attentional bias on minute details and problematic affect regulation) as well as the inclusion of criteria that were formulated too concretely and literally (e.g. miserliness, hoarding) to detect the underlying key disposition.
Thus, the following criteria have been developed as part of the alternative set of the DSM-5: There is at least a moderate level of impairment in personality functioning, which is manifested by the specified difficulties in two or more of the following four areas: identity, self-direction, empathy and intimacy. Apart from rigid perfectionism, there must be at least two of three of the following ‘pathological personality traits’: perseveration, intimacy avoidance and restricted affectivity. As such, the official and alternative criteria differ in four important ways: First, a diagnosis according to the official set of criteria requires any combination of four OCPD diagnostic criteria, whereas for a diagnosis according to the alternative set, rigid perfectionism must be present. Second, the criteria miserliness and hoarding have been removed in the alternative set whereas most of the alternative criteria (perseveration, intimacy avoidance and restricted affectivity) are not listed in the official set. Third, the official set is categorical whereas the alternative set combines categorical and dimensional diagnostic approaches. And fourth, the alternative criteria seem to be stricter and lead to less frequent diagnoses of OCPD based on these criteria.
Thus, most of the issues of the DSM-IV criteria were addressed in the alternative set of criteria of the DSM-5. However, the development of two different sets for clinical practice and research has in fact increased the heterogeneity of OCPD and further complicates the integration of research findings due to different diagnostic criteria. Thus, there is still a need for clarification and unification of the construct of OCPD for both research and clinical practice.
Epidemiology and Course of OCPD
Due to changing diagnostic criteria, the variety of tools used for the assessment of OCPD and the different populations investigated, findings on the epidemiology and course of OCPD are partially inconsistent. Nonetheless, a number of studies provide evidence that OCPD is the most prevalent personality disorder in the general population (for an overview, see deReus and Emmelkamp, 2012; for an inconsistent finding, see for example Lenzenweger, Lane, Loranger, and Kessler, 2007). Lifetime prevalence rates for OCPD according to DSM-IV criteria range from 3 to 8 %. In an outpatient population, OCPD was identified as the third most common personality disorder (diagnosed according to DSM-IV criteria) with a point prevalence rate of 8.7 % and in a psychiatric inpatient population as the second most prevalent personality disorder with a rate of 23.3 % (not specified which kind of prevalence) when considering DSM-III-R-criteria. As for sex distribution, some studies demonstrate the same rates for men and women whereas others indicate higher prevalence rates amongst men than women. Regarding further demographic characteristics, OCPD seems to be less common in younger adults as well as in Asians and Hispanics but more common in individuals with a high school education or less.
In terms of the course of OCPD, an increasing number of studies show that personality disorders including OCPD are less stable and persistent than originally assumed. Shea and colleagues (2002) found that a significant majority of OCPD subjects (58 %) no longer meet DSM-IV diagnostic threshold at a 12-month follow-up. Grilo and colleagues (2004) reported a remission rate of 38 % within a 24-month follow-up period whilst remission was defined as having two or fewer OCPD criteria for 12 consecutive months. In contrast to these findings, other data suggest that OCPD remains stable or even worsens with age. These diverging results may be explained by the finding that some OCPD criteria (e.g. rigidity, problems delegating, hoarding) are more stable and trait-like than others (miserly behaviours, strict moral behaviours) that can change in severity and/or expression over time. However, the inconsistency of findings might also be a result of methodological differences as described before.
Co-occurrences of OCPD
OCPD has been found to co-occur with a variety of mental as well as medical conditions. Due to the large amount of studies reporting co-occurrence rates of OCPD and other mental disorders, we focused on studies in which structured interviews and DSM-IV criteria were used for assessment purposes. Studies from non-clinical populations indicate that a lifetime diagnosis of OCPD is moderately common in individuals with 12-month diagnoses of anxiety disorders (23–24 %), affective disorders (24 %) and/or substance-related disorders (12–25 %). Amongst patients with anxiety disorders, a lifetime diagnosis of OCPD is most common in individuals with 12-month diagnoses of panic disorder (23–38 %, generalized anxiety disorder (34 %), social phobia (33 %) and specific phobia (22 %). Amongst patients with affective disorders, lifetime prevalence rates of OCPD are comparably high in individuals with 12-month diagnoses of unipolar (23–28 %) and bipolar disorders (26–39 %). However, amongst patients with substance use disorders, prevalence rates of lifetime OCPD are higher in individuals with 12-month diagnoses of alcohol or drug dependence (15–29 %) than in individuals with alcohol or drug abuse (9–13 %). Studies from clinical samples demonstrate moderate prevalence rates of lifetime OCPD in individuals with lifetime diagnoses of alcohol dependence (31 %), panic disorder (17 %), hypochondriasis (15–22 %), eating disorders (13 %) and unipolar depression (14 %). Moreover, there is growing evidence for a considerable co-occurrence of OCPD with Cluster A personality disorders, in particular with paranoid and schizotypal personality disorders, which have led to the question whether OCPD should continue to be classified as a Cluster C personality disorder. Finally, it has recently been found that OCPD is very common amongst individuals suffering from medical conditions such as joint hypermobility syndrome/Ehlers–Danlos syndrome hypermobility type and Parkinson’s disease. High rates in joint hypermobility syndrome/Ehlers–Danlos syndrome hypermobility type were explained with an elevated need of a“hyper-control” in congenitally hypermobile subjects due to musculoskeletal consequences or associated features, such as joint instability and lack of proprioception, which occur early in their life. The association of OCPD with Parkinson’s disease was explained by similar dysfunctions in the fronto-basal ganglia circuitry.
OCPD and Obsessive–Compulsive Disorder
The relationship between OCPD and obsessive–compulsive disorder (OCD) has long been a source of much controversial debate (e.g. deReus and Emmelkamp, 2012). Consistent with the classification of OCPD and OCD as distinct mental disorders in the DSM, some researchers assume that both disorders constitute different mental conditions that are not specifically related to each other. Accordingly, it is a common use in clinical practice to distinguish OCPD from OCD due to its ego-syntonic character and the absence of obsessions and compulsions. However, the utilization of these criteria to separate both disorders from each other can be questioned as clinical manifestations of OCPD are not always ego-syntonic (e.g. perfectionism) and manifestations of OCD are not always ego-dystonic (e.g. contamination pre-occupation). Moreover, many researchers hypothesize that both conditions are strongly related to each other or even overlap conceptually and share many common features, for example compulsions (see for a detailed overview, Pinto and Eisen, 2011 and Starcevic and Brakoulias, 2014; Baer, 1994). Some researchers even suggest that there might be a distinct subtype of individuals with OCD who also suffer from OCPD or that the comorbidity of OCPD and OCD indicates a marker of severity of OCD.
Empirical evidence regarding this theoretical debate is not in all parts consistent, but there appears to be a specific but rather small to moderate overlap between both disorders. Indication for this hypothesis comes from studies that utilized structured interviews and DSM-IV criteria demonstrating co-occurrence rates that range between 23 and 45 %. Lower co-occurrence rates were found in (earlier) studies in which DSM-III, DSM-III-R or ICD-10-criteria were utilized as well as clinical judgments, questionnaires, and semi-structured interviews for diagnostic assessment purposes. Further evidence for an overlap between OCD and OCPD originates from studies showing significantly higher co-occurrence rates between OCPD and OCD than between OCPD and the general population or other mental disorders (for contradictory findings, see Albert et al., 2004) (for more details, see Table 1). Even more evidence comes from studies demonstrating (significantly) higher comorbidity rates between OCPD and OCD than between other personality disorders and OCD. Moreover, studies investigating similarities and differences between both disorders specified that (pure) obsessions as well as contamination and cleaning-related symptoms seem to be specific for individuals with OCD, whilst rigidity and excessive self-control were found to be specific for individuals with OCPD. In contrast, symmetry and hoarding-related symptoms as well as compulsions were identified as common in both individuals with OCPD and OCD and seem to connect both conditions. Findings showing that OCPD and OCD seem to have both similarities and differences might—apart from methodological issues such as variety in study populations and the heterogeneity of the construct of OCPD—at least in part explain the variety of results on the relationship between OCPD and OCD.
Table 1. Overview and characteristics of studies comparing frequencies of OCPD in OCD with frequencies of OCPD in the general population or other mental disorders
OCPD = obsessive–compulsive personality disorder, OCD = obsessive–compulsive disorder, SCID = Structured Clinical Interview for DSM Disorders, SIDP-R = Revised Structured Instrument for the Diagnosis of Personality Disorders, DIS-R = Diagnostic Interview Schedule, Revised Version, DSM=Diagnostic and Statistical Manual for Mental Disorders
Hence, research so far indicates that there might be a particularly strong relation between OCPD and OCD for a subgroup of individuals who suffer from specific symptoms of both disorders. Studies specifically focusing on characteristics of individuals suffering from both disorders show that these individuals suffer from higher rates of doubting, symmetry and hoarding obsessions; cleaning, ordering, repeating and hoarding compulsions; and alcohol consumption as well as lower levels of insight and global functioning than individuals suffering from OCD alone. However, findings also consistently demonstrate that individuals who only suffer from OCD and subjects with a comorbid OCPD do not differ significantly with respect to sex, clinician-rated severity of OCD, duration of OCD, morbidity risk for OCD, levels of disability, positive family history for tic disorder/Tourette syndrome and distribution of gene variants. Finally, findings are inconsistent regarding possible differences in both groups in the age at onset of first OC symptoms, the severity of self-reported OCD symptoms and treatment response. Thus, in sum, there is at least some indication for the existence of an OCPD-OCD subtype.
Aetiology of OCPD
The literature on psychological and biological theories regarding OCPD is scant and often contradictory. Psychological etiological models on OCPD include psychoanalytic theories as well as the attachment theory. Psychoanalytic etiological models (for an overview, see Hertler, 2014) attribute the obsessive character formation to parental dominance, over-control and intrusiveness (e.g. rigid toilet training practices). However, the small number of studies that has been conducted so far does not provide any evidence for these etiological models. According to attachment theory, attachment issues are considered an important etiological factor. So far, at least two studies provide support for this hypothesis showing that individuals suffering from OCPD have never formed secure attachments, received less care and more overprotection during their childhood and failed to develop emotionally and empathetically (for an inconsistent finding, also see Perry, Bond, and Roy, 2007.
In terms of biological causes of OCPD, empirical evidence clearly provides support for the heritability of OCPD. However, findings on the extent of the impact of genes on the development of OCPD are inconsistent. Whilst Togersen and colleagues (2000) identified a heritability rate of 0.78 for OCPD, Reichborn-Kjennerud and colleagues (2007) found that genetic effects account for only 27 % of the variance of OCPD. Unfortunately, only few studies have dealt with specific genetic and neurobiologic abnormalities in OCPD so far, especially when compared to the vast amount of research that has been conducted on genetics and neurobiology in OCD (for an overview, see for example Karch and Pogarell, 2011 or Pauls, Abramovitch, Rauch, and Geller, 2014). Some of the few studies that have been conducted in individuals with OCPD indicate associations between OCPD and the dopamine D3 receptor Gly/Gly genotype, the serotonin transporter 5HTTLPR polymorphism and a blunted prolactin response to fenfluramine indicating a potential serotonergic dysfunction. However, it must also be noted that some of these findings could not be replicated and others were questioned by inconsistent empirical evidence. Thus, more research should be conducted to attain more consistent results on relevant genetic and neurobiological mechanisms in OCPD.
Table 2. Characteristics of studies investigating psychotherapy in OCPD
OCPD = obsessive–compulsive personality disorder, APD = avoidant personality disorder, MDD = major depressive disorder, PPD = paranoid personality disorder, GAS = generalized anxiety disorder, SCID = Structured Clinical Interview for DSM Disorders, DSM = Diagnostic and Statistical Manual for Mental Disorders, PD = personality disorder, PAF = Personality Assessment Form, PDE = Personality Disorder Examination, RCT=randomized controlled trial, CT = cognitive therapy, CBT = cognitive–behavioural therapy, IPT = interpersonal psychotherapy, MIT = metacognitive interpersonal therapy, DBT = dialectical–behavioural therapy, ST = Schema Therapy, COT = Clarification-Oriented Therapy, TAU = Treatment as Usual
Further biological models which try to explain the development of OCPD include amongst others the hypothesis that neurological regions of the limbic system are especially dense and well branched amongst individuals with OCPD.However, this hypothesis is not consistent with the findings by Reetz and colleagues (2008) who have conducted the only study in this field so far. They found the grey matter volume in the limbic cingulate to be reduced in individuals with OCPD compared to healthy controls.
Next to this hypothesis, in the context of biological causes, it has been stated that characteristic OCPD traits may represent, at least in part, compensatory tactics in response to pre-existing cognitive deficits, and finally it has been hypothesized that individuals suffering from OCPD show a decreased activity in the so called empathizing system (an evolutionary system that enables comprehension of intentional motivated behaviour characteristics of humans) and an increased activity in the so called systemizing mechanism (a system that enables comprehension for lawful and non-intentional events). Even though the latter three theories provide at least some explanation for the development of OCPD, all of them have been criticized for positing proximate but not ultimate explanations as well as for their failures in reckoning the heritability of OCPD traits themselves and in applying evolutionary thought and theory.
Treatment Seeking and Treatments in OCPD
Regarding treatment-seeking behaviour in individuals suffering from OCPD, evidence is mixed. Some findings suggest that individuals suffering from OCPD often seek treatment on their own and receive more treatment than, for example, individuals suffering from depression, whilst other studies suggest the opposite. However, from a theoretical perspective, decreased treatment-seeking behaviour in individuals with OCPD might be easily explained by the egosyntonic character of OCPD as well as the great need of individuals with OCPD for independence and control.
Main treatments for OCPD include pharmacological and psychological treatments (for an overview of studies on psychotherapy, see Table 2; for studies on pharmacotherapy, see Table 3). As for pharmacological treatments, there are only few research findings until now. The little research that has been conducted provides preliminary evidence for the efficacy of carbamazepine and fluvoxamine in reducing OCPD traits in individuals suffering from OCPD only and for citalopram in individuals suffering from OCPD and depressive symptoms. Regarding the efficacy of psychological treatments, more research has been conducted. However, these studies mostly consist of case studies or uncontrolled longitudinal designs with individuals suffering from comorbid disorders in addition to OCPD. Thus, there is a great need of randomized controlled trials with individuals solely suffering from OCPD.
Most recent studies investigating psychological treatments for OCPD have examined cognitive therapy (CT) or cognitive–behavioural therapy (CBT). Studies investigating the efficacy of CT suggest that it is effective in reducing symptom severity of personality disorder, depression and anxiety from pre to post. Moreover, findings suggest that variability in self-esteem as well as the therapeutic alliance, if handled well, is associated with significant improvement in cognitive therapy. Group CBT combined with escitalopram also showed to lead to improvements in anxiety, extroversion, agreeableness and emotional stability from pre to post, and distress level was identified as a significant predictor of CBT response.
In spite of this at least moderate support for CT or CBT in the treatment of OCPD, interpersonal psychotherapy has been proven to be even superior to CT in reducing depressive symptoms in a randomized controlled trial. Moreover, schema therapy was shown to be superior to a clarification-oriented psychotherapy and a treatment-as-usual condition at follow-up in terms of decreasing depressive disorders and increasing social and occupational functioning. Finally, few case studies also provide at least some evidence for the efficacy of schema therapy, as well as further psychological treatments, such as metacognitive interpersonal therapy, an adapted version of dialectical behaviour therapy, as well as supportive–expressive dynamic psychotherapy on various outcome measures, such as personality disorder symptoms, depression, anxiety, general functioning, and interpersonal problems. However, more research is needed to support these preliminary findings.
Table 3. Characteristics of studies investigating pharmacotherapy in OCPD
OCPD = obsessive–compulsive personality disorder, MDD = major depressive disorder, OCD = obsessive–compulsive disorder, SCID = Structured Clinical Interview for DSM Disorders, RCT = randomized controlled trial, DSM = Diagnostic and Statistical Manual for Mental Disorders
Conclusions
Recent theoretical developments and empirical findings have come up with important knowledge, particularly regarding the concept and associated diagnostic criteria of OCPD, as well as potentially effective treatments of OCPD. Rigidity, self-control and conscientiousness might be key components of OCPD (especially when compared to OCD), and the patient–therapist alliance, state anxiety as well as self-esteem variability might constitute important predictors of the efficacy of cognitive(–behavioural) treatments in OCPD. These findings are of particular interest and value for the theoretical and clinical understanding of OCPD. From a clinical perspective, it might be concluded that OCPD is a distinct disorder (when conceptualized correctly) that can be best treated with cognitive(–behavioural) treatments [C(B)T] (in combination with citalopram or fluvoxamin). Moreover, it might be reasoned that intense habitual anxiety and rigidity (in self-esteem) of individuals suffering from OCPD as well as a dysfunctional therapeutic relationship might decrease treatment outcome. However, findings also indicate that a special focus on the therapeutic alliance as well as the distress level and (self-esteem) variability might improve treatment outcome in C(B)T.
However, we must conclude that overall research on OCPD is still scant. Moreover, findings on epidemiology, course and co-occurring disorders are partly inconsistent. Given that the heterogeneity of the concept of OCPD might have had some impact on these diverging results, we emphasize the need of further identifying elements belonging specifically to OCPD (especially when opposed to OCD) and of verifying the recently suggested alternative set of criteria of the DSM-5 in order to reach a unified diagnostic set that can be applied both in clinical practice and research and might lead to more conclusive findings regarding epidemiology, course and co-occurrences of OCPD. Standardized (semi-)structured interviews should be used as well as longitudinal designs to further elucidate the relationship between OCPD and OCD. Finally, research involving large randomized controlled trials should continue evaluating the suggested etiological models of OCPD as well as treatments such as metacognitive interpersonal therapy and schema therapy.
References available in original article on National Library of Medicine.
