Obsessive-Compulsive Personality Disorder

An obsessive-compulsive personality disorder is characterised by a pervasive preoccupation with orderliness, perfectionism, and control (with no room for flexibility) that ultimately slows or interferes with completing a task. Diagnosis is by clinical criteria. Treatment is with psychodynamic psychotherapy, cognitive-behavioural therapy, and SSRIs. Because patients with obsessive-compulsive personality disorder need to be in control, they tend to be solitary in their endeavours and to mistrust the help of others. About 2.1 to 7.9% of the general population is estimated to have an obsessive-compulsive personality disorder; it is more common among men. Familial traits of compulsivity, restricted range of emotion, and perfectionism are thought to contribute to this disorder. Comorbidities may be present. Patients often also have a depressive disorder (major depressive disorder or dysthymia) or an alcohol use disorder.

Symptoms and Signs

Symptoms of an obsessive-compulsive personality disorder may lessen over a year, but their persistence during the long-term has not been studied. In patients with obsessive-compulsive personality disorder, preoccupation with order, perfectionism, and control of themselves and situations interfere with flexibility, effectiveness, and openness. Rigid and stubborn in their activities, these patients insist that everything is done in specific ways. To maintain a sense of control, patients focus on rules, minute details, procedures, schedules, and lists. As a result, the main point of a project or activity is lost. These patients repeatedly check for mistakes and pay extraordinary attention to detail. They do not make good use of their time, often leaving the most important tasks until the end. Their preoccupation with the details and making sure everything is perfect can endlessly delay completion. They are unaware of how their behaviour affects their co-workers. When focused on one task, these patients may neglect all other aspects of their life. Because these patients want everything done in a specific way, they have difficulty delegating tasks and working with others. When working with others, they may make detailed lists about how a task should be done and become upset if a co-worker suggests an alternative way. They may reject help even when they are behind schedule.

Patients with obsessive-compulsive personality disorder are excessively dedicated to work and productivity; their dedication is not motivated by financial necessity. As a result, leisure activities and relationships are neglected. They may think they have no time to relax or go out with friends; they may postpone a vacation so long that it does not happen, or they may feel they must take work with them so that they do not waste time. Time spent with friends, when it occurs, tends to be in a formally organised activity (eg, a sport). Hobbies and recreational activities are considered important tasks requiring organisation and hard work to master; the goal is perfection. These patients plan ahead in great detail and do not wish to consider changes. Their relentless rigidity may frustrate co-workers and friends.

Expression of affection is also tightly controlled. These patients may relate to others in a formal, stiff, or serious way. Often, they speak only after they think of the perfect thing to say. They may focus on logic and intellect and be intolerant of emotional or expressive behaviour. These patients may be overzealous, picky, and rigid about issues of morality, ethics, and values. They apply rigid moral principles to themselves and others and are harshly self-critical. They are rigidly deferential to authorities and insist on exact compliance to rules, with no exceptions for extenuating circumstances.

Diagnosis

Clinical criteria (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]). 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 shown by the presence of ≥ 4 of the following:

  • Preoccupation with details, rules, schedules, organisation, and lists
  • A striving to do something perfectly that interferes with completion of the task
  • Excessive devotion to work and productivity (not due to financial necessity), resulting in neglect of leisure activities and friends
  • Excessive conscientiousness, fastidiousness, and inflexibility regarding ethical and moral issues and values
  • Unwillingness to throw out worn-out or worthless objects, even those with no sentimental value
  • Reluctance to delegate or work with other people unless those people agree to do things exactly as the patients want
  • A miserly approach to spending for themselves and others because they see money as something to be saved for future disasters
  • Rigidity and stubbornness

Also, symptoms must have begun by early adulthood.

Differential diagnosis

Obsessive-compulsive personality disorder should be distinguished from the following disorders:

  • Obsessive-compulsive disorder (OCD): Patients with OCD have true obsessions (repetitive, unwanted, intrusive thoughts that cause marked anxiety) and compulsions (ritualistic behaviours that they feel they must do to control their obsessions). Patients with OCD are often distressed by their lack of control over compulsive drives; in patients with obsessive-compulsive personality disorder, the need for control is driven by their preoccupation with an order, so their behaviour, values, and feelings are acceptable and consistent with their sense of self.
  • Avoidant personality disorder: Both avoidant and obsessive-compulsive personality disorders are characterised by social isolation; however, in patients with obsessive-compulsive personality disorder, isolation results from giving priority to work and productivity rather than relationships, and these patients mistrust others only because of their potential to intrude on the patients’ perfectionism.
  • Schizoid personality disorder: Both schizoid and obsessive-compulsive personality disorders are characterised by a seeming formality in interpersonal relationships and by detachment. However, the motives are different: a basic incapability for intimacy in patients with schizoid personality disorder vs discomfort with emotions and dedication to work in patients with obsessive-compulsive personality disorder.

Treatment

  • Psychodynamic psychotherapy
  • Cognitive-behavioural therapy
  • SSRIs

General treatment of obsessive-compulsive personality disorder is similar to that for all personality disorders. Information about treatment for obsessive-compulsive personality disorder is sparse. Also, treatment is complicated by the patient’s rigidity, obstinacy, and need for control, which can be frustrating for therapists. Psychodynamic therapy and cognitive-behavioural therapy can help patients with obsessive-compulsive personality disorder. Sometimes during therapy, the patient’s interesting, detailed, an intellectualised conversation may seem psychologically oriented, but it is void of affect and does not lead to change. SSRIs may be useful.

Credit: Reviewed by Andrew Skodol, MD., for  MSD Manual, May 2018.