Ambika Agnihotri
Obsessive Compulsive Personality Disorder (OCPD) is a psychological
disorder that has been studied for a long time. However, the awareness about it
is not as widespread. Being the most common personality disorder in the general
population, it is associated with at least moderate impairment in psychosocial
functioning and reduced quality of life. Through this post, I wish to talk
about how we come to understand OCPD today, probable causes and treatment,
interpersonal distress and its co-morbidities.
An individual suffering
from OCPD experiences a demotion of all of life’s pleasures, such as love,
friendships, relaxation, etc. to labor, as if requiring lots of effort (Hertler,
2013). OCPD illustrates a chronic maladaptive pattern of excessive
perfectionism, preoccupation with orderliness and detail, and a need for
control over one's environment. These lead to significant distress in the
individual’s intrapersonal and interpersonal life. They find it difficult to
relax, feel obligated to plan out every activity and find unstructured time
intolerable. In addition, they are often characterized as rigid and controlling
(Cain, Ansell, Simpson & Pinto, 2015).
Janet, in 1905, talked about the development of
obsessions and compulsions surfacing in an individual after the ‘psychasthenic
state’ (Coles, Pinto, Mancebo, Rasmussen & Eisen, 2008). This is when
actions are performed incompletely, with a focus on order,
perfection and uniformity. Indecisiveness and restricted emotional
expressions are also characteristic of this state. Following these
observations, Freud wrote the ‘Character and Anal Eroticism’. He proposed the
anal triad, pointing towards the patterns of obstinacy, orderliness, and
parsimony.
Through the understanding gained by such
literature, OCPD has been listed in the DSM (Diagnostic and Statistical Manual
of Mental Disorders) since the very first edition. The nature of this disorder
kept changing as a result of new information and ways of understanding it.
Currently, in DSM-5, OCPD is characterized by a “pervasive pattern of
preoccupation with orderliness, perfectionism and, mental and interpersonal
control, at the expense of flexibility, openness, and efficiency as indicated by
four (or more) of (the) eight traits” (Riddle et al., 2016). In
addition, research proposes conscientiousness as being the hallmark
feature of OCPD, calling it ‘primarily a disorder of excessive
conscientiousness’ (Hertler, 2013). Further, it suggests that OCPD diagnosis
should hold conscientiousness necessary, though, not sufficient.
Talking about the causes of this disorder, different approaches look at
it through different lenses. I will be elucidating three of them, namely,
biological, neurological and attachment theory. The former provides evidence
for the heritability of the disorder. In some studies, the role of genes has
been illustrated by highlighting the associations between OCPD and Dopamine
(D3) receptor and Serotonin transporter (Diedrich & Voderholzer, 2015). In
addition, hoarding and indecisiveness, characteristic of the disorder, is
linked to two markers on chromosome 10, suggesting a possible genetic
vulnerability (Riddle et al., 2016). In a research study conducted by Reetz and
colleagues (2008), they looked into the neurological discrepancies in OCPD
patients and controls. They found out that grey matter volume in the limbic
cingulate was reduced in the patients. It was later hypothesized that OCPD
patients show decreased activity in the ‘empathising system’ and increased
activity in the ‘systemising system’. Moving on to attachment theory, the most
crucial factor is seen to be attachment issues. OCPD patients lack secure
attachments, might have faced parental dominance and overprotection, and
received less care. As a result, they fail to grow emotionally and
empathetically (Diedrich & Voderholzer, 2015).
OCPD patients suffer on the interpersonal front
too. In the research conducted by Cain and colleagues (2015), individuals
suffering from the disorder reported being overly controlling, vindictive and
cold, when it came to their relationships. Interpersonal warmth was perceived
as an irritant by them. A possible explanation might be that warmth in
others may trigger their interpersonal motives of being emotionally restrained,
rigid, and in control in relationships (Cain, Ansell, Simpson & Pinto,
2015). On a measure for empathy, they had low ratings of perspective
taking and they reported difficulties with being able to see things from
another's point of view. Personal distress was found to be high, indicating a
more self-oriented aspect of empathy like feelings of personal anxiety and
uneasiness in face of difficult interpersonal relationships. They
concluded that individuals with OCPD may have the capacity to
experience empathy and elicit the appropriate affective response,
similar to healthy controls, but are limited in their ability to do
so. Another important differentiation is that OCPD individuals use a ‘cognitive
and intellectualized’ style to cope with interpersonal situations by escaping
into fantasy rather than considering another's perspective.
Focusing on the treatment of OCPD patients, there
is a trend of low treatment-seeking behaviour. This may be due to the
overbearing need for independence and control. Broadly speaking, there are two
main approaches to treatment; pharmacological and psychological. For the
former, there is preliminary evidence for the effectiveness of carbamazepine
and fluvoxamine in reducing OCPD traits (Diedrich & Voderholzer, 2015).
Looking at the clinical or psychological approach, it has been found that CBT
(Cognitive-Behaviour Therapy) has been helpful in treating patients. These two
approaches often overlap when the treatment entails CBT often in
combination with citalopram or fluvoxamine. This has been found to work
well. However, intense habitual anxiety and rigidity, as well as a
dysfunctional therapeutic relationship might decrease treatment outcome. Nonetheless,
findings indicate that with a special focus on the therapeutic alliance,
distress level and self-esteem improvement can be seen in the treatment
outcomes in CBT.
There have been questions about the relationship
between OCD and OCPD. It has been argued that both the conditions are strongly
related to each other and even overlap as they share many common features, for
example, compulsion. Research indicates that there might be a particularly
strong relationship between these two, for a subgroup of individuals
who suffer from specific symptoms of both disorders. Individuals belonging to
this group suffer from higher rates of doubting, symmetry and hoarding
obsessions, cleaning, ordering and repeating and hoarding compulsions than
individuals suffering from OCD alone (Diedrich & Voderholzer, 2015).
Coles and his colleagues (2008) found elevated rates of OCPD in subjects with
OCD. Thus, the trend of co-morbidity between the two cannot be unseen. In
addition, OCPD is found to be co-morbid with anxiety disorders, affective
disorders, substance-related disorders, panic disorder, eating disorders,
hypermobility syndrome and Parkinson’s disease.
References
Cain, N. M., Ansell, E. B., Simpson, H. B., & Pinto, A. (2015).
Interpersonal functioning in obsessive–compulsive personality disorder. Journal
of personality assessment, 97(1), 90-99. doi:10.1080/00223891.2014.934376
Coles, M. E., Pinto, A., Mancebo, M. C., Rasmussen, S. A., & Eisen,
J. L. (2008). OCD with comorbid OCPD: a subtype of OCD?. Journal of psychiatric
research, 42(4), 289-296. https://doi.org/10.1016/j.jpsychires.2006.12.009
Diedrich, A., & Voderholzer, U. (2015). Obsessive–compulsive
personality disorder: a current review. Current psychiatry reports, 17(2),
2. doi:10.1007/s11920-014-0547-8
Hertler, S. C. (2013). Understanding obsessive-compulsive personality
disorder: reviewing the specificity and sensitivity of DSM-IV diagnostic
criteria. Sage Open, 3(3), 2158244013500675. doi:10.1177/2158244013500675
Reetz, K., Lencer, R., Steinlechner, S., Gaser, C., Hagenah, J., Büchel,
C., ... & Klein, C. (2008). Limbic and frontal cortical degeneration is
associated with psychiatric symptoms in PINK1 mutation carriers. Biological
psychiatry, 64(3), 241-247. doi:10.1016/j.biopsych.2007.12.010.
Riddle, M. A., Maher, B. S., Wang, Y., Grados, M., Bienvenu, O. J.,
Goes, F. S., ... & Knowles, J. A. (2016). Obsessive–compulsive personality
disorder: Evidence for two dimensions. Depression and anxiety, 33(2),
128-135. https://doi.org/10.1002/da.22452
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