A longstanding problem with the recognition and management of obsessive-compulsive personality (OCPD) is the misleading attempt to squeeze, in a metaphorical sense, a square peg into a round hole. As a square peg essentially unlike all other personality disorders, the attributes of OCPD consist entirely of excessive expressions of highly valued and socially adaptive characteristics, especially of Western cultures.
Notably, when any types of psychopathology co-exist with creative capacity and performance, the most prevalent impediments are symptoms of OCPD.
Although this adaptability of features is widely recognized by clinicians and others, the diagnosis and clinical management implications are not fully pursued. Despite historical variations in specific criteria included in the diagnosis, the core feature is maladaptiveness due to excessiveness of otherwise adaptive factors. Thus are included: conscientiousness and devotion to work, reliability and care for details, adherence to rules, morality, self reliance, firmness, drive for achievement and perfection, striving and maintaining mastery, orderliness, cleanliness, looking at both sides of an issue, thriftiness, preference for balance.
These factors are, in OCPD, turned respectively into overconscientiousness and workaholism, preoccupation with details, overcompliance with rules, scrupulousness, inability to delegate to others and self-righteousness, rigidity and stubbornness, perfectionism that interferes with task completion or diffuse and unrelenting perfectionism, preoccupation with control, order, spotlessness and purity, and rumination, miserliness, concern with symmetry. Because the diagnosis depends on such assessment of excess, a matter of degree rather than kind, accuracy and consistency is difficult both for patients and for evaluating clinicians.
From the clinical perspective, all of the designated OCPD extreme factors produce suffering and are therefore psychopathological. The picture is, however, often complex, because, despite suffering and disability, some adaptive factors may be retained with compensatory better functioning. This produces confusion, leading not only to diagnostic oversights but sometimes reinforcing these patients’ not uncommon fear of, or resistance to, treatment. The clinical challenge here is to elicit information carefully about degree of excessiveness of each feature and overall level of maladaptive functioning. Also important is exploration of connections with other intercurrent conditions. Persons with OCPD may not manifest overall impairment until they develop other disorders, the main ones being obsessive–compulsive disorder (OCD), eating disorder, mood disorders, and alcoholism.
I have shown, in studies of eating disorders, interconnections with OCPD. On the basis of long-term assessment, I described particular OCPD factors having distinct intercurrent psychopathological effects. In these studies eating disorder patients, in comparison with controls, significantly manifested habitual controlling, rumination, excessive perfectionism, extreme cleanliness, orderliness, rigidity, rumination, and scrupulous self-righteousness. Each of these characteristics contributed to the manifestations of their eating disorders: perfectionism was involved in the striving for unqualified thinness, cleanliness with inner sanitation and purging, orderliness in careful amassing of caloric lists and (often bogus) food characteristics, stubbornness in rock-bound dieting and weight loss, excessive morality as preoccupations with good and bad foods and practices.
Although mood disorder patients manifest a variety of personality disorders, or none at all, OCPD is often frequent. Again, maladaptiveness and suffering induced by the OCPD component is distinct, and assessment of extensiveness of each feature is important both for psychotherapy and pharmacological treatment. When patients with dysthymia or major depression manifest debilitating OCPD features, dual acting antidepressants—i.e. fluoxetine, paroxetine, sertraline, duloxetine—are beneficial for both immediate and prolonged effects. On the other hand, with absent or minimal OCPD features, other types of antidepressants may be satisfactorily used.
With respect to psychotherapy, OCPD features seem clearly to play an etiological role in mood disorder together with, or regardless of, genetic or chemical factors. Persons who are excessively or diffusely perfectionistic are bound to be subject to deep disappointments with their strivings that produce both mild and severe depressive diatheses. Similarly, in the face of losses and stresses, stubbornness, rigidity, and concern with control readily give way to extreme self-reproach. Excessive morality leads often to pervasive preoccupations with guilt.
Sociocultural biases tend to obscure connections between OCPD and alcohol abuse. The latter condition is commonly associated, by both laity and professionals, with images of persons who are down and out, disorderly, and often unclean, a far cry from any of the over-adaptive characteristics listed earlier. But a closer look at the high incidence of closet alcoholism among hard driving business executives, entertainment celebrities, and the incessant alcohol imbibing revels of other rich and famous people indicates that the same personality features that lead to success can, with OCPD excess, lead to alcoholic abuse and eventual rack and ruin.
Again, in addition to possible biological and genetic factors, anxiety generated by need for control, perfectionism, rigidity, and the setting of virtually impossible goals leads to pathological self-medicating attempts at control through an ameliorating substance. Alcohol abuse in these cases produces a psychopathological spiral where total abandonment of perfectionistic values leads to self-loathing and further abuse.
The extreme and socially alienating nature of otherwise adaptive facets of OCPD contributes to another complication in recognition and clinical management: patient shame and secrecy. Seldom will OCPD persons volunteer descriptions of their excessive characteristics but they will instead be evasive or righteously defend seemingly irrational behavior. If asked about excessive perfectionism, for example, they will often insist they simply try to do things well.
This shame and secrecy, which may be intrinsic also to formative factors in OCPD psychopathology, accounts in part for difficulties in obtaining treatment collaboration with such patients. It also plays a significant role in the marked variability in research results, as well as miscalculations about the true incidence of the condition (along with OCD which shares the secrecy problem) in the population at large. Developing patient confidence, multiple assessments, long-term contact, gathering broad information about degree of impairment, are critically important for both recognition and effective care of the OCPD disorder.