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For references, see the Bibliography page |
Essential Feature
The essential feature of the obsessive-compulsive personality disorder is a preoccupation with orderliness, perfectionism, and control at the expense of flexibility, openness, and efficiency. Individuals with OCPD are conscientious, scrupulous, and inflexible about morality, ethics, or values. They may force both themselves and others to follow rigid moral principles and very high standards of performance. They are inclined to be severely self-critical. These individuals are deferential to authority and rules. They insist on literal compliance, regardless of circumstances (DSM-IV, 1994, pp. 669-670).
The ICD-10 has an anankastic personality disorder characterized by doubts, perfectionism, conscientiousness, checking and preoccupation with details, stubbornness, caution and rigidity. There may be insistent and unwelcome thoughts or impulses that do not attain the severity of an obsessive-compulsive disorder. These individuals are also inclined to experience undue preoccupation with productivity to the exclusion of interpersonal relationships; they engage in pedantry and strict adherence to social conventions; they are likely to insist that others do things exactly the way they do them (ICD-I0, 1994, pp. 231-232).
Frances, et.al (1995, p. 378) describe individuals with OCPD as:
Benjamin (1993, p. 251) describes individuals with OCPD as being afraid of making a mistake or being accused of being imperfect. In response, they engage in a quest for perfection that results in inconsiderate domination of others and an inclination to blame and criticize people with whom they are connected. They engage in blind obedience to authority or principle. They are extremely self-disciplined, restrained, and self-critical.
According to Millon & Davis (1996, p. 505) OCPD is a conflicted personality style. Individuals with OCPD possess traits that are in conflict with one another. Their interpersonal style and intrapsychic structures can never be fully focused nor coherent due to internal schisms that can neither be escaped nor resolved. The essential conflict is between obedience and defiance. Behaviorally they are compliant; inwardly, they posses a strong desire to assert themselves and defy the regulations imposed upon them. Basically, individuals with OCPD consciously behave like the dependent personality disorder; unconsciously they feel like the antisocial personality disorder (Millon, 1981, p. 218). As with the dependent personality disorder, people with OCPD incorporate the values of others and submerge their own individuality. However, inwardly, they are defiant, and the more they adapt the more they feel anger and resentment (Millon & Davis, 1996, p. 505). Richards (1993, p. 255) also suggests that OCPD is comprised of qualities from the antisocial (aggressive) style and the dependent (submissive) style. In working with individuals with OCPD, the behavioral compliance is often accompanied by attitudinal resentment and anger.
Obsessive-compulsive personality disorder has changed names many times over the years. The following are examples:
Psychoanalytic: Anal character
DSM-I: Compulsive personality
DSM-II: Obsessive-compulsive personality
DSM-III: Compulsive personality disorder
DSM-III R: Obsessive-compulsive personality disorder
DSM-IV: Obsessive-compulsive personality disorder
ICD-9: Anankastic personality
ICD-10: Anankastic personality disorder (Pfohl & Blum, Livesley, editor, 1995, p. 262).
Pollak (Livesley, ed., 1995, p. 277) suggests that obsessive-compulsive personality traits are disseminated widely in the normal population. He believes that this personality is best understood as falling along a continuum of severity from an adaptive coping style to exaggerated and maladaptive expressions.
Unlike other personality disorders that are seen as part of a spectrum disorder, e.g. schizotypal personality disorder and schizophrenia, or as variants of an Axis I disorder or a normal trait, e.g., histrionic personality disorder and extroversion, OCPD is not currently seen as either in the same spectrum of illness or as part of a continuum with OCD (obsessive-compulsive disorder). OCPD and OCD are defined as separate and distinct disorders (McCullough & Maltsberger, Gabbard & Atkinson, editors, 1996, p. 999). The majority of individuals with OCD do not meet the criteria for OCPD; OCD is distinguished by the presence of obsessions and compulsions (DSM-IV, 1994, p. 671). Approximately 50% of individuals meeting the criteria for OCD also meet the criteria for one or more personality disorders. There are, however, two personality disorders that are more frequently comorbid with OCD than OCPD -- the avoidant personality disorder and the dependent personality disorder (Pfohl & Blum, Livesley, editor, 1995, pp. 270-281).
Most individuals with OCPD show traits of one or more of the other cluster C disorders. OCPD is also found in conjunction with passive-aggressive (negativistic) personality disorder or paranoid personality disorder. Individuals with OCPD may also develop various anxiety reactions, agoraphobia, depersonalization, somatization, and depressive disorders (Stone, 1993, pp. 349-350)(Richards, 1993, p. 256). According to the DSM-IV (1994, p. 671) systematic studies have resulted in OCPD being diagnosed about twice as often in males than females. Stone (1993, p. 346) suggests a ratio of 6:4 in men over women with OCPD.
Individuals with either OCPD or narcissistic personality disorder are obsessed with perfection. However, people with NPD think they have achieved it; those with OCPD are quite self-critical and are struggling to reach perfection. Individuals with NPD, APD (antisocial personality disorder), or OCPD are often quite miserly with others. However, people with NPD and APD are highly self-indulgent. Those with OCPD are miserly with both themselves and others (DSM-IV, 1994, p. 672). Individuals with either NPD or OCPD are hostile and have an inordinate need for interpersonal control; they are both competitive and have a driven lifestyle. However, people with OCPD appear to have an intact capacity for dedication and loyalty -- those with NPD apparently do not (Pollak, Livesley, editor, 1995, p. 279).
Self-Image
Individuals with OCPD see themselves as responsible. They believe that they must depend on themselves and that they can be overwhelmed if they do not have systematic rules and regulations to follow (Beck & Freeman, 1990, pp. 46-47). These individuals are as harsh in their judgement of themselves as they are with others (Millon, 1981, p. 226). They value control over most other virtues. They emphasize discipline, order, reliability, loyalty, integrity, and perseverance (McWilliams, 1994, p. 298). Individuals with OCPD are inclined to feel self-doubt and guilt if they do not live up to their ideals but they do not recognize their own ambivalence about achieving aspirations and meeting expectations (Millon, 1981, p. 226).
View of Others
Individuals with OCPD see others as too casual, irresponsible, self-indulgent, and incompetent (Beck & Freeman, 1990, p. 46). They are contemptuous of those who are frivolous and impulsive. They consider emotionally driven behavior immature and irresponsible. They do not usually recognize that they judge others in accord with rules that they themselves unconsciously detest (Millon, 1981, p. 226).
Unfortunately, OCPD insistence on doing things according to logical rules angers others. Some individuals with OCPD become aware of their impact on others but they do not understand it. Others with OCPD appear oblivious to the negative emotions they elicit. In fact, if confronted with this anger, individuals with OCPD are inclined to believe that these people have no right to be angry (Turkat, 1990, p. 85).
Lack of awareness of their controlling and annoying behavior results in individuals with OCPD feeling anything from confusion and bewilderment to being quite offended at the rejection or withdrawal they experience in social, work, or group situations.
Relationships
McWilliams (1994, pp. 284-287) suggests that control was a central issue in the OCPD family of origin. Whether or not that is the case, control is a major factor in current OCPD relationships. Their behavior with significant others is likely to be disrespectful and domineering. They are not necessarily attempting to behave negatively, but appear to be orchestrating the entire family to a pattern of orderliness, discipline, and safety. While their organized behavior may be effective in various work settings, it sets the stage for individuals with OCPD to engage in ongoing and unpleasant power struggles with members of their family.
Socially, individuals with OCPD tend to be polite and formal. They relate to others in terms of rank or status, with an authoritarian rather than equalitarian style. Accordingly, they are deferential, ingratiating, and obsequious with individuals of greater rank, power, or position. People with OCPD will go out of their way to impress those they define as in a superior status. They are quite anxious if they are unsure of their position with these individuals. On the other hand, people with OCPD are autocratic and condemnatory with subordinates. They often behave in a pompous and self-righteous manner. They are haughty and deprecatory but cloak their actions behind regulations and legalities. They justify their aggressive approach by referring to rules or to authorities higher than themselves (Millon, 1981, p. 225).
Issues With Authority
Individuals with OCPD are extraordinarily careful to pay proper respect to those in authority. Their conduct is beyond reproach. By allying themselves with those in power, individuals with OCPD gain considerable strength and authority for themselves. They obtain the protection and prestige of those with greater status and power. They also absolve themselves from blame if they associate their actions with the views of external authorities. By submerging their individuality, they lose personal identity but evade the potential negative impact of taking a stand of their own (Millon, 1981, pp. 228-229). Once the dominant people or the authority figures in the environment of individuals with OCPD are identified, they will follow orders from these people -- often to absurd lengths (Richards, 1993, p. 255). Even if, as suggested by Pollak (Livesley, ed., 1995, p. 279), individuals with OCPD do resist authority through furtive, withholding behavior, their inclination to disown their own responsibility through attribution of decision-making authority to others and to follow people in power with obsequious conformity can make them dangerous to people in subordinate positions. With individuals who are lower in rank, people with OCPD are uncompromising and demanding. Power over others provides them with a sanctioned outlet to vent their hostility (Millon, 1981, p. 229).
OCPD Behavior
OCPD is one of the passive personality disorders; individuals with OCPD fail to give direction to their own lives. They fear functioning independently and dread making mistakes or engaging in disapproved behavior. They become indecisive, restrained, and immobilized. These individuals are conflicted. They are socially compliant and interpersonally respectful. Underneath the conforming veneer are intense desires to rebel and assert themselves. They cannot because they remain trapped by their fear of intimidation and punishment. They experience severe physical tension and rigid psychological controls to inhibit their impulses and adhere to the expectations of others. Their prudent, controlled, and perfectionistic behavior derives from this conflict between hostility and fear of social disapproval. They can only partially resolve this ambivalence by suppressing resentment and engaging in overconforming behavior. Their disciplined self-restraint controls their intense, hidden oppositional and self-centered feelings. The powerful anger lurking behind their front of propriety and restraint occasionally breaks through into behavior (Millon & Davis, Clarkin & Lenzenweger, editors, 1996, pp. 290-309). Richards (1993, pp. 255-256) suggests that individuals with OCPD can and will behave in a passive-aggressive manner; they are just more successful than individuals with a passive-aggressive personality disorder at concealing their anger behind compliant behavior. Yet, for the most part, individuals with OCPD bind their rebellious and oppositional urges and defend against a behavioral breakthrough with excessive conformance and overt submissiveness. They manifest an extraordinary consistency; they show a rigid and unvarying uniformity in all significant settings. Not only do they follow the rules, they defend them. As a consequence, they can be seen by others as moralistic and self-righteous (Millon, 1981, pp. 217-225).
Individuals with OCPD are excessively devoted to work and productivity. Oldham (1990, p. 73) notes that these individuals invest all of their energy in work -- then become tense, strained, anxious, and overwhelmed by the amount of work they have to do. People with OCPD maintain control of their occupational demands through attention to regulations, details, procedures, and schedules. Unfortunately, they can be so focused on trivial details that they lose the major point of an activity. They are extremely careful and prone to repetition. They remain unaware that others become annoyed at the delays and inconveniences that result from their behavior. They may allocate time poorly, with major tasks being left to the last moment. Their perfectionism causes them significant distress. They may become so involved in making everything perfect that they are unable to complete major projects. Yet they are reluctant to delegate tasks. They stubbornly insist that things be done their way. They give detailed instructions about how things should be done and are surprised and irritated when others suggest creative alternatives. They may reject help, even when needed, because they believe no one else can do it right. Others become frustrated at their rigidity. People with OCPD often refuse to compromise even when they recognize that it is in their own best interests -- because of the principle of the thing (DSM-IV, 1994. pp. 669-670).
People with OCPD can be mediocre performers in situations that demand more than careful planning or attention to detail. Such situations trigger fear that their efforts will not be acceptable to themselves or others. They are also intolerant of situations that seem so lacking in structure that their need for control and orderliness will make them quite uncomfortable. They can find secure niches in bureaucratic structures where lines of authority are clear. They are inclined to impose many restrictions on others; they are perfectionistic and disciplined; they are harsh toward themselves and others when idealized standards are not met. They are usually attentive to ceremony and correctness; their style is constricted and lacking in confidence and variety (Richards, 1993, p. 256).
For individuals with OCPD, even vacations or leisure activities, if they engage in them at all, are serious tasks requiring planning and organization. Often, if going on a vacation, these individuals take work with them so time will not be wasted (DSM-IV, 1994, p. 669).
Individuals with OCPD are inclined to be pack rats. They hold tight to their possessions and regard discarding objects as wasteful. These individuals will hoard and protect their belongings against all intrusions even if significant others complain about the space taken up by what they have accumulated. Feeling deprived of so many wishes and desires in childhood, they protect what they have achieved as adults. This results in miserly, ungiving, and ungenerous behavior. They may live below their means so that spending can be controlled to provide for any mischance in the future (DSM-IV, 1994, p. 670) (Millon, 1981, p. 229).
Affective Issues
Despite their elaborate defenses, individuals with OCPD tend to have one of the most troubled personality styles in terms of psychiatric symptoms. Their cognitive and behavioral organization make them susceptible to the full range of affective disorders. They are plagued by both their own exacting standards and the high expectations they perceive others to hold for them (Millon, 1996, p. 205).
Individuals with OCPD are vulnerable to distress in situations in which they are unable to maintain control over their physical or interpersonal environment (DSM-IV, 1994, p. 670). Even if they are in a benign and accepting environment, they will either undo their chances for satisfaction or simply be unable to experience contentment. They are beset by a severe internal conflict that they can neither escape nor resolve. They believe they must find a place in society that is judged by others as responsible and productive; on the other hand, the more they adapt, the more they feel angry and resentful (Millon, 1981, p. 216). Their anger is often expressed indirectly, sometimes through rumination (DSM-IV, 1994, p. 671).
Individuals with OCPD proceed through each day meticulously following their routines. The rigidity of their behavior is necessary if they are to successfully control their seething antagonism. If they deviate from absolute adherence to rules and regulations, their anger may burst out of control and they risk exposing to others the resentment they really feel (Millon, 1981, p. 218). Richards (1993, p. 255) also suggests that people with OCPD are emotionally restricted because they fear an uncontrolled outburst of their own aggression -- leading to rejection by significant others. McWilliams (1994, p. 282) believes that the basic affective conflict in the OCPD is between rage and fear - rage at being controlled and fear of being punished.
Sperry (1995, p. 138) describes the OCPD emotional style as grim, angry, frustrated, and irritable. Individuals with OCPD are prone to depression, especially as they get older (Frances, et.al., 1995, p. 379). Millon (1996, pp. 205-207) also notes the OCPD vulnerability to major depression in later life. These individuals, who are conscientious, hardworking, and well-integrated into society are vulnerable to loss; they are sharply aware of their declining abilities and decreasing productivity as they age. They respond to these changes with self-punitive and self-denigrating thoughts. As they face the final years of their careers or approach retirement, they are confronted by the realization that they will not attain their all of their life goals nor will they meet their own standards of excellence. Another potential issue in the late onset of depression for individuals with OCPD is the barrenness of their existence after giving up so much of themselves to their rigid conformity. Major depression in individuals with OCPD tends to have an agitated and apprehensive quality.
Individuals with OCPD are also quite vulnerable to anxiety. They fear making mistakes and facing punishment for being less than perfect. They appear to have learned that there is a sanctioned but limited sphere of acceptable conduct. Benjamin (1993, pp. 246-251) suggests that OCPD developmental history may have included relentless coercion to perform correctly and follow the rules, regardless of the personal cost. As children, individuals with OCPD were punished for failure and were given few, if any, rewards for success. The most they could hope for was to avoid criticism or punishment. It was an environment of little warmth; the emphasis was on control. As adults, these individuals have learned to reduce their level of anxiety by incorporating this control. They restrict their activities to those that are permitted by the more powerful and potentially rejecting others. They adhere carefully to rules so that they do not engage in unacceptable behavior (Millon & Davis, Clarkin & Lenzenweger, editors, 1996, p. 299). Part of the reason that unstructured activities or situations are so anxiety-provoking for individuals with OCPD is the lack of safety involved in not knowing the rules of conduct or what behavior will ensure safety.
Defensive Structure
OCPD defenses are intellectualization, isolation of affect, undoing, reaction formation, displacement, and regression. These defenses are used to control anxiety at all costs with the heavy price of personal constriction (McCullough & Maltsberger, Gabbard & Atkinson, editors, 1996, p. 1001). This allows individuals with OCPD to appear deliberate and poised. However, they must manage the internal turmoil of their unresolved struggle between obedience and defiance which threatens to upset the balance they have so carefully developed. They must control against both external eruption of their anger and the internal disruption of emotions and impulses:
Individuals with OCPD attempt to not recognize the contradictions between their impulses and their behavior. They do this by restricting self-awareness and avoiding introspection. Not only do they accept authority-based demands and expectations; they believe them to be right. This can often bring these individuals institutional commendation and support. These rewards serve to reinforce their inclination toward self-righteousness and obedience (Millon, 1981, p. 226).
Stone (1993, p. 347) notes that individuals with OCPD live in the future (compared to the Cluster B individuals who live mostly in the present). They are obsessed with foreseeing all dangers and possible mistakes. Their behavior has the defensive quality of warding off parental or authority figure's anger by double-checking that no mistakes have been made (Stone, 1993, p. 347).
There are many service providers who rely on the same defensive patterns as do individuals with OCPD. They are also likely to overvalue order and correctness. Without awareness of this on the part of service providers, they are likely to collude with the OCPD clients' defenses; this is a common problem and it always impoverishes the treatment (McCullough & Maltsberger, Gabbard & Atkinson, editors, 1996, p. 1002).
The Obsessive-Compulsive Personality Disorder Coming Into Treatment
Individuals with OCPD often come in for treatment because their productivity or cognitive skills are slipping. They complain of depression and an inability to be productive. These individuals appear to be particularly sensitive to natural changes in cognitive skills due to normal aging (Turkat, 1990, p. 85). Another reason individuals with OCPD come in for treatment has to do with psychophysiological difficulties. They frequently experience psychosomatic disorders due to the problems they have with discharging tension. They may also experience severe anxiety, immobilization, impotence, and excessive fatigue (Millon, 1981, pp. 242-243). A third reason these individuals come in for treatment is a result of someone else's concern about their behavior. For example, they may have received a negative performance evaluation on the job because they are having difficulty getting along with others. Interpersonal difficulties for people with OCPD are related to their failure to grasp the impact of their own behavior. They are quite inept at reading other people's emotions and at experiencing and understanding their own. They usually deny they are having problems with others on the job and see the supervisor as having made false accusations (Turkat, 1990, p. 85).
Initially, clients with OCPD appear to be cooperative. They are polite, unemotional, rational, and detail oriented (Turkat, 1990, p. 84). These individuals will want to defer to their service providers and be perfect clients (Benjamin, 1993, p. 260). They will be serious, conscientious, honest, motivated, and hard-working. Over time, however, it will become apparent that they are inclined to be consciously compliant and unconsciously oppositional (McWilliams, 1994, p. 292). They are likely to replicate their conflicts with obedience and defiance within the treatment setting as in other areas of their lives.
Medication Issues
Generally, OCPD symptoms are not responsive to medication (McCullough & Maltsberger, Gabbard & Atkinson, editors, 1996, pp. 999-1000). Thus far, only medication for concurrent Axis I symptoms have been reported (Sperry, 1995, p. 152). Medication helpful to obsessive-compulsive disorder, e.g., clomipramine, is unlikely to benefit individuals with OCPD (Janicak, et.al, 1993, p. 519). Even if medication is tried, individuals with OCPD may have some difficulty with compliance because of their fear of loss of control. Alternatively, they may develop unrealistic expectations of medication (Ellison & Adler, ed., 1990, p. 59). Overall, therapy is the treatment of choice for OCPD (McCullough & Maltsberger, Gabbard & Atkinson, editors, 1996, pp. 999-1000) (Sperry, 1995, p. 152).
However, if the unremitting struggle with tension, interpersonal difficulties, and chronic dread of the future have resulted in depressive symptoms, antidepressant medication may make a difference. If individuals with OCPD can be less physically and psychologically strained, they may be able to focus with greater clarity on treatment issues.
Treatment Provider Guidelines
The first rule of treatment for service providers working with OCPD clients is ordinary kindness. These individuals are accustomed to being exasperating to others without fully comprehending why (McWilliams, 1994, p. 294). Working with them can be tedious. They are likely to engage in long monologues of self-justification, lofty goals and ambitions, and reasons why family members, intimate others, and subordinates at work need to be rigidly controlled (Stone, 1993, p. 348). The strained, affect-controlled, and detail-oriented speech of individuals with OCPD must be met with patience, tolerance, and the ability to listen without drifting off into personal reveries. Service provider boredom can be managed, to some degree, by listening to the patterns of behavior, attitudes, and beliefs that are consistent through various situations and relationships described by clients with OCPD. It is not beneficial to brush aside, no matter how gently, material that these individuals see as important in an effort to get on with affective issues. Their focus is often more businesslike and problem-focused; they are not as comfortable with an emphasis on emotional support and relationships (Beck & Freeman, 1990, p. 321). Pressure to prematurely focus on and experience emotions is both alien and alienating.
Be watchful of individuals with OCPD becoming conscientious clients, i.e. approaching treatment as a task that must be carefully attended to with hard-work and careful adherence to the ground rules of honest discourse. This may result in inhibited self-disclosure that is determined by what these individuals believe is expected of them. Their studied compliance and lack of genuineness must be addressed directly; treatment is not a set of duties that must be followed without deviation. It is a more naturally unfolding process that emphasizes personal experience and genuine expression of self (McCann, Retzlaff, ed., 1995, p. 149). However, keep in mind that clients with OCPD who bring their dogged persistence and task-orientedness to treatment are often able to stay with the treatment process, develop a good therapeutic alliance, and enjoy a favorable outcome (Stone, 1993, p. 350). The success of the treatment process with these individuals is a matter of managing their inhibitory defenses, utilizing their strengths, supporting their conscientious intentions, and accepting them in spite of their interpersonally problematic behavior. Individuals with OCPD do not generally inspire warmth in the people around them, including service providers. Their arrogant, argumentative, and self-justifying behavior can make them seem to be stronger or tougher than they really are. It is important to remember that their defensive structure covers vulnerability to shame, humiliation, and dread.
Transference and Countertransference Issues
Individuals with OCPD tend to be good clients; they are serious, conscientious, honest, motivated, and hard-working. However, they also tend to be consciously compliant and unconsciously oppositional. The combination of excessive conscious submission and powerful unconscious defiance can be maddening and countertransference is usually annoyed impatience. OCPD clients can also emit an atmosphere of veiled criticism that has the potential to undermine the clinician (McWilliams, 1994, p. 294). These individuals can feel genuinely grateful to effective service providers, but underlying their gratitude is a degree of hostility or aggression which can stimulate the service providers own aggression (Richards, 1993, p. 258).
Service providers who have a need to feel emotionally connected to their clients may focus on and become irritated by OCPD defenses -- and fail to recognize the emotional pain underlying these defenses. If service providers become irritated enough, they may try to conceal their anger and irritation by experiencing positive concern for OCPD clients, i.e., using their own defense of reaction formation and mirroring the OCPD defensive pattern. Also, these individuals' compulsive need to be good clients can be joined by the service providers' need to be good clinicians (Kubacki & Smith, Retzlaff, ed., 1995, pp. 174-175).
Because clients with OCPD are often not much fun to work with, particularly if they have passive-aggressive traits, they can evoke the countertransference issues of:
These concerns can lead to a treatment stalemate and must be addressed directly (Richards, 11993, p. 258) (Stone, 1993, p. 350) (Beck & Freeman, 1990, pp. 321-322) (Kantor, 1992, p. 69). Service providers must assist OCPD clients to utilize their treatment time advantageously. However, if boredom and frustration become more than the treatment providers can manage, this should be addressed via supervision or consultation. These clients will not become entertaining in their self-presentation and do not owe their clinicians a more lively group or individual session.
Treatment Techniques
Zimmerman (1994, pp. 113-115) suggests the following questions in the assessment of individuals with OCPD:
In treatment, clients with OCPD are most comfortable when the interaction is organized, detail oriented and unemotional (Turkat, 1990, p. 85). These individuals will have difficulty in treatment exploring emotional issues and their link to behavior. They are more likely to be responsive to self-control or affective management training. They will diligently follow instructions if enhanced control of emotional distress is a possibility. They will value training that allows them to recognize early stages of emotional distress and how to implement strategies to avoid sudden and extreme loss of emotional control (Donat, Retzlaff, ed., 1995, p. 54).
Short-term treatment can be beneficial in assisting clients with OCPD in crisis. Specific, focused goals to help these individuals to accommodate to change can be done in a limited number of sessions. Validation of feelings will help clients with OCPD to be relieved of guilt, self-doubt, and fear. Confrontation of OCPD defenses may be more effectively accomplished in group treatment. These clients may get in power struggles within individual sessions [their preoccupation with details and need for control can lead to an endless conflict over words, issues, and who is in charge (Sperry, 1995, p. 144)]. Group can diffuse this inclination. The group process also allows clients with OCPD to develop trust in several people (McCullough & Maltsberger, Gabbard & Atkinson, editors, 1996, p. 1000).
OCPD treatment is organized around three basic considerations: 1) attention to defenses; 2) softening and modification of superego rigidity; and 3) identification and working through of unconscious conflicts that generate symptoms (McCullough & Maltsberger, Gabbard & Atkinson, editors, 1996, p. 1001). Treatment must find a way to counter OCPD indecisiveness, ruminations, and suppression of emotion. Problem-solving methods will be useful (Stone, 1993, p. 349).
Clients with OCPD may not do well in family therapy. They are inclined to ally themselves with the treatment providers and experience difficulty entering the client role. They also experience extreme anxiety if forced to relinquish their defenses and expose their feelings to significant others (Millon, 1981, p. 243). McWilliams (1994, p. 297) actually suggests that clients with OCPD, with encouragement, can go beyond identification of affect to actually enjoying the experience of their feelings.
Interpersonal treatment of obsessive-compulsive personality disorder focuses on building the ego strength that is needed to recognize situations that set off regressive patterns. Five categories of therapeutic response in the interpersonal model are: facilitating collaboration, helping individuals learn about regressive behavioral patterns, teaching them to block maladaptive patterns, enabling the will to change, and teaching new patterns (Benjamin, 1993, p. 132). Benjamin (Clarkin & Lenzenweger, editors, 1996, p. 210) goes on to suggest that clients with OCPD should be assisted to:
Treatment Goals
Treatment for clients with OCPD will have to address the issue of control. For significant change, these individuals must develop tolerance for:
These areas of living cannot be controlled away, defended against, or dissolved in the drug of choice.
Cognitive therapy notes three maladaptive OCPD schemas: perfectionism, the need for certainty, and the belief that there is an absolutely correct solution for problems (Sperry, 1995, p. 141). Treatment goals in relation to these issues would include greater self-acceptance and tolerance for uncertainty and ambiguity. A major treatment goal for individuals with OCPD would be to make increments in their capacity and skills to take a more proactive (less reactive) role in dealing with the affairs of their lives (Millon & Davis, Clarkin & Lenzenweger, editors, 1996, p. 338).
Treatment goals must allow for acceptance of OCPD individuals' basic personality style and temperament. While personality can be modified in treatment, it is rarely transformed. Nevertheless, autonomy and realistic self-esteem can be expanded even if OCPD conflicts and defenses remain in place (McWilliams, 1994, p. 148). Oldham (1990, p. 5) maintains that personality styles are nonpathological versions of the personality disorders. Personality style is an individual's organizing principle. It is the orderly arrangement of attributes, thoughts, feelings, attitudes, behaviors, and coping mechanisms. It is the distinctive pattern of how a person thinks, feels, and behaves (Oldham, 1990, p. 15).
For individuals with OCPD, a more adaptive shift toward a personality style would result in a reduction of interpersonal strain, symptoms secondary to tension, depression, and dread of the future. Oldham (1990, p. 57) proposes nine traits and behaviors in the conscientious personality style (the non-disordered version of OCPD). These individuals:
Conscientious individuals have a strong, demanding inner authority; they have excellent self-discipline. They are generally reserved. Intimacy does not come easily to them. They like to be around people, but maintain an emotional distance. Conscientious individuals may appear overcautious, and ungenerous; nevertheless, they are capable of being devoted, emotionally steady, and reliable (Oldham, 1990, p. 66). The significant issue is that individuals can become a more adaptive version of themselves. They do not need, nor can they achieve, change so extreme that they transform themselves into another personality style.
Cluster C: Incidence of Co-Occurring Substance Abuse Disorders
Cluster C has a high incidence of co-occurring substance abuse disorders, though not as high as Cluster B (Nace, O'Connell, ed., 1990, p. 184).
Individuals with personality disorders, due to their frequent failures in self-regulation, have an increased inclination to use drugs and alcohol as alternative solutions to life problems. This failure in self-regulation and faulty adaptation to normal stressors can usually be attributed to deficiencies or disturbances in the personality (Richards, 1993, pp. 227-240). As Freud has said, intoxicating substances keep misery at a distance and provide a greatly desired degree of independence from the external world. With the help of drugs, anyone can withdraw from the pressures of reality and find refuge in a world of their own (Khantzian, Halliday, & McAuliffe, 1990, opening page). For individuals with OCPD, addictive or compulsive behavior may be an attempt to manipulate internal discomfort and negative feelings while continuing to adhere to rigid patterns of coping with external reality. Drug and alcohol use can be a means to manage the impact of tension and physiological strain on individuals with OCPD in the course of their usual day.
Individuals with OCPD may have some protection against drug/alcohol addiction because of the potential for loss of control involved in intoxication, dependence, and withdrawal. They are also disinclined to engage in the illegal and high risk behaviors involved in the use of street drugs. On the other hand, compulsive behaviors can become severely disruptive and exert harsh negative consequences. Almost by definition, these individuals are vulnerable to work addiction. Compulsive behaviors related to money and sexual behaviors are also common, e.g., compulsive hoarding, bargain-seeking, compulsive use of phone sex, etc.
Drugs of Choice for the Obsessive-Compulsive Personality Disorder
Milkman & Sunderwirth (1987, p. xiv) propose that the drug of choice for anyone is actually a pharmacologic defense mechanism; it is chosen by how well it fits with individuals' usual style of coping and how effectively it bolsters already established patterns for managing psychological threat. Richards (1993, p. 257) suggests that individuals with OCPD will respond positively to the relief afforded by drugs to their overloaded (and conflicted) psychological and physiological being. Drugs and alcohol can easily become an accelerating addiction for these individuals as they acquire ingrained habits with little effort. The function of OCPD addiction is usually escape/avoidance or modulation of painful affect. The drug of choice is primarily alcohol or a prescribed medication because these substances do not involve the risks intrinsic to illegal drug use.
Individuals with OCPD may be attracted to drugs that enhance work performance. They may seek CNS stimulants to increase their stamina and capacity for sustained productivity. While they may joke about excessive use of caffeine, they may well be attracted to stronger stimulants, such as amphetamines, in times of stress or when caffeine is not powerful enough to give them the boost they believe they need.
Dual Diagnosis Treatment for the Obsessive-Compulsive Personality Disorder
Richards (1993, p. 278) suggests that treatment failures for the dually diagnosed are often a result of neglecting to consider the function of the addiction, including the drug of choice, within the context of the psychopathology dominant in the individual. Dual diagnosis treatment must involve recognition of needs, behaviors and attitudes that foster addictive behavior. Specifically, new ways must be learned for dealing with OCPD drivenness and feelings of tension, fear, dread, and anger other than compulsivity. Peele (1985, p. 47) suggests that treatment focus be placed on the addicts' experience of the drug and alcohol use and how it fits into their psychological and environmental ecology, i.e., how the addictive behavior is used to cope with personal and social needs and changing situational demands. Peele believes that no substance or behavior is inherently addictive. Rather, people become addicted due to a combination of social, cultural, situational, personality, and developmental factors. Further, he suggests that unless the full range of addictive behaviors in a person's life is considered, e.g. substances used and compulsive behaviors delineated, the actual degree of addiction is not completely known (Peele, 1985, p. 103). Hoskins (1989, p. 13) proposes that addictions are formed in complexes in which each addiction reinforces the others. People usually agree to try recovery once they can no longer maintain three or more addictive options in their lives.
In assessing OCPD addiction, it is important to ascertain if the use of substances or the compulsive behaviors support compartmentalization by shoring up defenses (escape/avoidance or affect modulation) or provide an outlet for expressing unacceptable aspects of the self (facilitation). Individuals with OCPD tend to have muted expressions of addiction in contrast to other personality disordered individuals. They can remain functional addicts for long periods of time. With severe addiction, the extremes of the antisocial and dependent personalities are seen in individuals with obsessive-compulsive personality disorder, with aggressive grandiosity alternating with intense humiliation, shame, and guilt (Richards, 1993, pp. 256-257).
Interventions are rarely needed for addicted individuals with OCPD. Redirection from an authority figure, e.g. employer or physician, is often enough to prompt them to seek AOD treatment. Should they lapse or relapse, individuals with OCPD may be overwhelmed with guilt. With the intensity of their guilt, they are vulnerable to a complete loss of control and will need considerable support (Richards, 1993, p. 258).
In treatment, individuals with OCPD are good at following advice, accepting guidelines, and respond well to programmatic efforts that require note taking, records, measurements, and specific steps or sequences. Psychoeducation (for both personality issues and drugs) is important for these individuals to avoid stimulation of resistance (Richards, 1993, p. 257). They are likely to attend 12 Step Meetings when required to do so. However, service providers should be alert to the remarkable capacity these individuals have to evoke annoyance and rejection from others. They may need assistance to learn to utilize support groups well and to connect to a sponsor who will be both tolerant and patient.
Peele (1985, p. 156) suggests that a nonaddicted lifestyle includes an awareness (and acceptance) that negative feelings, insoluble problems and a sense of inadequate rewards will never disappear entirely. To move beyond addiction, individuals must be willing to tolerate the uncertainty of life and must believe they have the strength to withstand discomfort and generate positive rewards for themselves. These issues are similar to the personality dynamics generally confronting individuals with OCPD. Recovery from drug and alcohol abuse will engage these clients in work that is both difficult for them and important to general enhancement of personality functioning.
Confrontation usual to substance abuse treatment may be needed to launch a successful assault on the formidable array of defenses used by individuals with OCPD. However, given the level of fear and shame underneath the defenses, the support behind the confrontation must be apparent and reliable. Abstinence can be a prerequisite for treatment. These people often have such a powerful defensive structure that firm limits are beneficial to the treatment process. They are also quite adept at following instructions and may well be able to utilize this aspect of their personality structure to facilitate recovery behaviors.
Sharon C. Ekleberry, 2000