Cluster C: Obsessive-Compulsive Personality Disorder

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29 March, 2000

Cluster C: OBSESSIVE-COMPULSIVE PERSONALITY DISORDER (OCPD)

Mental Health Issues Treatment Issues OCPD & Addiction:
Dual Diagnosis Treatment Issues

Essential Feature: A pattern of preoccupation with orderliness, perfectionism, and control at the expense of flexibility and efficiency (DSM IV™, 1994).
Self Image: OCPDs see themselves as responsible (Beck); they are harshly self-critical; they restrain feelings and neglect themselves (Benjamin).
View of Others: OCPDs see others as too casual, irresponsible, self-indulgent, or incompetent (Beck). OCPDs have intense, conflictual feelings toward both themselves and others (Millon).
Relationships: OCPDs prefer polite, formal, and correct personal relationships. They relate to others in terms of rank or status (Millon). The baseline OCPD interpersonal position is inconsiderate domination, unfeeling adherence to authority and moral causes, and imbalanced devotion to perfection (Benjamin).
Authority Issues: Deferential and ingratiating with superiors, they are autocratic and condemnatory with subordinates. OCPDs will justify their aggressive behavior by recourse to rules or authorities higher than themselves (Millon).
Behavior: OCPDs have to do everything perfectly and may be exasperating to deal with. They have difficulty making decisions (Oldham) and a characteristic air of austerity and serious-mindedness (Millon).
Affective Issues: The affective experience of the OCPD is solemn, tense, and grim; they keep most emotions under tight control. Beset by severe internal conflict, the more OCPDs adapt, the more they feel anger and resentment (Millon).
Defensive Structure: OCPDs operate with a system of rules and standards (Beck). OCPDs live in the future, i.e., they obsess about foreseeing all dangers/problems (Stone). OCPDs' defenses are intellectualization, isolation of affect, undoing, and reaction formation (Sperry) (McWilliams).
The OCPD Coming Into Treatment: OCPDs tend to seek treatment because of depression or slipping productivity. OCPDs try to be good clients. They are serious, conscientious, honest, motivated, and hard-working. They also tend to be consciously compliant and unconsciously oppositional (McWilliams).
Medication Issues: Generally, OCPD symptoms are not responsive to medication. However, OCPD is frequently accompanied by depression. Antidepressant medication may be helpful.
Treatment Provider Guidelines: Treat OCPDs with ordinary kindness. They are accustomed to being exasperating to others although they do not fully comprehend why (McWilliams). The strained, affect-controlled, and detail-oriented speech of OCPDs must be met with patience, tolerance, and focus. Pressure to prematurely experience emotions can be both alien and alienating.
Countertransference Issues: OCPDs do not generally inspire warmth in the people around them. They can often be seen as stronger or tougher than they really are. It is important to remember that the defense structure covers vulnerability to shame, humiliation, and dread.
Countertransference is usually annoyed impatience; the combination of excessive conscious submission and powerful unconscious defiance can be maddening. OCPDs often emit an atmosphere of veiled criticism that can undermine the service providers (McWilliams).
Treatment Techniques: OCPD clients are likely to respond well to self-control or affective management training. Group can diffuse the inclination these individuals have to engage in power struggles in individual treatment.
Treatment Goals: OCPDs must develop tolerance for their own emotional vulnerability; their lack of control over people and situations; and, the presence of chance, uncertainty, and impermanence in their lives.
Incidence of Co-Occurring SA Disorders: Cluster C has a high incidence of co-occurring substance abuse disorders, though not as high as Cluster B (Nace).
OCPDs 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.
OCPD Drugs of Choice: No single pattern of substance use or abuse can be identified for any of the personality disorders.
In spite of an aversion to loss of control, OCPDs may be attracted to drugs that allow better work performance or greater stamina. They may also seek relief from the unremitting tension under which they live. Drugs of choice for OCPDs are usually alcohol or prescribed medication because of the lack of social disapproval for these substances (Richards).
OCPDs often have compulsive behaviors related to money and sexual behavior, e.g. compulsive hoarding or compulsive use of phone sex.
Dual Diagnosis Treatment: Determine if the addiction supports OCPD defenses or provides an outlet for expressing aggression (Richards). OCPDs tend to have a muted expression of addiction and they can remain functional addicts for long periods of time (Richards).
These individuals may need assistance to use 12 Step-Groups successfully. They are likely to evoke annoyance from others without working on their interpersonal behavior.
Confrontation usual to substance abuse treatment may be needed to launch a successful assault on OCPDs' formidable array of defenses. 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. OCPDs often have such a powerful defensive structure that firm limits are beneficial to the treatment process.

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Cluster C: OBSESSIVE-COMPULSIVE PERSONALITY DISORDER (OCPD)
Mental Health Issues	Treatment Issues	OCPD & Addiction: Dual Diagnosis Treatment Issues
Essential Feature: A pattern of preoccupation with orderliness, perfectionism, and control at the expense of flexibility and efficiency (DSM IV™, 1994). Self Image: OCPDs see themselves as responsible (Beck); they are harshly self-critical; they restrain feelings and neglect themselves (Benjamin). View of Others: OCPDs see others as too casual, irresponsible, self-indulgent, or incompetent (Beck). OCPDs have intense, conflictual feelings toward both themselves and others (Millon). Relationships: OCPDs prefer polite, formal, and correct personal relationships. They relate to others in terms of rank or status (Millon). The baseline OCPD interpersonal position is inconsiderate domination, unfeeling adherence to authority and moral causes, and imbalanced devotion to perfection (Benjamin). Authority Issues: Deferential and ingratiating with superiors, they are autocratic and condemnatory with subordinates. OCPDs will justify their aggressive behavior by recourse to rules or authorities higher than themselves (Millon). Behavior: OCPDs have to do everything perfectly and may be exasperating to deal with. They have difficulty making decisions (Oldham) and a characteristic air of austerity and serious-mindedness (Millon). Affective Issues: The affective experience of the OCPD is solemn, tense, and grim; they keep most emotions under tight control. Beset by severe internal conflict, the more OCPDs adapt, the more they feel anger and resentment (Millon). Defensive Structure: OCPDs operate with a system of rules and standards (Beck). OCPDs live in the future, i.e., they obsess about foreseeing all dangers/problems (Stone). OCPDs' defenses are intellectualization, isolation of affect, undoing, and reaction formation (Sperry) (McWilliams).	The OCPD Coming Into Treatment: OCPDs tend to seek treatment because of depression or slipping productivity. OCPDs try to be good clients. They are serious, conscientious, honest, motivated, and hard-working. They also tend to be consciously compliant and unconsciously oppositional (McWilliams). Medication Issues: Generally, OCPD symptoms are not responsive to medication. However, OCPD is frequently accompanied by depression. Antidepressant medication may be helpful. Treatment Provider Guidelines: Treat OCPDs with ordinary kindness. They are accustomed to being exasperating to others although they do not fully comprehend why (McWilliams). The strained, affect-controlled, and detail-oriented speech of OCPDs must be met with patience, tolerance, and focus. Pressure to prematurely experience emotions can be both alien and alienating. Countertransference Issues: OCPDs do not generally inspire warmth in the people around them. They can often be seen as stronger or tougher than they really are. It is important to remember that the defense structure covers vulnerability to shame, humiliation, and dread. Countertransference is usually annoyed impatience; the combination of excessive conscious submission and powerful unconscious defiance can be maddening. OCPDs often emit an atmosphere of veiled criticism that can undermine the service providers (McWilliams). Treatment Techniques: OCPD clients are likely to respond well to self-control or affective management training. Group can diffuse the inclination these individuals have to engage in power struggles in individual treatment. Treatment Goals: OCPDs must develop tolerance for their own emotional vulnerability; their lack of control over people and situations; and, the presence of chance, uncertainty, and impermanence in their lives.	Incidence of Co-Occurring SA Disorders: Cluster C has a high incidence of co-occurring substance abuse disorders, though not as high as Cluster B (Nace). OCPDs 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. OCPD Drugs of Choice: No single pattern of substance use or abuse can be identified for any of the personality disorders. In spite of an aversion to loss of control, OCPDs may be attracted to drugs that allow better work performance or greater stamina. They may also seek relief from the unremitting tension under which they live. Drugs of choice for OCPDs are usually alcohol or prescribed medication because of the lack of social disapproval for these substances (Richards). OCPDs often have compulsive behaviors related to money and sexual behavior, e.g. compulsive hoarding or compulsive use of phone sex. Dual Diagnosis Treatment: Determine if the addiction supports OCPD defenses or provides an outlet for expressing aggression (Richards). OCPDs tend to have a muted expression of addiction and they can remain functional addicts for long periods of time (Richards). These individuals may need assistance to use 12 Step-Groups successfully. They are likely to evoke annoyance from others without working on their interpersonal behavior. Confrontation usual to substance abuse treatment may be needed to launch a successful assault on OCPDs' formidable array of defenses. 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. OCPDs often have such a powerful defensive structure that firm limits are beneficial to the treatment process.