301.4  Obsessive-Compulsive Personality Disorder

Diagnostic Features

The essential feature of Obsessive-Compulsive Personality Disorder is a preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. This pattern begins by early adulthood and is present in a variety of contexts.

Individuals with Obsessive-Compulsive Personality Disorder attempt to maintain a sense of control through painstaking attention to rules, trivial details, procedures, lists, schedules, or form to the extent that the major point of the activity is lost (Criterion 1). They are excessively careful and prone to repetition, paying extraordinary attention to detail and repeatedly checking for possible mistakes. They are oblivious to the fact that other people tend to become very annoyed at the delays and inconveniences that result from this behavior. For example, when such individuals misplace a list of things to be done, they will spend an inordinate amount of time looking for the list rather than spending a few moments re-creating it from memory and proceeding to accomplish the tasks. Time is poorly allocated, the most important tasks being left to the last moment. The perfectionism and self-imposed high standards of performance cause significant dysfunction and distress in these individuals. They may become so involved in making every detail of a project absolutely perfect that the project is never finished (Criterion 2). For example, the completion of a written report is delayed by numerous time-consuming rewrites that all come up short of “perfection.” Deadlines are missed, and aspects of the individual’s life that are not the current focus of activity may fall into disarray.

Individuals with Obsessive-Compulsive Personality Disorder display excessive devotion to work and productivity to the exclusion of leisure activities and friendships (Criterion 3). This behavior is not accounted for by economic necessity. They often feel that they do not have time to take an evening or a weekend day off to go on an outing or to just relax. They may keep postponing a pleasurable activity, such as a vacation, so that it may never occur. When they do take time for leisure activities or vacations, they are very uncomfortable unless they have taken along something to work on so they do

not “waste time.” There may be a great concentration on household chores (e.g., repeated excessive cleaning so that “one could eat off the floor”). If they spend time with friends, it is likely to be in some kind of formally organized activity (e.g., sports). Hobbies or recreational activities are approached as serious tasks requiring careful organization and hard work to master. The emphasis is on perfect performance. These individuals turn play into a structured task (e.g., correcting an infant for not putting rings on the post in the right order; telling a toddler to ride his or her tricycle in a straight line; turning a baseball game into a harsh “lesson”).

Individuals with Obsessive-Compulsive Personality Disorder may be excessively conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (Criterion 4). They may force themselves and others to follow rigid moral principles and very strict standards of performance. They may also be mercilessly self-critical about their own mistakes. Individuals with this disorder are rigidly deferential to authority and rules and insist on quite literal compliance, with no rule bending for extenuating circumstances. For example, the individual will not lend a quarter to a friend who needs one to make a telephone call, because “neither a borrower or lender be” or because it would be “bad” for the person’s character. These qualities should not be accounted for by the individual’s cultural or religious identification.

Individuals with this disorder may be unable to discard worn-out or worthless objects, even when they have no sentimental value (Criterion 5). Often these individuals will admit to being “pack rats.” They regard discarding objects as wasteful because “you never know when you might need something” and will become upset if someone tries to get rid of the things they have saved. Their spouses or roommates may complain about the amount of space taken up by old parts, magazines, broken appliances, and so on.

Individuals with Obsessive-Compulsive Personality Disorder are reluctant to delegate tasks or to work with others (Criterion 6). They stubbornly and unreasonably insist that everything be done their way and that people conform to their way of doing things. They often give very detailed instructions about how things should be done (e.g., there is one and only one way to mow the lawn, wash the dishes, build a doghouse) and are surprised and irritated if others suggest creative alternatives. At other times they may reject offers of help even when behind schedule because they believe no one else can do it right.

Individuals with this disorder may be miserly and stingy and maintain a standard of living far below what they can afford, believing that spending must be tightly controlled to provide for future catastrophes (Criterion 7). Individuals with Obsessive-Compulsive Personality Disorder are characterized by rigidity and stubbornness (Criterion 8). They

are so concerned about having things done the one “correct” way that they have trouble going along with anyone else’s ideas. These individuals plan ahead in meticulous detail and are unwilling to consider changes. Totally wrapped up in their own perspective, they have difficulty acknowledging the viewpoints of others. Friends and colleagues may become frustrated by this constant rigidity. Even when individuals with Obsessive- Compulsive Personality Disorder recognize that it may be in their interest to compromise, they may stubbornly refuse to do so, arguing that it is “the principle of the thing.”

Associated Features and Disorders

When rules and established procedures do not dictate the correct answer, decision making may become a time-consuming, often painful process. Individuals with Obsessive-Compulsive Personality Disorder may have such difficulty deciding which tasks take priority or what is the best way of doing some particular task that they may never get started on anything. They are prone to become upset or angry in situations in which they are not able to maintain control of their physical or interpersonal environment, although the anger is typically not expressed directly. For example, a person may be angry when service in a restaurant is poor, but instead of complaining to the management, the individual ruminates about how much to leave as a tip. On other occasions, anger may be expressed with righteous indignation over a seemingly minor matter. People with this disorder may be especially attentive to their relative status in dominance-submission relationships and may display excessive deference to an authority they respect and excessive resistance to authority that they do not respect.

Individuals with this disorder usually express affection in a highly controlled or stilted fashion and may be very uncomfortable in the presence of others who are emotionally expressive. Their everyday relationships have a formal and serious quality, and they may be stiff in situations in which others would smile and be happy (e.g., greeting a lover at the airport). They carefully hold themselves back until they are sure that whatever they say will be perfect. They may be preoccupied with logic and intellect, and intolerant of affective behavior in others. They often have difficulty expressing tender feelings, rarely paying compliments. Individuals with this disorder may experience occupational difficulties and distress, particularly when confronted with new situations that demand flexibility and compromise.

Individuals with Anxiety Disorders, including Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Social Phobia, and Specific Phobias, have an

increased likelihood of having a personality disturbance that meets criteria for Obsessive-Compulsive Personality Disorder. Even so, it appears that the majority of individuals with Obsessive-Compulsive Disorder do not have a pattern of behavior that meets criteria for this Personality Disorder. Many of the features of Obsessive- Compulsive Personality Disorder overlap with “type A” personality characteristics (e.g., preoccupation with work, competitiveness, and time urgency), and these features may be present in people at risk for myocardial infarction. There may be an association between Obsessive-Compulsive Personality Disorder and Mood and Eating Disorders.

Specific Culture and Gender Features

In assessing an individual for Obsessive-Compulsive Personality Disorder, the clinician should not include those behaviors that reflect habits, customs, or interpersonal styles that are culturally sanctioned by the individual’s reference group. Certain cultures place substantial emphasis on work and productivity; the resulting behaviors in members of those societies need not be considered indications of Obsessive-Compulsive Personality Disorder. In systematic studies, the disorder appears to be diagnosed about twice as often among males.

Prevalence

Studies that have used systematic assessment suggest prevalence estimates of Obsessive-Compulsive Personality Disorder of about 1% in community samples and about 3%–10% in individuals presenting to mental health clinics.

Differential Diagnosis

Despite the similarity in names, Obsessive-Compulsive Disorder is usually easily distinguished from Obsessive-Compulsive Personality Disorder by the presence of true obsessions and compulsions. A diagnosis of Obsessive-Compulsive Disorder should be considered especially when hoarding is extreme (e.g., accumulated stacks of worthless objects present a fire hazard and make it difficult for others to walk through the house). When criteria for both disorders are met, both diagnoses should be recorded.

Other Personality Disorders may be confused with Obsessive-Compulsive Personality

Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Obsessive-Compulsive Personality Disorder, all can be diagnosed. Individuals with Narcissistic Personality Disorder may also profess a commitment to perfectionism and believe that others cannot do things as well, but these individuals are more likely to believe that they have achieved perfection, whereas those with Obsessive-Compulsive Personality Disorder are usually self-critical. Individuals with Narcissistic or Antisocial Personality Disorder lack generosity but will indulge themselves, whereas those with Obsessive-Compulsive Personality Disorder adopt a miserly spending style toward both self and others. Both Schizoid Personality Disorder and Obsessive-Compulsive Personality Disorder may be characterized by an apparent formality and social detachment. In Obsessive-Compulsive Personality Disorder, this stems from discomfort with emotions and excessive devotion to work, whereas in Schizoid Personality Disorder there is a fundamental lack of capacity for intimacy.

Obsessive-Compulsive Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effects of a general medical condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified).

Obsessive-compulsive personality traits in moderation may be especially adaptive, particularly in situations that reward high performance. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute Obsessive-Compulsive Personality Disorder.

 Diagnostic Criteria for 301.4 Obsessive-Compulsive Personality Disorder

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

1. is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost

2. shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)

3. is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)

4. is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)

5. is unable to discard worn-out or worthless objects even when they have no sentimental value

6. is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things

7. adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes

8. shows rigidity and stubbornness

2. Establish the focus of your remarks

 Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence

Delirium, Dementia, and Amnestic and Other Cognitive Disorders

Mental Disorders Due to a General Medical Condition

Substance-Related Disorders

Schizophrenia and Other Psychotic Disorders

Mood Disorders

Anxiety Disorders

Somatoform Disorders

Factitious Disorders