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Obsessive-compulsive personality disorder

Obsessive-compulsive personality disorder. Certainly the terms obsessive and compulsive are used on a variety of ambiguous ways in psychiatry. They are often used to describe the classic preoccupation with unwanted thoughts and compulsive behaviors. They are used to describe a personality style and they are used to describe a specific personality disorder. Obsessive-compulsive personality disorder is not obsessive-compulsive disorder. It does not involve as exclusive, intrusive, unwanted thoughts and compulsive behaviors. Thatís not what we are talking about. They are disorders of a very different character and how you treat them of course is very unique to obsessive-compulsive personality disorder.

Individuals with obsessive-compulsive personality disorder are characterized by limited ability to express warm and tender feelings, focusing on facts instead of feelings, because feelings provoke anxiety. They are often preoccupied with the right way of doing things and they insist on having things their own way. They are quite moralistic, often to the point of absurd rigidity and extreme insensitivity. Lists and routines dominate their lives. Decision-making is often very difficult for the obsessive-compulsive, as you know. They will try to reduce it to a science and then be unable to. Then often be paralyzed by indecision and fear of making a mistake. Other obsessive-compulsive traits may include extreme cleanliness and orderliness. At the healthier end of the spectrum people with this personality disorder can hold down stable jobs and have stable family lives, but many people are quite isolated due to their rigidity and fear of affect. In the interview, obsessive-compulsive individuals will usually be stiff and formal and express little emotion. They will often be detailed and quite circumstantial in their answers to questions.

Predominant defenses that are used are isolation of affect, undoing - essentially doing something and then taking it back, and intellectualization. Isolation of affect and intellectualization are really quite related. They are essentially draining thoughts and feelings that go with them. So this is my classic obsessional patient.

The diagnosis is characterized by perfectionism and inflexibility beginning at a very early age. In terms of etiology, classic psychoanalytic thinking talks about the anal phase of development in the genesis of obsessive-compulsive traits and toilet training is the standard metaphor for this. But essentially, the tension is between the assertion of oneís own autonomy and the development of self control. This doesnít necessarily have to happen around toilet training at all, but these issues of submission to authority, dominance versus submission, control - which is lack of control - are pervasive in the obsessive-compulsive individualís life. Many theorists talk about the role of rigid and controlling parents, but there are a few studies actually validating some of these theories about early family experiences. Recent studies suggest that obsessive-compulsives, because they are so sensitive to change, are more prone to depression particularly later in life and suicide than many other people.

The epidemiology: the prevalence is unknown with this disorder. Itís more common in the outpatient populations, as you know, and it is more frequently diagnosed in men than in women. Some of these individuals loosen up with age. Many people do not. In a smaller group of cases people will evolve into frankly obsessive-compulsive behaviors, although usually they do not.

In terms of the differential diagnosis, Iíve already said itís important to differentiate this from obsessive-compulsive disorder, basically by unwanted thoughts and compulsive behaviors. Obsessive-individuals may show features of other personality disorders, particularly schizoid and paranoid personality. Psychotherapy is basically the treatment of choice. There is little role for medication except for symptom relief for depression or anxiety. Often these people will seek psychotherapy on their own. Psychotherapy is long and slow.

The next category is personality disorder, not otherwise specified. Of course we have no idea what that is. Itís a wastebasket very often used for people with interpersonal dysfunction that we canít characterize and here we have a therapist writing.

Let me just say briefly some final thoughts on treatment. First of all, there are just a few principles Iím going to list. One is; itís important to focus on personís behavior and not on his or her explanations of the behavior. So the doctor is saying to this patient, "Running away from your problems does not count as exercise." Itís very important to focus on behavior and not listen to excuses, for most of these people. Other recommendations include maintaining a collaborative stance with people with personality disorder. They try to move you out of that stance into being someone to fight with, who takes care of them.

There are a variety of things and itís very difficult to maintain your stance as an expert and as a collaborator. Pay close attention to your own rescue fantasies because many of these people can elicit strong rescue fantasies and as you know you are bound to be disappointed when you try to rescue someone dramatically with a personality disorder. Set limits on any threats to safety and any threats to the treatment. Often while our own safety is not so much an issue, but the treatment is often jeopardized through acting out around times and bill paying and acquiring numerous other therapists. Itís very important to set boundaries clearly because these are often people who have great difficulty with interpersonal boundaries. Again, donít shield people from the consequences of their actions.

Expect you are going to have strong transference feelings with these people and management with peer supervision, support from your colleagues, getting oneís own therapy if need be. The main message is do not treat people with personality disorders alone. That is simply Ö that is probably the best recommendation I can give. Much of the trouble that we get into with people with these disorders is by becoming isolated and locked into a certain mode of dealing with someone without any input from the outside.