Obsessive compulsive personality disorder

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Anankastic personality disorder
ICD-10 F60.5
ICD-9 301.4

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Jesus Rosario Hernandez, M.D. [2]

Synonyms and Keywords: Anankastic personality disorder; obsession; OCPD; ritual

Overview

Obsessive compulsive personality disorder is a personality disorder that is characterized by a general psychological inflexibility, rigid conformity to rules and procedures, perfectionism, moral code, and/or excessive orderliness. Obsessive compulsive personality disorder (OCPD) is often confused with obsessive-compulsive disorder (OCD). This could be due to the more commonly known OCD and the similarities in name of the two disorders, however the mindsets are typically different and unrelated. Those who are suffering from OCPD do not generally feel the need to repeatedly perform ritualistic actions, a common symptom of OCD. Instead, people with OCPD tend to stress perfectionism above all else, and feel anxious when they perceive that things are not "right". People with OCPD may hoard money for future use, keep their home perfectly organized, or be anxious about delegating tasks for fear that they won't be completed correctly. There are four primary areas that cause anxiety for OCPD personalities: time, relationship, uncleanliness, and money. There are few moral gray areas for a person with fully developed OCPD; actions and beliefs are either completely right, or absolutely wrong. As might be expected, interpersonal relationships are difficult because of the excessive demands placed on friends, romantic partners and children.

Historical Perspective

Sigmund Freud was the first person to characterize what is now known as obsessive-compulsive or anankastic personality disorder as the anal-retentive character. This fixation fit into his theory of psychosexual development.

Differential Diagnosis

Epidemiology and Demographics

Prevalence

The prevalence of obsessive-compulsive personality disorder is 1200 per 100,000 (1.2%) of the overall population.[1]

Risk Factors

Natural History, Prognosis and Complications

Prognosis

Poor prognostic factors include:

  • Internalizing symptoms
  • Physical or sexual abuse in childhood
  • Parents with OCD
  • Cerebral dysfunction
  • Male gender
  • Tics syndrome[1]

Diagnostic Criteria

DSM-V Diagnostic Criteria for Obsessive Compulsive Personality Disorder[1]

A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

  1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
  2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

  1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
  2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

AND

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

AND

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

AND

D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possesssions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in skin-picking disorder; stereotypes, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; orrepetitive patterns of behavior, as in autism spectrum disorder).

Specify if:

With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true. With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.

With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.

Specify if:

Tic-related: The individual has a current or past history of a tic disorder.

Mnemonic

A mnemonic that can be used to remember the criteria for OCPD is LAW FIRMS.

  • L – Loses point of activity (due to preoccupation with detail)
  • A – Ability to complete tasks is gone (compromised by perfectionism)
  • W – Worthless objects (unable to discard)
  • F – Friendships (and leisure activities) excluded (due to a preoccupation with work)
  • I – Inflexible, overconscientious (on ethics, values, or morality, not accounted for by religion or culture)
  • R – Reluctant to delegate (unless others submit to exact guidelines)
  • M – Miserly (toward self and others)
  • S – Stubbornness (and rigidity)

Treatment

Treatment for OCPD normally involves psychotherapy and self help. Medication is generally not indicated for this personality disorder in isolation, but Fluoxetine has been prescribed with success. Anti-anxiety medication will reduce the feeling of fear and SSRIs can replace the chronic frustration with a sense of well-being, as well as reducing stubbornness and negative rumination. A mild tranquilizer can reduce alcohol dependence, if present. ADD medication can improve task completion by improving mental focus, which will provide visible success and improve outlook for recovery. Caffeine sensitivity may be an exacerbating factor.

Psychotherapy

  • Behavior therapy — Talking with a psychotherapist about ways to change compulsions into healthier, productive actions.
  • Psychotherapy — Talking with a trained counselor or psychotherapist who understands the condition.
  • Pharmacotherapy - A psychiatrist can prescribe medications which may make self-management and participation in other therapies possible and/or more productive.

Self Help

  • Educating family and friends about the condition will help them to manage behavioral problems more sympathetically, and to watch out for the warning signs.
  • Support groups may also be helpful in accepting and changing obsessive-compulsive behaviors.
  • Relaxation, meditation, exercise, regular sleep, and a balanced diet are all important factors in maintaining this focus.
  • Consult your healthcare provider if you are having difficulty sleeping and/or you are experiencing problems that prevent you from exercising regularly.
  • Keeping a diary may help the individual to identify those stressful situations that help to trigger compulsive reactions, enabling them to focus on more constructive activities.
  • Retained items, the result of hoarding, should be released, simultaneously reducing the shame associated with hoarding. Having an assistant to cull hoarded, collected, and stored items will facilitate the process.

References

  1. 1.0 1.1 1.2 1.3 1.4 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.



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