Clinical Context: Core Features and Functional Impairment
Obsessive-compulsive personality disorder (OCPD) is a chronic condition that involves a maladaptive pattern of excessive perfectionism, preoccupation with orderliness and details, and the need for control over one’s environment. The
DSM-5-TR defines OCPD as an enduring pattern that leads to clinically significant distress or functional impairment due to four or more of the following: preoccupation with details and order; self-limiting perfectionism; excessive devotion to work and productivity; inflexibility about morality and ethics; inability to discard worn-out or worthless items; reluctance to delegate tasks; miserliness toward self and others; and rigidity and stubbornness (
1). Cognitive and behavioral features associated with OCPD include indecisiveness (often related to the fear of making the wrong choice and manifested through exhaustive research of purchase options); difficulty coping with changes in one’s schedule or unwillingness to consider changes to one’s plans or usual routines; difficulty relating to and sharing emotions; anger outbursts when one’s sense of control is threatened; and procrastination (usually linked to high standards of perfectionism). Through our clinical work, we have also noticed other particular features among these patients, such as a tendency to overexplain or qualify statements with excessive details; paying extraordinary attention to detail and repeatedly checking for possible mistakes (often losing track of time); being mercilessly self-critical about their own mistakes or harshly judgmental of the missteps of others (or both); routinely missing deadlines or working through the night to meet the deadline at the last moment; difficulty spending money on both themselves and others; a tendency to not prioritize leisure or to approach recreational activities with such methodical intensity that progress is slowed or avoided (and these activities end up feeling like work rather than being restorative); difficulty going along with others’ plans; difficulty working in groups at school or work either because of their insistence on doing all of the work or micromanaging others’ efforts; and a detail-oriented way of processing information that can slow down reading or lead to rereading passages or rewatching video for fear of missing something (which then leads to a backlog of reading and viewing material).
The
DSM-5-TR notes that OCPD is one of the most common personality disorders in the general population, with an estimated prevalence ranging from 1.9% to 7.8% (
1). Individuals with this condition frequently present for treatment in mental health (
2) and primary care (
3) settings, yet OCPD remains an understudied phenomenon. Despite its prevalence and frequent attempts to seek treatment by those experiencing symptoms, there is no definitive empirically supported treatment for the condition. Further, OCPD remains an underrecognized and misunderstood phenomenon in the community. For example, a recent community survey found very low recognition rates for OCPD, with participants much more likely to correctly identify depression, schizophrenia, and obsessive-compulsive disorder (OCD) (
4). Clinicians should be aware of its core features and symptomatic behaviors so that they can assess for them and address them in psychotherapy. Even in the absence of a categorical diagnosis of OCPD, clinically significant traits such as perfectionism and rigidity can interfere in the treatment of anxiety and mood conditions.
OCPD traits are associated with significant functional impairment, across work or school, social, and leisure domains. The pursuit of perfection ends up being problematic (i.e., spending excessive amounts of time on trivial tasks, missing deadlines, or seeking extensions to write and rewrite assignments). Individuals with OCPD are typically seen as controlling and overly rigid and often expect their family, friends, and coworkers to conform to their “right” way of doing things. They may also be inflexible about matters of morality and ethics and attempt to impose their views on others. Consequently, individuals with OCPD often experience high levels of internal distress and impaired interpersonal functioning (
5). A recent study using well-validated measures of psychosocial functioning and quality of life found comparable levels of impairment in psychosocial functioning and quality of life among patients with OCPD compared with those with OCD (
6). Furthermore, among patients seeking treatment, OCPD and borderline personality disorder are associated with the highest economic burden of all personality disorders in direct medical costs and productivity losses (
7).
Similar to other personality disorders, impaired interpersonal functioning is a hallmark feature of OCPD. Clinical descriptions note that individuals with OCPD often experience interpersonal conflicts that may be triggered by their impossibly high standards for the behavior of others, rigidity, and difficulty acknowledging others’ viewpoints (
8), as well as their overreliance on rules and expectations for their own behavior and that of others in relationships. Individuals with OCPD may also be uncompromising and demanding (
9), and OCPD has been linked with anger outbursts and hostility, both at home and at work (
10). Cain et al. (
5) investigated interpersonal functioning in OCPD and found that individuals with OCPD reported hostile-dominant interpersonal problems and a tendency to be overly controlling and cold in their relationships. OCPD, in individuals compared with healthy controls, was also associated with less empathic perspective taking, which may underlie some of the interpersonal problems described earlier. The authors (
5) (p. 96) noted that individuals with OCPD “might have the capacity to experience sympathy and concern for others and might be able to intuit the appropriate affective response to another person..., but are limited in their ability to subsequently demonstrate the appropriate emotional response in a social situation or adopt the other person’s point of view.”
Of the core features of OCPD, research and clinical reports have highlighted the importance of perfectionism as a major contributing factor to functional impairment. The belief that anything less than perfect performance is unacceptable (termed maladaptive perfectionism) has been associated with depression symptoms (
11). Additionally, the belief that one will be judged against unrealistic standards by others (socially prescribed perfectionism) has been associated with poorer relationship adjustment (
12) and suicidal ideation (
13). In fact, Diaconu and Turecki (
14) found that among patients with depression, individuals with OCPD reported increased current and lifetime suicidal ideation, as well as a greater number of lifetime suicide attempts. These findings suggest that an OCPD diagnosis may be a risk factor for suicidality. Of special clinical concern, patients experiencing depression with OCPD reported fewer reasons for living and less anxiety on the fear of death scale, both prognostic indicators of suicide.
There is substantial heterogeneity within the OCPD population, given the polythetic diagnostic criteria for OCPD (i.e., individuals can meet criteria for the disorder with any combination of four out of the eight criteria). On the basis of our clinical observations, there appear to be distinct presentation style types of OCPD. We have identified at least two such types and refer to them as the
controlling type and the
anxious type. This distinction is consistent with the style types proposed almost a century ago by Lewis (
15): melancholy and stubborn versus uncertain and indecisive. These presentation style types are not meant to be mutually exclusive. Although individuals with OCPD may present with a predominant style, they may exhibit features of the other style, depending on the context. These style types differ in their behavioral, cognitive, affective, and interpersonal profiles. For example, in the behavioral domain, those with a controlling style are more likely to be rule bound, resistant to change in routines, verbally hostile, and prone to experience anger outbursts, whereas those with an anxious style are more likely to procrastinate, struggle with time management, and get mired in details. In the cognitive domain, those with a controlling style are more likely to be mistrustful, somewhat eccentric, and to apply their high perfectionistic standards to both themselves and others. On the other hand, those who present with the anxious style are more likely to be self-critical, indecisive (having particular difficulty filtering out extraneous information), perfectionistic toward themselves, and overly concerned about not meeting the expectations of others. In the affective domain, the controlling type is associated with irritability and chronic frustration, whereas the anxious type emphasizes anxiety and worry. Interpersonally, those presenting with the controlling type are more likely to be hostile, critical, and confrontational versus those with the anxious type, who are more likely to be submissive, people pleasing, and conflict avoidant. Given the differences in presentation and potential functional impairment between these presentation style types, the emphasis of psychotherapy in each case would also differ, as we outline further later in the description of cognitive-behavioral therapy (CBT) for OCPD. Although both style types would benefit from the use of behavioral experiments to increase flexibility and willingness to experience discomfort, those with the controlling style will additionally benefit from emotion regulation strategies.
On the basis of our clinical experiences, individuals with OCPD may present for treatment for a variety of reasons. As mentioned earlier, they may be experiencing distress related to not being able to complete tasks (or avoiding the start of tasks) at work or school because of time management problems or unreasonably high standards for the quality of their work. Consequently, these individuals may be feeling “stuck,” because they are not advancing in their academic or professional careers or are falling chronically behind in their goals. They may present because of low mood related to unrelenting self-criticism or being chronically let down by others not meeting their expectations. Another common reason for these individuals to present for treatment is tension or discord in an intimate relationship or pressure from a partner who is ready to leave the relationship. Anecdotally, these patients may also present in medical settings when their distress manifests as somatic complaints.
A Proposed Cognitive-Behavioral Therapy Model for OCPD
In this section, we propose a novel intervention consisting of elements drawn from and inspired by established, manualized CBT approaches: skills training in affective and interpersonal regulation (
46), ACT for perfectionism (
47), and CBT for perfectionism (
48).
When treating a patient with OCPD, it is important for the clinician to convey that the objective of CBT is not to change the core of who the individual is or to remove the individual’s standards for performance or turn them into someone who settles for mediocrity. Instead, the objective is to relax the individual’s rigid internalized rules (i.e., aiming for “good enough” instead of perfection) and replace them with guidelines that allow for greater flexibility, life balance, and efficiency while also replacing the relentless cycle of harsh self-criticism with self-compassion.
Throughout the process of CBT for OCPD, clinicians should engage the patient in identifying his or her values and how OCPD traits are interfering in the patient’s ability to move in the direction of those values. To be effective, the clinician must convey how making behavioral changes in the context of the therapy will bring the patient closer to their values. For example, when working on time management or activity planning, the patient will be encouraged to allocate time in his or her schedule in a way that maps on to his or her values. A useful metaphor for reclaiming time that is currently being expended on rigid, perfectionistic behaviors is the “dimmer switch of effort.” Rather than seeing the effort that one puts into a task like an on-off light switch (exerting maximum effort or not doing the task at all), the patient is encouraged to think about effort like a dimmer switch, in that effort can be modulated relative to the perceived importance of a task. That is, tasks considered to be of high importance or most aligned to one’s values would get the highest level of effort, whereas mundane and everyday tasks or chores (e.g., washing dishes, vacuuming) that may be considered of relatively less importance and less connected to bigger life values would be intentionally approached with limited effort. Likewise, when working on decision making, the patient will be encouraged to consider the relative importance of the decision before investing time and resources into it (flipping a coin or making a “snap” decision for choices that are inconsequential, and reserving research for only those decisions of greater relative importance). Further, the patient will prioritize a particular value and practice making decisions in the service of that value, despite discomfort or tension about not approaching the decision with the usual rule-based protocol.
Regarding the early stages of CBT for OCPD, we present the metaphor of a wallet or tank for mental resources. Life stressors and chronically living under the duress of rigid rules and perfectionistic practices reduce one’s store of mental resources. When resources are low, individuals with OCPD will be more vulnerable to burnout, manifested through low mood or anxiety (or both), and they will be much less likely to resist urges to control their environment and others. Self-care behaviors, including making time for enough sleep, a balanced diet, physical activity, socialization, and leisure or pleasurable activities, are needed to restore mental resources. The individual’s openness to self-care may be adversely affected by difficulty with time management or procrastination, excessive attention to work or productivity, and negative self-evaluation (e.g., guilt or self-criticism for not spending time on work or productivity goals). By problem solving ways to bolster each of these self-care domains, the patient will (over time) lower his or her vulnerability to distress and low mood and increase the mental resources available for making behavioral changes in CBT. As mentioned previously, making these behavior changes to prioritize self-care and balance, however, will require openness and willingness to experience discomfort in the form of physiological distress and unwanted emotions.
Skills training in modulating negative emotions and applying flexibility to relationships may be key components in treating OCPD, particularly in those with the controlling presentation style, because they may allow these individuals to better access support from others, including family, friends, and even the therapist. In other words, training in these skills may decrease alliance ruptures with the therapist and other supports in the patient’s life, potentially facilitating changes in OCPD symptoms.
Behavioral experiments can be an effective way to test perfectionism standards because they allow the individual to objectively collect his or her own data (in the real world) as to the validity of the standard and the likelihood of the unwanted outcome. When setting up a behavioral experiment, the clinician first helps the individual to identify a specific belief, rule, or standard to be tested and then crafts an experiment to test a violation of that belief, rule, or standard, allowing for experiential learning. Some examples of behavioral experiments include sitting down for dinner without first cleaning up the kitchen, walking across the grass in a new pair of boots, going to sleep before one’s roommates and releasing the responsibility for locking up, sending an e-mail or text without proofreading, and going on a trip without a packing list.