Obsessive Compulsive Personality Disorder

Personality disorders (Axis II)

Clinicals - History

Fact Explanation
Insecurity, anxiety, guilt, depressed or shame feelings Patient with OCPD tends to self-blame and feel responsible for anything bad that happens. Due their perfectionism and orderliness trait they constantly strive to fulfil their self set high standards and is continuously trying to attain perfection. On doing so to extreme degrees they tend to miss out on the important part of the task, leading to failure in completion of the task and becomes extremely disappointed and depressed with self. As a result s/he becomes extremely anxious, guilty, unhappy, insecure and shameful of self. Insecurity, anxiety, guilt, depressed or shame feelings
Patient with OCPD tends to self-blame and feel responsible for anything bad that happens. Due their perfectionism and orderliness trait they constantly strive to fulfil their self set high standards and is continuously trying to attain perfection. On doing so to extreme degrees they tend to miss out on the important part of the task, leading to failure in completion of the task and becomes extremely disappointed and depressed with self. As a result s/he becomes extremely anxious, guilty, unhappy, insecure and shameful of self.
Difficulty allowing self to experience strong pleasurable emotions (e.g., excitement, joy, pride) Difficulty allowing self to experience strong pleasurable emotions
(e.g., excitement, joy, pride)
Impaired relationships and leisure Due to excessive devotion to work and productivity s/he puts work before personal relationships or leisure time. Impaired relationships and leisure
Due to excessive devotion to work and productivity s/he puts work before personal relationships or leisure time.
Hoarding Patient is unable to discard worn-out or worthless objects. Hoarding
Patient is unable to discard worn-out or worthless objects.
Obsessional thoughts Maybe troubled by recurrent obsessional thoughts, that s/he experiences as senseless and intrusive. Obsessional thoughts
Maybe troubled by recurrent obsessional thoughts, that s/he experiences as senseless and intrusive.
Past history Review his/er interpersonal relationships, educational and work history, psychiatric and substance abuse history, and also legal history. These are important since significant number of areas of the patient's life would consist of various impairments. May also have a family history of OCPD. Past history
Review his/er interpersonal relationships, educational and work history, psychiatric and substance abuse history, and also legal history. These are important since significant number of areas of the patient's life would consist of various impairments. May also have a family history of OCPD.
Co-occurrence of OCPD with other personality and DSM Axis I disorders The co-occurrence of two or more psychiatric disorders is common in patients with OCPD such as obsessive–compulsive disorder (OCD), other anxiety disorders (most prevalent - panic disorder, social phobia and generalized anxiety disorder), eating disorders, mood disorders, substance use disorders, paedophilia and intimate partner violence; and hoarding (more the number of OCPD traits in a patient higher the risk of hoarding). Co-occurrence of OCPD with other personality and DSM Axis I disorders
The co-occurrence of two or more psychiatric disorders is common in patients with OCPD such as obsessive–compulsive disorder (OCD), other anxiety disorders (most prevalent - panic disorder, social phobia and generalized anxiety disorder), eating disorders, mood disorders, substance use disorders, paedophilia and intimate partner violence; and hoarding (more the number of OCPD traits in a patient higher the risk of hoarding).

Clinicals - Examination

Fact Explanation
Orderliness and perfectionism Expects self to be perfect (e.g., in appearance, achievements, performance). Tends to be conscientious and responsible. Overly concerned with rules, procedures, order, organization and schedule. Strives to do a task properly with increased attention to details and imposes all sorts of rules to maintain efficiency while attempting to attain perfection to a point that he/she misses on the significant parts of the task. As a result makes the task more difficult and at times even fails to complete it. Orderliness and perfectionism
Expects self to be perfect (e.g., in appearance, achievements, performance). Tends to be conscientious and responsible. Overly concerned with rules, procedures, order, organization and schedule. Strives to do a task properly with increased attention to details and imposes all sorts of rules to maintain efficiency while attempting to attain perfection to a point that he/she misses on the significant parts of the task. As a result makes the task more difficult and at times even fails to complete it.
Mental and interpersonal control Has a very controlling nature and a feeling of superior competence comparing him/herself to others. In situations where the OCPD patient feels they are unable to maintain control of their physical or interpersonal environment, tends to withdraw emotionally and becomes extremely upset or angry. But typically this anger is not directly expressed. A patient with OCPD have mixed feelings or contradictory ideas about something or someone over needs for individuation, emotional, physical nourishment and care. Thus, s/he tends to feel guilty over seeking individual, self-centered needs but is resistant to accept direction from others. Therefore, s/he passively adopts strict adherence to external rules and structure. This is to cope with the mixed feelings or contradictory ideas created by attempts to individuate and seek nurturance from others. Mental and interpersonal control
Has a very controlling nature and a feeling of superior competence comparing him/herself to others. In situations where the OCPD patient feels they are unable to maintain control of their physical or interpersonal environment, tends to withdraw emotionally and becomes extremely upset or angry. But typically this anger is not directly expressed. A patient with OCPD have mixed feelings or contradictory ideas about something or someone over needs for individuation, emotional, physical nourishment and care. Thus, s/he tends to feel guilty over seeking individual, self-centered needs but is resistant to accept direction from others. Therefore, s/he passively adopts strict adherence to external rules and structure. This is to cope with the mixed feelings or contradictory ideas created by attempts to individuate and seek nurturance from others.
Moral or ethical issues Strives to live up to their moral and ethical standards and is overly conscientious, scrupulous, and inflexible about matters of morality, ethics, or values. Moral or ethical issues
Strives to live up to their moral and ethical standards and is overly conscientious, scrupulous, and inflexible about matters of morality, ethics, or values.
Rigid and stubborn Takes comfort in a particular routine way of doing a task. Does not favour change and will only relent reluctantly in an argument. Adheres rigidity to daily routines and becomes anxious, angry or uncomfortable when they are altered. Rigidity, stubbornness, and perfectionism than average is displayed in children with a moderate to high inborn tendency of a systemizing mechanism that is developed out of an intersubjective matrix. It has been found that these traits may develop due to inflexible countermeasures by parents who may share the same genetic disposition. In the presence of a predisposition toward rage reactivity, intersubjective matrix handles the rage less than optimally causing failure in transforming the rage into healthy assertiveness. Rigid and stubborn
Takes comfort in a particular routine way of doing a task. Does not favour change and will only relent reluctantly in an argument. Adheres rigidity to daily routines and becomes anxious, angry or uncomfortable when they are altered. Rigidity, stubbornness, and perfectionism than average is displayed in children with a moderate to high inborn tendency of a systemizing mechanism that is developed out of an intersubjective matrix. It has been found that these traits may develop due to inflexible countermeasures by parents who may share the same genetic disposition. In the presence of a predisposition toward rage reactivity, intersubjective matrix handles the rage less than optimally causing failure in transforming the rage into healthy assertiveness.
Self-critical and self-blaming Sets unrealistically high standards for self and is intolerant of own human defects. Tends to blame self or feel responsible for bad things that happen. Self-critical and self-blaming
Sets unrealistically high standards for self and is intolerant of own human defects. Tends to blame self or feel responsible for bad things that happen.
Restrictive attitude toward emotion Restrictive particularly towards warm or tender emotions and is unwilling to show emotion. Restrictive attitude toward emotion
Restrictive particularly towards warm or tender emotions and is unwilling to show emotion.
Excessive devotion to work and productivity Puts work before personal relationships or leisure time. Excessive devotion to work and productivity
Puts work before personal relationships or leisure time.
Reluctance to delegate tasks May be very cautious in entrusting tasks to others and would have strict instructions as to how they are to be carried out. A patient with OCPD is ambivalent over needs for individuation. Reluctance to delegate tasks
May be very cautious in entrusting tasks to others and would have strict instructions as to how they are to be carried out. A patient with OCPD is ambivalent over needs for individuation.
Adopts a miserly spending style Both towards self and others. Money is viewed as something to be hoarded for future catastrophes and hence is stringent with money. Adopts a miserly spending style
Both towards self and others. Money is viewed as something to be hoarded for future catastrophes and hence is stringent with money.

Investigations - Diagnosis

Fact Explanation
Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) and the associated SCID-II Personality Questionnaire (SCID-II-PQ) On interviewing the patient and assessing the patient from the screening questionnaire a diagnosis of OCPD is made based on the eight diagnostic criteria of OCPD (DSM-IV OCPD): rigidity, miserliness, hoarding, preoccupation with details, perfectionism, reluctance to delegate tasks, inflexibility regarding morality, and excessive devotion to work. Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) and the associated SCID-II Personality Questionnaire (SCID-II-PQ)
On interviewing the patient and assessing the patient from the screening questionnaire a diagnosis of OCPD is made based on the eight diagnostic criteria of OCPD (DSM-IV OCPD): rigidity, miserliness, hoarding, preoccupation with details, perfectionism, reluctance to delegate tasks, inflexibility regarding morality, and excessive devotion to work.
Laboratory studies and central nervous system imaging Based on the medical, psychiatric, and social history; mental status examination; and physical examination, diagnostic possibilities can be narrowed down. It is crucial to identify any new-onset condition that has precipitated the personality change. Hence it is important to exclude medical disorders (e.g., hyperthyroidism),substance abuse disorders (e.g., alcohol dependence) and neurologic disorders (e.g., early dementia). Laboratory studies and central nervous system imaging
Based on the medical, psychiatric, and social history; mental status examination; and physical examination, diagnostic possibilities can be narrowed down. It is crucial to identify any new-onset condition that has precipitated the personality change. Hence it is important to exclude medical disorders (e.g., hyperthyroidism),substance abuse disorders (e.g., alcohol dependence) and neurologic disorders (e.g., early dementia).

Management - Supportive

Fact Explanation
Assignments Ask patients to monitor symptoms and read on their condition. This would increase their participation and give them a sense of control. Assignments
Ask patients to monitor symptoms and read on their condition. This would increase their participation and give them a sense of control.

Management - Specific

Fact Explanation
Pharmacotherapy Selective serotonin reuptake inhibitors (SSRIs): citalopram (20–60 mg/day) (Significant reduction in OCPD diagnoses after 24 weeks of treatment has been found with a decrease in OCPD traits as well. Pharmacotherapy
Selective serotonin reuptake inhibitors (SSRIs): citalopram (20–60 mg/day) (Significant reduction in OCPD diagnoses after 24 weeks of treatment has been found with a decrease in OCPD traits as well.
Psychotherapy Cognitive behavioral therapy (CBT) Metacognitive Interpersonal Therapy (MIT) Psychotherapy
Cognitive behavioral therapy (CBT) Metacognitive Interpersonal Therapy (MIT)

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