Obsessive–Compulsive Personality Disorder
Obsessive–Compulsive Personality Disorder (OCPD) is characterized by a generalized pattern of personality function deterioration (identity and self-direction) and interpersonal functioning deficit (rigid and persistent perfectionism), at the expense of efficiency, flexibility, and opening (American Psychiatric Association [APA] 2013). It was included in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 (Diedrich and Voderholzer 2015). It is also one of the ten personality disorders (PD) recognized by the American Psychiatric Association (Hertler 2015). Personality disorders features may present differently across the lifespan because of some maturation process and context changes (Schuster et al. 2013) (See “Mental Disorder”).
According to the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) (APA 2013) (See “Diagnostic and Statistical Manual of Mental Disorders-5”), the essential features of a personality disorder are the presence of pathological personality traits and impairments in self- and interpersonal functioning. Self-functioning impairments could be manifested by identity issues or self-direction difficulties, where the individual is not able to complete tasks and realize goals associated with rigid and unreasonably high and inflexible standards of behavior. Similarly, interpersonal functioning is impaired, characterized by lack of empathy, and intimacy and relationships with others are negatively affected by the rigidity and stubbornness (Mulay et al. 2018). The expression of the impairments in personality functioning is relatively stable across time and consistent across situations, is not better understood as normative for the individual’s developmental stage or socio-cultural environment, and is not solely due to the direct physiological effects of a substance or a general medical condition. Personality disorders are associated with ways of thinking and feeling about oneself and others that significantly and adversely affect how an individual functions in many aspects of life (Mulay et al. 2018). There are six distinct types based on the individual’s particular difficulties and on specific patterns of those pathological traits: borderline, avoidant, schizotypal, antisocial, narcissistic, and obsessive–compulsive; each type is defined by a specific pattern of impairments and traits (APA 2013).
Specifically, the obsessive-compulsive personality disorder is characterized by pathological personality traits related to compulsivity and negative affectivity. Compulsivity refers to a tendency toward repetitive habitual behaviors (Chamberlain and Grant 2018); in OCPD, it is manifested through rigid perfectionism and the rigid insistence that everything must be perfect, including the own performance, believing that there is only one right way to do things. Meanwhile, negative affectivity in OCPD involves the persistence at tasks long after the behavior has ceased to be functional or effective; in this perseveration, the individual continues the same behavior despite repeated failures. In sum, OCPD is characterized by a maladaptive pattern of excessive preoccupation with detail and orderliness, excessive perfectionism, and need for control over one’s environment; the perfectionism, that is considered a desirable trait in most cultures, is so excessive that it interferes with task completion; and individuals usually have poor cognitive flexibility and excessive need to control which results in significant dysfunction in socio-occupational domains (Thamby and Khanna 2019).
Among all the personality disorders, obsessive-compulsive personality disorder is perhaps most commonly linked with Obsessive–Compulsive Disorder (OCD); however, there are two different disorders whose relationship causes confusion (Hertler 2015). The main difference is that OCD is a chronic anxiety disorder, whereas OCPD is a personality disorder (Gordon et al. 2013). OCPD and OCD both overlap in terms of stereotyped and inflexible thoughts and behaviors involving orderliness, perfectionism, and list making (Eisen et al. 2006); however, in OCPD, such behaviors are pervasive in all aspects of a person’s functioning, whereas in OCD, it is usually restricted to one particular domain. Most patients with OCPD tend to present to clinicians with primary complaints of anxiety, depression, or sexual dysfunction rather than core symptoms of personality (Thamby and Khanna 2019).
Currently, the psychological and biological theories that try to explain the OCPD etiology are contradictory. Psychodynamic theories maintain that obsessive personality is familially forged, while Erikson pointed to a failure in the psychosocial stage with the conflict in autonomy versus shame, and, social learning theorists claimed that it is due to maladaptive vicarious learning (Hertler 2014). On the other hand, empirical evidence supports neurobiological causes (Reddy et al. 2016), neuropsychological changes (Fineberg et al. 2015), and heritability (Diedrich and Voderholzer 2015); in this sense, the obsessive personality, during the course of development, is organized around a preexisting executive control dysfunction and that strategy of living is the entirety of obsessive behavior (Hertler 2014).
Key Research Findings
OCPD affects, on average, 3–8% of the general population (Koutoufa and Furnham 2014); its prevalence decreases with increasing age, while differences in sex, education level, and marital status have not been found (Ekselius et al. 2001). Some studies suggest that the different symptoms of OCPD begin in childhood; in a retrospective study, adults with OCPD reported higher rates of perfectionism, inflexibility, and drive for order in childhood, compared to healthy controls, suggesting that these traits may presage the development of OCPD (Pinto et al. 2015). Other studies have focused on examining the temporal diagnostic stability of OCPD; in a two-year longitudinal study analyses, McGlashan et al. (2005) aimed to identify the criteria that were the most and the least enduring for personality disorders, and the findings show that symptoms remain prevalent over time, and rigidity, problems delegating, and perfectionism were the most prevalent and stable symptoms.
Among older adults 65 years and over, OCPD is the most prevalent personality disorder (5.3%); however, it is significantly fewer than in the young population (16.1%); older women are significantly more likely to have OCPD than men; widowed older adults, with high level of income and education, are at a greater risk (Schuster et al. 2013) (See “Geriatric Mental Health”).
Personality disorders in older adults are highly associated with disability, as well as with medical and mental disorders (van Alphen et al. 2015). OCPD is related to lifetime psychiatric comorbidities such as mood and anxiety disorders, as well as substance and alcohol use disorders (Schuster et al. 2013), OCD, body dysmorphic disorder, eating disorders (Fineberg et al. 2015), mood and anxiety disorders, paranoid personality disorder, and schizoid personality disorder (De Reus and Emmelkamp 2012). It is also highly related among other types of personality disorders (e.g., avoidant, dependent, etc.) (Schuster et al. 2013). In addition, it shares a high comorbidity with medical conditions like arteriosclerosis, heart disease, and gastritis (Schuster et al. 2013); even more, it has been found to be associated with Parkinson’s disease (Reddy et al. 2016) (See “Personality in Later Life”).
Clinical presentation of OCPD in older adults is often found as less “dramatic” compared to the younger age group (Mattar and Kahn 2017); the more observable and objective symptoms are often seen to decline in intensity and frequency with age; despite this, the underlying affective and identity disturbances together with the interpersonal difficulties are not found to decline (Mordekar and Spence 2008). Older adults with OCPD may express control behavior over specific demands related to the management of their space and/or objects at home; commonly, they do not want them to be touched, moved, cleaned, or altered (Lingiardi and McWilliams 2015). Thus, in this clinical presentation of OCPD, it may be difficult to ascertain whether the functional impairment, which may be part of the clinical symptoms, is due to an underlying personality disorder or due to the effects of aging itself (Mattar and Kahn 2017).
In old age, it is crucially important to recognize and effectively manage the difficulties associated with personality disorders, such as OCPD; the most prevalent personality disorder among older adults is OCPD (Schuster et al. 2013). Additionally, personality disorder dimensions have been found to explain the majority of the variance in suicidal ideation among older adults; it is therefore apparent that a failure to identify the diagnosis could be catastrophic especially in old age (Mattar and Kahn 2017).
Diagnostic criteria must be more precise when treating with older adults; the majority of psychological tests currently available are wholly unreliable in this age group; besides, personality characteristics may change during life, and thus the assessment must be adapted to the various age-related factors that may affect the interpretation of clinical findings (Mattar and Kahn 2017). Although one’s core personality is thought to remain stable over the adult years, modest variation may arise in terms of its expression with advancing age; for instance, an increase in obsessive–compulsive traits is common among older people and may reflect not so much a change in intrinsic personality as an adaptation of the person to failing powers or altered relationships and environments (Engels et al. 2003). Besides, recent evidence suggests that some of the DSM personality disorder criteria contain measurement bias across age groups; when older adults were compared to younger adults at equivalent levels of personality pathology, older adults were more likely to receive diagnoses of OCPD; in contrast, they were less likely to receive diagnoses of the other personality disorders; the possibility that a personality disease diagnosis could be more or less likely for older adults implies that particular personality disorders in older adults may be over- or underdiagnosed (Balsis et al. 2007).
Currently, there is a paucity of research into the treatment of OCPD. Treatment response, both to medication and/or psychotherapy, can be slow and incomplete as symptoms could be multiple and to some extent unspecific (Sachs and Erfurth 2018). Pharmacological treatment in older adults should be handled with caution due to the presence of physical comorbidities, especially when psychotropic medications are prescribed. The regulation of presynaptic and postsynaptic serotonin is considered a central strategy; selective serotonin reuptake inhibitors are a leading option in the treatment of OCPD (Sachs and Erfurth 2018). On the other hand, psychological treatment has many modalities: cognitive-behavioral, psychodynamic, and family therapy, among others (See “Psychotherapy”). The outcomes of cognitive behavioral therapy may be predicted by the level of suffering, the variability of self-esteem, and stronger initial alliances (Diedrich and Voderholzer 2015). Interventions designed to benefit environmental situations that threaten older adults with OCPD may prove to be useful and increase the possibility of forming a therapeutic alliance (Lingiardi and McWilliams 2015). Successful psychotherapy requires an accurate diagnosis (Mattar and Kahn 2017).
Future Directions of Research
The literature concerning personality disorder among older people is currently quite sparse. This might be because personality disorders themselves have been rather contentious and, traditionally, old age psychiatry services have tended to focus on the management of dementia and mood disorders like depression (See “Mood Disorders”); however, it is likely that a greater number of patients with personality disorders, and specifically with OCPD, will survive into old age, and thus it is necessary to investigate the complex needs and issues associated with aging among this group of people (Mordekar and Spence 2008).
The prevalence of OCPD in older adults is still unclear; the lower rates observed in increasing age groups could be biased. Older adults with OCPD diagnoses may not have been available for interview, because of a higher rate of premature mortality, hospitalization, or nursing home placement (Schuster et al. 2013).
Besides, as the causes of OCPD are not yet clear, epidemiological studies, controlled clinical trials, neuroscience, and genetic studies are required to strengthen the diversity of theories presented (Diedrich and Voderholzer 2015). Psychodynamic explanations are formal etiological models, but the models have not been supported by research, and cannot hope to be reconciled with the increasingly prominent demonstrations of the heritability of obsessive character; on the other hand, biological models, aside from not globally explaining obsessive character, have not satisfactorily explained the ultimate causes (Hertler 2014).
Derived from the high co-occurrence among personality disorders, the existence of discrete categorical disorders is questioned; the hypothesis is that OCPD and other personality disorders are not qualitatively distinct syndromes, but rather maladaptive variants of personality functioning that may be alternative manifestations of a single underlying process (Schuster et al. 2013). Likewise, longitudinal studies are needed to understand OCPD over time; prospective studies evaluating OCPD in children are needed to better understand the progression of these traits from childhood to adulthood and their ability to predict future psychopathology in old age (Pinto et al. 2015). More experimental studies are also needed to improve the assessment and treatment procedures. Experts recommend that professionals become familiar with personality disorders in older adults as they may differ from younger age groups (Mattar and Kahn 2017).
OCPD is characterized by a deterioration of personality, with a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. Diagnostic criteria are detailed in the DSM-5. In older adults, it shares comorbidities with other mental disorders, disability, and depression; its causality is still unclear. There are few studies around this disorder in older adults, so it is necessary to address the subject in order to provide better strategies for assessment and treatment in old age.
- McGlashan TH, Grilo CM, Sanislow CA et al (2005) Two-year prevalence and stability of individual DSM-IV criteria for schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders: toward a hybrid model of Axis II disorders. Am J Psychiatry 162(5):883–889. https://doi.org/10.1176/appi.ajp.162.5.883CrossRefGoogle Scholar
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