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Focus (Am Psychiatr Publ). Fall 2022; 20(4): 389–396.
Published online 2022 Oct 25. doi:10.1176/appi.focus.20220058
PMCID: PMC10187387
PMID: 37200888
Anthony Pinto, Ph.D.,
Jonathan Teller, B.A., and Michael G. Wheaton, Ph.D.
Author information Copyright and License information PMC Disclaimer
Abstract
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. It is one of the most common personality disorders in the general population, with an estimated prevalence ranging from 1.9% to 7.8%. Despite the fact that patients with OCPD often present for treatment, there is little empirical research on treatments for OCPD, and there is no definitive empirically supported treatment for the condition. This review provides an overview of OCPD, its core features, its common presentation style types, and its impact on functioning. We review the limited treatment research to date and focus on cognitive-behavioral approaches targeting core aspects of OCPD that directly affect functioning in these patients, emphasizing take-home points for clinicians. We also address questions and controversies related to OCPD and its treatment.
Keywords: Personality Disorders-Cluster C (Avoidant-Dependent-Obsessive-Compulsive), Perfectionism, Rigidity, Cognitive Behavioral Therapy
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.
Treatment Strategies and Evidence
Pharmacological Treatment
Despite its high prevalence in treatment settings, no medications have been approved by the U.S. Food and Drug Administration for the treatment of OCPD. However, the data that exist hint that OCPD traits may respond to pharmacotherapy consisting of serotonin reuptake inhibitors (SRIs), a class of medications widely used to treat anxiety and mood symptoms. In the only randomized controlled trial (RCT) of medication that exists for primary OCPD traits, Ansseau et al. (16) randomized 24 individuals with DSM-IV OCPD to receive either fluvoxamine (50–100 mg/day) or placebo for up to 12 weeks. Significantly greater improvement in OCPD traits was observed in the group receiving fluvoxamine compared with that in the placebo group. Several other studies have investigated the effect of SRI medications on OCPD traits in trials focused on other conditions. For example, Ekselius and von Knorring (17) completed a trial of sertraline and citalopram in 308 patients with depression who also had comorbid personality disorders. They reported that both medications were associated with reductions in dysfunctional personality disorder traits, although citalopram appeared significantly more effective at reducing OCPD traits. In a trial comparing clomipramine and imipramine for patients with OCD, Volavka et al. (18) reported that patients in the clomipramine group showed a greater decrease in scores on a measure of OCPD traits. Case reports and small open-label studies have investigated the response of OCPD traits to antipsychotics and mood stabilizers (19). To date, SRIs are the most commonly utilized medications to help individuals with OCPD, although there is a lack of high-quality studies of medications for primary OCPD, necessitating future research in this area.
Although there is no empirically supported gold standard treatment for OCPD, psychotherapy is recommended as the treatment of choice (20). Next is a review of the limited psychotherapy research in OCPD.
Psychodynamic Psychotherapy
Psychoanalytic views of OCPD have attributed the development of OCPD traits to overly strict parental discipline and parental overprotection (8). These theoretical accounts would suggest that disturbed early attachments are core to the development of OCPD traits (21). However, there has been relatively little empirical research on the relationship between attachment and OCPD traits. One recent study in an Iranian student sample found that OCPD traits were associated with an ambivalent-avoidant attachment style (22), although this study utilized a retrospective design. Another study found that individuals with OCPD had more secure attachment than individuals with borderline personality disorder (23). Early views by Freud and his contemporaries made a developmental link between OCPD and OCD, suggesting that OCPD traits were expressed prior to the development of OCD. A recent study of adults found childhood OCPD traits to be linked to an adult diagnosis of OCD (24). Similarly, in a sample of children with OCD, Park et al. (25) reported that OCPD traits in youths were associated with concurrent OCD symptoms. These data support the notion that childhood OCPD traits may, indeed, be linked to concurrent or subsequent OCD, although longitudinal study is needed.
Psychodynamic treatment for OCPD involves an insight-oriented approach that attempts to reveal how the OCPD symptoms function to protect the individual against internal feelings of uncertainty and insecurity. With this insight, patients then work to change their inflexible patterns of behavior and let go of their rigid demands for perfection in favor of a more reasonable outlook. A study by Barber et al. (21) suggests that supportive-expressive psychodynamic therapy is effective for treating patients with personality disorders, including OCPD. In this study, 14 patients with OCPD showed significant improvement after 52 sessions. However, this study did not include a control group. Two subsequent trials found that individuals with mixed personality disorders (including some with OCPD) treated with brief psychodynamic treatments experienced improved general functioning compared with waitlist control groups (26, 27). However, neither of these studies specifically investigated improvement among those with OCPD, and the study outcomes did not specifically assess for changes in OCPD symptoms. Further research should be conducted to determine the effectiveness of psychodynamic treatments for OCPD.
Cognitive-Behavioral Therapy
CBT typically involves a combination of both cognitive and behavioral techniques. The general cognitive therapy approach to treating OCPD involves identifying and restructuring the dysfunctional thoughts underlying maladaptive behaviors (28–30). For example, patients are taught to challenge “all-or-nothing” thinking by considering the range of possibilities that might be acceptable. Similarly, therapists might teach patients to recognize situations in which they overestimate the consequences of mistakes (catastrophizing) by examining the realistic significance of minor errors. CBT also includes behavioral elements, such as exposure to feared situations and stimuli through behavioral experiments (e.g., purposefully making small mistakes to observe the tolerability of actual consequences) (20). Some patients with OCPD may have difficulty establishing rapport because of their rigid thinking styles and difficulty with emotional expression. In light of this difficulty, Young’s schema-focused therapy (31) aims to identify and restructure patients’ maladaptive schemas as they are expressed in the therapy process.
Although several cognitive and behavioral approaches to OCPD have been described (32), very little empirical research has been conducted to test these treatments. Ng (33) conducted an uncontrolled trial in which individuals with treatment-refractory depression who also met DSM-IV criteria for OCPD were offered cognitive therapy focusing on OCPD. A total of 10 patients were treated; after an average of 22.4 sessions, all of the patients had a reduction in depression and anxiety symptoms, and nine patients no longer met diagnostic criteria for OCPD. However, this study was limited by a small sample size and the lack of a control group. In another study, Strauss et al. (34) conducted an open trial of cognitive therapy among outpatients with avoidant personality disorder (N=24) and OCPD (N=16) who received up to 52 weekly sessions. Of the patients with OCPD, 83% had clinically significant reductions in OCPD symptom severity, and 53% had clinically significant improvement in depression severity. However, this open trial did not include a waitlist control group or alternative treatment, precluding a firm conclusion about the effectiveness of CBT for OCPD.
Enero et al. (35) conducted the largest ever trial of CBT for OCPD. In this study, 116 outpatients who met DSM-IV criteria for OCPD were enrolled in a 10-week open trial of group therapy for OCPD, including psychoeducation, behavioral experiments, cognitive restructuring, and relapse prevention planning. Results indicated significant reductions in OCPD severity after treatment, and pretreatment distress predicted OCPD response rate such that patients with lower levels of trait anxiety and depression were more likely to show a response in OCPD symptoms after treatment. However, an important limitation of this study is that there was no control group. Handley et al. (36) conducted a controlled trial of group CBT, but it targeted clinical perfectionism rather than OCPD. In this study, 42 participants with elevated perfectionism and a range of anxiety, eating, and mood disorders were randomized to either group CBT or a waitlist control. Those who received group CBT for clinical perfectionism reported significantly greater reductions in perfectionism, depression symptoms, social anxiety, eating disorders, anxiety sensitivity, and rumination compared with healthy controls. Furthermore, the treatment group experienced significantly greater pre-post increases in self-esteem and quality of life compared with waitlist controls. Treatment improvements were maintained at the 6-month follow-up. These findings provide support for group CBT being an effective treatment for clinical perfectionism, as well as increasing quality of life and self-esteem.
There are little data to suggest which type of psychotherapy (psychodynamic or CBT) is more beneficial for OCPD treatment, as very few studies have directly compared these two therapies. In a study conducted by Svartberg et al. (37), patients with cluster C personality disorder were randomized to receive 40 treatment sessions of either cognitive therapy (N=25) or short-term psychodynamic therapy (N=25). In this sample, avoidant personality disorder was the most frequent diagnosis, although OCPD was also represented with 17 individuals meeting DSM-III criteria: eight in the cognitive therapy group (32%) and nine in the psychodynamic group (36%). The results indicated that both patient groups showed significant improvements on measures of symptom distress, interpersonal problems, and core personality pathology after treatment and at the 2-year follow-up. Additionally, there was no significant difference in improvement between CBT and psychodynamic therapy across the entire sample. However, the authors did not specifically compare treatment effects for the patients with OCPD in particular. It should also be noted that the CBT provided in this study was cognitively based and did not emphasize a behavioral approach. Thus, it is unclear whether CBT and psychodynamic therapy are equally effective, and further research is still needed in this domain.
Alternative Psychotherapies
Other treatment types for OCPD have been explored in single-case studies. For example, there have been two case studies on adapting metacognitive therapy for individuals with OCPD (38, 39). The aim of metacognitive therapy is to improve individuals’ ability to understand mental states and enhance awareness of their own emotions while also improving interpersonal functioning and empathy. This type of psychotherapy would seem well suited to the interpersonal problems frequently observed in individuals with OCPD, but more research is still needed. Lynch and Cheavens (40) have described an adaptation of dialectical behavioral therapy (DBT), called radically open DBT (RO-DBT), designed to target cognitive rigidity and emotional constriction, and report on its successful implementation with one individual with OCPD. More recently, Lynch (41) published a treatment manual for RO-DBT that focuses on treating disorders of overcontrol, including OCPD and anorexia nervosa. “Third-wave” cognitive-behavioral treatments, such as acceptance and commitment therapy (ACT), have shown promise for the treatment of personality disorders (42). The goal of ACT is to target experiential avoidance by encouraging patients to accept and endure negative inner experiences (e.g., emotions, thoughts, and memories) through the use of mindfulness training, metaphors, and behavioral therapy techniques. When applied to OCPD, ACT might involve educating individuals about the paradoxical consequences of experiential avoidance (i.e., attempts to control or eliminate unpleasant internal experiences such as emotional states often amplify those emotions and drive problematic coping strategies). ACT treatment for OCPD would, instead, encourage individuals to accept and tolerate negative emotional experiences rather than react in a compulsive or controlling way. For example, patients could work to mindfully tolerate distressing emotions caused by imperfection and sudden changes in routines without immediately trying to control the environment or situation. Although, to date, there have been no trials of ACT for OCPD, there was a recent RCT conducted by Ong et al. (43) that tested the efficacy of ACT for clinical perfectionism (44). In this study, a group of 53 individuals with clinical perfectionism received 10 weekly individual sessions of ACT. Compared with the waitlist group, those who received ACT experienced greater improvements in clinical perfectionism, well-being, functional impairment, distress, and processes of change. These findings suggest that using ACT to treat clinical perfectionism is feasible and efficacious.
Finch et al. (45) recently introduced an adaptation of good psychiatric management (GPM) for OCPD. GPM is a straightforward clinical management framework, informed by existing research, that is designed for generalist mental health clinicians. It has been previously adapted for other personality disorders. GPM is informed by core principles, including educating the patient about their diagnosis, building a meaningful life, and managing comorbid conditions and safety.
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.
Questions and Controversies
In this section, we outline some questions and controversies surrounding OCPD.
Confusion About the Nature of the Relationship Between OCPD and OCD
The similarity in nomenclature and significant historical association between OCPD and OCD has been a long-standing source of confusion and misconceptions among both treatment providers and the general public. In colloquial use, members of the public often use “OCD” to describe rigid patterns of behavior or perfectionism, which would typically be associated with an OCPD presentation. Early historical writings, including those of both Sigmund Freud in 1908 and Pierre Janet in 1904, linked features currently associated with OCPD (excessive perfectionism, miserliness, and obstinacy) as being precursors for the development of OCD. However, current conceptualizations suggest that, although they can co-occur, OCD and OCPD are distinct conditions and that OCPD is not a “minor” version or precursor of OCD. Although both can involve time-consuming, repetitive, and methodical behaviors (e.g., writing and rewriting written work, organizing and arranging belongings, and making lists), they can be differentiated by the presence of intrusive and upsetting obsessions in OCD (6). Specifically, whereas OCD symptoms are typically considered to be ego-dystonic, the symptomatic traits and behaviors associated with OCPD are typically ego-syntonic, as the individual experiences them as being appropriate and proper (in line with his or her sense of self). The distinctiveness of these conditions is most evident in studies of comorbidity, which typically find that only the minority of individuals with one condition also have the other. The ongoing confusion of these distinct conditions necessitates greater efforts to improve education and public outreach to be able to identify and differentiate between OCD and OCPD.
Is OCPD Best Conceptualized as a Categorical or Dimensional Construct?
Much of the existing research on OCPD and other personality disorders has utilized a categorical approach, focusing on the presence of discrete personality disorders as currently defined in the DSM-5. However, new models emphasizing dimensional approaches to personality pathology are gaining traction in the literature. Section III (emerging measures and models) of the DSM-5 appendix includes a hybrid dimensional-categorical model of personality pathology to be considered for future research. This model represents a major reconceptualization of the OCPD construct. Specifically, according to the new model, rigid perfectionism is the core personality trait required to diagnose OCPD, along with other optional characteristic OCPD traits, including perseveration (continuing the same behavior despite it not being functional), intimacy avoidance (impaired close relationships), and restricted affectivity (constricted emotional range). Currently, it is an open question for research whether this new model improves on the existing conceptualization of OCPD. The newly proposed OCPD criteria appear to be “stricter,” as perfectionism has become a required feature, whereas two existing diagnostic symptoms (inability to discard worn-out or worthless items and miserliness) have been dropped. The alternative conceptualization introduces several new potential OCPD criteria (e.g., restricted affectivity and intimacy avoidance), which require additional research attention to validate. Given that dimensional approaches to OCPD remain in their nascent stages, it may be some time before these models can be fully evaluated to determine whether they improve on the existing categorical system. It is important to note that considering personality traits to be dimensional in nature may have added clinical utility, as they may affect functioning even when an individual does not meet full criteria for a personality disorder. For example, perfectionism has been considered as a transdiagnostic phenomenon (48) that can lead to significant distress and functional impairment beyond the narrow context of diagnosed OCPD (11). Therefore, attention to traits such as perfectionism as dimensions may lead to improvements in treatments both within and beyond OCPD.
Does OCPD Interfere in OCD Treatment?
A substantial amount of literature has studied OCPD in the context of OCD. Despite this frequently noted comorbid condition, the literature remains surprisingly mixed in terms of the potential effect of OCPD on OCD treatment. Treatment guidelines (49) for adults with OCD have recommended that OCD be treated with either SRI medications or CBT, particularly that consisting of exposure with response prevention (EX/RP). For both of these treatment options, some data suggest that comorbid OCPD may make treatment less effective, whereas other data offer contradictory results. In terms of SRI medication, one trial (50) reported that patients with OCD with comorbid OCPD had significantly less improvement in their OCD symptoms than patients with OCD alone. In contrast, in another OCD treatment study, the presence of comorbid OCPD predicted better response to fluvoxamine (51). Meanwhile, other medication trials have found that comorbid OCPD was unrelated to OCD outcomes (52).
Similarly, findings in the literature on the effect of comorbid OCPD on psychotherapy for OCD are mixed. In one EX/RP trial, Pinto et al. (53) reported that comorbid OCPD was linked to poorer OCD treatment outcomes. A more recent EX/RP trial similarly found that individuals with more severe OCPD traits had lower odds of achieving remission after a standard course of EX/RP (54). In contrast, patients with comorbid OCPD were found to have better responses to a cognitively based CBT (utilizing cognitive restructuring and behavioral experiments to change underlying beliefs) (55). These mixed findings call for greater research to examine the effect of OCPD on OCD treatment. Moreover, it appears important to examine the role of specific OCPD features on treatment with different treatment variants.
Conclusions
OCPD is one of the most commonly occurring personality disorders. These patients also frequently present for treatment in both medical and psychiatric settings. The core features of OCPD include self-limiting perfectionism and rigidity, and individuals with OCPD report significant impairment in psychosocial functioning and quality of life. Living with a loved one with OCPD can be very challenging, and those individuals may need support to cope. OCPD should not be dismissed as an unchangeable personality condition. Although more work is needed to establish a gold standard treatment, OCPD appears to be treatable, and this article outlines aspects of CBT that we have found to be most helpful.
Footnotes
The authors report no financial relationships with commercial interests.
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