OCD and OCPD: A Case Study and Treatment

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It is not uncommon to hear lay people refer to themselves or others as "OCD". In many cases, these people are referring to specific patterns of behavior that may be associated with OCD, such as a need to do things a certain way, in a certain order, etc. These behaviors are often referred to in the vernacular as "anal" or "anal retentive" or simply controlling.

Obsessive Compulsive Personality Disorder

For those who take these behaviors to the extreme, driven by perfectionism or fear of being not good enough, the problem may be OCPD—Obsessive-Compulsive Personality Disorder. Unlike OCD, an anxiety disorder, people with OCPD do not experience the often bizarre, intrusive, unwanted obsessions on a regular basis; their compulsive behaviors are usually to control their environment or desired outcome, not to reduce the anxiety related to specific obsessive thoughts or compulsions.

Many people with OCPD experience anxiety, sometimes to the point of panic attacks, if they make a mistake, can’t control the outcome of a situation or control another person’s thinking or behavior. This anxiety is related to their fear of being perceived as imperfect, which is different from anxiety related to OCD where the anxiety is tied to the obsessive thoughts and need to carry out a specific mental or behavioral ritual. A primary difference between OCD and OCPD is OCD is considered an anxiety disorder with biological roots; OCPD is a result of personality traits (learned behavior) that create impairment in functioning, although OCPD may be accompanied by a separate anxiety disorder.

Sandy: A Very Strong and Competent Woman

Many years ago, I saw a woman in therapy who was very well organized and took extreme pride in her work—we will call her Sandy. She was a supervisor and reportedly a real go-getter for a small publishing company. Allegedly, the place could not continue to function without her. While there were no complaints about her work or work relationships in their very small office, she was exhausted. She pushed herself hard to do ‘everything’, and to do all of it perfectly. The result was that she worked very long hours and began to experience exhaustion and anxiety.

Sandy had been married to the same man for 30 years. She had adult children and grandchildren. Her life seemed to be going very well except for the oldest son who had recently moved back to their home. He had a problem with alcohol and was about to lose his wife and family. The reason Sandy came to therapy was to ‘fix’ him. She could not understand why he was so different from her other children and his parents. While she wanted him to get better, she did not want to bring in the family for therapy. She wanted me to help her understand him (without ever meeting him) and tell her what to do to correct the problem.

I convinced Sandy that our work together needed to focus on her, including her response to her son. We worked on relaxation techniques, which Sandy diligently used to help manage her anxiety at work. After meeting weekly for about two months, she missed an appointment and didn’t call to reschedule for a few weeks. Upon her return, she reported that she had been burned quite badly while burning some trash and she was hospitalized for a few weeks. She said that her husband wanted to come to the next session.

Sandy’s husband was delightful but very worried about Sandy. He was concerned that she was not reporting the full story in therapy. Reportedly, she was so insistent on getting the trash burned that she would not wait for her husband to do on his day off. Instead, she tried to do it herself on a day when the local weather advised against it (she checked before she decided to burn the limbs). The fire quickly got out of control due to gusts of wind, resulting in her severe injuries. Sandy felt ‘shame’ for making this choice that could have injured her granddaughter.

He also talked about her rigid adherence to ‘doing things her way’ that resulted in her doing all the housework, cooking, and cleaning. Most revealing, her husband said that she could not be pleased. And while she was not ‘mean’ about it, everyone knew they could not live up to her exacting standards at home, which greatly affected her relationships. The family had learned that Sandy believed she had to do everything herself to get it done properly. They stopped trying to please her, making jokes about her rigidity to ease the tension. However, they knew that Sandy silently judged and resented them for being incompetent. Sandy sadly agreed that these statements were true, and admitted that people at work may also fear her silent disapproval.  

Treatment for OCPD

Once all the facts were in, Sandy agreed to see our psychiatrist on staff. She began to improve with a combination of medication, relaxation techniques, and cognitive behavioral therapy. Sandy realized that her beliefs about herself and others were creating unrealistic expectations. She started working part-time and found that other people in her office could do a lot of the work she had done previously, although they needed the space to do it their way as long as the results were ‘good enough’.

As Sandy started to make changes in herself, she was able to accept her son for who he was as a person. They addressed the alcohol problem as a family and Sandy learned more about letting go of expectations of other people. Her husband dropped in for some therapy sessions, providing valuable perspective for Sandy and her treatment. After six months, she completed therapy but continued to take low doses of medication and practice relaxation techniques daily.

What We Can Learn About OCPD from Sandy

1. Family involvement is critical to effective treatment.

2. Unraveling irrational thoughts and beliefs are key to successful, long-term recovery for OCPD.

3. Relationships at work and home are often damaged and need to be repaired in cases of OCPD.

4. Relaxation techniques and mindfulness are very helpful for OCPD.

5. People with OCPD often appear to have everything under control—but the costs to them and their relationships are great.

6. People with OCPD often externalize, blaming other people or circumstances when they cannot control things.

7. Medication may be necessary for those who are unable to manage their anxiety with therapy and self-help alone.

8. It is not unusual to see substance abuse and anxiety in the same family—anxiety often underlies addictions.

9. Families often cope with tension through avoidance or inappropriate joking or teasing.

10. OCD and OCPD have some overlapping signs and symptoms, but the causes of these are very different.

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