Obsessivecompulsive anankastic personality disorder JLC

While DSM-IV labels this personality disorder as obsessive-compulsive personality disorder ( Table 14), ICD-10 prefers the term anankastic, previously used in

European psychiatry to refer to fearful, insecure, and compulsive individuals. The cardinal feature of this disorder is an exaggerated and pervasive attempt to control. Anankastic patients need to control those who are close to them, to control every uncertainty, and to control their own thoughts and emotions. The anankastic lacks an internal sense of security and tries to make the external world totally predictable. The anankastic is afraid of his own internal aggressive drives and avoids free emotional expression. Others perceive this kind of personality as characterized by inflexibility and stubborn inefficiency.

Table 14 DSM-IV diagnostic criteria for obsessive-compulsive personality disorder

Epidemiology

The prevalence of obsessive-compulsive personality disorders is about 1 per cent in community samples and up to 10 per cent in psychiatric patients, especially those with depressive and anxiety disorders. It is most frequent among males. Some obsessive-compulsive traits are sanctioned in some cultures, and a personality disorder should not be diagnosed unless the traits are markedly beyond the average for the culture.

Aetiology

Biological factors and learning seem to be involved in the aetiology of obsessive-compulsive personality disorder. The personality may be partly inherited. (102) Early psychodynamic theories linked obsessive personality to the anal phase of psychosexual development between the ages of 2 and 4, when libidinal drives come into conflict with parental attempts to socialize the child, especially in sphincter control and toilet training. Later psychoanalytic theory (103) emphasized earlier manifestations of the child's autonomy versus parental wishes. The expression of drives and emotions, including anger, is shaped by parental responses and may evoke shame and criticism. According to this theory, as children, obsessional patients were often praised for what they did as opposed to who they were. Feelings were relegated to the realm of weakness and shame. The child could avoid criticism by focusing on tasks and displacing anger. By adopting moralistic attitudes towards anger, the child gained affection and attention from the parents.

This dynamic sequence is reinforced in societies which are strongly influenced by the Protestant work ethic, in families where individual emotions are subordinated to the group, and in societies in which open expression of emotions is discouraged.

Clinical picture

The behaviour of an obsessive-compulsive personality has been consistently described as one of orderliness. The patient is preoccupied with details, and pays attention to rules, procedures, schedules, and punctuality. Patients with obsessional personalities often produce their own detailed lists of symptoms and are annoyed if any item is neglected or misinterpreted. They repeat actions and check for mistakes, despite the inconvenience and annoyance that result from this behaviour. As a consequence, their conduct is frequently inefficient. For example, the combination of unproductive perfectionism and rigidity may lead to difficulty in finishing a written report on time because of excessive correction and rewriting. Since this striving for perfection and order is time consuming, other areas of their lives often appear disorganized. One room or one desk drawer may fall into disarray, or parts of their social or family lives may be disorganized.

People with obsessive-compusive personality focus on work and productivity. It is difficult for them to take vacations or even to have free time. They do not enjoy leisure activity, which they may consider a waste of time. Often, they need to take work home to alleviate their anxiety. Hobbies and leisure pursuits become formally organized activities. They insist on perfect performance of sports or games and transform them into a serious task requiring careful organization and hard work. Leisure activities may be an unpleasant experience for the others involved, owing to the insistence on rules and standards.

Stubbornness is another characteristic of these people. They need things to be done in their way, and realistic arguments do not usually make them change their insistence. They need others to submit to their way of doing things, and often believe that no one can do the tasks as perfectly as they can. They give detailed instructions, insisting that their way is the only way of doing things, and are irritated if others suggest alternatives. Therefore, they generally insist in doing everything themselves and are unable to delegate, which increases their inefficiency at work. Paradoxically, their stubbornness is associated with doubt. Indecisiveness is a constant characteristic unless they have structured guidelines. They fear making mistakes or misjudgements, and delay repeatedly until they have enough data to take what they consider the only right decision. When rules do not dictate the correct answer to a problem or when procedures for tasks are not laid down, decision-making or task initiation may become a lengthy and painful process.

People with this personality disorder are characterized by excessive conscientiousness and scruples. They are inflexible about matters of morality, ethics, or values. Moral principles and standards of performance have to be followed rigidly, and respect for authority and rules is absolute. Failure to do these things leads to irritation, anger, and self-criticism.

These people are stingy and mean, and often live with standards far below their actual socio-economic status. They dislike spending, believing that money should be saved in case of future difficulties. They have great difficulty in discarding worn-out or worthless objects, believing that they might be useful some day. They may hoard objects such as newspapers or broken appliances, even when they have no sentimental value.

These people are humourless and lack spontaneity of emotional expression. Usually they do not express anger directly. However, they are often angry in situations in which they are unable to control the behaviour of themselves or others. Anger is generally manifested by indirect aggressive acts (such as leaving a small tip or not providing minor help when expected). Their management of anger is closely related to their attitude of dominance-submission toward authority figures. They may be excessively submissive to a person in authority whom they respect, but obstructive with an authority figure whom they do not respect.

The affect of the obsessive person is controlled and stilted. It is not flat or blunted, but constricted. They do not laugh or cry, and feel uncomfortable with people who express their feelings. Their mood is usually serious but may appear anxious or depressed. In a clinical interview they may sit in a stiff unnatural posture, and seldom make spontaneous comments about their emotions. They usually relate their history in a pedantic and circumstantial manner. If interrupted by a question from the doctor, they have to finish their monologue before answering. When asked about feelings, they answer with lists of facts and circumstances. They can label emotions and feelings, but are unable to display them.

In summary, obsessive personalities love order, neatness, and sameness, and hates novelty, spontaneity, and change. They need control, security, and certainty, and avoid creativity, art, and excitement. They mitigate anxiety by following strict rules and repress emotional expression by avoiding spontaneity. They fear their inner fragile and aggressive emotional world.

Course

Like other personality disorders, obsessive-compulsive personality disorder is present in early adulthood and tends to be persistent and constant. However, some adolescents with marked obsessive traits become warm, loving, and tender adults. On the other hand, intense obsessional traits in adolescence are occasionally a premorbid stage of schizophrenia ('pseudoneurotic schizophrenia'). The developmental relationship between obsessive-compulsive personality disorder and obsessive-compulsive disorder is controversial. In the past it was suggested that most obsessive-compulsive personality disorder evolved to a full obsessive-compulsive disorder, indicating that the two syndromes were expressions of the same basic disorder. More recent investigations (1°4) indicate that most obsessive-compulsive disorder patients do not have a comorbid obsessive-compulsive personality disorder. A variety of psychiatric disorders may present in a patient with obsessive personality, but depressive and anxiety disorders are the most common, followed by phobic, somatoform, and obsessive-compulsive symptoms. Hypochondriacal syndromes are commonly found in obsessive individuals when they lose control of situations.

Persons with this personality disorder may do well in jobs that demand working with detail, order, and structured procedures, and may adjust to interpersonal relationships with submissive spouses. However, they are particularly vulnerable to unexpected changes in their occupational and social environment. Late-onset depression is a common occurrence in obsessive-compulsive personalities.

Differential diagnosis

The main difficulty in diagnosing obsessive-compulsive personality disorder is to differentiate it from obsessive-compulsive disorder. The latter diagnosis is made when occupational and personal functioning is severely impaired as a consequence of doubt, indecisiveness, hoarding, or any other obsessive behaviour. In many, but not all, cases of obsessive personality, the traits and behaviours are egosyntonic and no resistance is present, in contrast with obsessive-compulsive disorder.

The perfectionism of obsessive personalities may be present in narcissistic personality disorder. However, narcissistic individuals tend to believe that they have achieved perfection, while obsessive individuals tend to be highly critical of their own achievements.

Social detachment and the lack of empathy and warmth may suggest schizoid personality disorder. However, obsessive individuals constrain their emotional expression to keep control of a situation, while schizoids lack the fundamental capacity for affective display or intimacy.

Not all individuals with obsessive traits have obsessive-compulsive personality disorder. Obsessive traits can be adaptive in some situations; it is only when they are maladaptive, inflexible, and persistently cause functional impairment that a personality disorder be diagnosed.

Treatment

Pharmacological treatment may be tried in patients with anxiety and distress due to intense doubts, indecisiveness, and scruples. Benzodiazepines may alleviate tension in these cases. Antidepressants with a serotonergic profile sometimes improve mood and global functioning.

Psychological treatment, focusing on perfectionism, rigidity, scrupulousness, and intolerance of failure, is the main therapeutic approach. Repressed aggression, guilt, and dependency needs should be addressed using a psychodynamic approach.

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