Objectives

• What are the DSM-IV criteria for the compulsive personality?

• The conscientious and conforming personalities are normal variants of the compulsive. Describe their characteristics and relate them to the more disordered criteria of DSM-IV.

• Explain how different personality styles combine to form each of the subtypes of the compulsive personality.

• Explain the meaning of the terms anal-retentive and anal-expulsive as used in early psychoanalytic tradition.

• How do the defense mechanisms of reaction formation, sublimation, undoing, and isolation of affect work in the compulsive personality?

• Explain the significance of guilt and shame in modern object-relations theories of the compulsive personality.

• Why is the interpersonal behavior of the compulsive described as hypernormal, contrived, and deliberate?

• Explain how parental overcontrol and an emphasis on perfection lead to the development of the compulsive personality.

• How can the compulsive cognitive style best be characterized?

• What is the fundamental core belief of the compulsive?

• Compulsives share characteristics with other personality disorders. List these other disorders and explain the distinction between each and the compulsive.

• What is the relationship between obsessive-compulsive disorder and the compulsive personality?

• Why are compulsives prone to body dysmorphic disorder?

• Why are compulsives difficult psychotherapy patients?

• List therapeutic goals for the compulsive personality.

Are there people in your life who seem just a little too efficient, well-ordered, and organized? You may have noticed these virtuous workers dutifully putting in long hours, attempting to ensure that their performance measures up to their self-imposed standard of flawlessness. They try to do everything they do perfectly to avoid the slightest mistake or flaw that would induce mountains of guilt and cause them to regard their performance as marred, if not ruined. Rigidly devoted to productivity, they rarely take time out for themselves or their families. Instead, they are known for arriving early and staying late and persevering until the job is not only done, but done to perfection. They set high, often unrealistic standards for themselves and expect the same from others, especially those who work under them. Anyone who takes too much free time is branded a "slacker" and gets no respect. In contrast, they are routinely appeasing to those in authority, seeking opportunities to prove themselves as selflessly committed to the "greater cause." In their private lives, they are often rigidly dogmatic in matters of morality, ethics, and values. Everything is by the book; nothing is on the sly. What they believe they hold as absolute truth, so much so that others see them as exceptionally stubborn.

Such individuals exemplify the obsessive-compulsive personality pattern; for convenience, they are referred to simply as compulsives in this chapter. As Donald (see Case 7.1) demonstrates, they seek to assuage their anxiety about any number of factors by plunging themselves ever deeper into detail (see criterion 1). "Success by micromanagement" might be their motto: If you can just gather enough information and organize that information in the right fashion, things will work out okay and you will be protected from harm or at least from disapproval. We might speculate, for example, that Donald probably has his socks and pants color-coded and systematized, which can be sorted in advance so that everything matches, thus saving time in the morning.

The opening paragraph of Donald's case is particularly striking. Donald can detail everything to which his stomach is sensitive. When he goes in for a checkup, the doctor need not be concerned that the patient will omit some small piece of crucial information. He may, however, run into the opposite problem, which may be the greater of two evils. Donald's responses are comprehensive to a fault. If allowed, he will undoubtedly indulge in a lengthy treatise about his dietary habits, outlining specific foods and quantities, and sharing any relevant research he has already done on the subject, leaving the doctor in the awkward position of having to either agree or risk losing any rapport with his patient. Donald thrives in the details, but he tends to overwhelm others with it because he expects them to value it just as much as he does. In fact, he becomes condescending when they don't. Others are subject to fault, but not Donald. To him, any doctor who doesn't hear him out is simply not being professional.

In his work life, Donald's devotion to detail supports his perfectionism (see criterion 2). He prides himself on his ability to get work done (see criterion 3) and get it done perfectly. We can imagine that his desk is cleaned off at the end of each day, with every pencil sharpened so that tomorrow starts smoothly. Indeed, Donald is probably proud that he has parlayed this character trait into occupational success. In his view, the rapid promotion to a middle-management position validates the superiority of his approach to life and justifies his contempt for the "average worker," whom he no doubt considers "sloppy" or "neglectful." Donald will always be tapped whenever there's paperwork to do and details to control, but he isn't likely to be the person that the board of directors looks to develop some imaginative new product or to construct broad corporate strategy.

Donald sought assistance because of unexplained stomach pains and nightmares. "My stomach has always been queasy," he noted. "I'm very sensitive to dietary factors." These he enumerated in burdensome detail, ranging from exotic brands of spices, to cabbage, certain brands of soda pop, and on to smog and stuffy interiors.1 Recently, though, the discomfort has begun to interfere with his sleep. The nightmares, in which he loses complete control, he finds frightening and intolerable.

At the same time, he was quick to note that he could usually bear the discomfort in silence and go about his day normally. Without fail, he arrives at work early so he can "smooth things out" before the day officially starts. Donald also stays after the others have left to anticipate "kinks" they might otherwise confront in the morning. "Even though my wife complains I don't spend enough time with her, and even when the discomfort is intense," he states, "I can maintain an efficient operation in the workplace." Privately, his wife notes that Donald is someone who "tends to make up his mind about things, and keep it made up."

By his own admission, he is a perfectionist, a characteristic that has allowed him to advance quickly to a middle management position. He scrupulously supervises the work of his subordinates and is quick to discipline them for their mistakes. "People don't understand that work is a virtue, " he states with a certain indignance. For this reason, he is often reluctant to trust a job to others, "cause I know they'll screw it up." When forced to deviate from this rigid style, he begins to experience physical discomfort, including stomach pains and nightmares.

Donald seems invested in being a "good patient." He prides himself on being able to answer the intake questions with precision, even though his responses are often time-consuming and unnecessarily qualified. He flounders, however, without the aid of a formal structure. His comfort returns when it is suggested that he speak about his "average day." In the lengthy description that follows, Donald relishes detail, accuracy, predictability, and efficiency. He believes dogmatically in the virtues of a healthy lifestyle, exercising daily, eating balanced meals, sleeping eight hours a night, and attending church regularly. He is offended by implications of the slightest impropriety. He has never drunk or smoked, has always been a good saver, and has never taken a vacation from work.

Donald's history explains much of his current situation. As a child, he secured approval by doing as he was told and showing interest in primarily solitary activities such as reading and coloring. He remembers trying to color between the lines, and feeling that the picture was ruined if there was one errant mark, a metaphor for his entire life. He remembers his parents as distant and stern. Any horseplay met with swift discipline. Outside school, Donald rarely played with other children, because his parents disapproved of their poor manners. His parents affectionately called him "our little man." Two years ago, Donald married Rachel, who is eight years older. When asked about the age gap, he explains that he was attracted to her mature attitude and serious approach to life. They have a stable, if somewhat unromantic, relationship. Rachel and Donald have lunch with his parents on Sunday after church, and Donald visits them alone every other Wednesday after work.

Compulsive Personality Disorder DSM-IV Criteria

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

(1) is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost

(2) shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)

(3) is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)

(4) is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)

(5) is unable to discard worn-out or worthless objects even when they have no sentimental value

(6) is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things

(7) adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes

(8) shows rigidity and stubbornness

1 Numbers mark aspects of the case most consistent with DSM criteria, and do not necessarily indicate that the case "meets" diagnostic criteria in this respect.

Reproduced with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

Donald constantly appears to be restrained and defended, as if he were anticipating some impending catastrophe. For example, he fears that he will make a mistake and that his superiors will secretly take note of it, recording it somewhere in the dreaded database created specifically for Donald's failings. He can already imagine them saying in a stern voice, "Donald, that's your second mistake this year. We're watching you." He carries this condemning voice around inside him, and it ensures that he labors perpetually under the same kind of threat that he inflicts on those under him. That's why he doesn't trust his subordinates to do their own jobs competently (see criterion 6). Donald would tell you, "You can't take your eyes off them." They can't be trusted to perform up to his standards, and without constant supervision, it is likely that even the best of them would soon regress into what, for him, would be regarded as "irremediable slackership." Worse, if they screw up, Donald has his own voice to atone to. So, he anticipates problems, stays late, and puts in the hours necessary to make sure everything runs shipshape.

If you lived down the block from Donald and his family, you would probably know him as a morally sound, upstanding citizen of your community. As you got to know him better, however, you would begin to see more and more of his rigidity in matters of values, ethics, and morality (see criterion 4). He and the family always make it to church and always make it there in a timely manner, with the kids neatly dressed. For Donald, God is just the top-level manager in the hierarchy, the ultimate superior whom he must please, but he does not feel this at a conscious level. Donald does have rebellious tendencies, but he cannot afford to be aware of them. Instead, he buries them so deep that not even he can see them; then he does just the opposite so that he can be absolutely comfortable with himself. Donald is dogmatic in his beliefs, a quality he and others sometimes mistake for passion. He overconforms to armor himself against impropriety. His religion and morality are entirely by the book, but he is not known to be a forgiving person despite his religion's teachings to the contrary. Instead, he tends to be self-righteous, and he is not above using the rules to bring a little sorrow to someone who doesn't know how to follow orders or doesn't have the kind of serious attitude that he respects; this includes the people who work for him.

Donald's dogmatism, in fact, extends beyond matters of morality and religion to just about everything in his life, and this is expressed in his considerable stubbornness (see criterion 8). In fact, Donald can't afford to change his mind about anything because that would imply that he was wrong, and he must be on his guard against mistakes. To him, people who change their minds are wishy-washy. They lack the courage of their convictions. So, Donald stands pat and argues his points, stringently committed to his point of view, regardless of genuine convictions.

Given the portrait of Donald, we are now in a position to examine additional issues, which form the plan of this chapter. First, we compare normality and abnormality; then we move on to variations on the basic compulsive theme. After that, psychody-namic, interpersonal, and cognitive perspectives on the compulsive personality are described. These sections form the core of what is scientific in personality. By seeking to explain what we observe in character sketches like Donald's, the goal is to move beyond literary anecdote and enter the domain of theory. As always, we present history and description side by side, noting the contributions of past thinkers, each of whom tends to bring into focus a different aspect of the disorder. Developmental hypotheses are also reviewed but are tentative for all personality disorders. Next, the section

"Evolutionary Neurodevelopmental Perspective" shows how the existence of the personality disorder follows from the laws of evolution. Also included are a comparison between the compulsive and other theory-derived constructs and a discussion of how compulsive personalities tend to develop Axis I disorders. Finally, we survey how the disorder might be treated through psychotherapy, again organizing our material in terms of classical approaches to the field: the interpersonal, cognitive, and psychody-namic perspectives.

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