This disorder is characterized by a preoccupation with rules, details, organization, orderliness, and internal and external control. People with Obsessive-Compulsive Personality Disorder are highly perfectionistic, and they apply their overly strict standards to their own behavior and that of others. This preoccupation with details, lists, schedules, routines, organization, and perfectionism is so engrossing that the major point of the activity or project often becomes obscured, "lost in the details." They are paragons of rigidity, inflexibility, scrupulosity, and inefficiency. They tend to be stubborn, rigid, serious, exacting, in-terpersonally formal, overly conscientious, and moral. Their pervasively rigid, moralistic, and uncompromising style negatively impacts their interpersonal relationships.
Often described by others as workaholics, people with this disorder forgo pleasurable activities and friendships for the sake of productivity. Ironically, their productivity often suffers because the point of many activities is lost among the rules, regulations, lists, and schedules to which they scrupulously and conscientiously adhere. Delegation of responsibility or work to others is unheard of, usually for fear that the task will not be completed their way (the right way). Individuals with this disorder are controlled and controlling. They are emotionally constricted and have trouble expressing affection. They prefer an intellectualized and logical approach to life and relationships, devoid of spontaneity, creativity, and joy. They demand that others submit to their wishes and have a hard time considering alternative points of view. They frequently hoard their money, possessions, and feelings and are stingy in their spending on themselves. They are also unable to get rid of worthless objects. A vivid metaphor for this type of pathology is that sufferers "do not see the forest for the trees." Often, their preoccupation with the details, rules, and regulations leaves them unable to perceive the broader context, forever failing to appreciate the "big picture."
A distinction should be made between this personality disorder and Obsessive-Compulsive Disorder (OCD), which is an anxiety disorder coded on Axis 1. Individuals with Obsessive-Compulsive Personality Disorder typically do not have true obsessions (intrusive thoughts that flood the person's mind) or compulsions (behaviors that the person feels compelled to perform, usually to counter their obsessional thoughts) that define OCD. Moreover, those with the personality disorder are not typically anxiety ridden, although they are scrupulous, punctilious, assiduous, and meticulous.
Obsessive-Compulsive Personality Disorder is a particularly good illustration of the dimensional nature of personality traits and the distinction between "style" and "disorder" (discussed in detail in Chapter 11). In many contexts, some obsessive-compulsive behavior is highly adaptive. The traits of being organized, setting high standards for performance, being punctual, and committed to work are highly valued in professional life. A question we have posed to students during training is "Who would not want their neurosurgeon to be exacting and perfectionistic during their surgery, making sure everything is completed perfectly?" As obsessive-compulsive traits become more pronounced, pervasive, and central, however, performance and productivity begin to suffer because the person's rigidity and perfectionism become paralyzing. Like many of the personality disorders, a little bit of some of the traits can be adaptive. Once the traits move to the extreme end of the continuum, they result in dysfunction and impairment, conceptualized as a shift from style to disorder. Table 4.3 shows the DSM-IV-TR diagnostic criteria for Obsessive-Compulsive Personality Disorder.
Potential Age-Bias of Criteria
Compared with the other personality disorders, Obsessive-Compulsive Personality Disorder seems to have the least
Table 4.3 DSM-IV-TR Diagnostic Criteria for Obsessive-Compulsive Personality Disorder (Code: 301.4)
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
Source: From Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, American Psychiatric Association, 2000, Washington, DC: Author. Copyright 2000 by American Psychiatric Association. Reprinted with permission.
deficiency in terms of criteria likely to be problematical in their application and relevance to individuals in later life. On the surface, Criterion 3 (is excessively devoted to work and productivity to the exclusion of leisure activities and friendships) may not be appropriate in the late-life context because older adults have lower formal employment rates than younger and middle-aged adults. In defense of this criterion, however, the terms work and productivity do not necessarily imply being in a paid position, so sharp criticism of this criterion may not be justified.
A more reasonable critique, however, may be directed at Criterion 7 (adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes). This criterion may be problematical among some older adults, given that financial pressures are common among older people (with poverty being especially common among older women and minorities) and therefore, having to be cautious with savings makes good sense. Another mitigating circumstance about the present cohort of older adults is that many current 80- and 90-year-olds were children of the Great Depression in the 1930s, and many were indelibly marked with concerns over food and possessions, supporting a cohort effect for this criterion. To the extent that an older person's concern about finances and thrifty spending habits are reasonable and contextually valid, it would be less likely to be a sign of an obsessive-compulsive personality. Lifelong stinginess, especially when money has not been in short supply, is more indicative of this type of personality pathology.
Theorized Pattern in Later Life and Possible Impact of Aging Older people are often stereotyped as being rigid, which is a hallmark feature of Obsessive-Compulsive Personality Disorder. Indeed, popular but pejorative characterizations of aging are that older people typically become set in their ways and have "hardening of the attitudes." In contrast, there is little evidence that older adults become more rigid in personality as a function of normal aging. Where increased rigidity is observed, it is usually an understandable reaction to physical or emotional threats or crises. A related point is that older people, in general, are not any more resistant to change than younger people, despite the popularity of this myth. In fact, the ability to adapt depends more on lifelong traits of either flexibility or inflexibility than on anything inherent in later life (Butler et al., 1998). These caveats having been said, old age may be a particularly challenging phase of life for older adults with Obsessive-Compulsive Personality Disorder.
Increased dependency on others is likely to be an especially difficult stressor for obsessive-compulsive older adults. Their lifelong pattern of doing things their own way makes them resistant to change and unable to tolerate needing help from others. Believing there is only one way to accomplish tasks, they have a great deal of difficulty in being flexible with lost or reduced physical and cognitive functions. One of our patients, a physically ill 80-year-old man recently admitted to a skilled nursing facility, bemoaned that he could no longer enact his lifelong motto, "My way or the highway," when dealing with his doctors, physical therapists, and the nursing home staff. Older adults with Obsessive-Compulsive Personality Disorder may resent or be offended when offered help, which they interpret as a statement that they are not in complete control. When receiving help becomes inevitable, obsessive-compulsive older adults may react with catastrophic depression.
Another potential stressor is retirement. Older individuals with Obsessive-Compulsive Personality Disorder are likely to cope poorly with retirement, especially where they have had occupational success and have come to define their identity largely through their work role and accompanying prestige and status. Although they are resistant to and uncomfortable with change, retirement brings about a host of new routines that they must painstakingly develop. This often leads obsessive-compulsive older adults to experience a great deal of distress. It is hard for them to enjoy the fruits of their labors and relax. To do so would be perceived as a waste of time.
Another pattern is that the problem of hoarding useless items often becomes more evident in later life. One of our older patients with Obsessive-Compulsive Personality Disorder habitually collected newspapers and magazines, unable to discard them even after having read them. Over many years, the stacks became so large that it became nearly impossible to move from room to room except for a small path that he kept clear. Furthermore, his basement was overflowing with old papers, and his garage was mostly filled with useless, broken appliances (e.g., toasters, blenders, microwave ovens) that he refused to discard even after buying new ones. His thought process, seen by him as reasonable, was "You never know when you might need them." There are other, organic, reasons contributing to hoarding (such as dementia), and these possibilities should be considered as well.
A further problem facing older adults with Obsessive-Compulsive Personality Disorder is that they typically do not have adequate social support networks in place. A lifetime of devotion to work and productivity, rather than to the development of relationships and interests, coupled with emotional coldness and distance, typically leaves these individuals without many supportive relationships. Depression is a common emotional reaction when aging obsessive-compulsive types realize that their lifelong devotion to order and schedules has prevented them from achieving connections and meaningful relationships, even with family members. Because they lack appropriate supports, all the vicissitudes of aging are likely to be compounded in their impact.
We conclude this section by briefly noting a potentially adaptive function of the obsessive-compulsive personality style that we have seen in a few cases. Older adults who conscientiously take care of themselves, stick to an active daily regimen, and keep busy with many details may derive some benefit. One of our elderly patients (with obsessive-compulsive personality features) scrupulously adhered to an exercise routine (bike riding and weight lifting) that kept him in terrific physical shape for much of his life. He experienced difficulties, however, when fatigue caused by cancer and his chemotherapy prevented him from exercising as much as he had previously.
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