The Case of Louis Obsessive Compulsive Personality Disorder

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Louis M. was referred to the psychologist by his internist who had cared for Louis and his wife for many years. The physician lived in the same town and knew Louis not only as a patient but also as an active resident of the community. Louis's name was frequently cited in the town's weekly newspaper. He was outspoken, relied on well-documented facts, and had served over the years as a town selectman and chairman of the town's project development committee.

His civic activities were in addition to his vocation as an attorney specializing in tax law. He was a partner in a prestigious law practice in the city, his being the only ethnic name on the roster, a distinction of which he was proud.

Louis was born the second of two sons to immigrant parents who lived in the Italian district in a large metropolitan area. His father, Luigi, worked as a gardener for the diocese, putting in long hours in backbreaking work. Although he enjoyed working with his hands in the soil, Luigi desperately wanted his sons not to follow him in his line of work, but to get an education and make something of themselves. To this end, he and his wife were extremely frugal, saving their money only to spend on their sons. Louis's mother was a pious, devout, and fearful woman. She harbored a great, quiet anger, her life governed by duty and sin. She raised her sons to be clean of body, heart, and mind, and to repent and pray away any transgressions. The brothers, both handsome and intelligent boys, grew to be fiercely competitive, jockeying for position within the family, seeing who could be the best behaved in their parents' eyes. When one or the other did something bad, the other brother would make certain to let their mother and father know about it. The transgression would then be met with a punishment. Most often, while they were young, this meant Luigi removing his belt and meting out a few whips across the erring boy's back and buttocks to make sure that the wrongdoing was never repeated, and to get the devil out of the boy's soul.

Louis learned early that cleanliness was next to godliness and that godliness was the most valued virtue. He learned to be exceptionally neat and to live his life according to the rules. When there was no rule to fit an occasion, Louis would create one, until there were many rules he needed to follow. If he did not follow them, he would feel uncomfortable, worried, and frightened. Louis did not like change. He liked things just the way they were, to remain in order, and to be predictable. As a little boy, he learned to polish his shoes and would line them up along the closet floor with the toes evenly aligned. His brother would torment him by disturbing the order or alignment of the shoes. Although their parents would not indulge fussiness in their children's eating behavior ("Eat what you're served and be grateful for it"), Louis would insist that the different foods on his plate be kept separate and not touching. At school, his desk always received the teacher's compliments for tidi ness. Louis was held up as a model for the other students, who paid him back by taunting him on the playground. In his desk, as with his closet and dinner plate, all the items were kept separate and perfectly aligned. The homework he turned in was impeccably neat. If there was one crossed-out word, one erasure, Louis would do it over again until he achieved a final, perfect product.

Louis's propensity toward perfection, strong work ethic, and dedicated avoidance of sin led others to describe him as being somewhat dour, with a peculiar intensity. They also recognized that these same characteristics would likely ensure his success in life and would carry him far.

After high school, Louis earned a full academic scholarship to a Catholic university out of state, which afforded him a fine education as well as permission to leave his parents without committing the sin of going against their wishes. He made a few friends at college, but mostly he concentrated on his studies with an eye toward law school. Earning a near-perfect grade point average, Louis went directly on to law school following graduation. He was able to avoid military service due to mild scoliosis, a condition that did not limit his activities but that earned him a rejection from the military.

He completed law school at age 24, and moved back to the city where his parents lived, sharing an apartment with another fellow also just beginning a law career. Louis assumed a position as a law clerk with an old and honorable firm specializing in tax law. Although now living on his own, he continued to have dinner with his parents at least once a week. When he was 27, his clerkship completed, and his law career effectively launched, Louis proposed marriage to Marie, the young woman he had been courting over the previous year. Marie, 4 years Louis's junior, was a beauty, with thick, flaxen hair and the bluest of blue eyes. Trained as a legal secretary, she worked for the law firm next door to Louis's office. She saw him daily, and while deferential to attorneys, she one day got the courage to ask Louis if he would like to join her for a short walk after lunch. Flattered, he agreed, and so their relationship was launched, culminating in marriage the following year. It was not a highly romantic relationship, as Louis was stilted in expressing anything that suggested weakness or a lack of control, and he kept his emotions tightly wrapped. But Marie was an expressive, warm young woman who idealized Louis and believed that his ever-present cool head was a hallmark of great intelligence and maturity.

Two major changes in Louis's life contributed to the expression of psychopathology and increased distress. One was his retirement from the law practice, and the other was the development of hypertension and cardiovascular disease leading to his discontinuing community activities. Together, these effectively created a double retirement. Subsequently, Louis manifested several problematic behaviors. He developed sleep difficulties and began to grossly overeat, gaining considerable weight, which added to his medical morbidity. Now at home for most of the day, he became watchful of Marie and sharply critical of her every move, lashing out at her for not doing things the right way or for being sloppy. On one occasion, he swept the contents of a kitchen cabinet onto the floor in a pique of anger after discovering that Marie had not securely replaced the cap on a peanut butter jar. Typically, Louis's temper outbursts were followed by his verbal self-flagellation and compulsive overeating. "I am so bad. You should have never married me. I'm a horrible, bad person, Look at me: A sick, fat old man. I don't know why you don't hate me."

Individuals with Obsessive-Compulsive Personality Disorder (OCPD) structure their lives around a triad of orderliness, perfection, and control, which is expressed both internally and interper-sonally. Dedication to this triad limits their flexibility, efficiency, and ability to compromise or to change course, even when indicated. Their characteristic overattention to detail means sacrificing regard for the big picture. They often lose sight of the purpose of an activity or project, instead getting bogged down in the details of its organization and plans.

Their strict reliance on rules is frequently imposed on others. They can therefore be very difficult people to please, to work for, and to live with. In Louis's case, he was fortunate to have had a long-term secretary/office manager at work who shared many of his OC traits. In addition, she was socially adept and able to run interference for him with clients who were at risk of annoying Louis and thereby causing an inappropriate show of temper. Things were very different at home, however, with a wife who was a big-picture person, governed more by intuition and empathy than by rules and intellectualization.

As exemplified by Louis, individuals with OCPD often experience marked distress when they cannot gratify their perfectionist tendencies and need to embrace excellence as the exclusive stan dard. Those with OCPD are typically devoted to work, often are regarded as workaholics, and are intense and overly conscientious about whatever task they undertake. It is easy to see how this devotion to productivity and fastidious attention to detail can take the pleasure out of even a pleasurable activity.

The essence of OCPD, a need to maintain control, is accompanied by several erroneous beliefs that support the disorder. These beliefs include that perfection is attainable, that negative events can be avoided if rules are followed, and that the head must govern the heart. While often attracted to their opposite, a personality with a more histrionic style, they tend to become intolerant of those who allow emotions to reign over clear thought. They consider such individuals to be out of control and thus in need of being controlled. They are often perceived by others as being stilted, especially in the affective domain, which is inherently unfettered by rules. Often respected by others because they are honest as the day is long and perfectly fair, they rely on morals as codified rules, which are immutable and unbendable.

Being profoundly rule-governed, when those with OCPD cannot apply a rule, they tend to become overwhelmed by anxiety and, cogni-tively, by doubt and uncertainty. It can be difficult for them to make a decision, as they are prone to anguish over the pros and cons attending any choice, becoming immobilized by indecision as no decision is considered perfect or without risk. These same traits and tendencies, however, enable many with OCPD to be high achievers. Consistent with the prototypical Type A personality, they can be hostile, competitive, and time urgent, but ultimately the master of the universe.

Following several transient ischemic attacks portending an actual stroke, Louis did indeed suffer a cerebrovascular accident (CVA), which was mild but nonetheless resulted in a hospitalization of several days' duration. During this time, his physician was able to reach Louis and explain that his life—both its quantity and quality—was in jeopardy if he did not make some changes. Louis willingly participated in the hospital's cardiac rehabilitation program, which included exercise, nutrition, and stress management components. He declined the opportunity to join a support group with other patients, but did accept his physician's referral to meet privately with a psychologist.

It is important to understand that people with OCPD are likely to resist accepting psychological treatment, as they consider that this places them in a one-down position relative to the therapist. This, then, harkens a loss of control, which they fear at their core. An advisable approach to establishing a therapeutic alliance is to join the patient at the level of the head, rather than the heart, and to reinforce the concept of the treatment as a collaborative venture, always under the patient's control.

After Louis's individual psychotherapy got underway, and the alliance was well established, couples therapy was suggested to Louis and Marie. The goals for this were threefold: improve their communication and positive connection; reduce the expressions of Louis's displaced anger and need to control; and enable each spouse to come to know, and relate to, the other as they are now.

The individual treatment plan incorporated four types of therapy: Pharmacological, Cognitive-Behavioral, Psychodynamic, and Supportive. For Louis, the first order of (therapeutic) business was to treat an underlying depression. This was presented to him in terms of a biological deregulation requiring chemical correction, especially because he would otherwise regard depression as a moral weakness. He was started on a course of SSRIs and had a favorable response. The medication helped him by decreasing his worries, obsessive ruminations, and compulsive eating. The same medication has anxiolytic properties as well as serving as an antidepressant. Although Louis said he did not feel any different on the medication, his wife reported that he was distinctly less irritable and less likely to explode. Over time, she also reported that he was much less likely to walk around saying nasty things about himself. About this, Louis almost concurred, allowing that maybe it was true.

Cognitive-behavioral therapy addressed his worries and anxiety through identifying and testing Louis's underlying maladaptive core beliefs. These included his excessive sense of responsibility, his belief that there is only one way of doing something, that truth is objective, and that less than perfect control is equated with chaos.

Biofeedback was also added to his treatment plan. Louis did very well with this stress reduction technique, especially well suited to his OC tendencies.

The psychodynamic modality worked on uncovering historically significant material and on linking and labeling Louis's history of experience with emotions.

The greatest focus was on the material that most strongly informed the development of Louis's dysfunctional core beliefs. These included the emotional neglect by his parents, singularly focused on earning a living and bringing up the boys right; the psychological torment by his brother when their sibling rivalry turned sadistic; the instilled fear of a punitive God; and the danger inherent in normal human weakness.

With OCPD, the most common defense mechanisms are isolation of affect (doing), undoing, and reaction formation. For Louis, isolation of affect was dominant. It was evident when he spoke of his father whipping him "for my own good" when he was a child seen as transgressing a rule. Louis recounted these episodes without memory of the way they made him feel (terrified, ashamed, etc.). The role of the therapist then is to become (model) the voice of affect and to encourage the connection between the feeling and experience. Once the more distal linkages are made, Louis is encouraged to make these connections with current experiences. For example, when his wife makes plans for them to dine out with friends, for him to recognize that he feels anxious because he believes he will lose control and eat unhealthily or excessively. The next step is to work to identify actions he can take to avoid this behavior and thus prevent the anxiety from escalating.

Supportive psychotherapy included reinforcing Louis's compliance with his nutritional and exercise regimens, including a psy-choeducational component addressing the connection between mind and body (and between feelings and behaviors).

In psychotherapy with those with OCPD, the transference is often reflected through ways the patient attempts to secure control in the relationship. This can be expressed directly though his challenging the therapist or opposing interpretations or assignments. Even gentle inquiry can be misperceived as the therapist's attempt to achieve control. It can also be expressed in more veiled ways, such as through setting and changing appointments, requiring the therapist to accommodate the patient.

The countertransference in working with those with personality disorders in general is likely to be powerful. With the individual with OCPD, boredom is frequently experienced, as the patient is typically humorless and wedded to the cognitive. His presentations lack playfulness, spontaneity, and the affective coloration that so enriches and enlivens a therapy. This paucity of emotional tone can, over time, lead to feelings of impatience for the patient to finally "get it," and a temptation to advance the therapy too hard, too soon.

The most central belief contributing to the OCPD pathology is that of order and perfection as being obtainable if only the rules are followed. They strive mightily to reach the Holy Grail of Perfection. They overvalue themselves while undervaluing others, as few others are seen as maintaining their level of anticipation of contingencies and attention to detail. Above all, they value achievement and productivity and leave little time for relaxing and letting down their guard. Although often highly intelligent, they lack psychological-mindedness and insight; they cannot entertain the point of view of others, where this differs from their own. Their way is the right way. Their truth is the only truth.

Having an OCPD is time consuming, labor intensive, and not much fun. Although hard to live with or work for, these individuals are always hardest on themselves. They are most fearful of loss of control and of the threat of needing to be dependent. It is easy then to understand how this personality disorder can be especially challenged and threatened by the vicissitudes of old age. Louis functioned well during his industrious, workaholic years. He became distressed and symptomatic when he lost the foci for his dominant personality traits on retirement from work and development of health problems that limited his activities.

Other Personality Disorders and Aging: Sadistic, Self-Defeating, Depressive, Passive-Aggressive, and Inadequate

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