In the last article on Theodore Millon’s examination of obsessive-compulsive personality disorder, we saw that such an individual is over-conscientious in the minutiae, opinionated, proud of his supposed rationality and integrity, perfectionistic and sanctimonious and concrete-mindedness. S. Rado continues this thesis in 1959, presupposing the truth of the “anal” character of those with OCPD:
“If the mother is overambitious, demanding and impatient…then the stage is set for the battle of the chamber pot. Irritated by the mother’s interference with his bowel clock, the child responds to her entreaties with enraged defiance, to her punishments and threats of punishment with fearful obedience. The battle is a seesaw, and the mother…makes the disobedient child feel guilty, undergo deserved punishment and ask forgiveness…It is characteristic of the type of child under consideration that his guilty fear is always somewhat stronger; sooner or later, it represses his defiant rage. Henceforth,, his relationship to the mother and soon to the father will be determined by…guilty fear over defiant rage or obedience versus defiance. A few words should be added about the obsessive patient’s “ambivalence.”…we trace these manifestations uniformly to the underlying obedience-defiance conflict…He ponders unendingly: must he give in, or could he gain the upper hand without giving offense.”
David Shapiro, writing in 1965, likewise wanted to bridge ‘orthodox’ psychoanalytic theory while also empirically characterizing the cognitive distortions and tendencies to which such individuals are predisposed.
“The obsessive-compulsive’s attention, although sharp, is in certain respects markedly limited in both mobility and range. These people not only concentrate; they seem always to be concentrating. And some aspects of the world are simply not to be apprehended by a sharply focused and concentrated attention. Specifically, this is a mode of attention that seems equipped for the casual or immediate impression.”
Salzman, writing in 1985, has also examined certain tendencies associated with OCPD in his literature:
“The overriding purpose of the behavior is to attempt to achieve some security and certainty for the person who feels threatened and insecure in an uncertain world. The possibility o controlling oneself and the forces outside oneself by assuming omniscience and omnipotence can give one a false illusion of certainty. Therefore, the main ingredient is control. As the defenses become overriding, a person may form patterns of behavior which are congealed and enduring. The obsessive personality, then, is manifested by meticulous, overly cautious, fearful and phobic behavior. Such obsessive individuals are afraid to risk new adventure or to go into new situations where the issues are unclear. They always take exaggerated precautions with regard to every move in their lives.”
More recent analysts have examined tendencies having to do with interpersonal conduct, cognitive style and self-esteem. Gabbard, for example, writing in 1994, seeks to explain the developmental background of the individual with OCPD beyond the anal stage:
“Obsessive-compulsive persons are also characterized by a quest for perfection. They seem to harbor a secret belief that if they can only reach a transcendent stage of flawlessness, they will finally receive the parental approval and esteem they missed as children. These children often grow up with the conviction that they simply did not try hard enough, and as adults, they chronically feel tht they are “not doing enough.” The parent who seems never satisfied is internalized as a harsh superego that expects more and more from the patient.”
In a work on stress response syndromes and character style, Horowitz, writing in 1974, explained the obsessive-compulsive personality as a disorder of information processing in interpersonal communications. He tries to integrate traditional analytic understandings with those of the cognitive-perceptual style of the patient. Beck and Freeman, writing from the cognitive perspective, in 1990, articulate several important features of the OCP
“There are certain cognitive distortions…that are characteristic o OCPD. Among these is a dichotomous thinking, the tendency to see things as all-or-nothing and in strictly black-and-white terms. It is this tendency that underlies the obsessive’s rigidity, procrastination, and perfectionism. Without this primitive, global style of thinking, the obsessive would see the shades of gray that are obvious to others. Another cognitive distortion in which the obsessive-compulsive frequently engages is magnification or catastrophizing.
For the obsessive, the importance or consequences of an imperfection or error become greatly exaggerated. A characteristic of many obsessives is thinking in terms of “shoulds” and “musts.” This primitive, absolutistic and moralistic style of thinking leads them to do what they should or must do according to their strict internalized standards, rather than what they desire to do or what is preferable to do.
They see themselves as responsible for themselves and others. They believe they have to depend on themselves to see that things get done. They are accountable to their own perectionistic conscience. They are driven by the “shoulds.” Their instrumental beliefs are imperative: “I must be in control,” “I must do virtually anything just right,” “I now what’s best,” “You have to do it my way,” “Details are crucial,” “Peole should do better and try harder,” “I have to push myself (and others) all the time,” “People should be criticized in order to prevent future mistakes.””
Influenced by the writings of Sullivan and Karen Horney, Leary (1957) contributed to an interpersonal understanding of obsessive-compulsive personality disorder:
“These individuals employ strong and conventional security operations. They present themselves as reasonable, successful, sympathetic, mature. They avoid the appearance of weakness or unconventionality…These individuals often give the impression of maturity and parental strength.
Patients whose overt security operations strive towards normality do not present the typical neurotic symptoms when they appear in the psychiatric clinic. They are not anxious or depressed. They do not report interpersonal failures. They do not complain of timidity, isolation, distrust, etc. They tend to describe their emotional adjustment as adequate and normal.
Why then, do they come to the clinic? The overwhelming majority of these patients are not self-referred, but have come at the request of a physician. Their symptoms are psychosomatic or physical.”
Benjamin, also writing from an interpersonal perspective, says the following of the OCP:
“There is a fear of making a mistake or being accused of being imperfect. The quest for order yields a baseline interpersonal position of blaming and inconsiderate control of others. The OCD’s control alternates with blind obedience to authority or principle. There is excessive self-discipline, as well as restraint of feelings, harsh self-criticism, and neglect of the self.
Forces himself or herself and others to follow very strict and harsh standards, and is mercilessly self-critical if he or she makes a mistake. Rigidly deferential to authority and rules. Compliance with authority, rule, or priniciple is quite literal. No rule bending or consideration of extenuating circumstances is likely. Rigidly follows his or her moral principles. For example, he or she won’t lend a dollar to a needy friend because he or she believes: “Neither a borrower nor a lender be.””
It was typical in the 1960s to subject characteristics to quantitative scrutiny. Sandler and Hazari, writing in 1960, examined the responses of 100 patients to a questionnaire on obsessive personality traits using the centroid method of factor analysis. Millon says the following of the results:
“Their results indicated that obsessional character traits cluster in a different group than do obsessional symptoms. More significantly, they found that the character pattern cluster did indeed correspond to classical analytic features (e.g., systematic, methodical, thorough, well ordered, consistent, punctual, and meticulous). In another factor analytic study, a similar pattern of findings was obtained and cross-validated with both preselected and random patients..As they phrased their results: “The obsessive factor both in the original and in the current study contains defining traits which were all predicted from psychoanalytic theory.” Among these traits were emotional constriction, orderliness, parsimony, rigidity, superego, perseverance, and obstinacy. Also reflecting the empirical bent of the period, Walton and Presley (1973) rated 140 patients in an effort to extract distinctive components using a factor analytic matrix. Although blurred by certain intrusive “schizoi” elements, one of the components extracted was termed obsessional, having comprised features such as stubbornness, meticulousness, and officiousness.”
Costa and Widiger (1993) examine the OCPD in terms of the five-factor model of personality. They report the following:
“These features are clearly maladaptive, extreme variants of conscientiousness. Conscientiousness involves a person’s degree of organization, persistence and motivation in goal-directed behavior. Conscientious individuals tend to be organized, reliable, hard-working, self-disciplined, businesslike, and punctual. People who are overly conscientious are excessively devoted to work, perfectionistic to the point that tasks are not completed.”
So also Cloninger, writing in 1987:
“Obsessional personality is narrowly defined here in terms of the basic response characteristics of low novelty seeking, high harm avoidance, and low reward dependence, which is associated with the second-order traits of being rigid, alienated, and self-effacing. The second-order cluster of “rigid-patient” traits caused by the combination of low novelty seeking and high harm avoidance includes patient or unassertive behavior and preoccupation with maintaining order and saety by attention to rules and organizational details.”
Theodore Millon argued that the OCP is characterized by a passive-ambivalent attitude. He said that the four features one should note from the OCPD are restrained affectivity (emotionally controlled grim and cheerless), cognitive constriction (narrow-minded; overly methodical and pedantic in thinking), conscientious self-image (practical, prudent and moralistic), and interpersonal respectfulness (ingratiating with superiors; formal and legalistic with subordinates). Millon wrote the initial 1975 working draft for the DSM-III Task Force:
“This pattern is typified by behavioral rigidity, emotional overcontrol and a conscientious compliance to rules and authority. Everyday relationships have a conventional, formal and serious quality to them and there is a conspicuous concern with matters of order, organization and efficiency. Perfectionism, small-mindedness and a lack of cognitive spontaneity are manifested in a cautious indecisiveness, procrastination and a tendency to be upset by deviations from routine. The characteristic air of austere and disciplined self-restraint precludes informality and easy relaxation. Since adolescence or early adulthood at least 3 of the following have been present to a notably greater degree than in most people and were not limited to discrete periods nor necessarily prompted by stressful life events.
1. Restrained affectivity (e.g., appears unrelaxed, tense, joyless and grim; emotional expression is kept under tight control).
2. Conscientious self-image (e.g., sees self as industrious, dependable and efficient; values self-discipline, prudence and loyalty).
3. Interpersonal respectfulness (e.g., exhibits unusual adherence to social conventions and properties; prefers polite, formal and correct persona relationships).
4. Cognitive constriction (e.g., constructs world in terms of rules, regulations, hierarchies; is unimaginative, indecisive and upset by unfamiliar or novel ideas and customs).
5. Behavioral rigidity e.g., keeps to a well-structured, highly regulated and repetitive lie pattern; reports preference for organized, methodical and meticulous work).”
He proposed the following modifications in criteria for a later draft in response to preliminary personality committee discussions:
“Excessive emotional control (e.g., unable to relax, lack of spontaneous emotional response).
B. excessive concern with matters of order, organization and efficiency (e.g., unduly meticulous, reliance on schedules).
C. Interpersonal reserve (e.g., relations with people are unduly conventional, serious and formal).
D. Excessive conformity to internalized standards (e.g., moralistic or excessively judgmental of self or others).
E. Indecisiveness (e.g., procrastination rumination).”
The disorder was characterized in the following manner in the DSM-IV:
“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:
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.”
Next, it was categorized in the following way in the DSM-V:
“A. Significant impairments in personality functioning manifest by: 1. Impairments in self functioning (a or b): a. Identity: Sense of self derived predominantly from work or productivity; constricted experience and expression of strong emotions. b. Self-direction: Difficulty completing tasks and realizing goals associated with rigid and unreasonably high and inflexible internal standards of behavior; overly conscientious and moralistic attitudes. AND
2. Impairments in Interpersonal functioning
(a or b):
a. Empathy: Difficulty understanding and appreciating the ideas, feelings, or behaviors of others.
b. Intimacy: Relationships seen as secondary to work and productivity; rigidity and stubbornness negatively affect relationships with others. B. Pathological personality traits in the following domains:
1. Compulsivity, characterized by: a. Rigid perfectionism: Rigid insistence on everything being flawless, perfect, without errors or faults, including one’s own and others’ performance; sacrificing of timeliness to ensure correctness in every detail; believing that there is only one right way to do things; difficulty changing ideas and/or viewpoint; preoccupation with details, organization, and order.
2. Negative Affectivity, characterized by: a. Perseveration: Persistence at tasks long after the behavior has ceased to be functional or effective; continuance of the same behavior despite repeated failures.”