History

Fact Explanation
Insecurity, anxiety, guilt, depressed or shame feelings Patient with OCPD tends to self-blame and feel responsible for anything bad that happens. Due their perfectionism and orderliness trait they constantly strive to fulfil their self set high standards and is continuously trying to attain perfection. [2] On doing so to extreme degrees they tend to miss out on the important part of the task, leading to failure in completion of the task and becomes extremely disappointed and depressed with self. As a result s/he becomes extremely anxious, guilty, unhappy, insecure and shameful of self. [2] [4]
Difficulty allowing self to experience strong pleasurable emotions (e.g., excitement, joy, pride) [2]
Impaired relationships and leisure Due to excessive devotion to work and productivity s/he puts work before personal relationships or leisure time. [2]
Hoarding Patient is unable to discard worn-out or worthless objects. [2]
Obsessional thoughts Maybe troubled by recurrent obsessional thoughts, that s/he experiences as senseless and intrusive. [2]
Past history Review his/er interpersonal relationships, educational and work history, psychiatric and substance abuse history, and also legal history. These are important since significant number of areas of the patient's life would consist of various impairments.[3] May also have a family history of OCPD. [1]
Co-occurrence of OCPD with other personality and DSM Axis I disorders The co-occurrence of two or more psychiatric disorders is common in patients with OCPD such as obsessive–compulsive disorder (OCD), other anxiety disorders (most prevalent - panic disorder, social phobia and generalized anxiety disorder), eating disorders, mood disorders, substance use disorders, paedophilia and intimate partner violence; and hoarding (more the number of OCPD traits in a patient higher the risk of hoarding). [1]
References
  1. DE REUS ROB J.M., EMMELKAMP PAUL M.G.. Obsessive-compulsive personality disorder: a review of current empirical findings. [online] December, 6(1):1-21 [viewed 06 June 2014] Available from: doi:10.1002/pmh.144
  2. SHEDLER J.. Refining Personality Disorder Diagnosis: Integrating Science and Practice. American Journal of Psychiatry [online] 2004 August, 161(8):1350-1365 [viewed 06 June 2014] Available from: doi:10.1176/appi.ajp.161.8.1350
  3. WARD RK. Assessment and management of personality disorders. Am Fam Physician [online] 2004 Oct 15, 70(8):1505-12 [viewed 06 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15526737
  4. CUMMINGS JA, HAYES AM, CARDACIOTTO L, NEWMAN CF. The Dynamics of Self-Esteem in Cognitive Therapy for Avoidant and Obsessive-Compulsive Personality Disorders: An Adaptive Role of Self-Esteem Variability? Cognit Ther Res [online] 2012, 36(4):272-281 [viewed 07 June 2014] Available from: doi:10.1007/s10608-011-9375-x

Examination

Fact Explanation
Orderliness and perfectionism Expects self to be perfect (e.g., in appearance, achievements, performance). Tends to be conscientious and responsible. Overly concerned with rules, procedures, order, organization and schedule. [2] Strives to do a task properly with increased attention to details and imposes all sorts of rules to maintain efficiency while attempting to attain perfection to a point that he/she misses on the significant parts of the task. As a result makes the task more difficult and at times even fails to complete it. [2] [1]
Mental and interpersonal control Has a very controlling nature and a feeling of superior competence comparing him/herself to others. [1] In situations where the OCPD patient feels they are unable to maintain control of their physical or interpersonal environment, tends to withdraw emotionally and becomes extremely upset or angry. [2] But typically this anger is not directly expressed. [4] A patient with OCPD have mixed feelings or contradictory ideas about something or someone over needs for individuation, emotional, physical nourishment and care. Thus, s/he tends to feel guilty over seeking individual, self-centered needs but is resistant to accept direction from others. Therefore, s/he passively adopts strict adherence to external rules and structure. This is to cope with the mixed feelings or contradictory ideas created by attempts to individuate and seek nurturance from others. [3]
Moral or ethical issues Strives to live up to their moral and ethical standards and is overly conscientious, scrupulous, and inflexible about matters of morality, ethics, or values. [1]
Rigid and stubborn Takes comfort in a particular routine way of doing a task. Does not favour change and will only relent reluctantly in an argument. Adheres rigidity to daily routines and becomes anxious, angry or uncomfortable when they are altered. [1] Rigidity, stubbornness, and perfectionism than average is displayed in children with a moderate to high inborn tendency of a systemizing mechanism that is developed out of an intersubjective matrix. It has been found that these traits may develop due to inflexible countermeasures by parents who may share the same genetic disposition. In the presence of a predisposition toward rage reactivity, intersubjective matrix handles the rage less than optimally causing failure in transforming the rage into healthy assertiveness. [3]
Self-critical and self-blaming Sets unrealistically high standards for self and is intolerant of own human defects. Tends to blame self or feel responsible for bad things that happen. [2]
Restrictive attitude toward emotion Restrictive particularly towards warm or tender emotions and is unwilling to show emotion. [2]
Excessive devotion to work and productivity Puts work before personal relationships or leisure time. [1] [2]
Reluctance to delegate tasks May be very cautious in entrusting tasks to others and would have strict instructions as to how they are to be carried out. [1] A patient with OCPD is ambivalent over needs for individuation. [3]
Adopts a miserly spending style Both towards self and others. Money is viewed as something to be hoarded for future catastrophes and hence is stringent with money. [1]
References
  1. DE REUS ROB J.M., EMMELKAMP PAUL M.G.. Obsessive-compulsive personality disorder: a review of current empirical findings. [online] December, 6(1):1-21 [viewed 06 June 2014] Available from: doi:10.1002/pmh.144
  2. SHEDLER J.. Refining Personality Disorder Diagnosis: Integrating Science and Practice. American Journal of Psychiatry [online] 2004 August, 161(8):1350-1365 [viewed 06 June 2014] Available from: doi:10.1176/appi.ajp.161.8.1350
  3. HERTLER STEVEN CHARLES. A Review and Critique of Obsessive-Compulsive Personality Disorder Etiologies: Reckoning With Heritability Estimates. Eur. J. Psychol. [online] 2014 February, 10(1):168-184 [viewed 07 June 2014] Available from: doi:10.5964/ejop.v10i1.679
  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington, DC: American Psychiatric Association; 2000. [viewed 07 June 2014] Available from: http://justines2010blog.files.wordpress.com/2011/03/dsm-iv.pdf

Differential Diagnoses

Fact Explanation
Adjustment disorder [1] Various emotional or behavioural symptoms develop in response to a certain identifiable stressor (a stimulus that disturbs the normal physiologic or psychological equilibrium of the individual). On exposure to the stressor marked distress occurs. [3] Stressors may be a single event or multiple. Adjustment disorders are coded to the subtype that best characterizes the predominant symptoms such as depressed mood, anxiety, mixed anxiety and depressed mood, disturbance of conduct , mixed disturbance of emotion and conduct and other non-specific symptoms. [4]
Obsessive–compulsive disorder (OCD) Characterized by obsessions (unwanted, recurring and stressing thoughts, ideas or images) and compulsions (repetitive behaviours carried out in order to decrease anxiety and/or tension caused by obsessions). An overlap between OCPD and the Axis I OCD has been an ongoing debate for long. [2]
Narcissistic Personality Disorder These patients may also commit to attain perfectionism and believe that others are incapable of doing things as well as them. But s/he is more likely to believe that they have achieved perfection, whereas those with OCPD are usually self-critical. [4]
Schizoid Personality Disorder Both SPD and OCPD have a characteristic trait of apparent formality and social detachment. But in OCPD this trait arises due to discomfort with emotions and excessive devotion to work, whereas in SPD there is a fundamental lack of capacity for intimacy. [4]
Axis I psychiatric disorder Depression. [1]
Central nervous system disorder Early dementia. [1]
Medical disorder Hyperthyroidism. [1]
Substance abuse or dependence Alcohol dependent patients were most frequently found with the personality disorders: obsessive–compulsive, borderline, narcissistic and paranoid personality disorder). OCPD traits were found to be second prevalent in cocaine-addicted patients. [1]
References
  1. WARD RK. Assessment and management of personality disorders. Am Fam Physician [online] 2004 Oct 15, 70(8):1505-12 [viewed 06 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15526737
  2. DE REUS ROB J.M., EMMELKAMP PAUL M.G.. Obsessive-compulsive personality disorder: a review of current empirical findings. [online] December, 6(1):1-21 [viewed 06 June 2014] Available from: doi:10.1002/pmh.144
  3. GUR S, HERMESH H, LAUFER N, GOGOL M, GROSS-ISSEROFF R. Adjustment disorder: a review of diagnostic pitfalls. Isr Med Assoc J [online] 2005 Nov, 7(11):726-31 [viewed 06 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16308997
  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington, DC: American Psychiatric Association; 2000. [viewed 07 June 2014] Available from: http://justines2010blog.files.wordpress.com/2011/03/dsm-iv.pdf

Investigations - for Diagnosis

Fact Explanation
Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) and the associated SCID-II Personality Questionnaire (SCID-II-PQ) On interviewing the patient and assessing the patient from the screening questionnaire [2] a diagnosis of OCPD is made based on the eight diagnostic criteria of OCPD (DSM-IV OCPD): rigidity, miserliness, hoarding, preoccupation with details, perfectionism, reluctance to delegate tasks, inflexibility regarding morality, and excessive devotion to work. [1]
Laboratory studies and central nervous system imaging Based on the medical, psychiatric, and social history; mental status examination; and physical examination, diagnostic possibilities can be narrowed down. It is crucial to identify any new-onset condition that has precipitated the personality change. Hence it is important to exclude medical disorders (e.g., hyperthyroidism),substance abuse disorders (e.g., alcohol dependence) and neurologic disorders (e.g., early dementia). [2]
References
  1. ANGSTMAN KB, RASMUSSEN NH. Personality disorders: review and clinical application in daily practice. Am Fam Physician [online] 2011 Dec 1, 84(11):1253-60 [viewed 06 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22150659
  2. WARD RK. Assessment and management of personality disorders. Am Fam Physician [online] 2004 Oct 15, 70(8):1505-12 [viewed 06 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15526737

Management - General Measures

Fact Explanation
Assignments Ask patients to monitor symptoms and read on their condition. This would increase their participation and give them a sense of control. [1]
References
  1. WARD RK. Assessment and management of personality disorders. Am Fam Physician [online] 2004 Oct 15, 70(8):1505-12 [viewed 06 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15526737

Management - Specific Treatments

Fact Explanation
Pharmacotherapy Selective serotonin reuptake inhibitors (SSRIs): citalopram (20–60 mg/day) (Significant reduction in OCPD diagnoses after 24 weeks of treatment has been found with a decrease in OCPD traits as well. [1]
Psychotherapy Cognitive behavioral therapy (CBT) Metacognitive Interpersonal Therapy (MIT) [1]
References
  1. DE REUS ROB J.M., EMMELKAMP PAUL M.G.. Obsessive-compulsive personality disorder: a review of current empirical findings. [online] December, 6(1):1-21 [viewed 06 June 2014] Available from: doi:10.1002/pmh.144