Obsessive Compulsive Personality Disorder

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OBSESSIVE-COMPULSIVE
PERSONALITY DISORDER
Edited by

Jon E. Grant, M.D., M.P.H., J.D.

Anthony Pinto, Ph.D.
Samuel R. Chamberlain, M.B.B.Chir., Ph.D., M.R.C.Psych.
 Note: The authors have worked to ensure that all information in this book is
accurate at the time of publication and consistent with general psychiatric and
medical standards, and that information concerning drug dosages, schedules,
and routes of administration is accurate at the time of publication and consis­
tent with standards set by the U.S. Food and Drug Administration and the gen­
eral medical community. As medical research and practice continue to advance,
however, therapeutic standards may change. Moreover, specific situations may
require a specific therapeutic response not included in this book. For these rea­
sons and because human and mechanical errors sometimes occur, we recom­
mend that readers follow the advice of physicians directly involved in their care
or the care of a member of their family.
All names used in case vignettes are pseudonyms, and some details have
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Library of Congress Cataloging-in-Publication Data
Names: Grant, Jon E., editor. | Pinto, Anthony, editor. | Chamberlain, Samuel, editor. |
American Psychiatric Association Publishing, issuing body.
Title: Obsessive-compulsive personality disorder / edited by Jon E. Grant, Anthony
Pinto, Samuel R. Chamberlain.
Description: Washington, D.C. : American Psychiatric Association Publishing, [2020] |
Includes bibliographical references and index. |
Identifiers: LCCN 2019034531 (print) | LCCN 2019034532 (ebook) | ISBN 9781615372249
(paperback) | ISBN 9781615372805 (ebook)
Subjects: MESH: Obsessive-Compulsive Disorder—therapy | Obsessive-Compulsive
Disorder—diagnosis | Compulsive Personality Disorder—therapy | Compulsive
Personality Disorder—diagnosis
Classification: LCC RC533 (print) | LCC RC533 (ebook) | NLM WM 176 | DDC 616.85/
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 Contents
Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

1 History and Epidemiology of OCPD . . . . . . . . . 1

Julius Burkauskas, Ph.D.
Naomi A. Fineberg, M.B.B.S., M.A., M.R.C.Psych.

2 Diagnosis and Clinical Features of OCPD. . . . 27

Y.C. Janardhan Reddy, M.D.

3 OCPD and Its Relationship to

Obsessive-Compulsive and
Hoarding Disorders . . . . . . . . . . . . . . . . . . . 49
Michael G. Wheaton, Ph.D.
Anthony Pinto, Ph.D.

4 OCPD and Its Relationship to

Eating Disorders . . . . . . . . . . . . . . . . . . . . . 71
Kaitlyn Wright, B.A.
Scott J. Crow, M.D.
 5 OCPD and Its Relationship to Impulsivity and
Impulse-Control Disorders. . . . . . . . . . . . . . 85
Jon E. Grant, M.D., M.P.H., J.D.
Samuel R. Chamberlain, M.B./B.Chir., Ph.D.,
M.R.C.Psych.

6 OCPD and Aggression. . . . . . . . . . . . . . . . . 99

Emil F. Coccaro, M.D.

7 Gender and Cultural Aspects of OCPD . . . . 109

Leonardo F. Fontenelle, M.D., Ph.D.
Julliana N. Quintas, M.D.
Lucy Albertella, Ph.D.

8 Psychobiology of OCPD. . . . . . . . . . . . . . . 127

Dan J. Stein, M.D.
Christine Lochner, M.D.

9 Psychotherapy for OCPD . . . . . . . . . . . . . . 143

Anthony Pinto, Ph.D.

10 Pharmacological Treatment of OCPD . . . . . 179

D. Ashkawn Ehsan, M.D.
Jon E. Grant, M.D., M.P.H., J.D.

11 Impact of Personality Disorders on

Parenting . . . . . . . . . . . . . . . . . . . . . . . . 217
Bekir B. Artukoglu, M.D.
Angeli Landeros-Weisenberger, M.D.
Michael H. Bloch, M.D., M.S.
12 Positive Aspects of OCPD . . . . . . . . . . . . . 233
Samuel R. Chamberlain, M.B./B.Chir., Ph.D.,
M.R.C.Psych.
Jon E. Grant, M.D., M.P.H., J.D.

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
CONTRIBUTORS
Lucy Albertella, Ph.D.
Research Fellow, Brain and Mental Health Laboratory, Monash Insti­
tute of Cognitive and Clinical Neurosciences and School of Psycholog­
ical Sciences, Monash University, Clayton, Victoria, Australia

Bekir B. Artukoglu, M.D.

Postdoctoral fellow, Yale Child Study Center, New Haven, Connecticut

Michael H. Bloch, M.D., M.S.

Associate Professor, Yale Child Study Center, New Haven, Connecticut

Julius Burkauskas, Ph.D.

Clinical Psychologist, Laboratory of Behavioral Medicine, Neuroscience
Institute, Lithuanian University of Health Sciences, Palanga, Lithuania

Samuel R. Chamberlain, M.B./B.Chir., Ph.D., M.R.C.Psych.

Psychiatrist and Clinical Fellow, Department of Psychiatry, University
of Cambridge; Cambridge and Peterborough NHS Foundation Trust,
Cambridge, UK

Emil F. Coccaro, M.D.

Clinical Neuroscience Research Unit, Department of Psychiatry and Be­
havioral Neuroscience, Pritzker School of Medicine, University of Chi­
cago, Chicago, Illinois

Scott J. Crow, M.D.

Professor of Psychiatry, University of Minnesota, Minneapolis, Minnesota

D. Ashkawn Ehsan, M.D.

Assistant Professor, Department of Psychiatry and Behavioral Neuro­
science, University of Chicago, Chicago, Illinois

ix
x Obsessive-Compulsive Personality Disorder

Naomi A. Fineberg, M.B.B.S., M.A., M.R.C.Psych.

Professor of Psychiatry, University of Hertfordshire, Hatfield, UK; Con­
sultant Psychiatrist, Highly Specialized Obsessive Compulsive Disor­
der and Body Dysmorphic Disorder Service, Hertfordshire Partnership
University NHS Foundation Trust, Welwyn Garden City, UK

Leonardo F. Fontenelle, M.D., Ph.D.

Professor, Monash Institute of Cognitive and Clinical Neurosciences,
Monash University, Clayton, Victoria, Australia

Jon E. Grant, M.D., M.P.H., J.D.

Professor, Department of Psychiatry, University of Chicago, Chicago,
Illinois

Y.C. Janardhan Reddy, M.D.

Professor of Psychiatry and Head, Obsessive-Compulsive Disorder
(OCD) Clinic, Department of Psychiatry, National Institute of Mental
Health and Neurosciences (NIMHANS), Bangalore, India

Angeli Landeros-Weisenberger, M.D.

Associate Research Scientist, Yale Child Study Center, New Haven,
Connecticut

Christine Lochner, M.D.

Department of Psychiatry, Stellenbosch University, Cape Town, South
Africa

Anthony Pinto, Ph.D.

Associate Professor of Psychiatry, Donald and Barbara Zucker School
of Medicine at Hofstra/Northwell, The Zucker Hillside Hospital; Di­
rector, Northwell Health OCD Center, Glen Oaks, New York

Julliana N. Quintas, M.D.

Psychiatrist and mastership candidate, Obsessive, Compulsive, and
Anxiety Spectrum Research Program, Institute of Psychiatry, Federal
University of Rio de Janeiro, Rio de Janeiro, Brazil

Dan J. Stein, M.D.

Department of Psychiatry and Mental Health, University of Cape
Town, Cape Town, South Africa

Michael G. Wheaton, Ph.D.

Assistant Professor, Department of Psychology, Barnard College, New
York
 xi

Kaitlyn Wright, B.A.

Graduate student, School of Social Work, University of Michigan, Ann
Arbor, Michigan

DISCLOSURE OF INTERESTS
The following contributors to this book have indicated a financial inter­
est in or other affiliation with a commercial supporter, a manufacturer
of a commercial product, a provider of a commercial service, a nongov­
ernmental organization, and/or a government agency, as listed below:

Michael H. Bloch, M.D., M.S. is on the Scientific Advisory Board of

Therapix Biosciences and receives research support from Biohaven
Pharmaceuticals, Neurocrine Biosciences, Janssen Pharmaceuticals,
and Therapix Biosciences. He also receives research support from the
National Institutes of Health, Tourette Association of America, Brain
and Behavior Research Foundation (formerly National Alliance for Re­
search on Schizophrenia and Depression [NARSAD]), and the Patter­
son Foundation.

Samuel R. Chamberlain, M.B./B.Chir., Ph.D., M.R.C.Psych. consults for

Cambridge Cognition, Shire, P1Vital, Ieso Digital Health, and Promentis
Pharmaceuticals. He receives a stipend for his role as associate editor at
Neuroscience and Biobehavioral Reviews and at Comprehensive Psychiatry.

Jon E. Grant, M.D., M.P.H., J.D. has received research grants from Na­
tional Institute of Mental Health, National Center for Responsible
Gaming, and Forest and Roche Pharmaceuticals. He receives yearly
compensation from Springer Publishing for acting as editor-in-chief of
the Journal of Gambling Studies and has received royalties from Oxford
University Press, American Psychiatric Association Publishing, Norton
Press, and McGraw-Hill.

The following contributors have indicated that they have no financial

interests or other affiliations that represent or could appear to represent
a competing interest with the contributions to this book: Bekir B. Artu­
koglu, M.D.; Angeli Laneros-Weisenberger, M.D.
INTRODUCTION
Beginning in 2001, the National Epidemiologic Survey on Alcohol and
Related Conditions (NESARC) was the first national survey in the
United States to assess rates of the DSM-IV (and later DSM-5) personal­
ity disorders (American Psychiatric Association 1994, 2013). The
NESARC data showed that obsessive-compulsive personality disorder
(OCPD) not only was the most common personality disorder, with a
prevalence of 7.8%, but also was approximately two times more com­
mon than any other personality disorder (Grant et al. 2004). Notably,
however, a PubMed search for OCPD yields only about 300 publica­
tions, whereas a search for borderline personality disorder yields al­
most 8,000. Given the high prevalence of OCPD and the relative lack of
research in this area, we felt that a textbook devoted exclusively to
OCPD was needed to inform people of what is currently known about
OCPD and to highlight important areas that need more investigation.
The study of OCPD is important from both clinical and research per­
spectives. OCPD not only is prevalent but also is associated with signif­
icant morbidity (lower quality of life and problems in overall
psychosocial functioning) (Mancebo et al. 2005; Pinto et al. 2014) and
increased health costs (Diedrich and Voderholzer 2015; Fineberg et al.
2014). Recent years have seen a rapid increase in understanding of the
phenomenology, neurobiology, and psychology of this disorder, as well
as of the domains of perfectionism, cognitive rigidity, and procrastina­
tion (all key domains underlying OCPD). Unfortunately, although many
clinicians encounter patients with OCPD (elevated rates are observed in
patients with a variety of mental health disorders), clinicians often do not
diagnose OCPD, may incorrectly diagnose it as obsessive-compulsive
disorder (OCD) or attention-deficit/hyperactivity disorder, and are fre­
quently unaware of the treatment options for the disorder.
Many clinicians are also unaware of the personal consequences of
OCPD. This lack of awareness in turn leads physicians and psycholo­
gists to ignore OCPD in both mental health and primary care settings.
Toward that end, Chapter 1, “History and Epidemiology of OCPD,”
presents the evolution of OCPD in DSM and its place in the World
Health Organization’s International Classification of Diseases (ICD) no­

xiii
xiv Obsessive-Compulsive Personality Disorder

menclature. A primary aim of this book is to educate treatment provid­

ers about OCPD. In furtherance of this aim, the text addresses the
diagnosis and evaluation of individuals with OCPD. Many people can
readily spot personality characteristics of themselves within the OCPD
criteria; understanding when these characteristics rise to the level of a
disorder is important. Chapter 2, “Diagnosis and Clinical Features of
OCPD,” addresses this issue and highlights phenomenologically how
the disorder is different in degree, but not in kind, from the personality
characteristics that many of us exhibit.
Clinicians’ lack of awareness of OCPD often stems from the diagnos­
tic confusion between OCPD and other mental health problems. Four
chapters in this book focus on common mental health disorders that are
often difficult to disentangle from OCPD. First, Chapter 3 takes on com­
parisons between OCPD and the two most common misdiagnoses,
OCD and hoarding disorder. The chapter provides a thorough ap­
proach to differentiating these disorders, because they may require
unique treatment interventions. OCPD has also been linked with eating
disorders (discussed in Chapter 4), impulse-control disorders (Chapter
5), and aggression (Chapter 6), either as a co-occurring personality disor­
der to these other problems; as the primary problem with dysfunctional
eating, impulsivity, and aggression as symptoms of the personality pa­
thology; or as a compensatory reaction to these other issues.
A growing area of interest in mental health is how the presentation
of psychiatric disorders may or may not be influenced by gender and/
or cultural factors. This topic, discussed in Chapter 7, not only is of re­
search interest but also may affect how treatment providers diagnose
and assist people with OCPD based on culture and gender.
Treatment providers often assume that “one size fits all” in terms of
treatment. This may not be the case for OCPD, which is a complex per­
sonality pathology with a potentially heterogeneous etiology. Much of
the treatment literature on OCPD has been based on different theories
regarding OCPD’s similarities to other disorders (e.g., OCD) or on the
primary domain that providers feel drives the personality pathology
(e.g., perfectionism, cognitive rigidity). As a result, treatment providers
caring for people with OCPD have multiple treatment options at their
disposal. Chapter 9, on psychotherapeutic treatment approaches, dis­
tills the various cognitive-behavioral therapies for OCPD, the rationale
behind their use, their effectiveness in helping people with OCPD, and
the limitations of the current psychological interventions. Similarly,
Chapter 10, on pharmacological treatment approaches, reviews the cur­
rent state of drug treatment for OCPD and the rationale for what has
been tried.
To further enhance treatment options, both treatment providers and
researchers look to possible developmental, psychological, and behav­