Dr Robert London

Helping OCPD Patients Break Free

Clinical Psychiatry News - Volume 35, Issue 7, Page 19 (July 2007)

Making a breakthrough with a patient with obsessive-compulsive personality disorder can be daunting.

But once you begin to evaluate the patient's anxiety or depressive symptoms and the patient begins to describe in exquisite detail the events of his life—both longitudinally and day to day—the clarity of OCPD emerges and in many cases, directs the therapeutic intervention.

Early in treatment, it becomes apparent that the patient has an endless attention to detail, critical analysis of his own behavior and that of others, plus a need to be in almost absolute control of his environment.

Rigid thinking is pervasive. Add to those patterns the patient's endless “should have, would have, could have” analyses or, as respected early 20th century psychiatrist Karen Horney called it, the “tyranny of the shoulds.” Albert Ellis, Ph.D., considered these concepts as well in attempting to discuss and better understand obsessive-compulsive personalities.

Many theories aim to explain this personality disorder, ranging from, of course, the psychoanalytic ideas of Dr. Sigmund Freud and Dr. Wilhelm Reich to the interpersonal analytic theories of Dr. Harry Stack Sullivan, in addition to those of the behaviorists. The behaviorists focused on poor learning that reinforces behavioral characteristics of OCPD.

The main point in treatment is this: How do we get these uptight people to be more “down loose” when it comes to punishing themselves and those around them, since this is what leads to the anxiety, frustration, and depressive symptoms that bring them in for help?

I once treated a dentist who was angry, anxious, and depressed—all at once—because he could not get his Little League baseball players to arrive on time for practices and sometimes games. The dentist, a perfectionist, also had a tough time getting the young players picked up at a specific time. After the dentist exploded in anger at his entire family over these matters, his wife made it clear that she had had enough of his unhappy, stress-inducing behavior and that it was time for professional help. The patient was referred to me.

The presenting set of problems did revolve around anxiety and stress, including at times a depressed mood that the patient described as his reason for seeking help at the urging of his wife. But what really triggered the appointment and visit? The final straw was his blowup about the young baseball players' punctuality—or lack thereof.

During the first evaluation visit, the patient kept referring to me as a psychologist. When I made it clear that I was a psychiatrist and that there are significant differences between the two professions, he managed to find ways to hold on to his notion in a manner that made him right in his mind, even though he did know the difference.

In discussing the time frame that I had in mind for our work together, I suggested 3-month blocks. If he felt better or wanted to leave before the 3 months were over, it would be no problem. His immediate response was contrarian and true to form: He wanted to work in 2-month blocks. I agreed immediately (to make a point). He was surprised by my lack of rigidity.

Over the course of eight visits, the dentist and I discussed other issues that frustrated him, such as his dental lab technician's inefficiency and the inability of the local school system to get things right. Essentially, the dentist's belief system about so many issues proved unshakable, so I decided to focus on the learning aspect of my learning, philosophizing, and action (LPA) technique.

Again and again, I encouraged him to focus on the 15 players on the baseball team. I got him to think about the broader context in which these 15 players lived. We figured out that when the 15 players' families were taken into account, their trips to the fields probably involved their family members, which might have added up to 100 or more people. Fifteen residences and maybe 30 automobiles were part of the scenario.

Add at least 25 jobs of parents and a few divorces (which means some of the kids might have had more than one home), and so went the analysis. I asked him to add those variables into his coaching framework. He did a great job at figuring it all out.

When I jokingly proposed that I take over the team, the dentist made it very clear that that would be impossible. I did not live in his town or know the people, so how could I possibly understand the parameters of coaching the team, as the variables “he” had figured out needed time and flexibility? At the moment he said that, the patient noted that he might be getting “it.”

Now I was ready to shift back to his insistence on referring to me as a psychologist rather than a psychiatrist. His thinking opened up a bit on this one. He knew my educational background, but his personality dynamics made him very slow in admitting that these definitions did matter. I took heart in knowing that he had made progress and was thinking about his dogmatism. His family dynamics also improved, which was another bonus.

Clearly, the patient and I had established a therapeutic alliance. The aim was to help him understand that there are multiple variables in almost any given situation, as well as many ways to solve problems on the continuum from the concrete to the abstract.

He remained organized and continued to like things to be more perfect than less, but he became more accepting of other situations and better able to recognize different methods of problem solving, specifically and conceptually. Overall, life got better.

Let me know some of your thoughts on treating obsessive personality disorders, and I will try to pass them along to my readers.

PII: S0270-6644(07)70426-5


© 2007 Elsevier Inc. All rights reserved.