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Obsessive Compulsive PD. Mnemonic - Perfection Preoccupied with details, rules, plans Emotionally restricted Reluctant to delegate tasks Frugal Excessively.

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Presentation on theme: "Obsessive Compulsive PD. Mnemonic - Perfection Preoccupied with details, rules, plans Emotionally restricted Reluctant to delegate tasks Frugal Excessively."— Presentation transcript:

1 Obsessive Compulsive PD

2 Mnemonic - Perfection Preoccupied with details, rules, plans Emotionally restricted Reluctant to delegate tasks Frugal Excessively devoted to work Controls others Task completion hampered by perfectionism Inflexible Overconscientious about morals, ethics Not able to discard belongings

3 History Freud (1908) Anal Stage of Development Anal Triad Parsimoniousness, Order, Obstinancy Jones (1919) Described a sense of time pressure, frugality with money, preoccupation with cleanliness

4 History Schneider (1923) Anankastic Kempt, pedantic, proper, constrained and insecure Reich (1933) Living machines, indecisive, and plagued with doubt

5 History Lazare (1966) Freud’s view plus… emotional constriction, perseverance, rejection of others, rigidity, strong SE

6 Differential Diagnosis

7 OCD versus OCPD Behaviors Intrusive Thoughts Uncomfortable Specific - cleaning Negative Reinforcement Anxious Drugs work AVD, DEP Traits No Intrusive Thoughts Comfortable General - perfection Positive Reinforcement Not Anxious Drugs don’t work “None”

8 DSM History DSM-I: Compulsive personality DSM-II: Obsessive-compulsive personality DSM-III: Compulsive personality disorder DSM-III-R: Obsessive-compulsive personality disorder DSM-IV: Obsessive-compulsive personality disorder sounds a little obsessive to me

9 DSM Definition Control, mental and interpersonal Orderliness Perfectionism Not.. flexibile, open, or efficiency. Mnemonic: COP’s FOE 1%, more men

10 ICD Anankastic Personality ICD removes DSM parsimony, and adds the features of indecisiveness and the need to plan activities in alterable detail. 3/8 Criteria

11 Media Examples Dragnet (Dan Aykroyd) Star Trek (Leonard Nimoy)

12 Media Example As Good As it Gets OCD and OCPD

13 Reasons for Therapy a) productivity or cognitive skills are slipping b) inability to be productive c) severe anxiety, immobilization, excessive fatigue d) other referred

14 Interview Considerations Difficult to interview (loads of details – boring to listen to) Tend to control interview Lots of “news” little “weather” Detached, devoid of emotion

15 Themes Misses the forest for the trees Humourless, lacking spontaneity Goal is to accomplish work Fixated on details Rigid and inflexible Hoards money Few leisure activities, can’t relax

16 Cause control a family of origin issue afraid of making a mistakes punished for making mistakes few rewards for competent behavior

17 Cause Stone - OCPD live in the future obsessed with dangers and possible mistakes

18 Psychoanalytic – Anal Fixation too high expectations (too harsh) no expectations…. (too lenient) unhealthy development anal-retentive (harsh standards) (stingy, overly regulated, excessive need for productivity)

19 Psychic Conflict Antisocial Compulsive

20 Ego Defenses Why do we employ them? Ward off anxiety Bend Reality Project the Ego

21 Ego Defenses Isolation of affect – strips an idea from the feeling Idea is conscious, but feelings are kept unconscious

22 Ego Defenses Undoing – involves an action, that symbolically repents or make amends for the conflicts, stresses or unacceptable wishes

23 Ego Defenses Reaction Formation – an impulse is transformed into it’s opposite Calm exterior hides angry interior

24 Ego Defenses Displacement – redirects an unacceptable impulse toward something less threatening e.g., anger toward parents (as child) is directed at subordinates (as adult)

25 Kernberg

26 Trait Perspective

27 Compulsive Styles No sharp boundaries exist between normality and pathology. Conscientious (Oldham and Morris) Conforming (Millon) C- C+ Obsessive Compulsive

28 NEOAC SZD AVD DEP HST NAR ANTLL COMH SZT BDLHLL PAR See commentary below slide to understand letters and numbers


30 Theory - Millon a conflicted personality style conflict is between obedience and defiance Desire to assert themselves and inwardly defy the regulations imposed upon them

31 Millon’s Biosocial Theory ActivePassive ambivalent Negativistic NEG Compulsive COM Negativistic = oppositional, resisting, stubborn Compulsive = controlling, orderly, perfectionistic

32 Millon’s Evolutionary Theory

33 Theory - Millon consciously behave like the dependent personality disorder unconsciously they feel like the antisocial personality disorder incorporate the values of others and submerge their own individuality.

34 Millon - Subtypes Conscientious (pure) Bureaucratic (with narcissism) Puritanical (with paranoia) Parsimonious (with schizoid) Bedeviled (with negativistic)

35 Assessing OCPD


37 MMPI Scale 7 Spike tends to assess 1) general discontent with the world 2) obsessional concerns 3) anxiety 4) indecision, poor concentration, self- devaluation

38 Therapy Crisis brings them in (not traits) Seek an expert opinion on issue Tend to control interview “Drone on” Intellectualized material Want to be perfect patient

39 Therapy Concerns Transference Experience therapist as demanding Sub-level irritability Countertransference Boredom Badge client about emotional restriction

40 Pharmacotherapy Does not deal with traits For “symptoms” Very attuned to side effects Wants lots of information May want to read the CPS Medications that impair productivity will be stopped immediately

41 Cognitive Therapy

42 Automatic Thoughts Events Schema Emotions Behavior Others’ Behavior Distortions “A critical comment” “That comment is unjustified” Anxiety, Anger No emotion Work Work Work - perfectionism Passive-aggression, procrastination Rationalized, detailed comments Respect Passive Bored I will maintain standards, do not be late Be impeccable with your word Details and rules are important Stick with a workable plan Shoulds

43 Negativistic

44 Negative reactions when asked Overestimates the demands of task Tardiness Authority figures are ridiculed Criticism is resented Obstructs the efforts of others Procrastinates Evaluation of performance is unrealistically positive Recall for Obligations is faulty

45 History Kraepelin (1913) and Bleuler (1924) Negative attitudes, easily frustrated, irritated US Military Psychiatrists (WW II) “passive aggression” “immature reaction to wartime stress” Reich (1945) – complained constantly Spitzer (1977) – consider this a state

46 History DSM-II – passive aggressive DSM-III – passive aggressive (cluster C) DSM-IV – excluded Why? – considered a state Too much overlap with other PDs Unofficial – negativistic

47 DSM-III-R Criteria Procrastinates Sulky, irritable, argumentative Deliberately slow Protests – unreasonable demands Forget obligations Believes is doing a much better job Resents suggestions Obstructs efforts of others Unreasonably scorns authority Passive Aggressive 5/9

48 DSM-IV-TR Passively resists tasks “Misunderstood” “unappreciated” Sullen and argumentative Criticizes and scorns authority Envy and resentment toward others Persistent complaints Alternates: defiance and contrition Negativistic - 4/7

49 Media Examples Columbo (TV series) The War of the Roses

50 Psychosocial Causes “Great Expectations” from parents Expect a lot but don’t adequately support, differential treatment for other children e.g., do all the laundry, work like an adult (when a child), having to support parent as child Triggers hostility – resentment of authority

51 Epidemiology and course Very common defense 1%, no gender differences Do not lead happy existences Frequent anxiety, mood, and somatic difficulties Numerous and serious difficulties in long- term, intimate relationships Employment problems

52 Interview Considerations Difficult to interview May become resentful and evasive Hard for them to be responsible Addressing anger brings more of it…. Problems due to bad luck and others They want support and empathy

53 Negativistic Themes Procrastination Indecisiveness Constant victimization “Forgets” Obstructive Continual conflict with authority Says yes, but acts no

54 Ego Defenses Passive aggressive behavior Hypochondriasis Denial (who me?) Rationalization (excuses)

55 Co-morbidity Negativistic MOOD Anxiety Substance Abuse

56 Evolutionary Theory - Millon

57 Trait Perspective



60 Other considerations If needs are expressed, and are not met satisfactorily – results in hostility Tend to idealize – constantly disillusioned Tend to grumble excessively “injustices” are buried but not forgotten Love the “pity party” (they get the sympathy they did not get as a child)

61 Psychodynamic Aspects Blend of: Dependency Entitlement Help-rejecting complainers Solicit help, but actively reject it

62 Therapy insight therapy, high rate of failure behavior does not distress them They seek support Listen and empathize, gain rapport Therapist will ultimately be criticized because they “aren’t doing anything”

63 Therapy Concerns Themes provoking anger emerge Pointing this out results in anger Self-esteem is very poor Can’t handle feedback Result: they don’t grow, remain psychologically stunted

64 Therapy Concerns Transference Unaware of behavior Authority treated with envy/contempt They hone in on your weakness Countertransference Can be quite strong Start to dislike these clients Hard to be empathetic

65 Automatic Thoughts Events Schema Emotions Behavior Others’ Behavior Distortions “A critical comment” “I have a right to be pissed off” “FY” Anger, Rage Provocative Actions – motivational issues Counter attack Passive-aggression, procrastination, “FO” It is intolerable is someone criticizes you Anger, Distance I am inferior Filtering I am being mistreated You will meet all my needs Cognitive Therapy

66 Group Therapy “Confrontation on a group level is a powerful motivator for change” Why? – hard to rationalize that a group of people are wrong.

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