Helping OCPD Patients Break Free

By London, Robert T. | Clinical Psychiatry News, July 2007 | Go to article overview

Helping OCPD Patients Break Free


London, Robert T., Clinical Psychiatry News


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. …

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