Obsessive-Compulsive (Anankastic) Personality Disorder: A Poorly Researched Landscape with Significant Clinical Relevance

By Reddy, M.; Starlin, M. et al. | Indian Journal of Psychological Medicine, January-February 2016 | Go to article overview

Obsessive-Compulsive (Anankastic) Personality Disorder: A Poorly Researched Landscape with Significant Clinical Relevance


Reddy, M., Starlin, M., Reddy, Swetha, Indian Journal of Psychological Medicine


Byline: M. Reddy, M. Starlin, Swetha. Reddy

Introduction

The constellation of features similar to the obsessive-compulsive (anankastic) personality disorder (OCPD) was first described by Pierre Janet in 1903 as the "psychasthenic state." This was later endorsed by Freud in his 1908 work entitled, "Character and Anal Eroticism." [sup][1] In 1952, the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM) made it a diagnosable psychiatric condition. However, unlike other personality disorders, it has been included in all the revisions of the DSM including the DSM-V. Prevalence studies have identified OCPD as a common disorder with a point prevalence rate of 8.7% in an outpatient sample and with a prevalence rate of 23.3% in a psychiatric inpatient sample, according to DSM-IV and DSM-IIIR criteria, respectively. [sup][2]

Co-Occurring Conditions

It is associated with multiple co-morbid conditions. According to an excellent recent review by Diedrich and Voderholzer [sup][2] the most frequent ones are anxiety disorders with a prevalence of 23-24% and affective disorders with a prevalence of 24%. Among the anxiety disorders, Obsessive-compulsive disorder (OCD) is one of the best researched co-morbid disorders, which has co-occurrence rates of 23-45%. Though Pierre Janet initially posited "psychasthenic state," as a necessary condition for the development of obsessive-compulsive symptoms, later researchers like Berg et al . [sup][3] contended that the direction of the relationship is obscure, and it might be that OCPD develops as a coping strategy after the onset of OCD. Whichever may be the direction of the relationship, many agree that majority of people suffering from OCD have at least one personality disorder [sup][4],[5] and that there are high rates of OCPD. Some have even suggested that OCD with OCPD has to be considered as a separate sub-type. [sup][6] We can even consider that certain patients with "poor insight OCD" subtype, instead of being delusional, might fit into the category of OCD with OCPD traits (i.e., poor insight interpreted as ego-syntonicity) and might respond to selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy (CBT)-exposure and response prevention with/without antipsychotic augmentation, as is the case with resistant OCD.

Since 1920s many researchers found the presence of OCPD traits in significant number of people suffering from the depressive disorder. [sup][7],[8] In routine clinical practice, many practitioners observe an occurrence of premorbid OCPD traits such as perfectionism, high moral standards, in the people suffering from the depressive disorder. Co-occurrence of OCPD in depressive disorder has been associated with accelerated relapse of depression. [sup][9]

The DSM-V diagnosis of disruptive mood dysregulation disorder (DMDD), which is subsumed under the depressive disorders, may also be theoretically related to OCPD due to the fact that many depressive patients have OCPD traits and that the OCPD traits of perfectionism and rigidity might predispose the individual to irritability and impulsive aggression, more so in the adolescents. In a study [sup][10] which examined co-occurrence of impulsive aggression and several Axis I and II conditions ( n = 118), 24% of clinic-referred patients with impulsive aggression had OCPD compared to 52% who had antisocial personality disorders; among self-referred patients with impulsive aggression, 52% had OCPD. Further investigation into the co-occurrence of behavioral disinhibition and OCPD is warranted.

OCPD trait of perfectionism has been shown to be associated with the core psychopathology of Eating disorders and somatoform disorders such as body dysmorphic disorder (BDD), hypochondriasis and chronic fatigue syndrome. OCPD and Perfectionism are proposed by some, as predisposing factors for eating disorders. [sup][11]

Fineberg et al . …

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