Pinto Talk 10/24/13 PintoTalk102413
Announcer: Blog Talk Radio
Dr. Marcia Kimeldorf: Hello, everyone. Good afternoon, and welcome to our blog talk radio show – Novel treatments and developments for Obsessive-Compulsive Disorder. I'm Dr. Marcia Kimeldorf, and I am a clinical psychologist, and a project manager for OCD treatment and research at the New York State Psychiatric Institute and Columbia University Medical Center in Washington Heights, New York City. We are nearing the end of our series, which kicked off on October 1st with an overview of OCD by two of our OCD experts, Dr. Helen Blair-Simpson, adult psychiatrist, and director of the center for OCD and related disorders, and Dr. Moira Rynn, child psychiatrist, and director of the division of child and adolescent psychiatry here at Columbia. Throughout the month we've had some great talks, including ones about front line and novel treatments for OCD, nuts and bolts of therapy for OCD, how to parent a child with OCD, information about hoarding disorder, and how to support a loved one with OCD.
Today we are joined by Dr. Anthony Pinto, Assistant Professor of Clinical Psychology and Psychiatry, and Research Scientist here at Columbia. Today's show will have three parts – First, Dr. Pinto will be talking about Obsessive-Compulsive PERSONALITY Disorder, OCPD, and how it differs from Obsessive-Compulsive Disorder, OCD. Second, he'll be joined by a patient who we will call "John", to preserve his anonymity. John has struggled with OCPD traits and behaviors and he will describe how OCPD has impacted his life. Third, we'll take some questions from our listeners. Before we begin I'd like to cover a few housekeeping tips. Anyone can join this talk by either dialing 347-996-5875 on a phone, or by going to blogtalkradio.com/columbiapsychiatrynyspi. If you have a question for Dr. Pinto, you can press 1 to speak to our host at any time, or
send us a question through Twitter, by mentioning the handle, @columbiapsych. We will address questions in the order in which they're received. However, if you do submit a question that we are unable to get to, we'll follow up with you, offline. With that, Dr. Pinto, we're real excited to have you here today.
Dr. Anthony Pinto: Thanks, Dr. Kimeldorf, I'm really pleased to participate in this blog talk, and excited to talk about Obsessive-Compulsive Personality Disorder, OCPD, and my goal here today is really to raise awareness about this condition that is impairing, yet often overlooked, and it's been the focus of relatively little research given how common it is, and so my objective today will be to talk about what does OCPD look like, how does it impact functioning, how can it be differentiated from OCD, or Obsessive-Compulsive Disorder, and to talk a little bit about some treatment approaches.
MK: OK, that sounds great.
Can you start off by telling us then what is OCPD, and what would you say are its most prominent features.
AP: OCPD is one of the most frequently diagnosed of the personality disorders. In studies that have been done in the community, we find that up to 8% of people meet the criteria for OCPD. In studies that have been done in clinic settings or mental health settings, that number is higher, upwards of 10%. OCPD is a constellation of maladaptive personality traits that lead to functional impairment or distress. Two of the core clinical features are self-limiting perfectionism, or, perfectionism that's driven by very high standards, and leads to an individual not being able to meet deadlines. The other core feature is rigidity, which often impacts interpersonal functioning,
because the individual tends to only see things their way, and it's very difficult for other people to sway them, once they've made a decision, on a particular issue. Some other symptoms that have been described in the diagnostic and statistical manual, which is the manual used by mental health providers to make diagnoses, are the following: so, OCPD includes a preoccupation with order, details, rules, so these are people that are likely to make extensive lists. They are people that will insist on having objects or their possessions in a particular order, they tend to get bogged down in details. A second symptom is an excessive devotion to work and productivity. So these are people who will choose work or pursuits over leisure activities. They tend to be inflexible
about morals and ethics, they can be critical or judgmental of others, in terms of morals or values. They tend to have an inability to discard worn out or worthless items, which can result in clutter in their homes. They have a reluctance to delegate tasks, which means that they tend to want to complete work assignments on their own and not share work with others. If they do give parts of their work to other people, they tend to micromanage the others. And lastly, they tend to be miserly with regards to spending money both on themselves and others. Some associated features of OCPD are indecision or fear of making wrong choices. They have lots of difficulty when it comes to change, so any sudden changes in their schedule or routine will upset them,
because they tend to be rule-bound, and routine-oriented. They have difficulty sharing emotions, or tend to be emotionally over-controlled. They also tend to have anger outbursts when their sense of control is threatened. And finally, another feature of OCPD is procrastination which is often tied to their perfectionism.
MK: OK, great, that's very helpful. Can you now describe for us a case of someone who HAS OCPD so we can get a better idea of what these traits and behaviors look like?
AP: Sure. I'm thinking of a case of a patient I'll call "Betty" who I'd seen some time ago, but I think her case nicely illustrates some of the symptoms I just described. Betty is a 30 year old schoolteacher without previous treatment. She describes having a book collection that she dusted daily and would not let anyone else including her husband touch, insisting that she liked the books arranged a certain way.
She insisted her husband get into bed at night before her so that she could make sure that nothing in the house had been moved after she went to bed. If they were late for an engagement, she was unable to modify her routine of getting ready. Both at work and at home, she refused to allow others to do tasks that might be helpful to her as she felt that only she could perform these tasks correctly. When leaving the house, she insisted on driving or walking a predetermined route, despite any obstacles, such as traffic, that presented themselves along the way. She was critical and outspoken about shortcuts that she thought other teachers took in their work. These patterns of behavior and attitudes in her work caused major marital conflict and conflict with other teachers.
MK: Oh wow, OK, that's very interesting. So I think one of our main goals here is to differentiate between OCD and OCPD. So now perhaps you could speak about the difference between OCD and OCPD, and the commonalities as well, between these two disorders.
AP: Thanks, yeah.
There is unfortunately a lot of confusion out there, both amongst the lay public and clinicians about OCD and OCPD and that's one of the main reasons we wanted to do this talk, as part of OCD awareness month. One unfortunate thing is there's an overlap in the names between these conditions. They sound alike so people often lump them and some assume that OCPD is a minor version of OCD, but they are in fact qualitatively different conditions, though there is a relationship between them, as I will explain. Both OCD and OCPD are impairing disorders, marked by ritualized behaviors. So, what that means is, in both conditions you will see ritualized or methodical behaviors such as list-making, organizing belonging, or checking or editing work, the difference though is that in OCD
the compulsive behaviors are done in order to prevent or reduce distress, or prevent some dreaded event, and it's connected to their obsessions, which are these intrusive thoughts, or fears. In OCPD, the individuals do not have obsessive thoughts. They don't have these intrusive, unwanted thoughts that are distressing to them. In fact, in OCPD, they feel that the way their behaviors or attitudes are correct, and they often don't understand why others don't share their world-view. They would actually want other people to see things their way. So, just to recap that, in OCD the individual is performing behaviors and having thoughts that they don't want to be having, but they feel compelled
to do so because of anxiety related to their thoughts. In OCPD, the behaviors are consistent with how they see themselves, the traits are consistent with how they see their personality. There is evidence for a relationship between these conditions. If you look at samples of patients with OCD, about a quarter to a third of them will also have OCPD. We also know that when you look at the families of patients with OCD, the relatives of people with OCD are twice as likely to have OCPD. There is also an overlap in the symptom presentations. So in OCD, you may see a patient who has rituals that involve ordering, where they feel like objects need to be at right angles
or arranged symmetrically, and this does overlap with this preoccupation with order that you often see in OCPD. And in OCD patients often talk about incompleteness or an uncomfortable internal feeling unless actions are completed a certain way, and that overlaps with perfectionism, and OCD.
MK: OK, great. That's very helpful. So tell me, now that we sort of understand a little more about how they're different, tell me, is there any treatment for OCPD, and, so what does it consist of?
AP: We know from research that people with OCPD seek treatment at high rates, both in primary care settings, and in mental health settings. Even though these individuals don't always name OCPD traits as their presenting problem. To answer your question, there are a variety of psychotherapy or talk therapy approaches that have been applied to OCPD.
But what is lacking is treatment that's backed by research evidence, and that's something we've been working on here at Columbia. What we've been doing is trying to map the core features of OCPD onto established treatments and modifying these established treatments to better address the symptoms and presentation of OCPD. We've been working on combining different approaches that involve cognitive-behavioral therapy as well as emotion regulation. The emotional regulation will deal with the emotional overcontrol I talked about earlier, and the cognitive behavioral therapy is meant to directed at the perfectionism and the rigidity that often gets in the way of these individuals. I'll talk more about this when I talk to my patient "John" in a few minutes. In a nutshell, the treatment involves
teaching interpersonal skills, both to help the individual flexibly engage in relationships and help them to develop a stronger alliance with the therapist as well as with other significant others, and the treatment directed at perfectionism, rigidity, is helping them to challenge high standards by testing new behaviors and tackling procrastination. So with that being said, I'd like to turn to John, who we're really happy has come today, because we can talk about the features and talk about the treatment but the best way to learn about this condition is through a personal account, so I'm happy to have John here. I've been working with John here at the New York State psychiatric institute at Columbia Medical Center, and he has agreed to participate in this webcast. I want to clarify that John has been dealing with
OCPD for most of his life. He does not have OCD, so he is here to demonstrate the effect of OCPD on his functioning in his life. So first of all, thanks John for being here. When did you first notice these symptoms of OCPD?
John: I guess as far back as I can remember, maybe to around when I was 6 years old, I guess I do remember just kind of being preoccupied with order, how my room organized, how I had my toys set up. I really, that's the way I liked it, I like it that way, and I would have a problem, if my brothers or other people would come into my room and get things out of my order, the way I liked them. At least at that point, it was kind of just, things that really didn't kind of get in the way of my life, but then, as I grew up, and went to school, I definitely started to notice, writing assignments, I have a really big problem with procrastination, definitely my high standards getting in the way
of me completing assignments. So procrastination definitely started to show itself, as I went through school.
AP: So John, I think what would be really helpful to our listeners is if you could describe how OCPD has impacted some of the major domains of your life. So, if you don't mind, can we talk a little bit about how OCPD has been getting in the way in terms of your school or work, I know you are a graduate student and you're also working.
John: Ah, yeah, I guess the most pervasive thing seems to be perfectionism and a kind of getting bogged down in details, on any sort of assignment that I'm doing. If I have one little minor detail that I feel like I'm missing, that gets in the way of me completing the rest of the particular writing or research assignment because I really just feel like I have to find that one thing before I can move on, so any sort of paper that I'm writing, I find myself being stuck on page 1,
so often just trying to just get that just perfect, before I can even move on to the rest of the paper. I notice that in like readings at school, everything always kind of took a lot longer for me to compete than other people, and I think it was just having been obsessed with the details about the assignment or trying to understand every particular thing that I'm dealing with. One really good example is when I go to write an email, it should be an email that I think most people would take them 5 minutes, not even that to write, but for me, I would spend upwards of half hour to an hour sometimes, writing an email, making sure that all my grammar and punctuation was perfect, making sure that it said exactly what I wanted to say, that it came off just right. I especially at school with working in groups, has always been a huge problem for me, not only because I'd never felt comfortable delegating anything to anybody else, but I also just thought that, whatever way I thought we should do the project, that's the way
that it should be done. So naturally we've had some conflicts with that. And then, yeah, just overall procrastination would just be a huge problem for me. I always, every single assignment that I got, I said, OK, this is not going to happen, I'm going to get this done in time, I'm going to spend a lot of time on it, but then it came to the very last day before the deadline, I'm scrambling and doing it all at once, and I guess my goal was that I'd try to get it great, spend a lot of time on it and do it just the way I want, but then I would end up pushing it off and end up having it be no where near what I wanted it to be.
AP: Thank you. And let's talk a little bit about romantic relationships and how OCPD gets in the way there.
John: Ah, yeah, I guess because a lot of what I do to myself, is I have a lot of extremely high standards, I would also often hold my significant other to those high standards as well, and that was just
by myself would be a bad point but then I would be very argumentative with them, pretty much anything that we could argue about, where I thought we weren't seeing eye to eye, I would really harp on that. If I noticed a flaw in them, I tended really to focus on those and really just kind of ignore anything else good about them, and I guess as far as emotionally, it kind of became very hard to express affection toward them, but at the same time even if I had maybe negative emotions towards them I was also fearful of expressing THOSE emotions as well. So a lot of just, kind of fearful things going on in there.
AP: Great. Thank you for sharing that. In terms of hobbies or interests, I know this is something else that you have talked to me about, how does OCPD get in the way there?
John: I guess even in my free time, even if I'm doing something where I'm trying to enjoy myself, I still feel like
I have a really hard time being spontaneous, I would feel like, if I were going to go enjoy myself, everything had to be planned out, otherwise I wouldn't have a good time. I would be, maybe, frustrated if a friend came up to me and said, hey, do you want to go grab drinks right now or go do something that was, that I hadn't planned on, something, if I didn't think that things were set up to go right, then, I wouldn't have a good time.
AP: And finally, in terms of your home life, what have you noticed there, in terms of OCPD
John: Just, doing any sort of a chore, is, I guess, really a chore, with me, can be very frustrating because every little thing that I do, there's a right way to it. If it's not done in that right way, then I get really upset. The best example might be the dishwasher, I kinda always had this idea that the dishwasher had to be loaded in one particular way and if it didn't get loaded in that way then we were going to have horribly dirty dishes, I guess, and
I could not understand why any roommate I had, that didn't come across to them, they didn't get that, so anytime I'd open the dishwasher and they'd put something in there I'd freak out and have to reorganize it. With shirts I always thought that would be best, I had to have an ironed shirt, a perfectly iron shirt, before I could go into work. That's just the way it had to be. A lot of things around my house, I just kind of feel like, if I don't have control over it, then it makes me very uneasy.
AP: So let's talk a little bit now about treatment, I remember when you first called me, you had been in contact with other mental health providers, and you had described to them some trouble focusing, trouble getting tasks completed, and when you first approached me, you thought that perhaps you had attention deficit hyperactivity disorder,
and as we went through our evaluation, and you shared some of these traits and behaviors with me, it came clearer to us that this could be OCPD. And so, we've been working now in treatment, and I wonder if you could tell our listeners a little bit about what you have found to be helpful to you in treatment.
John: The first thing that's been very helpful with regulating my emotions, and I guess it's funny because up until when I was doing treatment I would often find that any time I would be asked how I'm feeling or what my emotions were like I wouldn't know, I would just say "I'm not sure what I'm feeling", or I always had a hard time expressing them. But now, I think the treatment has helped me a lot to be more emotionally aware, to be aware with what it is I'm feeling, and being able to
write out my feelings that I'm feeling at a particular time, and it's been very helpful to connect the feelings I'm having with thoughts that I'm having. You know, why am I feeling particularly, why the thought that I'm having in my head that's leading to that. So the emotional part has been very helpful. And then also just testing any of these high standards that I have, has been really helpful, and kind of doing these experiments, almost with myself, to, you know, OK, I think that whatever I'm doing has to be done a particular way, has to be done to a standard, if I test that and find out that it's OK not to, then it's been great, because, for instance, with my leisure time, I always thought that everything had to be specifically planned and that if I didn't have that, then I wasn't going to enjoy myself, but I did experiments where I went out without a plan, and had a wonderful time, you know, enjoying myself. Or back to ironing my shirts, I thought if I went to work with a wrinkled shirt that I would be, everyone would think I'm a fool,
and that I would be embarrassed, and that it would just be horrible, but I went to work with a wrinkled shirt one day, and the world didn't explode, everything was great, I had a great day at work, and nobody seemed to notice, so those are the biggest things that have been really helpful in overcoming a lot of this.
AP: Great. And I know we've also talked about behavioral exercises for procrastination, which was another piece, on that you had been dealing with.
John: Yeah. It's been so helpful. Even though I never though of it before, but testing it has been so helpful, and I just want to say, that I'm really grateful for the work the team at Columbia Medical has been helping me with this, and really grateful for all the work they're doing with OCPD and kind of bringing more awareness of it, and it's been great.
AP: Thanks a lot, John. This has been really great and I think very helpful for our listeners to hear the first-hand account of
your experiences with the condition, and with the treatment, I appreciate your time today.
John: Thank you.
MK: Absolutely, I agree. Thank you so much, John, and thank you Dr. Pinto as well, for educating us today. We have some really good questions from today's callers. I'd like to take a quick moment to welcome anyone who may have just tuned into the show to let them know we are here with Dr. Anthony Pinto, Assistant Professor of Clinical Psychology and Psychiatry and Research Scientist here at Columbia. If you would like to ask our expert a question, please press 1 to speak to our host at any time, or send us a question through Twitter, by mentioning the handle @columbiapsych. Now let's go on to our first question. OK, this one is from a Mom in Queens. She says, "my daughter is in treatment for her OCD, but she has OCPD as well. Can you explain a bit about how her OCPD might affect her ability to be successful with her exposure and response prevention therapy".
AP: Yeah, that's a great question and I appreciate
the listener calling in. When an individual has OCPD or if they have a maladaptive form of perfectionism, that can interfere in exposure and response prevention treatment. Remember, exposure and response prevention is one of the gold-standard treatments for OCD, and it involves the individual facing those situations or the particular triggers for their OCD and not doing their compulsions or their rituals. So when somebody has perfectionism, my experience has been these individuals tend to perseverate over details of therapy instructions and they become really worked up about whether they are doing the treatment correctly. They can also sometimes be argumentative about the rationale for the treatment, and
feel like it is wrong not to do rituals, and so that can impact their compliance or their adherence with the treatment. If the treatment is not going perfectly in their minds, they might be more likely to give up or throw in the towel feeling like why bother if it's not going to be perfect. Sometimes individuals with perfectionism in this OCD treatment might avoid doing the exposures on their own for fear that they're not doing them correctly. They might also resist generalizing these exposures to other related situations. The perfectionism and rigidity can sometimes cause difficulty in building the therapeutic alliance as I mentioned earlier, and these people might be more sensitive to feeling like a failure
if the progress in treatment is moving slowly. So these are all things that it is important for a clinician to be aware of if they have a patient that's presenting with perfectionism, so that these things can be addressed in addition to the frank OCD symptoms.
MK: OK, that's really helpful. Thank you. Here's our next question, from a professor in upstate New York. He asks, "Do we know what causes OCPD?"
AP: That is a big question, and I could spend a whole blog talk talking about that, but in the interests of time, what I can say is, sadly, we don't have all of the necessary research needed to answer that question. We do know from the research that has been done that there is certainly a genetic component to OCPD. When you look at twin studies, when they look at the concordance of one twin to another in terms of OCPD,
there's a very high rate of OCPD concordance, meaning, if one twin has it, the other one is very likely to have it. Those rates are high on the level of other conditions like bipolar disorder, even higher than you would see in some other conditions. So we have a sense that genetics are involved, as with many of the psychiatric conditions. We don't have a good handle on brain functioning or the role of neural circuits or neural pathways, because there's never been an imaging study of OCPD that's been done. We're excited here at New York Psychiatric Institute and Columbia Medical Center to be starting a brain imaging study now, and that's something that we're going to be focusing on and hope to get a better sense of what is happening in the brain. And,
the other aspect of this is the environment, what is the role of the environment in the development of OCPD and there have been lots of conjecture dating back to early 1900s, from Freud and other contemporaries about the role of the environment, and parenting, and unfortunately a lot of that has not been supported by empirical research. We need to better understand that as well. The short answer is, all of this is work in progress, so please stay tuned.
MK: Right, OK, sounds like, yes, there's a lot more to build, ever. OK, well our next question is from a man who emailed us all the way in Cincinnati, Ohio. He asked, "are there medications that can help with OCPD?"
AP: Another good question. And this is yet one more area where further study is needed. So far there's only been one small study on the use of serotonin medications in OCPD.
That study suggested that serotonin reuptake inhibitors, often referred to as SRIs, may be effective, but of course it's hard to draw any hard conclusions based on only one small study.
MK: Sure. OK. I think we have time for one more question. This question is from a young man in Brooklyn, who asks, "Why are there so many more resources for the understanding and treatment of OCD than there are for the treatment of OCPD?".
AP: I think that because OCPD is a personality condition there's a wrong assumption out there that this is just the way people are, and that they're not going to change, and that treatment won't help, but I hope we've demonstrated today with the powerful testimony of John that progress or treatment is certainly possible, and there are treatment approaches that are being developed,
there are psychotherapies out there, that can be helpful, if the clinician is informed about OCPD. OCD has received a lot of attention in the media, and there's a vastly growing awareness of what that is in the lay public. OCPD is not there yet, so what we need is more research to help us understand what the causes are, how to best treat it, we need more awareness in terms of the media, in terms of shedding light on this, and also spreading the word that even though something is a personality condition, it can be treated, there is help available for family members. We want to represent that hopeful message today. It is important for anyone who is seeking treatment to question their treatment provider,
about OCPD, and to access resources that are out there. The International OCD foundation is a foundation that is geared towards Obsessive-Compulsive Disorder, but many of those individuals, because of the high correspondence or relationship between OCD and OCPD, many of those clinicians that are treating OCD will also be informed about OCPD. Just to wrap up, I really want to encourage people to be good consumers, and to ask specifically about OCPD.
MK: Thank you. OK well we've reached the end of our show today. I'd like to thank Dr. Pinto very much for such an informative discussion on Obsessive-Compulsive Personality Disorder, and how it differs from Obsessive-Compulsive Disorder, and I also want to really thank John so much for sharing his experiences with us. Also thank you to all of our listeners for tuning into Blog Talk Radio for today's show.
If we couldn't get to your question today, do leave your contact information with our host, and we will be happy to follow up with you offline. I'm about to give out two important phone numbers, so this would be a good time to take out your pens, or your cell phones if you'd like to note them down. For more information about OCD treatment and research opportunities for adults, you can call us at 212-543-5462. And for information for children or teens, you can reach us at 212-543-5592. Now we are also always available to provide free, confidential screenings for OCD and OCPD during regular business hours, and you can schedule those by calling either of those numbers I just mentioned. For those of you who can't reach the New York City area, as Dr. Pinto mentioned, you should please visit ocfoundation.org for information about providers closer to you. If you enjoyed our show, be sure to join us for future episodes on OCD which have been taking place
every Tuesday and Thursday in October, from 3:00 to 3:30 Eastern Standard Time. We have two more really exciting talks lined up. Our next show will be on Tuesday, October 29, where Dr. Blair Simpson and Dr. Sameer Sheth will be talking about neurosurgery for OCD. Once again you can join the talk by either dialing 347-996-5875, or by going to blogtalkradio.com/columbiapsychiatrynyspi. Thank you for tuning in, and have a great day.