Expert Interviews: Naomi Fineberg on Obsessive Compulsive Personality Disorder (OCPD)
Dr. Eric Hollander: OK! Well, Hello. My name is Doctor Eric Hollander, and I'm with the Spectrum Neuroscience Treatment Institute here in New York, as well as Albert Einstein College of Medicine, and we're hosting the International College of Obsessive-Compulsive Spectrum Disorders this week in New York City. We have a number of international experts in OCD and related conditions, and we're very fortunate today to have Professor Naomi Fineberg, who comes to us from the UK, where she runs the National Health Service program for treatment-resistant Obsessive-Compulsive Disorder. She trained at University of Cambridge, and is with the University of Hertvenshire, and I thought that we would talk a little bit about Obsessive-Compulsive Personality Disorder, where people don't really have a good understanding of that, and how it differs from Obsessive-Compulsive Disorder
itself, and what are some of the characteristics. And I know that you've done a great deal of research looking at neurocognitive difficulties in people with OCD, and Obsessive-Compulsive Personality Disorder. So maybe we can start by, just tell us a little bit about Obsessive-Compulsive Personality Disorder, what is that.
Dr. Naomi Fineberg: Thank you for inviting me, Eric, and you're absolutely right there is a great deal of confusion between Obsessive-Compulsive Disorder and Obsessive-Compulsive Personality Disorder, so I'm delighted to be able to talk a little bit about the personality disorder, and try and tease apart the differences with Obsessive-Compulsive Disorder. Personality disorders in general are thought to represent pervasive problems with character and behavior that start early in life and produce all sorts of difficulties -- interpersonal, and social difficulties for people. In the case of
Obsessive-Compulsive Personality Disorder there's a pathological focus on orderliness, perfectionism, need for control, a focus on detail, and a difficulty with change, at the expense of openness, flexibility, and efficiency, which really gets in the way of people functioning and getting on with their lives. The difference between Obsessive-Compulsive Personality Disorder and OCD is that whereas people with OCD get involved in various ritualistic behaviors and have intrusive thoughts, that they recognize as being senseless, be they checking or washing rituals, or needing to get things right, in the case of the Obsessive-Compulsive Personality, the person really has a set of values and a sense of self that makes them feel that
there is rationale for doing these behaviors, so they feel these behaviors are really very important, so they don't necessarily recognize them as being alien to them ... yet, by the same token, they're terrifically time-consuming, they result in slowness, they inhibit people, and people with this disorder come across as being inflexible, rigid, and difficult to live or work with.
EH: Now, what usually brings people with Obsessive-Compulsive Personality Disorder into treatment. Why do they come into treatment?
NF: Very often, they come into treatment because they become unwell in some other way. A large proportion of people with personality disorders, about 70%, get depression. They also suffer with anxiety disorders, they suffer with Obsessive-Compulsive Disorder as well
EH: Mmm, hmm.
NF: And it's often these secondary conditions that bring them into
treatment, but you know it's really interesting, that when you look in primary care and counseling, people with Obsessive-Compulsive Personality Disorder are the commonest kind of personality disorder, in that, receiving treatment for mental problems. I think it's rarely recognized as being the primary problem, it's the secondary co-morbidity that brings people into treatment.
EH: Now are these individuals difficult to live with, or are they hard to work with?
NF: There are huge adaptive advantages, being meticulous, and conscientious, and workaholic, but there are also negative points. People feel a need to complete work before they can move on, so this really slows them down. They find unpredictable change very difficult so they may get irritable and anxious, and even come across as
aggressive if they're challenged in that way, so they do come across as being judgmental, irritable, lacking a sense of humor, and inflexible. So, whereas there are advantages in having these personality traits, if you have the full disorder, once it becomes more severe, it's actually very difficult to live with, and to live with somebody with those problems.
EH: So do they have a higher rate of divorce, for example, or do they frequently have difficulty on their jobs?
NF: There's a high celibacy rate.
EH: Uh huh
NF: People have difficult staying in work, people have difficulty with their marital relationships, yeah.
EH: And this sort of rigid, perfectionistic pattern, does it start very early in life?
NF: It starts early, present by adolescence, rather like OCD and the other obsessive-compulsive spectrum disorders, and
generally runs a life-long course, though it may possibly be amenable to treatments, but, as you pointed out, people with this disorder, despite the fact it is really quite common, very rarely come for treatment for that disorder. There have been very few treatment studies looking at pure Obsessive Personality Disorder. It's usually treated together with some other disorder. We don't have a great deal of data on it.
EH: Do people with Obsessive-Compulsive Personality Disorder, do they have obsessions, or compulsions?
NF: Well, not strictly defined if you require the obessions and compulsions as I said to have this ego-dystonic, this alien quality, but they have intrusive doubts, they have intrusive thoughts, they have repetitive checking, repeating behaviors, needing to get things absolutely correct. So if you broaden the concepts
of compulsions and obsessions, they do have disabling repetitive thinking, and behavior patterns, that are disabling.
EH: Now are there features of Obsessive-Compulsive Personality Disorder present in other disorders, for example, people with Asperger's Syndrome? Is it similar to the rigidity that you might find in that condition?
NF: I think the phenomenological evidence that we have suggests the difficulties that people with Asperger's in managing sudden and unpredictable change, is very similar on the face of it, to the difficulties that people with Obsessive-Compulsive Personality face, and I think there would be great value in trying to probe that domain, and look at the similarities and differences. As far as I'm aware, no one has actually done a head-to-head comparison of those two groups.
EH: And how about the issues of
morality and scrupulousness, is that characteristic of these individuals?
NF: Yes, hyper-judgmental, hyper-moral. And that may talk to this need for completeness and perfection.
EH: Uh huh.
NF: That everything has to be perfect, while the self has to be perfect, and one judges others as needing to be perfect too. That there's a, there's a feeling of discomfort in the presence of incompleteness and imperfection, which drives the need for perfection.
EH: So how do you treat people with Obsessive-Compulsive Personality Disorder?
NF: Well, there are various approaches you could use ... there's interest in psychological techniques such as cognitive remediation therapy, which tries to target this focus on details, of information processing problem, where people tend to look at the detail rather than the whole picture. Try and help people expand one's horizons,
by encouraging that, and motivating them to deal with change, and to get used to change, and that involves training exercises. And the other form of treatment could be using a drug treatment commonly used for Obsessive-Compulsive Disorder, a Selective Serotonin Reuptake Inhibitor, and there's some data suggesting in my experience, patients can become more flexible, less anxious, less rigid, when treated with an SSRI.
EH: Now, can you describe the neuro-cognitive impairment that's sort of characteristic of both Obsessive-Compulsive Personality Disorder and then also Obsessive-Compulsive Disorder?
NF: Well as I mentioned, there haven't been many studies in the disorder as a pure form, and, but, the studies that have been done, and we've just recently completed a study, show some of the similar
abnormalities in Obsessive-Compulsive Personality Disorder that you see in Obsessive-Compulsive Disorder, namely, difficulty shifting attentional set, so this is a difficulty with cognitive flexibility, people will focus on a particular stimulus and then have great difficulty shifting their attention to something new, when prompted to do so. They'd rather stick with the same thing, and I think that really talks to the clinical problems that they show. It's hard for them to multi-task, it's hard for them to move on, they get stuck on the same theme.
EH: Uh huh.
NF: Similarly, they show cognitive slowness on an executive planning task, they think longer about it before they make a move, and that's, again something where this task is also impaired in people with OCD, so I think that shows an area of congruence.
EH: Mmm hmm.
NF: But there's also some rather new data, suggesting that people with OCD [OCPD -- ed.] actually have stronger persistence than people with OCD, and that may be an area of divergence, where they may persist for longer without reward.
EH: Can persistence be advantageous?
NF: It's, I suppose it's context-dependent, but if you continue to live a life despite reward, it might lead to a very impoverished, uh, impoverished existence.
EH: OK. So what are three points that you'd sort of like to emphasize to our viewers, what do you think is important in terms of a take-home message
NF: I think the take-home message is that Obsessive-Compulsive Dis ... PERSONALITY Disorder is common -- it's easily confused with OCPD [OCD -- ed.]; it's likely to be treatable; and it's associated
with a great deal of distress and disability and needs to be better researched.
EH: Mmm Hmm. OK. Anything else you'd like to highlight or cover or ...?
EH: OK. Well, thanks very much for visiting with us in New York, and looking forward to the International College of Obsessive Compulsive Spectrum Disorder Conference.
NF: Thanks very much for having me. My pleasure.