OCD vs OCPD: Differential Diagnosis

Introduction

In clinical practice clients may present with symptoms of obsessive thinking or compulsive behaviors. As we evaluate these clients more closely, we may wonder if their overall presentation indicates a diagnosis of Obsessive-Compulsive Disorder (OCD). Or, could your client be exhibiting signs of Obsessive-Compulsive Personality Disorder (OCPD) instead?

The goal of this blog post is to take a look at OCD vs OCPD and to explore the differential diagnosis between the two.

A few case examples

A middle-aged woman is finding it increasingly difficult to leave her home to shop, run errands, or engage in activities out of the home with friends and family. She fears that she has forgotten to check to see if the stove is turned off inside the house and that the garage door has closed all the way when she left the house. If the stove is on there could be a fire. If the garage door is left open, someone could easily break into her home. In her mind, her safety and the security of her home is at stake. So, she finds herself circling the block and returning to her home multiple times in order to go inside to check the stove and then to “make sure” that the garage door is indeed closed and secure. On some days it may take her an hour to finally drive to her destination. Even while at her destination she continues to worry about the stove and the garage door. She knows that most people don’t have this problem, but it’s just something she has to do. If she doesn’t, then she feels certain that something “bad” will happen.

This person has been diagnosed with Obsessive-Compulsive Disorder.

A business-professional man in his mid-50s has prided himself on his career accomplishments. Growing up, he was always interested in following the rules and doing “the right thing.” He’s a hard worker and has been recognized in his field as a top-achiever. Although he has recently received a promotion and is now a manager, he’s having difficulty with the concept of delegation. He sees his team as having an easy rapport with each other, but believes that such camaraderie is basically a waste of valuable work time. He has a few select friends that he schedules time to talk with occasionally. These friends are also business professionals, so the majority of the conversations are about careers and detailed work projects.

This person has been diagnosed with Obsessive-Compulsive Personality Disorder.

What is Obsessive-Compulsive Disorder?

“Obsessive-Compulsive Disorder (OCD) features a pattern of unwanted thoughts and fears (obsessions) that lead you to do repetitive behaviors (compulsions). These obsessions and compulsions interfere with daily activities and cause significant distress.”

Mayo Clinic

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In evaluating someone for the possibility of OCD vs OCPD, it is helpful to look at general themes of obsessions and/or compulsions that may be present.

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Note: I’ve written a blog post on The Heart’s Way, Imagery and Insights blog (which is for more of a general readership) that does a deeper dive into the topic of OCD. For this additional information, click on the link: Understanding Obsessive-Compulsive Disorder.

What is Obsessive-Compulsive Personality Disorder?

According to the DSM-5, four (or more) of a total of eight symptoms (or contexts) must be present in order for the OCPD diagnosis to be present.

Additional OCPD information

“OCPD is a personality type where the need for perfectionism in all aspects of life takes precedence. Individuals with OCPD hold high standards which originate from dysfunctional beliefs thought to be established early in adolescence. Straying away from these rigid beliefs can cause inner cognitive dissonance, leading them to push their beliefs onto others, creating difficulties in social interactions. Inflexible cognitions such as ‘my way is the correct way’, ‘I must own the truth’ and ‘all is not well unless it’s done this way’ are deeply ingrained, so that they are resistant to acknowledging alternatives to their ways of thinking. In OCPD, inadequacies are only recognized in others and the external environment and patients do not harbor ego dystonia or question themselves.”

BJPsych Bulletin

Obsessive-Compulsive Personality Disorder is believed to be prevalent in approximately 1-2% of the general population. This statistic rises within psychiatric populations.

OCPD can occur with these psychiatric comorbidities:

• Depression
• Eating Disorders
• Illness Anxiety Disorder (categorized in the DSM-5 under Somatic Symptom and Related Disorders

Individuals with OCPD are often high-functioning and reluctant to admit to any problems or difficulties in their functioning. As with personality disorders in general, family members/spouses can often provide valuable collateral information in making the OCPD diagnosis.

OCD vs OCPD – Making a differential diagnosis

• A statement about OCD: “There’s a difference between being a perfectionist – someone who requires flawless results or performance, for example – and having OCD. OCD thoughts aren’t simply excessive worries about real problems in your life or liking to have things clean or arranged in a specific way.” In OCD, obsessions and compulsions affect one’s quality of life. (Mayo Clinic)
• OCD vs OCPD longevity and course of signs/symptoms:
  • OCD usually begins in teens or young adult years, although it can start in childhood. Symptoms typically begin gradually and will vary in severity throughout life, usually associated with level of underlying anxiety. Symptoms can worsen with increased stress.
  • OCPD is a personality disorder, which means that it involves personality traits that are long-standing, inflexible, atypical, and cause difficulties in some way. OCPD behaviors tend to be persistent and unchanging over the long term.
• OCD symptoms indicate the presence of diagnosable obsessions and/or compulsions. These obsessions and/or compulsions significantly interfere with an individual’s quality of life and ability to function. True obsessions and/or compulsions are not present with OCPD.
• Feelings about obsessive behaviors or thoughts: “People with OCD often feel distressed by the nature of their behaviors or thoughts, even if they are unable to control them. People with OCPD, however, typically believe that their actions have an aim and purpose.” (Very Well Mind)

Treatment options for OCD vs OCPD

Treatment options differ for OCD vs OCPD. Both may include the use of psychiatric medications, but therapy options are varied.

Treatment options for OCD include:

• The use of psychiatric medications
• Behavior therapy indicated for the treatment of OCD is known as exposure and response prevention. In this type of treatment clients are deliberately exposed to a feared object, situation, or thought either in reality or in their imagination. The idea of this controlled exposure is for the client to not engage in the compulsive behavior in response to the feared stimuli.

Treatment options for OCPD include:

• Psychiatric medications, particularly if the individual is experiencing a comorbid disorder, such as depression.
• “Cognitive-behavioral therapy (CBT), which focuses on helping you notice and, eventually, change the negative thought patterns associated with OCPD.
• Psychodynamic therapy, which is intended to help you understand your conscious and unconscious thoughts and emotions, so you can make healthier choices in your daily life.” (Very Well Mind)

This post contains links to additional resources (highlighted in blue above.)