Obsessive-Compulsive Personality Disorder as a Risk Factor for Eating Disorders

Definition

The definition of obsessive-compulsive personality disorder (as well as all other personality disorders) has remained unchanged from the DSM-IV (American Psychiatric Association 1994) to the current version, the DSM-5 (American Psychiatric Association 2013).

Obsessive-Compulsive Personality Disorder

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and presented in a variety of contexts, is indicated by four (or more) of the following:

• 1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.

• 2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).

• 3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).

• 4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).

• 5. Is unable to discard worn-out or worthless objects even when they have no sentimental value.

• 6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.

• 7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.

• 8. Shows rigidity and stubbornness (American Psychiatric Association 2013).

In the ICD-10 (World Health Organization 1992), this personality style is given the label of anankastic personality disorder with the following definition provided:

Personality disorder characterized by feelings of doubt, perfectionism, excessive conscientiousness, checking and preoccupation with details, stubbornness, caution, and rigidity. There may be insistent and unwelcome thoughts or impulses that do not attain the severity of an obsessive-compulsive disorder.

Obsessive-Compulsive Personality Disorder Versus Obsessive-Compulsive Disorder

While some individuals have both obsessive-compulsive disorder and obsessive-compulsive personality disorder, it is more common that they occur without the comorbid condition. However, obsessive-compulsive personality disorder is the most commonly co-occurring personality disorder alongside obsessive-compulsive disorder.

Historical Background

Obsessive-compulsive personality was first described by Freud over 100 years ago. It appeared as a diagnosable mental disorder in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 1952). Since then, along with other disorders in the manual, a shift occurred from a brief description of the condition to an operationalized definition in which a specific number of criteria need to be met in order to obtain the diagnosis. For instance, the definition of obsessive-compulsive personality in the personality disorders section of the DSM-II (American Psychiatric Association 1968) was as follows:

This behavior pattern is characterized by excessive concern with conformity and adherence to standards of conscience. Consequently, individuals in this group may be rigid, over-inhibited, overconscientious, over-dutiful, and unable to relax easily. This disorder may lead to an obsessive-compulsive neurosis, from which it must be distinguished.

The distinction between obsessive-compulsive personality disorder and obsessive-compulsive disorder is long-standing. The transition to operationalized polythetic criteria sets occurred with the publication of the DSM-III (American Psychiatric Association 1980), and the definition of compulsive personality disorder was as follows:

At least four of the following are characteristics of the individual’s current and long-term functioning, are not limited to episodes of illness, and cause either significant impairment in social or occupational functioning or subjective distress:

• 1. Restricted ability to express warm and tender emotions, e.g., the individual is unduly conventional, serious and formal, and stingy.

• 2. Perfectionism that interferes with the ability to grasp “the big picture,” e.g., preoccupation with trivial details, rules, order, organization, schedules, and lists.

• 3. Insistence that others submit to his or her way of doing things and lack of awareness of the feelings elicited by this behavior, e.g., a husband stubbornly insists his wife complete errands for him regardless of her plans.

• 4. Excessive devotion to work and productivity to the exclusion of pleasure and the value of interpersonal relationships.

• 5. Indecisiveness: decision-making is either avoided, postponed, or protracted, perhaps because of an inordinate fear of making a mistake, e.g., the individual cannot get assignments done on time because of ruminating about priorities.

This is not identical, but similar, to the polythetic criteria system in which any four (or more) symptoms (now of eight possible symptoms rather than five, as described in the prior section) may be present in order to meet the criteria for the disorder.

Current Knowledge

Obsessive-compulsive personality disorder is estimated to occur in approximately 3–8% of the general population but at higher rates among those with eating disorders, with widely ranging estimates of 3–60%, depending upon the sampling and assessment strategies utilized.

Indeed, obsessionality and perfectionism are known among both clinicians and researchers to be core features in many individuals with eating disorders and restricting-type anorexia nervosa in particular. However, the question is whether such traits, often captured within the diagnosis of obsessive-compulsive personality disorder, are truly risk factors for eating disorders. This question can be most definitively answered using a prospective research design by assessing the personality of individuals who do not have any signs of an eating disorder and following them over time to track who later develops an eating disorder. Due to the very challenging nature of such research, it is limited; however, the existing data do suggest that obsessive-compulsive personality is a likely risk factor for the development of eating disorders. That is, those individuals who have such traits (in the form of maladaptive levels of perfectionism, rigidity, or an obsessive- compulsive personality disorder diagnosis) are more likely to later develop an eating disorder than those who have low levels of these traits or the absence of obsessive- compulsive personality disorder.

A different methodological strategy is the family study, in which one examines patterns of disorders in relatives of probands with an identified disorder, such as the presence of obsessive-compulsive personality disorder in the relatives of individuals with an eating disorder. These few such studies that have been conducted have found elevated rates of obsessive-compulsive personality disorder in the relatives of probands with restricting-type anorexia nervosa, even when the individual with anorexia nervosa did not have obsessive-compulsive personality disorder. This suggests that this form of eating disorder shares some familial liability with obsessive-compulsive personality traits. Thus, family study evidence points toward shared etiology, and other prospective study, as well as retrospective study, evidences point toward obsessive-compulsive personality disorder as a risk factor for eating disorders.

Importantly, rigid perfectionism, considered a hallmark symptom of obsessive-compulsive personality disorder, has been found to function as both a risk and maintaining factor for eating disorders. That is, those high in maladaptive perfectionism develop eating disorders at greater rates than those lower in perfectionism. In addition, those with high levels of perfectionism are more likely to persist in their disorder than those who are less perfectionistic. While these findings characterize the state of the field’s understanding of this personality trait and its relationship to eating disorders, it should be noted that it is not a relationship that is exclusive to eating disorders, as perfectionism likewise has been identified as both a risk and maintaining factor for depression and anxiety disorders.

Most of this research in the field of eating disorders has focused upon the diagnosis of anorexia nervosa. In fact, numerous authors have noted the remarkable homogeneity in personality presentation among those individuals who persist with restricting-type anorexia nervosa. There are some data to suggest that obsessive-compulsive personality traits are associated with a poor outcome in anorexia nervosa. Thus, some recent efforts have been made to utilize personality traits in order to classify individuals with eating disorders in a more clinically useful way using empirically derived personality subtypes, as well as tailor treatment approaches based upon personality and temperament. Cognitive-behavioral interventions for perfectionism and cognitive rigidity have been developed as novel adjunctive treatment approaches for eating disorders in response to the above findings.

Current Controversies

There are two separate areas of controversy worthy of note. The first concerns methodological challenges specific to identifying risk factors for eating disorders. The second concerns the categorical approach to defining obsessive-compulsive personality, a critique which applies to all personality disorders.

The first issue is a challenge for other areas of psychopathology (e.g., depression) but for none more so than eating disorders. In order to definitively identify a risk factor for a disorder, that risk factor must be established before the onset of the disorder and be predictive of the development of that disorder. The necessary requirements for such a study include assessment at least at two different points in time in which the individual changes status on the outcome of interest (Jacobi et al. 2004). A prospective design is the ideal research design through which to identify risk factors because for obsessive-compulsive personality disorder (or any other condition) to be a true risk factor, it must temporally precede the outcome variable of interest, in this case, the eating disorder (Lilenfeld et al. 2006). However, there are significant challenges in conducting such research. Due to the relatively low base rates of eating disorders, prospective studies are extremely difficult to execute with this population. As a result of this challenge, other methodological designs have been utilized, but they pose problems in definitively identifying a risk factor. A recovered study design utilizes individuals who have recovered from an eating disorder in order to identify disorders or traits that remain elevated after recovery, with the assumption that this may be reflective of the individual’s premorbid state. A major problem with this approach is that eating disorders (as well as other disorders like depression) are thought to potentially leave a “scar” upon personality or other characteristics such that although there is recovery from the disorder, the individual may have changed as a result of having experienced the disorder and, thus, a recovered presentation may not reflect the premorbid presentation. This is particularly important to note with eating disorders that may involve profound physiological impact as a result of starvation and other disruptive eating and weight-control behaviors. A second alternative research design that has been utilized to obviate the need for the more difficult prospective study is a retrospective recall study. The individual and sometimes family informants are asked to report on the individual’s traits before the onset of the disorder in which risk factors are being sought. The obvious limitation of this design is recall bias. These limitations being noted, both recovered study and retrospective study designs have identified obsessive-compulsive personality disorder (or hallmark traits such as perfectionism) as likely eating disorder risk factors. A final related note is that because personality disorder diagnoses ought not to be made until early adulthood, or late adolescence at the earliest, requiring the categorical definition of obsessive-compulsive personality disorder is not sensible, since the most typical age of onset for eating disorders is mid-adolescence through young adulthood. Therefore, identifying this pathology on a continuum, as with maladaptive perfectionism, utilizing a well-established psychometrically sound measure such as one of two Multidimensional Perfectionism Scales (Frost et al. 1990; Hewitt and Flett 1991), may be preferable.

Regarding this second issue, the debate over whether a categorical or a dimensional approach to classifying psychopathology has been ongoing for decades. There is no area of psychopathology in which this has been more hotly debated than personality disorders. While most clinicians, as well as personality and psychopathology researchers, agree that personality pathology falls on a continuum, discrete disorder categories have advantages, such as ease of communication among professionals and facilitating efforts to find causes of discrete syndromes. These, among other reasons, have led to the retention of a predominantly categorical system in the DSM. While there was some move toward increased dimensionality in the DSM-5, the categorical structure was retained. Personality disorders is the one area which was poised to move toward a much more hybrid categorical-dimensional model, but very shortly before publication of the manual, it was decided that the original personality disorder categories from the DSM-IV would be retained with no changes “in order to preserve continuity with current clinical practice,” despite ample research supporting a more dimensional classification of personality pathology. This hybrid model, which is likely to be used by many researchers, can be found in Section III “Emerging Measures and Models” under the heading “Alternative DSM-5 Model for Personality Disorders.” Personality disorders are defined by impairments in both personality functioning and pathological personality traits. Obsessive-compulsive personality disorder was one of six of the original ten personality disorders retained in this alternative model. The proposed diagnostic criteria for this alternative model of obsessive-compulsive personality disorder are as follows:

• (a) Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:

  • 1. Identity: Sense of self derived predominantly from work or productivity; constricted experience and expression of strong emotions.

  • 2. Self-direction: Difficulty completing tasks and realizing goals, associated with rigid and unreasonably high and inflexible internal standards of behavior; overly conscientious and moralistic attitudes.

  • 3. Empathy: Difficulty understanding and appreciating the ideas, feelings, or behaviors of others.

  • 4. Intimacy: Relationships seen as secondary to work and productivity; rigidity and stubbornness negatively affect relationships with others.

• (b) Three or more of the following four pathological personality traits, one of which must be (1) rigid perfectionism:

  • 1. Rigid perfectionism (an aspect of extreme conscientiousness (the opposite pole of detachment)): Rigid insistence on everything being flawless, perfect, and without errors or faults, including one’s own and others’ performance, sacrificing of timeliness to ensure correctness in every detail, believing that there is only one right way to do things, difficulty changing ideas and/or viewpoints, and preoccupation with details, organization, and order.

  • 2. Perseveration (an aspect of negative affectivity): Persistence at tasks long after the behavior has ceased to be functional or effective; continuance of the same behavior despite repeated failures.

  • 3. Intimacy avoidance (an aspect of detachment): Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.

  • 4. Restricted affectivity (an aspect of detachment): Little reaction to emotionally arousing situations, constricted emotional experience and expression, and indifference or coldness.

Any clinician who treats individuals with eating disorders can attest that the above definition aptly captures the personality style of nearly everyone with the restricting subtype of anorexia nervosa who does not transition to another type of eating disorder. This proposed move to require rigid perfectionism as the hallmark trait in obsessive-compulsive personality disorder is indeed consistent with clinical and research findings of most individuals with eating disorders, particularly those with restricting-type anorexia nervosa.

Future Directions

The hybrid dimensional-categorical personality disorders model presented in the DSM-5 may hold the greatest promise for future research on personality risk factors for eating disorders. In addition, in order to most definitively identify a true risk factor, that factor must be present before the onset of the disorder. This poses methodological challenges given the relatively low base rates of eating disorders (though notably higher when disordered eating is conceptualized on a continuum), because large samples are needed to be studied through the period of risk (for which there is some variation) in order to adequately power a prospective study of personality risk factors for eating disorders. Very few such studies have been conducted. Therefore, more sophisticated, longitudinal, prospective research is needed. Most prospective research in the field of eating disorders has been limited by inconsistent outcome and predictor measures, small sample sizes, modest follow-up periods, and failure to control for baseline eating pathology. Prospective research is time-consuming and costly, but necessary to identify true personality risk factors for an illness. Collaborative efforts are advisable in order to accomplish this task.

Cross-References

Anorexia Nervosa

Perfectionism

Personality Disorders as Comorbidities in Eating Disorders

Personality-Based Approaches to Classification