Obsessive-Compulsive
Personality Disorder:
Case
Presentation and Treatment Plan
Within
these United States
obsessive-compulsive personality disorder (OCPD) affects 1% of the populace of
which 3%-10% of mental health patients are sufferers (BrainPsychics.com,
2012). Generally, this condition is
described as an Axis II, DSM-IV-TR mental disorder referring to an obsession
with perfection and the overt need to sustain order and control of people or
situations (Butcher, Mineka, & Hooley, 2010). Although OCPD is commonly confused with
obsessive compulsive disorder (OCD) as the two share a number of like symptoms,
the most significant variance is that individuals afflicted with OCD experience
unwanted thoughts whereas OCPD sufferers consider their thoughts as accurate
(Vorick, 2010). Additionally, OCPD symptoms
are comprised of a preoccupation with rules and orderliness, extreme
perfectionism, desire to control situations, inflexibility, miserliness,
stubbornness, and the inability to dispose of broken or useless objects
(Butcher et al., 2010). As a
practitioner, it is imperative to assess, diagnose, and treat OCPD patients in
an advantageous and proficient manner.
In effort to do so, a combination of psychodynamic
psychotherapy, cognitive-behavioral therapy (CBT), and group therapy are widely
employed. Psychodynamic psychotherapy
promotes the comprehension of one’s thoughts and emotions. On the other hand, CBT enables patients to
improve levels of distress, interpersonal relations, and personality
functioning (Ng, 2005). Additionally,
group therapy serves as a secondary intervention enabling sufferers to
associate with like-minded individuals in order to alleviate a sense of
isolation (Psych Central, 2012). Hence,
the utilization of such methods provides a comprehensive approach to treating
OCPD symptoms, resolving issues, and establishing functionality and normalcy
with potential long term success. In
effort to illustrate such treatment the following hypothetical case describes
an adult OCPD patient inclusive of a detailed description of the case,
treatment plan, self-critique, challenges, and ethical issues.
For these purposes,
Janice, a probable OCPD sufferer, has been referred to a professional
psychiatric service by her employer. She
is a 37 year old, department store manager.
Additionally, although Janice is stunningly attractive, she is single,
never married, has no children. Also,
she maintains very little contact with her extended family as she has relocated
for career purposes, working 55-60 hours per week. With limited spare time, Janice typically reads
romance novels, listens to rhythm and blues and soft rock, and enjoys watching
reality television at her leisure. Most
of her companions are childhood friends which remain in her hometown and she
has had difficulty fostering new relationships as she spends most evenings and
off-days at home. According to reports
from her employer, within the past 6 months various employees have repeatedly
expressed concern to the district manager that Janice is indecisive and seemingly
lacking effective leadership skills.
From week to week, Janice alters various procedures, operations, and
scheduling, disturbing the continuity from one shift to the next. For instance, previously, full-time employees
were granted two, 15 minute breaks along with a 30 minute lunch. However, Janice eliminated the 15 minute
breaks. Additionally, she increased the
projected sales goal per employee despite the recent decline in store
profits. Most recently, Janice has taken
on various responsibilities of the floor supervisors. Instead of delegating these tasks, she feels
as if a hands-on approach ensures the job is done properly. Furthermore, she has eradicated store
sponsored company outings and holiday parties stating that, “the less time
employees spend at leisure, the more time and dedication they can devote to the
company.” However, these actions have
inadvertently compromised employee morale, productivity, and sales.
In consideration of the
aforementioned, Janice craves control and perfection towards her employees and
in terms of her position, has difficulty delegating tasks, her work-life
balance is distorted, and she has curtailed the leisure of her employees as
well. In addition, she is stubborn,
requiring employees to fully comply or face suspension or termination. Consequently, numerous employee complaints
and the decrease of sales prompted the employer to refer her to psychiatric
assistance or resign. Prior to the
initial therapeutic session, the practitioner read Janice’s file inclusive of
employee complaints, company referral, sales and productivity records, and work
history in order to acclimate himself with her experience and determine his
initial approach. However, this
information is insufficient in explicating her condition. Therefore, further inquiries must be implemented. For the intake session, the practitioner
aspired to assess Janice utilizing a generalized intake assessment, a
Conscientiousness-Related Scale, the NEO Personality Inventory – Revised (NEO-PI-R), and
an OCPD Component Scale, the Dimensional Assessment of Personality
Pathology-Basic Questionnaire (DAPP-BQ). First, the intake
evaluation provides pertinent data in regards to basic personal information and
history, overview of status and need, authorization and informed consent,
confidentiality, guidelines, and the development of provisional treatment plans
(Seligman & Reichenberg, 2009).
Next, the NEO-PI-R
evaluates 240 items measuring personality factors in terms of general and
underlying components. These include
competence, order, dutifulness, achievement-striving, self-discipline, and
deliberation (Samuel & Widiger, 2011).
Then, the DAPP-BQ utilizes a 290 or 560 item questionnaire in which the
subject responds from strongly agree to strongly disagree in order to assess
personality in regard to affective liability, social avoidance,
conduct problems, and compulsivity (Samuel, Simms, Clark, Livesley, &
Widiger, 2010). In short, comparing
Janice’s symptoms along with her life and health history to OCPD
characteristics provides an effective diagnosis. Given the length of these evaluations, the
practitioner designated 6 hours for the intake session, offering 15 minute
breaks every 60 minutes.
As
the assessments are completed, the practitioner begins to note problematic
concerns regarding Janice’s condition.
Prevalent issues include her overwhelming need to control her
environment, the lack of constructive extra-curricular activities, omitting
other individuals from her personal life, and her apparent stinginess and
depression. These factors may indicate
Janice’s single status, the reason she does not have children, and her
difficulty fostering new relationships.
Additionally, she may have experienced some traumatic events or damaging
relationships in the past which promoted her desire to maintain organization
and power in a detrimental manner.
In
effort to assist Janice in overcoming these phenomenon and achieving favorable,
long term success the practitioner may establish long term goals. Such aspirations include effectively
communicating with employees, increasing her confidence in others, being
productive outside of work, and maintaining past relationships while fostering
new relationships. Now, in order to
realize such goals, Janice must implement the following: (1) determine and
consistently maintain rules and regulations in the workplace, (2) assign tasks
to employees and create a system of checks and balances, (3) participate in an
outdoor activity at least once per week, (4) enroll in an organizational
activity outside of group therapy at least twice per month, (5) contact a
family member or childhood friend weekly on a designated day, and (6) maintain
a journal in which she illustrates the quality of her interactions throughout
the day. Applying these practices allows
Janice to modify her behavior and ultimately her pessimistic thoughts. Over time, she becomes more aware of how
unrealistic her preoccupation with perfectionism, order, and control has been
and her OCPD symptoms should decrease.
Additionally,
post-assessment, the practitioner should explicate the treatment methods and
interventions which are to be utilized.
Janice should know what to expect as well as her role and responsibility
along with that of the practitioner and the therapeutic organization. Accordingly, the practitioner has opted to
employ psychodynamic psychotherapy, cognitive-behavioral therapy (CBT), and
group therapy. Over the course of 12
weeks, Janice is to meet with the practitioner every Monday afternoon from
6pm-7:30pm, 90 minute sessions. The
first 5-15 minutes consists of discussion and follow-up in relation to the past
week’s experience. The remaining 75-85
minutes are divided in half consisting of psychodynamic psychotherapy and
CBT. Psychodynamic psychotherapy, also
referred to as insight-oriented therapy, “focuses on unconscious processes as
they are manifested in a person’s present behavior” (Haggerty, 2006). In addition, this approach enables the client
to divulge her emotional expression and interpersonal relatedness (McKay,
2011). Within this methodology, the
client is encouraged to openly express themselves, self-reflect, and develop
patience with the intent of developing coping skills, internal awareness,
personal acceptance, and self-confidence (Poulsen, Lunn, & Sandros, 2010). The objective of this approach is to increase
the client’s self-awareness and recognizing how their present behavior was
shaped by their past. The second half of
the session employs CBT. In general,
“cognitive clinicians believe that thoughts lead to emotions and behaviors and
that, through awareness and modification of their thoughts, people can change
their feelings and actions” (Seligman & Reichenberg, 2010, p. 241). Hence, as Janice becomes more conscious of
her thought process and is persuaded to think differently, in turn she may
alter her behavior and response.
Additionally, CBT enables the subject to decrease psychotic symptoms
such as depression, foster hope, and enhance functionality (Lincoln, Ziegler,
Mehl, Kesting, Lüllmann, Westermann, &
Rief, 2012). As a secondary
intervention between sessions, Janice is required to attend one hour group
sessions once per week for the duration of the 12 weeks with the option to
continue subsequent to one-on-one therapy as deemed necessary. Furthermore, group therapy is considered a
more advantageous means of dealing with the subject’s resistance, decision
making, level of comfort, and interpersonal proficiency. In addition to these methodologies, a
pharmacological approach may be implemented as needed. Janice’s plausible depression or anxiety may
be treated with antidepressants or betaxolol, respectively. However, many consider medication an
unfavorable method of treatment for OCPD patients as the drug may stimulate
dependency (Ribeiro, 2011).
During the
therapeutic process it is imperative to measure the client’s progress and
status. In effort to effectively
determine Janice’s progress on a weekly basis, the practitioner should consider
her journal use and content, information from the employer, feedback from the
group therapist, reports from Janice’s organizational activity, recognize her
body language and demeanor as she discloses information concerning her weekly
encounters and endeavors, as well as how she responds to instruction and
criticism. These measures indicate
whether or not she is adhering to therapy and actively incorporating the
practices advantageous to realizing her aspirations.
Another critical
component of the case presentation is the clinician signature or policy
statement. Typically, this form is employed
to protect the practitioner and the psychiatric staff from prosecution and
unwarranted recovery (Porter, 2010).
Accordingly, this itemized listing includes general principles, role
implications, use of colleagues’ names, use of dates, on-call responsibilities,
disability documents, forensic documents, treatment plans, administrative
reviews, prescriptions for medications, prescription privilege, telephone
transmissions or prescriptions, billing documents, treatment authorizations,
authorization reviews, managed care contracts, and a conclusion in which the
practitioner signs the document (Glenn, 1997).
These factors express the organizational guidelines, purposes,
responsibilities and requirements, practices, recommendations, expectations,
and endorsements.
Although the
previously discussed methods and interventions are advantageous means of
treating OCPD, as a practitioner it is imperative to recognize one’s strengths
and weaknesses in relation to the patient.
Personally, effective listening, substantial research, adequate
interviewing, self discipline, empathy, reframing and motivational techniques,
and a non-judgmental persona are beneficial skills to possess within the
psychological field. Furthermore, the ability
to focus on interests, problem solving, fulfilling healthy living, assisting
those in distress, resilience, gratitude, and cultivating high quality
relationships are advantageous qualities.
Embracing and utilizing these traits and techniques sustains the notion
that assisting Janice throughout her therapeutic process is an attainable
personal goal. However, lack of
therapeutic experience is a reasonable issue.
Having never dealt with an OCPD patient, or any type of client for that
matter, may pose a concern. Janice may
desire to utilize a more experienced professional with further
credentials. Additionally, her symptoms
and drive could be considered positive attributes given they were
normalized. Hence, it may be challenging
to treat Janice or modify certain behaviors which could be considered admirable
to an extent. Furthermore, a personal
sense of well being or adequacy may impede the process. Generally, “the less aware we are of our
motives, feelings, thoughts, actions, perceptions, the more they control us and
the more we stay stuck in old patterns that don’t work anymore” (Pologe,
2006). In effort to personally overcome
such factors; I must discover and incorporate into constant, every-day
consciousness, that which is being masked, distracted from, or indirectly acted
out. Failure to do so results in the
inability to assist Janice in terms of self-realization and self-awareness.
Other challenges
associated with the case are client responsibility, blind spots,
self-disclosure, and ethical issues.
First, as the
client, Janice has a responsibility to actively participate and provide
input. Moreover, she must display
honesty, open communication, complete external assignments, maintain
appointments, keep me abreast of any changes or progress, assist in planning
goals, follow through, wear appropriate attire, and refrain from overlapping or
visiting multiple clinicians. By
fulfilling these obligations and adhering to requests and requirements, Janice
enhances the likelihood of a successful and effective process.
Second, the most
significant blind spot in relation to treating Janice is the fact that some
issues have the potential to be more difficult to empathize with from a male
versus female perspective. In effort to
conquer this matter I must give consideration to women’s plight, the Janice’s
individual history, and confer with female colleagues and senior clinicians
when applicable.
Third,
self-disclosure raises probable concern as well. At times, I may deem it necessary to disclose
personal information which is relevant to Janice’s circumstances in an attempt
to provide helpful information and insight.
In addition, self-disclosure fosters rapport, temporarily removes some
of the focus away from the client’s issues, and conveys empathy. However, the risks of self-disclosure includes
the fact it may be considered narcissistic or disruptive, or that the client
may feel obligated to respond in a similar mode as the clinician. Also, Janice may respond negatively to the
information or gain too much power and information against me. Furthermore, excessive information or exposure
occurring early on in the process may be damaging (Murphy & Dillon, 2011).
Lastly, ethical
issues must be upheld. In particular,
boundaries may present an issue. Janice
is an attractive, single woman with few interpersonal attachments. From her perspective she has the potential to
become attracted as in certain instances victims are drawn to the supporter or
sponsor. From a personal perspective,
Janice is beautiful, age appropriate, and available. However, I must refrain from abusing the
client-clinician relationship and resist any impending temptations. Additionally, a social relationship may
render Janice ineligible to seek services in the future if needed, cause the
her to consider the treatment as unprofessional or inefficient resulting in a
formal complaint or lawsuit, or simply disregard her best interest, deterring
ongoing personal development.
Furthermore, forming a social relationship could “impair the psychologist's
objectivity, competence, or effectiveness in performing his or her functions as
a psychologist” (APA, 2002).
In
conclusion, in effort to treat a patient suffering from a personality disorder
such as OCPD, the practitioner should provide a case presentation and treatment
plan. These tools enable the
practitioner to outline and adequately inform the patient of the process,
responsibilities, guidelines, and objectives.
In order to assess, diagnose, and treat an OCPD sufferer such as Janice,
implementing a comprehensive approach is most advantageous. Thus, the usage of a psychodynamic
psychotherapeutic approach, cognitive behavioral therapy, and group therapy are
beneficial and appropriate methodologies to employ. Such techniques enable Janice to effectively
address her past and emotional welfare, modify her thoughts which ultimately
influence her behavior, and receive support from her peers. As she enthusiastically implements such
practices she increases her potential to realize long term success and maintain
functionality. Additionally, as the
practitioner, an awareness of the challenges associated with the case and the
knowledge and ability to overcome them is imperative to the process.
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