The literature describing the treatment of OCPD is somewhat confusing because of a lack of clear distinction between OCPD and OCD. This is especially true of the older literature and the earlier pharmacological studies reporting efficacy in obsessional syndromes. Generally, symptoms of OCPD have not been regarded as responsive to biological interventions. Favorable treatment responses to a variety of psychotherapies are consistently described. Intensive dynamic therapies, including psychoanalysis, continue to be recommended as the treatment of choice for OCPD.
No medications specific for the treatment of OCPD are currently available. The serotonin reuptake inhibitors used in the treatment of OCD have not been carefully studied in the OCPD population. There are a few anecdotal reports of the efficacy of these medications in patients with OCPD, but controlled studies are lacking. Nonspecific anxiolytic agents may be used, but the chronic nature of OCPD presents the potential problem of medication dependency. Swartz (1998) reported that betaxolol, a long-acting ÞÂ-adrenergic blocker, was useful in anxious patients with OCPD. Antidepressants may be useful in OCPD patients with significant depressive symptoms. One study reported that the presence of compulsive personality disorder was a positive predictor of response to serotonergic antidepressants. Ekselius and von Knorring reported that patients with comorbid major depression and OCPD responded to sertraline or citalopram with a reduction in OCPD symptoms.
Short-term individual therapy may be useful for patients with OCPD, especially those in crisis. Specific, focused goals in helping the individual accommodate to change can be accomplished in a limited number of sessions, generally 10-20. Suess suggested that focusing on validation of the patient’s current feelings will help to relieve guilt, self-doubt, and fear and that growth and change are possible within the limits of short-term therapy.
In one study of a 16-session brief therapy, moderate changes in personality, a decrease in negative and ambivalent self-references, and an increase in positive self-references were reported. Procrastination and narcissism also decreased. Because long-term psychotherapy is becoming less available for many patients, further study of the efficacy of brief therapy for OCPD is indicated.
Some authors report a favorable response in OCPD patients treated in the group setting. Confrontation of the patient’s defenses may be more effective in group therapy settings than in individual treatment. Issues that can be confronted in the group setting include modification of cognitive style, assistance with decision making, modification of harsh superego, increased comfort with emotional needs, increasing comfort with affective experience, resolution of control issues, and modification of interpersonal style. Advantages of group therapy include a diffusion of power among group members, which lessens the potential for the “tug-of-war” that is common in individual treatment, as well as an opportunity to develop trust in a number of group members.
Group consensus and peer pressure may lessen resistance. The emphasis on here-and-now interaction among the group members brings conflicts to life. The therapeutic process within the group, with its potential for alternating roles, helps to increase patient flexibility.
Cognitive and Behavioral Therapy
Although much of the data on cognitive treatment have focused on affective illness, exploring the exaggerated perception of risk in obsessional patients may be helpful in diminishing their anxiety (Hamilton and Alagna 1984). Various behavioral treatments, especially exposure with response prevention, have been very efficacious in the treatment of rituals in OCD patients. In patients with obsessional thinking without compulsive behaviors, this treatment is much less useful. Because the thinking of patients with OCPD tends to be ego-syntonic and not intrusive, behavioral approaches do not appear to be helpful.
Dynamic Psychotherapy and Psychoanalysis
Individual psychodynamic psychotherapy or psychoanalysis continues to be the treatment of choice for patients with OCPD. Although formal outcome studies evaluating the efficacy of these treatments have not been carried out, decades of good experience with these admittedly time-consuming approaches have persuaded most clinicians of their value.
Indirect and uncompelling empirical support for this treatment derives from Winston et al., who described 25 patients with Cluster C disorders who were treated with dynamic therapy for a mean length of 40.3 sessions. Although many patients will require longer treatment, those in this sample improved significantly by all measures compared with others on a waiting list. Follow-up at an average of 1.5 years showed continued benefit. In an uncontrolled study, Barber et al. reported on 14 patients with OCPD treated with 52 sessions of time-limited supportive-expressive dynamic psychotherapy. By the end of treatment, only 15% of the patients retained their diagnosis.
Revision date: July 5, 2011
Last revised: by Jorge P. Ribeiro, MD