Practical considerations often make full psychoanalysis for patients with OCPD impossible, but for correctly selected candidates, extended psychoanalysis (five times per week) is highly desirable. Indeed, many, if not most, experienced psychoanalytic clinicians agree with Fenichel’s (1945) judgment that psychoanalysis is the treatment of choice. Patients who lack the capacity to distance themselves from transference developments and to subject them to reality testing are not suitable for full psychoanalysis, which is more stressful than dynamic psychotherapy. Successful psychoanalysis requires a good capacity for forming a therapeutic alliance that will stand up under the strain of treatment. A preliminary trial of dynamic therapy is indicated when the sturdiness of the patient is in doubt.
The basic principles of psychoanalysis in treating OCPD patients are similar to those of psychodynamic psychotherapy, but the more intensive engagement of full psychoanalysis offers definite advantages. In psychotherapy, a full transference neurosis is not likely to emerge, and the therapist contents himself or herself with working with those transference fragments that appear over the course of the work. Although working with an incompletely organized transference can lead to positive results, the fact remains that anything short of full transference analysis (transference is the major resistance in both of these treatments) leaves substantial portions of the work incomplete.
Although psychodynamic psychotherapy can go far in clarifying the patient’s typical maladaptive patterns of defense, the understanding of the underlying dynamic forces that give rise to the symptoms in the first place is likely to remain excessively intellectual. Complete psychoanalysis offers the patient the opportunity to enter fully the depths of the transference experience. The deeper conflicts, deriving from the triangular family phase of the patient’s childhood (the Oedipus complex), are activated in an emotional way in psychoanalysis, so that the therapeutic reach, inasmuch as it is not only intellectual, is stronger and more profound. The cruel, hostile, controlling character attitudes that mark the OCPD patient arise from a defensive childhood regression driven by the oedipal child’s fearfulness, helplessness, and self-protectiveness. Psychoanalysis offers the opportunity to recover these feelings, to repeat them in the transference, and to work through them in a unique way.
OCPD, although often confused with OCD, is a distinct disorder characterized by a pervasive pattern of rigidity and inflexibility. Interpersonal and work relationships suffer as a result of the need to control and the preoccupation with perfection.
Treatment of this disorder continues to be primarily psychotherapeutic, in dynamic individual therapy, psychoanalysis, or intensive group settings, although well-designed studies of treatment outcomes are lacking. Further exploration of short-term psychotherapies is indicated.
Revision date: June 22, 2011
Last revised: by Andrew G. Epstein, M.D.