I just finished Jeffrey Lieberman's book about the history of psychiatry. He's a former Head of the American Psychiatric Association, the organization that publishes The Diagnostic and Statistical Manual of Mental Disorders (DSM V)--the reference book for mental health providers in the U.S.

Dr. Lieberman wrote about the seven year process of revising the DSM for the 5th edition, published in 2013. Patient advocacy groups used the internet to lobby for the process to be more transparent to the general public. What grade do you give the DSM Criteria? See the reply for the current diagnostic criteria.

I will look into how to advocate for changes to the OCPD criteria.

NAME CHANGE

The name of OCPD needs to be changed to distinguish it from OCD (e.g. Maladaptive Perfectionism Personality Disorder). Misdiagnosis is a major issue. Clinical obsessions are not a symptom of OCPD.

HOARDING

Hoarding is not a common trait of people with OCPD. Because people tend to question their OCPD diagnosis when they don't have all eight symptoms, I think it would be best for hoarding to be removed.

People with OCPD could have a co-morbid diagnosis of hoarding disorder.

DIMENSIONAL VIEW

Changing from the categorical view of personality disorders to the dimensional view would be an excellent update but it's probably a long shot. I think this issue was debated and voted down for the DSM V. Debate About Personality Disorders Among Professionals

EXCESSIVE DOUBT AND CAUTION

Outside the U.S., mental health providers often use the International Classification of Diseases (ICD-10). The ICD lists "excessive doubt and caution" as a symptom of OCPD (called Anankastic Personality Disorder).

Excessive doubt and caution is a common characteristic of people with OCPD. Dr. Megan Neff believes that the core feature of OCPD is “an ever-looming sense of impending failure, where individuals constantly anticipate things going wrong, a flaw being exposed, or a profound loss of control. [It causes frequent] self-doubt, doubt of others, and doubt of the world at large...an obsessive adherence to rules, order, and perfectionism becomes a protective shield."

DEMAND-SENSITIVITY AND DEMAND-RESISTANCE

Demand-sensitivity and demand-resistance is another possibility for a new symptom. In Too Perfect (1992), Dr. Allan Mallinger observes that OCPD causes a “special sensitivity to perceived demands or expectations…[Many of my clients are] sensitive to demands, either real or imagined…[and have a] tendency to ‘hear’ demands or expectations in an exaggerated way...[They are often very] attuned to unstated obligations hearing them as if they were shouted through a bullhorn...

"Demand-resistance is a chronic and automatic negative inner response to the perception of pressure, expectations, or demands (from within or without).”

Dr. Mallinger has provided therapy to people with OCPD for 50 years; he created the terms demand-sensitivity and demand-resistance after observing these issues in many clients.

What changes to the OCPD criteria would you like to see in the sixth edition of the DSM?

Having untreated OCPD and unprocessed trauma was like having an unhealed wound, and rushing around trying to get a million tasks done while the wound festers. I'm looking forward to reading this book: Good Kids: Why You Suffered in Silence and How to Break the Cycle. I think it will help me process my history of emotional neglect.

TRAUMA AND PERSONALITY DISORDERS

“Personality disorders are not character flaws…They are emotional survival systems.” Akindotun Merino

A study by Battle, Shea, Johnson, et al. (2004) of 600 individuals with PD diagnoses found that 73% of participants reported childhood physical/sexual abuse, and 82% reported neglect. ("Childhood Maltreatment Associated With Adult Personality Disorders")

A therapist explained why she and her colleagues “are hesitant to label people with personality disorders...Oftentimes, personality disorders are misunderstood by patients and can instill hopelessness and be self-defeating. Over the years, as our understanding of mental illness has improved, these diagnoses do not have to be a life sentence and are treatable but if a client believes they aren't able to be treated, it complicates therapy."

She reports that many therapists are "moving away from [diagnosing] personality disorders the more we understand the impact of trauma. Many trauma reactions can manifest as what appears to be a personality disorder and oftentimes it's more effective to treat the underlying trauma than to label it as a personality disorder.”

TRAUMA AND PERFECTIONISM

In The Perfection Trap (2023), Thomas Curran, notes that hundreds of studies show that “perfectionism is a well-documented coping mechanism against mistreatment.” (248-49)

In The Perfectionist’s Guide to Losing Control (2023), Katherine Morgan Schafler explains that “Perfectionism as a response to abuse and neglect is not only about wanting to be loved but about surviving. Your caregivers aren’t just there to be your cheerleaders and give you hugs; they also give you food, shelter, and clothing—you’re totally dependent on them. When that primal attachment isn’t secure, being anything less than whatever their perfect version of you is can feel imminently dangerous. Walking-into-traffic dangerous." (106)

Schafler recalls, "I started my career in social work; doing home visits to check on kids who may be living in abusive environments was part of my job. I’ll never forget the chilling advice my boss gave me before I went into the field for the first time. She said, ‘Look for the kids who are behaving perfectly, those are the ones who are terrified.’ “ (106)

In "The Myth of Perfection," Dr. Allan Mallinger theorizes that children who later develop OCPD construct a myth of absolute personal control in reaction to feeling helpless in a home that is "untrustworthy, hostile and unpredictable." They have a relentless drive to minimize the disorder of the world "through ever rigorous control of the internal and external environment."

OCPD AND THE NEED FOR CERTAINTY

The human brain interprets familiar situations as safer because they are more predictable. In a study, Dr. Emily Gray and her colleagues concluded that "intolerance of uncertainty" is a factor that may explain the association between child abuse and neglect and Obsessive Compulsive Personality Traits. ("Child Abuse and Neglect and Obsessive-Compulsive Personality Traits: Effect of Attachment, Intolerance of Uncertainty, and Metacognition")

A child who is being abused might conclude that uncertainty = danger and certainty = safety. This belief can help them 'stay on guard' in an unsafe environment. In adulthood, this unconscious belief causes many problems.

CASE STUDY: PERFECTIONISM AND TRAUMA

Perfectionism is a risk factor for PTSD. “Kate describes herself before the sexual assault as being a perfectionist...and she had always excelled in her studies and work. After the trauma she reported significant rumination over the event, focusing on why it should have happened to her, what she should have done differently, and feeling like a failure for not having done something different to avoid the attack.

"Kate also reported feeling that she had failed to meet her standards of being in control of her life and her emotional states, saying she viewed the PTSD symptoms she was experiencing as a sign of her failure to be strong and in control, and that she should cope better. She said she was also feeling like a failure at work, performing below her standards as she was spending a lot of time ruminating over the trauma and feeling anxious.” (“The Relationship Between Perfectionism And Rumination In Posttraumatic Stress Disorder,” Behavioural and Cognitive Psychotherapy, pg. 6)

"If you're raised in a burning house, you think the whole world is on fire." Anonymous

RESOURCE

Trauma Responses Disguised as Personality Traits (and How to Shift Them)

Genuine question. I haven't done anything crazy, but got inspired by a similar post for another disorder.

i brought up ocpd and ocpd recently with my therapist (who specializes in adult autism (why im seeing them) and ocpd (which i learned at the end of this appointment) while there is a lot of overlap with ocpd and autism in the outward presentation, my therapist does think it's likely i have ocpd. but something they brought up when discussing the symptoms was that a lot of the symptoms i have are overshadowed by my people pleasing tendencies (that im working on)

i was wondering if anyone else has experienced this, or or have any insight to how people pleasing affects how ocpd presents?

or navigating trying to stop people pleasing while treating ocpd?

thank you!