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Section 17
Obsessive Compulsive Disorder

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PERSONALITY CLASSIFICATIONS AND OCD
As you may know, many people who have Borderline Personality Disorder also suffer from obsessive compulsive disorder. THE DSM-IV DIAGNOSTIC manual used by mental health professionals in the United States contains a set of diagnoses called personality disorders that are applied to people with long-term maladaptive patterns of thinking and behaving. Many of the labels are well known: paranoid, hysterical, psychopathic, narcissistic, and, yes, obsessive-compulsive.

You probably recognize what obsessive-compulsive personality disorder is like. It represents the extreme of what in general parlance is referred to as obsessive-compulsive behavior. It describes the person who is perfectionistic, punctual, aloof, and inflexible, when severe obsessive-compulsive personality results in a sort of malignant fussiness. One patient of mine timed family members every time they showered, yelled when anyone put a fork in the dishwasher with the prongs facing down, and insisted on saving the carpet by having family members walk up and down the stairs on newspapers.

Until recently, the unquestioned assumption among mental health professionals has been that obsessive-compulsive personality leads directly to obsessive-compulsive disorder. That is why, of course, they were both referred to as obsessive-compulsive in the first place. The two disorders were thought simply to represent different levels of severity of the same basic problem; the rigidity and inflexibility of obsessive-compulsive personality was thought to cause by unconscious mechanisms the obsessions and compulsions of OCD. When I was in training there was no doubt about this link. Yet, although this theory is still cited in newspapers and magazines, the fact is that experts in the field no longer believe it.

First of all, researchers have found that obsessive-compulsive personality is not, after all, a necessary condition for the development of OCD. Recent studies suggest that obsessive-compulsive personality disorder is not even the most common personality disorder that is found among people who have OCD. A 1993 study by Russell Noyes and colleagues at the University of Iowa, for instance, found that although 80 percent of OCD patients suffer from personality disorders, it is dependent personality disorder-fear of decisions, under-assertiveness, excessive leaning on others-that is present in more than half of patients. This finding agrees with what is found in clinical practice. Instead of being detached and emotionally cool, as are people with obsessive-compulsive personality disorder, OCD patients are nervous and clinging.

Secondly, the idea that OCD is caused by any personality disorder has been called into question. In a 1992 study at Harvard, Michael Jenike and his colleagues looked at seventeen patients who were diagnosed as having both OCD and personality disorders. Ten of these patients responded well to medications and behavioral therapy for their obsessions, and when tested again after treatment, nine of the ten no longer had their personality disorders. What these findings suggest is that when people with OCD have personality disorders, it may well be the obsessions and compulsions that are causing the personality problems, not the other way around.

Studies such as these cause mental health professionals to question whether the diagnoses referred to as personality disorders are truly valid and reliable. Other approaches to personality may be better. One well-researched new scheme for describing personality is that introduced in 1987 by Dr. Robert Cloninger, chairman of the Department of Psychiatry at Washington University in St. Louis. I like Dr. Cloninger's approach and so do my patients. It's easy to understand, and it doesn't involve negative labels, such as "hysteric" or "paranoid."

THE TRIDIMENSIONAL PERSONALITY THEORY
In it's simplest form, Dr. Cloninger's model suggests that most of the important differences between our personalities may be accounted for by three key qualities or dimensions: harm avoidance, novelty seeking, and reward dependence.

"Harm avoidance" refers to the urge to escape from unpleasant experiences. People low in harm avoidance tend to be carefree, confident, relaxed, optimistic, uninhibited, outgoing, and energetic. Those who are high in harm avoidance, on the other hand, tend to be timid, inhibited, apprehensive, tense, shy, easily fatigued, and pessimistic about the future.

"Novelty seeking" describes a capacity to be exhilarated by new experiences. Everyone likes excitement now and then, but people who score high in this dimension live for it. They are impulsive, fickle, quick-tempered, extravagant, and disorderly risk-takers. Daredevils fit here. Those who are low in novelty seeking are reflective, loyal, stoic, slow-tempered, and orderly. They're good scouts.

"Reward dependence" refers to the need to be reinforced by approval from others. Those on the low end of this personality dimension tend to be detached, emotionally cool, practical, and tough-minded. People high in reward dependence are sympathetic, eager to help, and sentimental. They're people-pleasers.

Consider some of the combinations. A person who is low in harm avoidance, high in novelty seeking, and low in reward dependence is fearless, impulsive, explorative, and doesn't care what people think. In the extreme this is the criminal personality type. Think Charles Manson. If reward dependence is changed from low to high while the other two factors stay the same, then a person is impulsive and explorative but also emotionally vulnerable. He or she craves activity and excitement but needs positive feedback. This is the attention-seeking, dramatic, gullible individual; perhaps an example would be Marilyn Monroe. Each of the combinations of Cloninger's traits corresponds to a recognizable character.

OCD sufferers, according to Dr. Cloninger's theory, are high in harm avoidance, low in novelty seeking, and high in reward dependence. Recent studies from the universities of Iowa and Toronto have confirmed the strong correlation of OCD to high harm avoidance and low novelty seeking. There is suggestive evidence tying OCD to high reward dependence. OCD sufferers are timid, sentimental, good scouts, people-pleasers. That description fits a surprisingly large number of my OCD patients.

The term harm avoidant fits me to a T. Novelty seeking? When I was a child, my family visited New York City. My brother wanted to see Broadway; I wanted to stay in the hotel room and play cards. My brother is now in the foreign service; I'm living in my hometown. And reward dependence? I can't remember even once making my parents mad at me. This is simply the typical personality pattern of the person who develops OCD.

Of considerable value in Cloninger's personality classification scheme is the fact that, for the first time, personality types have been connected to brain chemistry. Correlations are introduced between, for instance, harm avoidance and the level of the neurotransmitter serotonin; between novelty seeking and the neurotransmitter dopamine. This link allows patients to gain an appreciation of the interrelation between OCD's psychological roots and the biochemical causes of the disorder.
- Osborn, Ian, Thoughts and Secret Rituals: The Hidden Epidemic of Obsessive-Compulsive Disorder, Pantheon Books: New York. 1998.

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Personal Reflection Exercise #10
The preceding section contained information about obsessive compulsive disorder. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 17
What are the three key components in the tridimensional personality theory for a client diagnosed with OCD? Record the letter of the correct answer the Answer Booklet.