Recognizing OCPD can be complicated. So in this episode, Dr. Ramani decodes the criteria that mental health professionals use to diagnose this personality disorder. These are the features of OCPD you need to know.
Transcript featuring Dr. Ramani Durvasula
Kyle Kittleson: We use the DSM to actually define what these orders are. Can you briefly explain what the DSM is and how that works?
Dr. Ramani: Yeah. The DSM is the Diagnostic and Statistical Manual of Mental Disorders that’s put out by the American Psychiatric Association. It gets updated anywhere from every five to eight years as more research comes around and we learn more about how these disorders move and get treated and what they look like, and so on and so forth. So, in the DSM, they describe the personality disorders. And there’s some shift there. They’re changing how we’re even looking at some of these diagnostic formulations. But what the DSM does is basically, it gives us the list of all the symptoms, and it says, “You need to have this many symptoms for this much time. You got to make sure it’s this, and it’s not that.” And then you go through it. We spend years and years and years getting trained in its use.
I’m not going to sit here and say it’s absolutely right. Like all documents like that, it has its flaws. But it’s what we use. And just to give all of our MedCircle members a context is that also there is a diagnostic manual that’s called the International Classification of Diseases. We’re now in the 10th version of that book. That’s put out by the World Health Organization.
For most diagnoses, the ICD-10 and the DSM-5 overlap in terms of mental disorders. There’s a few variants here and there, but some people might say, “Wait a minute, I get this weird statement from my therapist, and it has this ICD-10 code. Is that wrong?” No. In fact, insurers require ICD-10 codes. But the manuals are very similar. They represent years of research. And it’ll change, and it’ll change, and it’ll change over time. So, that’s it.
Kyle Kittleson: So what does the DSM say about OCPD?
Dr. Ramani: Okay, when we look at a personality disorder, like OCPD, there’s going to be sort of two ways we’re going to think about this. One is the old-school way. They list eight characteristics, and you have to get four or five of them to get [inaudible]-
Kyle Kittleson: That’s the way I like.
Dr. Ramani: That’s the way you like. But DSMs gone in a new direction that I do like.
Kyle Kittleson: Okay.
Dr. Ramani: And what they do is they’re looking at impairments and how the person identifies from the perspective of the self and how they function interpersonally. And within those two areas, self and interpersonal functioning, they look at specific areas. So under self, we look at identity, and we look at goal direction. Under interpersonal functioning, we look at empathy and intimacy. And we look at impairments across these areas.
So when we look at something like OCPD, and the kinds of impairments we might see, for example, in identity is that they derive too much of their identity from productivity, the things they do, the way they manifest themselves, whether at work, whether in their home. It’s like their identity is not them. It’s their organized house or their very, very busy, busy career.
When it comes to their sense of goal direction, their goals are overly informed by work and productivity. Many of us have goals of, “I want to be happy. I want a balanced life. I want to be there when I have grandchildren.” Theirs will be like, “I want to meet this deadline, and I want to get this award, and I want to stay at this company this long. And I want to start this many companies.” It’s very work-oriented.
When we move into the interpersonal realm when we talk about OCPD, when we talk about patterns of empathy, their empathy is often somewhat restricted. Because they are so focused on their rigid worldview that they often miss their mark with other people because they want things to follow their rules, their order, their control.
Kyle Kittleson: That makes sense.
Dr. Ramani: That it will not be experienced as empathy by other people. It may not be truly a lack of empathy per se, but if it’s getting in the way of what their rigid rules of order, they’re not going to take the time to recognize what that other person’s needs are. And regarding intimacy, people with OCPD actually have a relatively restricted range of intimacy. Work gets in the way of getting into close, intimate relationships. So in other words, work is always going to win.
So if they’ve got a deadline, “We’re canceling the vacation.” They’ve got work to do, “We’re not going to have sex.” So it’s very much work getting in the way. Productivity, work, orderliness, and even a sense of a morality can even get into that. Is this right? Is this wrong? Their miserly cheap quality can make it difficult to get close to other people because they’ll often make it almost seem somewhat transactional. Like, “Well, you did this for me. I’ll do that for you, but you have to do this. And it costs me this much. And this month I paid this much rent, so I expect this. We’re not going to go out to dinner because you actually owe me this much money.” It feels icky, so that really curtails that space of intimacy.
Now, when we go back to that old-school way where we list the symptoms, you have to get four or five of those symptoms to qualify. As with any DSM diagnosis, we are looking for the fact that these people are experiencing social and occupational impairment or experiencing significant distress that they themselves are uncomfortable. Okay?
Kyle Kittleson: But what if they don’t feel like there is an impairment, and they don’t feel distress?
Dr. Ramani: Then, you don’t diagnose them.
Kyle Kittleson: Then you can’t diagnose them. So even if all the writing is on the wall, your marriage fell apart, your kids don’t talk to you, and you’re like, “I don’t care because I’m doing great at work.”
Dr. Ramani: The only way we can extend that reasoning a little bit, and when you look at the work of like real architects of the DSM, like Dr. Allen Frances, who is a psychiatrist, they’re going to take the stance that if a person’s marriage has fallen apart, they’re estranged from their kids, and all they do is work, that is a social impairment because all these social relationships have gotten damaged. But a really orthodox person might say, “They don’t think it’s an impairment.” You see? So what I’m saying, we may have to make a bit of a subjective judgment. The pattern is there. The pattern’s not healthy. The pattern’s maladaptive.
Kyle Kittleson: Pattern, pattern, pattern, pattern. Yeah.
Dr. Ramani: That’s the bottom line.
Kyle Kittleson: Okay. Good for me. I was thinking that out of all of the series I’ve shot with MedCircle, I think this is the first time money and an attitude towards money has come up in a disorder. Am I wrong?
Dr. Ramani: Yeah, a little bit because I would say that it definitely played a role in things like narcissism and, in some degree, antisocial personality disorders.
Kyle Kittleson: But is it in the DSM?
Dr. Ramani: It’s not in the DSM. That’s a good point.
Kyle Kittleson: This is listed on the DSM.
Dr. Ramani: Yes, you are right. And there is some controversy sometimes about whether that miserliness piece, what does something we statistically call load on the whole diagnosis. Some people feel like the miserliness doesn’t it doesn’t again, statistically fit as well as some of the other symptoms. But, as of right now, in 2019, it’s on the list. So you’re right. But it’s an attitude about money. You’re right. It’s a miserly attitude about money, and that the money represents control, the money represents something else. And so it’s like they’re hoarding the money. These are folks who keep saving their money for some future day that never comes. So, they’ve got money everywhere. And then, in fact, as these people get older, people will be like, “Oh my God, how is it that you have so much money in the bank? You wouldn’t even buy this kid something for their birthday, and you got two million in the bank. It’s because they were really miserly.
Kyle Kittleson: Yeah. Yeah.
Dr. Ramani: So, that’s why.
Kyle Kittleson: Okay. So that is the four areas that are currently going on.
Dr. Ramani: Yeah.
Kyle Kittleson: Now, what about, is it eight or nine actual traits?
Dr. Ramani: It’s eight.
Kyle Kittleson: Okay. Can we go through those?
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1. Preoccupation with Details & Order
Dr. Ramani: Yeah. The first one is that these are people who are preoccupied with lists and order and organization to such a degree that actually the original point of the activity is lost. So, these are the people who will create color-coded alphabetized filing systems and spend months on it, and then they’re not even clear why they did this. And they’ll put up some incredible bulletin board with all these color codes on it, and then the time will have passed for this thing to happen. So, there’s a tremendous inefficiency, but they actually do literally get preoccupied. They will spend hours. They’ll stay up late. And again, it can look virtuous to the world, but they’re working hard on something that often as, I often view it, they lose the plot.
Kyle Kittleson: Yes. Yeah. I get that. All right, what about number two?
2. Perfectionism Interfering with Task Completion
Dr. Ramani: Okay. The second criteria is really perfectionism, and their perfectionism gets in the way of getting a task done. This is an interesting criterion in OCPD because perfectionism is just that. In some ways, it’s almost like a form of self-sabotage. The person says, “I won’t hand in my paper until it’s perfect.” So then they don’t hand it in on time, and then they get an F. And this can happen in a deadline at work. It can happen in a lot of ways. So, the perfectionism becomes the obsession, and then they don’t get the task done because they’re so focused on getting it perfect, whatever it may be. It may be a creative project. It may be a work project. It may be a school project. But again, it’s that perfectionism getting in the way of task completion.
3. Neglects Other Areas of Life for Work
So the third is that they’re excessively devoted to work and productivity to the neglect of other activities in life, such as social relationships and other things that matter in life. And it’s time. They’ll work weekends. They’ll work late. They’ll work at home. They work all the time. And not necessarily because they have to. That’s the key. Because someone might say, “I am working two jobs because that’s the only way I can…”
Kyle Kittleson: That’s right.
Dr. Ramani: Because I have to pay the mortgage. That’s a different conversation. Okay? It’s a necessity. That person says, “If tomorrow somebody gave me the money, I’m out. I’m done. I’m doing this because I got to pay tuition and this and that.” This is really that person who is devoted to productivity and work above all else. This is the mom who spends more time decorating the house for the holidays than actually playing with her kids.
Kyle Kittleson: Right.
Dr. Ramani: It’s like that.
Kyle Kittleson: And these people are working, but correct me if I’m wrong, not even that efficiently.
Dr. Ramani: Not efficiently. So that doesn’t help either.
Kyle Kittleson: Right.
Dr. Ramani: Right? Because they’re slow at it. I mean, it is sort of lovely to collaborate with them because they’ll be able to pull that color-coded binder off the shelf, but time goes by. Time goes by.
Kyle Kittleson: Okay. So that’s one, two, and three. What about number four?
4. Overly Conscientious about Minor Rules
Dr. Ramani: The fourth is that they’re over conscientious about matters of morality. They’re scrupulous about what they think is the right way. And the DSM makes it very clear that this is not otherwise accounted for by cultural or societal standards. So, for example, there may be cultures in the world where there are very rigid rules of order around how a certain gender can behave or whatever other rules of order they may have. That’s not what we’re talking about here. These are people who are really over conscientious about a certain viewpoint or pattern or rule that has to be followed without exception.
Kyle Kittleson: Could you give an example of that?
Dr. Ramani: You are at a table at a place to eat, and some people are getting the buffet and some people order à la carte. And one of the à la carte people tries to take a dessert off of one of the buffet people’s plate. A person with OCPD would say, “You’re stealing. They were very clear that the people who get the buffet can only eat the buffet, and if you get à la carte, you cannot eat this. So if you want cheesecake, you’re going to need to order your own cheesecake because I don’t want to get in trouble because you ate my cheesecake.”
Kyle Kittleson: Wow. Okay. All right.
Dr. Ramani: That’s what I’m talking about.
Kyle Kittleson: All right.
Dr. Ramani: Very much are like, “We absolutely cannot park there.” And it’s a Sunday, and it’s a bank. The sign says, “Parking only for the bank.”
Kyle Kittleson: That’s a stressful way to live.
Dr. Ramani: Yeah.
Kyle Kittleson: Yeah.
Dr. Ramani: Yeah.
Kyle Kittleson: Okay. Number five
5. Unable to Discard Worn Out or Worthless Objects
Dr. Ramani: Number five’s an interesting one because it almost feels a little bit like what we see in hoarding disorder, which is they’re unable to discard worn-out or worthless objects. And it has nothing to do with sentimental value. Okay? So these are people who will keep old T-shirts, old jeans, old dishes. The difference between them and a hoarder is they will store it up in an organized way. So you’ll find they will get storage units, and the storage unit will be off alphabetized, “Jeans from the 1960s.”
Kyle Kittleson: Oh my goodness. Okay, so we know where those are.
Dr. Ramani: “Old Mickey Mouse T-shirts.”
Kyle Kittleson: But why are they keeping them?
Dr. Ramani: I know that MedCircle will be featuring a series on hoarding, so MedCircle members can tune in to see some of the similarities and differences. But we do know that hoarding is a decision-making issue. A lot of what’s around hoarding is they have trouble getting around the emotion and realizing that an old broken lawnmower can be thrown out. Because emotion gets in the way, they get overwhelmed, they keep the object. So in the case of OCPD, there is this sense of it’s not the magical thinking of OCD like “If I throw this out, something terrible’s going to happen.” Or “I’m throwing away a memory or something.” It goes back a little bit to some of the miserliness we’ve been talking about that, “I may need this, so I’m keeping it. We may be able to use these for a costume one day.”
Kyle Kittleson: Yes.
Dr. Ramani: It’s that sense of this could be useful. It’s almost a very reasoned rational, even though it is irrational because they’re now paying all this money for a storage unit or something like that to store all this stuff. But it’s not in this sort of overtaking the environment, chaotic, overwhelming way. It’s just silly. Yeah.
Kyle Kittleson: I understand that. All right, that was number five.
Dr. Ramani: Five.
Kyle Kittleson: Okay, so what about number six?
6. Intense Reluctance to Delegate Tasks
Dr. Ramani: Number six gets at this idea of their unwillingness to delegate tasks and responsibilities to other people. They’re reluctant to delegate tasks because they don’t feel like anyone else can do it right. So they’ll try to do everything themselves. And if you do do it, they’ll fix what you did. So they might as well have done it themselves in the first place. So when people say, “Can I help?” They’ll be like, “No, no, I got it. I got it.” And even in a workplace, they’ll say, “How about you delegate the budgets over to Joe,” and he won’t trust Joe to do it right. So he’ll stay until midnight and do it himself. There’s even sometimes a little risk of a martyr thing going on then like, “Yeah, Joe, can’t do it, so I’m going to stay late.” But they won’t delegate. And again, that contributes to the inefficiency because they’re really not someone who should be writing the budget.
Kyle Kittleson: And that is their identity.
Dr. Ramani: That’s their identity.
Kyle Kittleson: “I’m the guy who stays until midnight to make sure it’s done right.”
Dr. Ramani: Yeah.
Kyle Kittleson: You know, a lot of these, I’m thinking, would be terrible traits to have if you were trying to start a business.
Dr. Ramani: Oh yes, absolutely. And yet many people like this do try to start businesses.
Kyle Kittleson: Exactly.
Dr. Ramani: Yeah.
Kyle Kittleson: Exactly. Yeah. That’s been sticking out in my head a lot. Okay, two more to go. Number seven.
7. Miserliness – Excessive Desire to Save Money
Dr. Ramani: Number seven gets back to that miserly style we’re talking about. They’re miserly not only in spending on others, even about themselves. So they’ll be wearing the same shoes from 1984. They’ll be wearing clothes from a long time ago. They’ll still have a pot or a pan with a loose handle that was 30 years old. And it’s not just frugality because sometimes we admire that. Right? We live in a very throwaway society. But the thing doesn’t work very well. So they don’t spend on themselves. They don’t spend on others, which can feel sort of uncomfortable and icky for people near them at a time when someone expects even a token gift like a birthday or Christmas or Hanukah or any holiday gift, they really don’t produce. And when they do, it’s begrudgingly and often really suboptimally.
And it’s miserly about everything. It’s about going out to dinner. It’s about vacations. They really do hoard money for a future emergency or event.
Kyle Kittleson: And that never comes?
Dr. Ramani: And then, like I said, then that never comes. Then they’ve missed life. And they now, may be very old and have a lot of money or they just never spent their money.
Kyle Kittleson: Is it a fear of not having money later?
Dr. Ramani: There’s an anxiety theme that runs through OCPD for sure. So it may very well be a fear. It could also be control. When you’ve got money, you’ve got control.
Kyle Kittleson: Control. Yeah.
Dr. Ramani: And control and anxiety are kissing cousins. They go together. They match. But it does feel like it’s more of a control thing. And they will sometimes use money as a tool of control. But it feels miserly. It feels scroogie. It feels uncomfortable. And getting into conversations about money with them doesn’t feel good.
Kyle Kittleson: If they have a child and the child gets into a college, and they have the money to pay for it, is that something that they would likely spend money on? Or is that something they’d say, “Look, that’s an expensive college. You need to figure it out yourself.”
Dr. Ramani: Yeah. Yeah, I think that in more cases than that, if you really did have some of a full-blown OCPD, they might take the attitude of, “Well, I told you I’d give you enough for a state school, so here’s that $5,000.” And that other school is 65,000, but this person has plenty of money, they may still expect their child to take on loans. And listen, that’s what I’m saying. In our culture, we sometimes view that as virtuous. Make the kid take responsibility.
Kyle Kittleson: Yeah, work your way through [inaudible].
Dr. Ramani: But, now you can afford it, your kid’s now holding a quarter million or more in student loans. So it can, again, it can make people very uncomfortable because “I feel like I’ve been such a good family member with this person. It’s been a shared journey, and they’re hoarding this money.” Who knows, maybe they have a fantasy that they’ll live forever if they’ve got it. I don’t know. But it is very uncomfortable. It sets a very uncomfortable tone to all kinds of relationships, even in work. They’ll be miserly about spending at work. People will say, “Could we rent a better office? We’re not all fitting.” “No, no, no, no, no.” And you’ll see that the business may not be able to grow because of that miserliness.
Kyle Kittleson: The hypocrisy there, if that’s the right word, is crazy because these people work so hard, and they want so much, and they want to keep all this money, but this investment that would possibly grant them all of that, they won’t make.
Dr. Ramani: But you’re focusing on the wrong thing. It’s the work as a day-to-day process versus the big vision.
Kyle Kittleson: [inaudible].
Dr. Ramani: They’re not narcissists. They don’t have the big grandiose vision. It’s about the treadmill of it all. It’s about doing the work, making the binders, filing it, like that. It’s the drudgery piece of it that they get stuck into. They’re not visionary, not by any stretch.
Kyle Kittleson: Understood. All right, last one.
8. Rigidity & Stubbornness
Dr. Ramani: The last one is actually probably one of the crowning qualities, which is rigidity and stubbornness. They’re rigid. They’re rigid in everything. They’re rigid in matters of morality. They’re rigid on “We said we’re going to this restaurant. This is the restaurant we’re going to.” They won’t budge. They’re very stubborn. Once they get a point of view, they stick to that point of view no matter what. Sometimes people admire their conviction. They’re like, “Wow, they are not budging.”
Kyle Kittleson: They really believe that. Yeah.
Dr. Ramani: But you can get stuck. I mean, times change. People change. Life requires a certain amount of flexibility. We associate flexibility with resilience. And in this way, OCPD is a pattern that really suggests a sort of lack of resilience.
Kyle Kittleson: How many of these do you have to have?
Dr. Ramani: At least four.
Kyle Kittleson: Okay.
Dr. Ramani: You could have all eight, but you have to have at least four.
Kyle Kittleson: Is one that you would say really represents the disorder more than the other traits?
Dr. Ramani: I would say it’s the first one. It’s the preoccupation with order to the point where the activity gets lost. Because that could apply to home. That could apply to work. There is this inefficient workplace preoccupation. I’d say that and then followed by interestingly the last one, the rigidity and the stubbornness.
Kyle Kittleson: Okay. Well, the screening process will be fascinating to learn about what happens when someone actually gets that diagnosis of OCPD. Dr. Ramani, when we come back.