Therapy Can Work

Katherine Rabinowitz, LP, M.A., NCPsyA

Licensed Psychotherapist & Psychoanalyst
Union Square, Greenwich Village, New York, NY

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Therapy Can Work

Katherine Rabinowitz, LP, M.A., NCPsyA

Licensed Psychotherapist & Psychoanalyst
Union Square, Greenwich Village, New York, NY

Obsessive Thinking & Compulsive Behavior

Introduction

The terms “OCD”, and “anal”, (as in, “you’re so anal”) have become common in everyday speech in this country. While it is generally agreed that obsessive thinking means just what you’d think it means, thinking too much about some things, it is important to point out that two disorders exist with similar names. And while they share some characteristics (in both cases people tend to obsess and act compulsively), they are in fact very different from each other, having distinct symptoms and implications for treatment. Below, a brief definition of the two, followed by their primary differences, and below that, an elaboration of each disorder.

Obsessive Compulsive Disorder (OCD) is clinically defined as an anxiety disorder characterized by obsessive, distressing, intrusive and irrational thoughts, and is related to compulsions (tasks and rituals) that are performed repeatedly in an attempt to rid the self of the obsessions.

Obsessive Compulsive Personality Disorder (OCPD), also called anankastic personality disorder, is a personality disorder, characterized by perfectionism, rigid conformity to self-imposed rules and regulations, strict adherence to moral and ethical code, and a generally inflexible personality structure.

Differences & Similarities

OCD

  • Set of acute, uncontrollable intrusive, irrational thoughts, images or impulses that cause tremendous anxiety
  • Need to perform ritualistic actions in attempt to “neutralize” the anxiety
  • Acute and persistent anxiety from specific preoccupations that are seen as threatening
  • Recognition that the rituals make no sense, but feeling compelled to do them anyway
  • Can occur at any point in life
BOTH

  • Tendency to obsess and to act compulsively
  • Cause great anxiety
  • Interfere in varying degrees with life functioning
OCPD

  • Deeply embedded personality style of perfectionism and need to do things “the right way” causing levels of anxiety when not followed
  • No intrusive thoughts or need to perform ritualistic actions
  • Need to control self, others and external environment
  • Belief that the need for order, following procedures and their own moral code is normal and appropriate
  • Begins by early adult life

OCD

OCD, or Obsessive-compulsive disorder, is by far the more serious of the two, and, according to recent research, occurs in less than 5% of the general population. It interferes with everyday functioning in life because the rituals needed to quell the anxiety become increasingly time-consuming, and make it difficult if not impossible for the person to have a normal routine and social life. The onset can occur at any point in development, and it is a difficult disorder to live with, a cause for deep embarrassment.

While there is not common agreement about the cause of OCD, several theories are acknowledged as plausible, and there is evidence of a neurological origin. It is often found in families, so there is reason to infer a genetic connection. Also being researched are the possibility of a genetic mutation, abnormalities in certain areas of the brain and in serotonin, a neurotransmitter. It is not yet fully known if the occurrence of these abnormalities are the cause or the result of OCD.

The obsessions are not about real-life worries (financial issues, health problems, troubled family situations, etc.), even if these worries are excessive. Instead, they are irrational and (though many others exist), tend to be among a common cluster of symptoms:

These obsessions, which are experienced as intrusive and distressing in the extreme, come to dominate the person’s every waking moment. Even after it is unmistakably clear that there is no danger (the gas is definitely off and the door is manifestly locked), suddenly you’re not sure and have to go back one more time to check. Hence the epithet “disease of doubt”.

It’s no fun to be plagued by these recurring thoughts, and every attempt is made to ignore them or banish them. After all, they’re frightening, or disgusting, or clearly inappropriate. Most people with OCD know this (children are an exception). They know these thoughts make no sense. Sometimes, they even know that they are making them up. Yet they truly cannot help it. The thoughts come back, again and again and again.

They begin to cause such distressing anxiety, it cannot be ignored, so something has to be done. Some kind of ritual, usually acknowledged as absurd, is put into place to relieve the anxiety and make the obsessive thoughts go away. The belief is that if it is performed, it will prevent the bad thing from happening, and the thoughts will be suppressed.

These rituals are known as compulsions, because one is driven, or compelled to perform them. There is no choice. If they are not performed, the anxiety noticeably increases. Like obsessions, compulsions tend to fall into one of several categories of behaviors, and are often not realistically connected with the threat or danger they are designed to prevent. They can be mental or physical, and most commonly involve:

At first, the ritual works. The mantra is repeated, and, see? Mother didn’t die of a heart attack because you forgot to call when you said you would. The stove got checked four times so the house did not burn down, and saving all those newspapers so you could read the news kept the terrorists from attacking. Phew. It worked. But then, slowly the doubt makes its way back in, and next time, the prayer has to be repeated seven times, and the stove checked five times. There is no long-lasting feeling of reassurance or comfort. It’s always temporary, and more and more time and effort are required to feel relief. Everything becomes about these rituals. You must perform the compulsions to try to control the obsessions, but eventually they control you, even when they seriously interfere with daily life, or the anxiety is overwhelming.

Treatment is recommended if the disorder has progressed to such an extreme that it has an adverse effect in your life or those around you. However, since it is a disorder that tends to progress, early intervention is desirable. In advanced cases, medication is sometimes indicated.

I am not a physician and cannot prescribe medication. And though I prefer to first try working on the issues troubling you in a purely talk-therapy situation, if medication might be indicated, I will refer you for a psychiatric evaluation.

OCPD

OCPD (Obsessive compulsive personality disorder, sometimes called anankastic personality disorder) is what we refer to when we think of someone we call “anal.” It is a personality disorder and encompasses one’s general outlook and beliefs – an extreme exaggeration of a not uncommon “style” of being in the world. We all have styles, and an OCPD style can pay off – good grades, a strong work ethic, punctuality, reliability are not such bad things, generally speaking. A Type-A personality does not necessarily have OCPD. Here, too, it’s not really a disorder unless it’s so extreme and pervasive that someone has difficulty leading a normal life because of it. So what does an OCPD look like? Men tend to be more susceptible than women, and according to the DSM V (the Diagnostic and Statistical Manual of Mental Disorders) published by the American Psychiatric Association), the following are typical symptoms:

Contributing Factors

Though researchers have not pinned down a specific cause of OCPD, several factors have been identified as contributors. Like OCD, with which it shares some symptoms, OCPD can run in families, so a genetic link is possible, but has not been definitively documented. Some parenting styles can give rise to OCPD. In a family where even minor infractions are invariably punished and good behavior rarely if ever rewarded, and where emotional warmth is lacking, it is not surprising that a child’s sense of security and means of avoiding punishment comes from a rigid adherence to the rules. There are also religious and cultural influences. Some societies value certain traits which, in and of themselves may not necessarily be a cause for the disorder, but when combined with strict parenting styles and a genetic predisposition, could engender it.

Issues of Control

Taking a closer look, this person has a chronic preoccupation with rules, orderliness and control, and becomes very upset when not in control. It’s not only themselves that OCPD’s feel they need to control – it’s other people and their environment as well. Since that is generally impractical (if not impossible), an OCPD tends to be reluctant to allow others to do things, because they’re not going to do it right. (Guests, for example, can’t help out with the dishes because they’ll use the wrong sponge or too much water.)

“You have your way. I have my way. As for the right way,
the correct way, and the only way, it does not exist.”
~Friedrich Nietzsche

In OCPD, there are not generally obsessive and intrusive thoughts, and compulsions designed to repel them (though it is not unknown for someone to have both disorders). Instead, the disorder is fueled by anxiety over things not being or being done “right.” Their way of being has to conform to very strict self-imposed standards, and they genuinely believe their way is the correct way. They may accept that someone else does it differently, but it’s clearly inferior. In fact, it’s wrong. To OCPD’s, there are two ways of doing things: their way and the wrong way. There’s very little gray area, especially when it comes to morally perceived issues: it’s right or it’s wrong.

Doing things wrong (or seeing them done wrong) generates considerable anxiety, so part of what drives this person is the need to avoid being wrong. This personality is marked by rigidity and stubbornness. They are also often perceived by others as self-righteous, and difficult. To them, their way is so obviously correct that righteous indignation springs forth readily when matters are not conducted according to their inflexible expectations. They are often unusually deferential to those they consider worthy of respect, but utterly contemptuous of those they do not.

Work-Related Issues

They tend to be successful in the workplace. They are often workaholics, but not so much because they love the work. It’s because their need for control is so intense, they are unable to let go of it and delegate tasks to others. They’re the only ones who are going to get it done right. The perfectionism in these situations is about the anxiety generated when the rules are broken. Hence, they are micromanagers on the job, and seem to do best in situations where they work alone.

Not surprisingly, their success at work often comes at the expense of personal relationships, since their commitment and devotion to work preclude time (or ability) to relax. It is common for them to take work along on vacation, in order to avoid “wasting time.” Their inflexibility bleeds into their relationships. Their friends, family and significant others regard them as domineeringly rigid, because they are held to the same impossibly high standards. OCPD’s may withdraw emotionally or get very angry when not in control or things are not done as they feel so obviously “make sense.”

It is not unusual for people with OCPD to have difficulty expressing affection or tenderness. Emotion is communicated stiffly, if at all, and they can be oblivious to what this must be like for the people they claim to love. Being around emotionally expressive people (or those who are not in control of themselves, for example, by being drunk) can be very unsettling and uncomfortable.

Change Causes Anxiety

Change can be terrifying because it implies something unknown, which means giving up a sense of control, potentially a cause for anxiety. The OCPD feels absolutely comfortable doing the same things in the same order with the same objects all the time, and would rarely change the route to work by a single block, move the furniture around, or do something spontaneously. To feel safe it has to be planned in advance. And throwing out no longer useful objects (an old answering machine that uses cassette tapes, for example) even though they have been replaced, or buying something new simply because the old one is hopelessly out of style or shabby, is offensive to their sense of thrift and practicality. (What if we need it someday?)

Because the moral imperative is so deeply entrenched, people with OCPD, unlike OCD’s, do not feel their preoccupations are at all out of the ordinary or inappropriate. There is an intensity to their need to maintain control and do things the right way that can be off-putting to those around them, but it is not typical for them to recognize that, because it should be so obvious that this is how it should be done.

Though it can be a serious impediment to gratifying interpersonal relationships, OCPD is not clinically diagnosed as a disorder unless it has significantly interfered with making one’s way through life. Unless it causes problems professionally (such insistence on following the rules or getting it right that the task can’t be completed) or in a relationship (their inflexibility and difficulty with emotions make the partnership sufficiently ungratifying for the other), someone with an OCPD style might not need therapy.

Therapy is threatening per se to someone entrenched in this way of being because it implies change and change implies loss of, well, you get the idea. So who’s to say that a person content to remain single and dedicated to work and routine should change. But if you’re unhappy with yourself and would like some things to be different without having to completely abandon who you are, treatment can help you soften some of the more calcified aspects to your personality, while allowing you to keep your core values. You can remain a conscientious, hard-working, generally thrifty person, but with less rigidity, a tempered sense of right and wrong, and better able to forge new relationships with people. Therapy can work.

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