Introduction

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, personality disorders involve long-standing, persistent, inflexible, and maladaptive ways of experiencing, relating to, and thinking about oneself and the environment, which are associated with impairment in intrapersonal, social, occupational, and academic functioning (American Psychiatric Association [APA], 2013). As such, disturbances in self-concept are key characteristics of personality disorders. Indeed, the alternative DSM-5 model of personality disorders that was proposed to supersede the DSM-4 models – but was moved into Section III of the manual prior to publishing (emerging measures and models) – highlighted this to an even greater degree, with characteristic symptoms described for each personality type within the self (identity and self-direction) and interpersonal (empathy and intimacy) directions (APA, 2013). The personality disorder diagnostic classification embraces a wide variety of personality disorder presentations, with specific types comprising the paranoid, schizoid, schizotypal (cluster A, the “odd, eccentric” disorders); antisocial, borderline, histrionic, narcissistic (cluster B, the “dramatic, emotional, erratic” cluster); and avoidant, dependent, and obsessive–compulsive personality disorders (cluster C, the “anxious, fearful” cluster). This chapter describes the involvement of self within the anxious and fearful cluster, and focuses on the most common and most researched disorder within this cluster – obsessive–compulsive personality disorder (OCPD) – as an exemplar for the impact of self-concept in etiology, maintenance, and treatment within the cluster C personality disorders. This chapter summarizes and builds on previous theorizing by notable workers in the field, particularly Guidano and Liotti (1983), Beck, Freeman, and Davis (2004), and Millon (2011; Millon & Davis, 1996), along with our own previous theorizing in the area, which integrates and builds on work from these authors (see Kyrios, 1998; Kyrios, Nedeljkovic, Moulding, & Doron, 2007).

Phenomenology of OCPD

OCPD is characterized by eight behavioral or personality traits: rigidity and stubbornness, perfectionism that interferes with task completion, hypermorality and scrupulosity, overattention to detail, miserliness, an inability to discard worn or useless items, excessive devotion to work, and an inability to delegate tasks (APA, 2013). When recast in the alternative model of the DSM-5 as self and other-oriented, these were noted to reflect: difficulties in identity (sense of self derived predominantly from work or productivity; constricted experience and expression of strong emotions), self-direction (difficulty completing tasks and realizing goals, associated with rigid and unreasonably high and inflexible internal standards of behavior; overly conscientious and moralistic attitudes); along with difficulties in empathy (understanding others) and intimacy (work and rigidity interfering with relationships); accompanied by personality traits of rigid perfectionism (must be present), perseveration, intimacy avoidance, and restricted affectivity. The restricted affectivity trait interestingly reflects earlier versions of the DSM criteria for OCPD, but is only considered an associated feature for the working criteria used in the DSM-5.

Anankastic Personality Disorder in the International Classification of Diseases – 10 (World Health Organization, 1992) is largely consistent with the criteria for OCPD, albeit omitting the miserliness and hoarding criteria in favor of feelings of doubt and caution, and behaviors of excessive pedantry and adherence to social conventions. Indeed, the miserliness and hoarding criteria in DSM-5 can be seen as holdovers from early psychoanalytic descriptions of the anal personality type; Freud considered hoarding behaviors to be a manifestation of the anal stage of development, alongside other characterological aspects now considered to represent OCPD, such as orderliness, obstinancy, and parsimony. However, the hoarding criterion is the least specific and has the lowest positive predictive value of the nine criteria for OCPD in the DSM-IV (Grilo et al., 2001; cf. Pertusa et al., 2008) and now is usually considered to be better accounted for by hoarding disorder, which often shares with OCPD the personality trait of perfectionism (see Moulding, Mancuso, Rehm, & Nedeljkovic, Chapter 13 of this volume, for a discussion of self-concept and structure in hoarding disorder).

OCPD is one of the more common personality disorders, with lifetime prevalence rates of 3–8% (APA, 2013; Diedrich & Voderholzer, 2015; Grant, Mooney, & Kushner, 2012). Individuals with OCPD often present with other mental disorders, including anxiety and affective and substance-related disorders (Grant et al., 2012), as well as eating disorders, hypochondriasis or illness anxiety, and neurological movement disorders (Kyrios, 1998). OCPD accounts for up to 10% of cases in clinical practice (APA, 2013) and represents a major hurdle to successful treatment (Kyrios, 1998). OCPD is not to be confused with obsessive–compulsive disorder (OCD). While earlier psychoanalytic theories placed these two disorders on a continuum, with OCPD on the less severe end and OCD at the more extreme end, there is now research and clinical consensus that there is a distinction between the two disorders (Eisen et al., 2006). However, while a specific relationship between OCPD and OCD is not supported by the data (Black, Noyes, Pfohl, Goldstein, & Blum, 1993; Wu, Clark, & Watson, 2006), they share (non-specific) similarities in their associated characteristics, particularly in the domains of perfectionism and the need for control. Eisen et al. (2006) found that preoccupation with details, hoarding, and perfectionism (i.e., three of the eight criteria for OCPD) were significantly more common in individuals with OCD than in individuals without OCD. Furthermore, the relationship between these criteria and OCD demonstrated a unique association relative to depressive and other anxiety disorders. Calvo et al. (2009) reported that OCPD was more common in parents of children with OCD, with the same three criteria being more frequent. Therefore, while the OCPD diagnostic classification is not uniquely associated with OCD, certain characteristics of OCPD are associated with OCD. Nevertheless, there has been some confusion, particularly in the earlier literature, with a lack of distinction between these two disorders. Consistent with this, the concept of self-ambivalence discussed in the chapter on OCD (Ahern & Kyrios, Chapter 12 in this volume) takes a prominent role in some of the theoretical approaches to OCPD described below. However, unlike in OCD, where studies have empirically defined and provided support for the role of self-ambivalence (Bhar & Kyrios, 2007), there has been no such empirical research to provide support for the theorized role of self in OCPD. Further, even if there are specific common features that may share common underlying factors, research is also needed to examine the differential etiological pathways that lead to OCPD versus OCD.

In terms of phenomenology, Millon (2011) described eight characteristic patterns of individuals with OCPD: (a) a tendency for them to be highly regulated in their expressiveness and appearance (e.g., tense, restrained, and serious demeanor), which hides an inner ambivalence and insecurity, fear of disapproval, and intense feelings of anger; (b) an overly respectful interpersonal manner characterized by social correctness, formality, a highly developed sense of morality, and a high degree of respect for persons of authority; (c) a highly regulated cognitive style typified by a high adherence to conventional rules, schedule, and hierarchies; (d) a conscientious self-image characterized by a highly disciplined and responsible self, with a dedication to perfection and productivity and that exhibits reservations regarding participating in recreational activities; (e) a high degree of defensiveness against the conscious experience of socially unacceptable thoughts, images, and impulses; (f) activation of a wide range of defenses in response to discomfort associated with emotional responses such as anger, defiance, resentment, and rebelliousness; (g) a compartmentalized morphological organization – that is, a rigid compartmentalization of their inner world, which allows little interaction between drive, memory, and cognition; in order to prevent ambivalent images, feelings, and attitudes spilling into consciousness; and (h) a solemn, overly sensitive, or anhedonic temperament or mood, which could be constitutionally based. Such patterns are said to fall on a continuum ranging from normal and adaptive through to pathological and maladaptive, although contextual factors define what constitutes dysfunction (Pollak, 1987). The characteristics listed all implicate either implicitly or explicitly the role of self, be it in terms of self-image, self-ambivalence, self in relation to others, and self-regulation.

Numerous OCPD subtypes have been identified which may present different challenges and may therefore require differential management strategies. Millon and Davis (1996) discuss five adult subtypes: (a) the conscientious subtype, characterized by conformity to rules and authority because of a fear of rejection or failure; (b) the puritanical subtype, who is characteristically strict and punitive, highly controlled, self-righteous, and extremely judgmental; (c) the bureaucratic subtype, who is traditional and who values formality, and who has a powerful identification with bureaucracy, which provides a set of rules, regulations, and firm boundaries to contain feared inner impulses; (d) the parsimonious subtype, who protects against the prospect that others might recognize the inner emptiness that they experience, and who is identifiable by a meanness and defensiveness against loss; and (e) the bedevilled subtype, who experiences discord, as their need to conform with the wishes of others clashes with a yearning to assert their own interests, leading to chronic feelings of resentment and conflict. While the identification of these subtypes may be useful, research has yet to establish their validity, the need for idiosyncratic interventions, or even their distinctive etiologies. However, self-concepts are again implicated throughout these types, including an inner emptiness, a fear of inner impulses and a repression of inner wishes, as well as a fear of rejection.

Etiology of OCPD

From an etiological perspective, the role of self is implicit across various theoretical models of OCPD, ranging from early psychodynamic approaches to the more modern constructivist approaches of Guidano and Liotti (1983) and of Millon and Davis (1996), which emphasize the concept of self-ambivalence in the etiology and maintenance of OCPD, to recent cognitive models by Kyrios (1998; Kyrios et al., 2007) and Beck and colleagues (2004), who incorporate aspects of self-view within the core systems associated with the development and maintenance of the symptoms.

Attachment, post-rationalist and evolutionary perspectives on self in OCPD

Attachment theory (Bowlby, 1969, 1973, 1988) may represent a plausible basis on which to integrate the various approaches to the etiology of personality disorders, given the increasingly recognized significance of attachment relationships to psychopathology (Kyrios, 1998; Mikulincer & Doron, Chapter 3, this volume). Based upon the security of an individual’s attachment to significant others, basic trust in the world is created which enables the individual to explore their environment and hence to gain a sense of self-control and the ability to deal effectively with difficulty, uncertainty and complexity in the world (Bowlby, 1988). According to Guidano and Liotti (1983), obsessive–compulsive personality reflects an ambivalent attachment style, which developed from parents conveying rejecting attitudes behind an outward facade of attentiveness. Parents of individuals with OCPD are said to be typically emotionally undemonstrative and forbid not only the expression of emotion but the feeling of emotion. They tend to set high ethical standards and make unrealistic demands. Positive regard is conditional and rewards are difficult to achieve within this family environment.

Given these early life experiences, post-rationalist approaches such as Guidano and Liotti’s (1983) theorized that the internalized sense of self is characterized by a split pattern of self-recognition. That is, individuals simultaneously believe they are loved, accepted, and worthy of love; and unloved, rejected, and unworthy of love. This significantly reduces the possibility of the individual developing a single integrated sense of self (Guidano, 1987). The self-concept is ambivalent and incorporates polarized extremes, and self-regard consequently fluctuates between “acceptable” and “unacceptable.” Given that any uncertainty is perceived as intolerable, to maintain a positive self-image, ambivalence needs to be controlled for and certainty re-established. The commitment to certainty is therefore a commitment to a unified and definite self-identity. Thus the “perception of a unitary identity is equated with the perceived certainty of having control of oneself” (Guidano, 1987, p. 180). It should be noted that, like earlier psychodynamic approaches which viewed OCPD as being on a continuum with OCD, the concept of self-ambivalence has also been applied when describing the cognitive affective structure of those with OCD, albeit with some alterations to the nuance such as how such ambivalence is resolved (see Bhar & Kyrios, 2007; Ahern & Kyrios, Chapter 12, this volume).

Millon’s (2011) evolutionary perspective provides an alternative conception of the operation of ambivalence within OCPD. In this model, self-ambivalence is created in OCPD through the struggle between obedience and deviance, and this ambivalence is resolved through inflexible obedience. Oppositional thoughts are repressed in favor of rigid adherence to rules and social expectancies. To illustrate, this can be seen in the relationship of individuals with OCPD to others. The awareness that others do not share their perfectionistic standards can result in individuals with OCPD experiencing internal conflict between fearing social disapproval and expressing feelings of hostility (Millon, 2011). The belief that others’ performances are unsatisfactory can result in the perception of increased responsibility and a need for control over feelings of frustration. As such, individuals with OCPD have a strong need to control their social and physical environment, and they find it hard to trust others as they perceive them to be irresponsible and incompetent (Beck et al., 2004; Millon & Davies, 1996). Hostility towards others develops from an assumed coercion that the individual has to accept the standards imposed by others, an assumption that is derived from their early experiences of constraint and discipline in response to times when they had contravened parental rules (Millon & Davis, 1996). Fear of social disapproval evolves from such other-directedness and an assumption that they may be rejected for any possible infringement of such strict and restrictive moral codes. Hence, individuals with OCPD are likely to become preoccupied with perfectionism, control of self and environment, along with order, rules, and regulations, in order to resolve their ambivalence towards others. However, individuals with OCPD also fear revealing their internalized hostility. They experience a fear that these feelings may spiral out of control and reveal their imperfections, resulting in their rejection by others (Millon, 1981). This internal struggle results in further attempts for control, rigidity of behavior, and in affective restriction (McWilliams, 1994).

Individuals with OCPD compartmentalize many aspects of their lives (Millon & Davies, 1996) and rigidly allocate times for every task. In their attempts to maintain control they can disregard their emotional reactions to events and suppress memories. Such efforts for emotional and cognitive control lead to a lack of knowledge regarding the self and difficulties with regulating their emotions. While the compartmentalization may be successful to some extent (e.g., avoiding thinking about relationship issues during weekdays), at other times it may fail (e.g., they may consistently ruminate about these topics during weekends or on vacation times). In addition, a total absorption in the task at hand may result in lashing out at any disturbance. In some cases, such compartmentalization may lead to extreme feelings of detachment from the self, difficulties recalling recent important life events and a continuous sense of never “feeling emotion” or “being in the world.” This in turn is likely to further feed into self-ambivalence.

Cognitive perspectives

Cognitive perspectives on OCPD tend to focus closely on characteristic thinking styles and perfectionism. Individuals with OCPD have a rigid cognitive style: with characteristics such as dichotomous (black-or-white) thinking, the use of inflexible rules and on overattentiveness to detail where they “can’t see the wood for the trees” (Kyrios, 1998). The sense of autonomy in individuals with OCPD is affected by their central cognitive themes of “should” and the need for control (Beck et al., 2004). This can be seen in their views of self and others, their main beliefs, and the main cognitive strategies they utilize. Cognitive theories note that OCPD is characterized by a conscientious self-image (Beck et al., 2004; Millon, 2011). This includes seeing the self as industrious, reliable, efficient, loyal, disciplined; a fearfulness towards making errors; and dedication to perfection. These aspects of the self are overvalued. Individuals with OCPD hold themselves accountable to their perfectionistic evaluative standards. A lack of self-confidence and indecisiveness can be compensated for through strong conviction to their high standards and disciplined self-restraint (Beck et al., 2004; Millon, 2011). They tend to be as harsh in their self-judgments as they are in their judgments of others. These negative self-evaluations are generally indicative of a self-schema that emphasizes control and order.

Individuals with OCPD are threatened by disorganization and imperfections. To protect against this threat, they utilize cognitive strategies characterized by perfectionistic standards, control, and the application of rules. Beck et al. (2004) suggest that individuals with personality disorders demonstrate patterns of behavior that are both under- and overdeveloped. In particular, OCPD is characterized by an overdeveloped sense of control, responsibility, and systemization, while spontaneity and playfulness are underdeveloped. These strategies act as compensatory factors for a vulnerable self-concept. However, while on one hand these strategies are used to protect a vulnerable self-concept, they lead to restriction and a lack of self-complexity. Individuals with OCPD also apply their excessively high standards to others in an attempt to minimize their own weaknesses (Beck et al., 2004). Others are often perceived as incompetent, irresponsible, and self-indulgent. In turn, this can lead to inner hostility and difficulties with relationships.

Individuals with OCPD show an excessive, dysfunctional devotion to achievement, activities of mastery, and work. Their basic insecurity, fear of exploration, and intolerance for uncertainty hinders the development of a range of social roles. Rather than having several social roles, individuals with OCPD overinvest in socially sanctioned, structured social roles such as job competence. This is likely to lead to lower self-complexity, which has been defined as “the number of aspects one uses to cognitively organize knowledge about the self, and the degree of relatedness of these aspects” (Linville, 1985, p. 97). Possessing a greater number of well-developed but disparate areas of self-concept is associated with improved psychological adjustment and a resilience to stressors or disruption within the valued life domains (see Clark, Chapter 5 of this volume for discussion). Conversely, there is extensive evidence from the social-cognitive literature that lower self-complexity is associated with greater affective extremity, greater vulnerability to stressors and failures, more negative self evaluations, a greater level of depression, and poorer adjustment following traumatic experiences (Dixon & Baumeister, 1991; Linville, 1985, 1987; Rafaeli-Mor & Steinberg, 2002).

Perfectionism is a predominant theme characterizing OCPD, and the role of self-concept has been extensively implicated in perfectionism (see e.g., Gregory, Peters & Rapee, Chapter 10, this volume). For example, Flett, Hewitt, and Martin (1995) have suggested that procrastination is a response to a form of social evaluation that involves the perceived imposition of unrealistic expectations on the self. Flett, Hewitt, Davis, and Sherry (2004) suggested that such procrastination is related to a strong fear of failure due to perfectionistic standards. This fear of failure is either associated with, or a byproduct of, feelings of personal inferiority, inefficacy, and low self-acceptance. While self-oriented perfectionism is sometimes associated with procrastination, socially prescribed perfectionism shows a more robust relationship, reflecting introjected beliefs regarding standards that others require one to meet. Flett and colleagues suggest that this relationship is mediated by automatic cognitions regarding perfectionism, stemming from schemas that the self should be ideal; this conception is similar to conceptions of OCPD as inflexibly adhering to ethical or moral codes with repeated attempts to prove their worth through achieving “perfection” and avoiding “failure” (Guidano & Liotti, 1983). Such avoidant tendencies would serve to place the individual in a high-stress position familiar to any student completing assignments, whereby the impending deadline for tasks serves to further pressure the individual, leading to a dysfunctional pattern of avoidance that only serves to increase the stress. Clinical descriptions of individuals with perfectionism or OCPD note that such individuals may never complete their assigned tasks. Such failure to perform tasks would feed into the affected individual’s trust of others.

Accompanying such perfectionistic standards, there is a strong belief in achieving correct solutions and that mistakes should be avoided, with any failure being viewed as intolerable (Beck et al., 2004; Kyrios, 1998). “Shoulds” and “musts” are characteristic of individuals with OCPD, with individuals setting up unrealistic expectations of themselves and others. If these expectations are not met, extreme personal criticism results. Consequently, the individual’s self-worth suffers; this is particularly the case as the characteristic dichotomous thinking associated with perfectionism, which is rife in OCPD, leads individuals to think that any deviation from what is “right” is automatically “wrong.” In essence, their goal is to eliminate mistakes in an attempt to have total control over themselves and their environment.