Obsessive Compulsive Personality Disorder Hypochondriasis and Body Dysmorphic Disorders

Patients with obsessive-compulsive personality disorder (OCPD) are preoccupied with details, order, and control. Although their labels are similar, these patients differ in substantial ways from patients with obsessive-compulsive disorder (OCD). OCD patients have recurrent disturbing thoughts or obsessions that create marked subjective distress. Patients with hypochondriasis are obsessed about fear of an illness triggered by somatic sensations. Patients with body dysmor-phic syndrome obsess about a bodily defect, such as a malformed nose, which is not readily apparent to an observer. OCD patients may be driven to ritualistic or compulsive behaviors, such as handwashing or checking rituals. Patients with hypochondriasis and body dysmorphic syndromes are often compulsively "doctor shopping." These behaviors help them manage, control, and distract them from intense anxiety.

The core adaptive traits of patients with OCPD are orderliness, attention to detail, and an emphasis on rational thinking and logic. These traits are lifelong patterns that many patients use adaptively in their professional life. Patients with OCPD often view these traits as a personal strength. However, often their attention to detail leads them to perfectionist beliefs, worry, or ruminations that they must not make mistakes or be imperfect. They can interpret rules, regulations, and values rigidly and stubbornly. Patients with OCPD often ruminate and are prone to interpret minor physical changes as worrisome somatic complaints (McGuire and Shore, 2001).

Because they are uncomfortable with feelings and emotions, patients with somatic presentations may be unconsciously motivated to seek reassurance from their physician. They may fear disorderliness and dirt. The compulsive, critical, controlling, self-righteous side of their personalities often creates difficulty in relationships with co-workers, friends, and family. They can be stingy, orderly, and obstinate. Physicians, who often have obsessive-compulsive traits themselves, may feel irritated and competitive with these patients about who controls the diagnostic workup or treatment plan.

Patients with OCPD use defense mechanisms such as intellec-tualization, isolation, displacement, doing/undoing, and reaction formation. Using reaction formation, they may behave in a superficially deferential or obsequious manner to repress from themselves and hide from others their critical and self-righteous feelings. These defenses are used against their anger and dependency needs, which are often consciously denied. Illness often represents a dangerous threat to the sense of self-control in OCPD patients. A past illness can lead to a future somatic presentation. The physician should understand and empathize with this loss of self-control while helping the patient regain some control in the management of the problem. Struggle or conflict with the patient over control of medical care should be avoided. Reality distortions, including excessive perfectionism, idealization of logic, and avoidance of feeling, can be gently elicited, explored, and worked through with the patient.

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