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When Does Perfectionism Become a Personality Disorder?

Attention to detail, fastidiousness and self-belief are widely celebrated in Western society, but for people with obsessive-compulsive personality disorder, those traits can bring a lifetime of pain

About six months into treatment, my therapist leaned forward in her chair and asked me a question that would change my life: “Have you heard of OCPD?” 

I hadn’t. It sounded a lot like OCD, or obsessive-compulsive disorder. But she explained to me that it was quite different from that condition, which manifests as intrusive thoughts that come suddenly and trigger compulsive acts. “People with OCD know that their urges, these obsessions, don’t make any sense. But with obsessive-compulsive personality disorder, people who have it usually don’t think there’s a problem. They live for years thinking their behavior is proper,” she continued.

OCD is fundamentally an anxiety disorder, and in many cases, the stimuli that trigger distress have nothing to do with real-life events. In contrast, people with OCPD usually project their beliefs and rules on the people and environments around them, feeling righteous about their conduct despite evidence of problems mounting in their wake. 

My therapist ran down a list of OCPD traits: stubbornness, perfectionism, a need to do things “my way,” anxiety over disorder, black-and-white logic about important decisions. She went on to explain how the disorder can create friction with other people, especially loved ones, and why it can lead to crippling procrastination and internal struggles at work, even for those who are outwardly successful. 

In that moment, I flashed back to every terrible fight and depressive cycle I’d gotten stuck in over three decades of life, often triggered by the people I love most. I finally had the words to describe a pattern of behavior that led me to constantly criticize not just myself, but others in my orbit. I wondered if the wild, arrogant anger that spilled out at strange times, regardless of whether I was arguing about politics or laundry detergent, was a result of all that pressure. But when I rushed home and searched online for modern breakthroughs and advice on OCPD, I was surprised at how little I could find.

The history of the diagnosis dates back to 1908, when Sigmund Freud detailed the “anal-retentive” character, featuring a meticulous, rigid and self-reliant nature shaped by childhood trauma. In 1952, OCPD debuted in the first edition of Diagnostic and Statistical Manual of Mental Disorders as a “compulsive personality,” defined by, among other things, an excessive adherence to rules and the “standard of conscience.” Even then, the disorder was understood as distinct from OCD, despite the similarity in name, because of the obvious differences in patient awareness and behaviors.

But scientific study has stagnated in the decades since, leaving the disorder to be misunderstood by the public and mental health clinicians alike, says Anthony Pinto, a licensed psychologist at Northwell Health OCD Center and foremost expert on OCPD. “The state of what we know about OCPD is quite limited. We need to know the science behind it in order to develop better treatments,” Pinto says. “The science hasn’t risen to the need, because we know OCPD is a highly prevalent condition, affecting three to eight percent of the population. Given those numbers, you’d think there would be more at this point.” 

Part of the problem may be how elusive OCPD is to spot. Pinto observes that traits like attention to detail, fastidiousness and self-belief are widely celebrated in Western society; in many cases, people with OCPD appear to be hyper-competent and confident to others. As author Joshua Kendall argues in his 2013 book America’s Obsessives, some of the world’s most iconic entrepreneurs and leaders likely had undiagnosed OCPD. His list includes Apple co-founder Steve Jobs, whose obsession with things done the “right way” set the stage for legendary temper tantrums and sky-high demands that often only made sense to him.  

It’s this sort of behavior that also leads some health-care professionals to dismiss traits of OCPD as useful, rather than harmful, Pinto says. Unsurprisingly, people with OCPD are often the fiercest defenders of the fact that there’s nothing “wrong,” sometimes ignoring the scars they leave on people around them. 

So it was with me: For the longest time, I thought everything would be fine if people would just bend to my perspective, instead of being so sensitive to my demands. It was easy to feel that way, when I was so sure that my persistence and independence were responsible for my successes.

But living with OCPD can push people to depression and anxiety as they burn out from the pressure of, well, themselves. Which is how I found myself, two years ago, frozen on the floor of my living room, with work dread mounting and very little energy to do anything but sleep. It was the endpoint of a terrible breakup with someone I didn’t want to lose, which mirrored the downward spiral happening in my professional life. 

“People with OCPD can chronically feel frustrated with themselves because they feel like they’re not achieving enough, or they’re frustrated by everyone around them because they can’t meet an imagined standard,” Pinto says. “It affects various domains, and then the overall quality of life.” 

The spiral finally convinced me to go to therapy, which is where I first found the words to articulate my experience. A visit with a professional, however, doesn’t guarantee help for everyone. 

Greg Brooks, 26, was admitted to a mental facility and diagnosed with severe bipolar disorder in 2013. He received focused treatment to address his mood cycles, but for years, he struggled to maintain romantic relationships, stumbling through a series of breakups. It was only when Brooks pored through his old medical paperwork that he came across his psychiatric evaluation and saw he had tested highly for OCPD, without anyone mentioning it. Like me, he dove into the internet to learn more, only to find few specialists and even fewer support networks. 

“When you’re left on your own like that, it becomes a very painful transition with very little support,” Brooks says. “It’s dispiriting to confront this, especially if you don’t have the time and funds to seek the right answer.” 

Last fall, Brooks launched a biweekly Zoom support group for people who have OCPD, as an offshoot of a Facebook group he had been frequenting. He initially envisioned it as a “book club”  event, with assigned readings on OCPD followed by moderated discussions. But he quickly realized that the diverse groups of faces that showed up on his computer screen weren’t just seeking structured information about OCPD — they needed a safe environment to vent and, ultimately, find community. 

“People with OCPD, especially men, tend to get very angry when things don’t go their way. So you see people in very stressful transitions in their lives as a result of OCPD. They’ve been given ultimatums and they have to change within a short timeframe and it probably won’t happen perfectly. There’s going to be some grieving that’s going to have to happen, because things were broken. How do you work through that?” he says. “OCPD is so pervasive that it may outlive your relationship. I know mine did.”

Through the Zoom, Brooks met Cale Livingston, 34, who now helps him run the biweekly meetings. They’ve also decided to launch a podcast together to discuss the origins of OCPD and how to grapple with it in daily life. Growing up in a conservative Christian family, Livingston struggled to get out from under the thumb of a controlling father. Being gay, but closeted, only made things harder. “It always felt like something was wrong, but I didn’t know what part of myself was to blame,” he says. 

Four years ago, as he turned 30, Livingston finally booked an appointment with a therapist and realized, after a diagnostic test, that he had OCPD traits. Despite his newfound awareness, Livingston admits he didn’t address it directly in therapy. Instead, it took a breakup with an ex, full of gaslighting and messy emotions, for him to start confronting a pattern that OCPD had wrought. 

“You see people go through this identity crisis, wondering whether they’ve been toxic all along. But it happens when you peek behind your own curtain of awareness and realize what’s going on. Until that happens, it’s hard to make any headway with fixing OCPD,” Livingston says. 

Treating OCPD often comes down to a blend of psychotherapy, such as dialectical behavioral therapy, medication (namely SSRIs), and mindfulness techniques to help manage a swirl of intense feelings and beliefs. Unfortunately, OCPD hasn’t been studied via randomized controlled trials, which Pinto notes are the “gold standard” for assessing the effectiveness of mental-health treatments. There is a misconception that OCPD isn’t a cause of major suffering or impairment, which impacts the amount of research attention and funding it receives, he says. “I did a study where I compared individuals with OCPD versus those with OCD, which most laymen would believe is highly disruptive to life. But in the data, I saw no real differences between those conditions in terms of quality of life issues,” Pinto says. “Yet today, OCPD just isn’t given the same weight in terms of its capacity to harm.” 

The damage doesn’t just hurt the person with the disorder, it can also affect their relationships over an entire lifetime. “Adam,” a 35-year-old in the Midwest who asked to remain anonymous for privacy reasons, says that he never realized how much he had endured until last year, when his father was hospitalized for chronic pain — the result of him stubbornly ignoring health problems for months on end. As part of his release, Adam’s father was screened for mental health disorders, and OCPD appeared at the top of the list. At first, Adam was stunned, but then it clicked.

“I guess the issue with him was that he’s an extremely smart, extremely capable man. He was always able to think of superior solutions,” Adam tells me. “A lot of the time it’s just… sometimes those superior solutions aren’t the ones the person who is hurting actually wants.”

The catharsis for Adam has come with more hurt, too, because his father is still unwilling to consider his diagnosis seriously. Instead, he’s returned to a pattern of demanding, controlling behaviors, such as expecting Adam to manage all of his appointments and be on call at all times. 

Sometimes, the only solution is setting boundaries, Adam says, explaining how painful it is to drift further from his father as he fails to recognize how much pain his son is in because of his behavior. “You want to ascribe intent, but the person with OCPD often doesn’t even realize what they’re doing to you,” Adam says. “Coping with this stuff requires seeing that it’s hard. We throw around words like ‘boundaries’ but never hear what it’s like to set them in a hostile environment.” 

In this struggle, the small victories stand out. When Adam told his father that he needed space, and firmly rejected the temper tantrum that ensued, a wholly new response arose. “He told me, ‘Well, if that’s how it is, then it doesn’t matter if what I’m doing is right or wrong. The only thing that matters is how you feel.’ And it’s the only time I’ve ever heard him say that,” Adam says. 

Advocacy around mental illness is a movement that continues to build momentum as the public grapples en masse with anxiety, depression and existentialism under pandemic conditions. Yet the story of OCPD depicts the huge gaps in awareness that remain — especially when the disorder has traits that can pass as valuable to society. 

Brooks is critical of how there are countless books and seminar programs on perfectionism, workaholic behavior and burnout, all “sold a la carte” without any connection to the mental disorders that fuel such behaviors. “I wish people could talk about these issues and add that you can be diagnosed for these traits, and get professional help,” he says. “You don’t have to wait until things have reached a dysfunctional level to do that.”

Maybe that’s why my treatment feels kind of “a la carte” too — a mash of self-help books, checklists and pointed conversations in therapy, with no real finish line in sight. But after years of struggling with feeling overwhelmed by the pace of life, and underwhelmed by everything I do, putting the right label on the struggle has been cathartic.

For too long, I was sure that I saw the world, and all its flaws, with clarity. Hearing the words “OCPD” is what sparked doubt. And change might be possible because of it.