Compulsive Personality Disorder, Case vignette (1)

A CASE OF Compulsive Personality Disorder

By: THEODORE MILLON et al.

Notes:

(1) Numbers mark aspects of the case most consistent with DSM criteria as follow, and do not necessarily indicate that the case “meets” diagnostic criteria in this respect.

(2) Patient's name has been changed in respect to confidentiality, and name mentioned is not of a real existent person.

Case of Donald

Donald sought assistance because of unexplained stomach pains and nightmares. “My stomach has always been queasy,” he noted. “I’m very sensitive to dietary factors.” These he enumerated in burdensome detail, ranging from exotic brands of spices, to cabbage, certain brands of soda pop, and on to smog and stuffy interiors. Recently, though, the discomfort has begun to interfere with his sleep. The nightmares, in which he loses complete control, he finds frightening and intolerable. (1)

At the same time, he was quick to note that he could usually bear the discomfort in silence and go about his day normally. Without fail, he arrives at work early so he can “smooth things out” before the day officially starts. Donald also stays after the others have left to anticipate “kinks” they might otherwise confront in the morning. (3) “Even though my wife complains I don’t spend enough time with her, and even when the discomfort is intense,” he states, “I can maintain an efficient operation in the workplace.” (8) Privately, his wife notes that Donald is someone who “tends to make up his mind about things, and keep it made up.” (2)

By his own admission, he is a perfectionist, a characteristic that has allowed him to advance quickly to a middle management position. He scrupulously supervises the work of his subordinates and is quick to discipline them for their mistakes. “People don’t understand that work is a virtue,” he states with a certain indignance. For this reason, he is often reluctant to trust a job to others, “cause I know they’ll screw it up.” When forced to deviate from this rigid style, he begins to experience physical discomfort, including stomach pains and nightmares. (6)

Donald seems invested in being a “good patient.” He prides himself on being able to answer the intake questions with precision, even though his responses are often time-consuming and unnecessarily qualified. He flounders, however, without the aid of a formal structure. His comfort returns when it is suggested that he speak about his “average day.” In the lengthy description that follows, Donald relishes detail, accuracy, predictability, and efficiency. He believes dogmatically in the virtues of a healthy lifestyle, exercising daily, eating balanced meals, sleeping eight hours a night, and attending church regularly. (4) He is offended by implications of the slightest impropriety. He has never drunk or smoked, has always been a good saver, and has never taken a vacation from work. (7)

Donald’s history explains much of his current situation. As a child, he secured approval by doing as he was told and showing interest in primarily solitary activities such as reading and coloring. He remembers trying to color between the lines, and feeling that the picture was ruined if there was one errant mark, a metaphor for his entire life. He remembers his parents as distant and stern. Any horseplay met with swift discipline. Outside school, Donald rarely played with other children, because his parents disapproved of their poor manners. His parents affectionately called him “our little man.” Two years ago, Donald married Rachel, who is eight years older. When asked about the age gap, he explains that he was attracted to her mature attitude and serious approach to life. They have a stable, if somewhat unromantic, relationship. Rachel and Donald have lunch with his parents on Sunday after church, and Donald visits them alone every other Wednesday after work.

DSM-IV Criteria

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
(1) is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
(2) shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)
(3) is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)
(4) is over-conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)
(5) is unable to discard worn-out or worthless objects even when they have no sentimental value
(6) is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things
(7) adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes
(8) shows rigidity and stubbornness

References

(1) Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

(2)Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

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