The period in human development when we go from being the protected child under our parents’control, to being aware of our independence and autonomy, generally takes place from the ages of 12 to 21. It is at this point that we realize that mom and dad are not always going to be there to bail us out. It is during this time that we realize that mom and dad are not going to be the ones to make play dates for us. It is during this phase that we realize that other people outside our family have opinions about who we are, whether we are admirable, worthy or likeable. It is at this stage where most forms of emotional turmoil and mental illness develop.

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The form of mental illness I am going to be discussing in this article is the development of an obsessive-compulsive personality. For it is in adolescence and early adulthood that an obsessive-compulsive personality type generally begins to manifest itself. It is at school that a person tries to gain control of a world that seems to be slipping out of control. One needs to produce a high level of work and receive grades that demonstrate one’s security and stability. The goal of a perfectionist is to study to the point where no questions can be asked for which he/she cannot provide complete and perfect answers. A perfectionist believes that he needs to protect himself from the potential of his world crashing in around him, because it might be discovered that he is imperfect or that he does not have all the answers.

 

Many instances of a perfectionistic personality originate from some form of trauma, whether acute or prolonged, that overwhelms the developing mind and spirit. Children and adolescents often do not have the mental and emotional resources needed to deal with these traumas, and as a result engage in a primitive effort to gain control of a world which otherwise seems to be threatening and unmanageable.
 

Often perfectionism in school is driven by both a need to protect one’s identity, to keep oneself from being seen as anything less than the best, and/or the need to maintain a sense of being in control and scaving off further potential mayhem and chaos. Many times the severity of this condition is completely concealed and unknown to parents, siblings, and not to mention, the best of friends. A person with this condition lives in silent torment, while the rest of the world applauds him or her as being a conscientious, capable and “together” student.

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Often adolescents with this developmental condition live precariously between maintaining a high grade average at the sacrifice of sleep, free time and social diversity. On occasion, the perfectionist is discovered because of a sudden dramatic contrast in grade performance. I have worked with a number of adolescents who, at the beginning of college, are finding that their grades are deteriorating. It is not uncommon to see a fifth grade report card with an almost straight A average, turn into a six grade report card with a C- average. There seems to be no apparent explanation for this contrast, and often parents and professionals are confounded in their search for an explanation of what seems to be completely incomprehensible. Their parents are confused because they’ve never mentioned a single word about the nature and severity of the need to function at their highest level.

 

Oftentimes, the symptom of distractibility is noticed first. This can be misconstrued as symptomatic of attention Deficit Disorder (ADD). For example, perfectionism often involves reading and re-reading and difficulties in concentrating. Sentences and words of written form are read and/or re-read, not because of distractions but because of the need to make sure that the word is comprehended exactly. Often this struggle is not conveyed in a way to derive an appropriate diagnosis. Occasions arise where distractibility plays a part, but not because of a neurological measure. Rather it is because the word is still being processed and solved to create a complete sense of understanding and control, rather than not being able to focus on a specific idea for a prolonged period of time.

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When parents become involved in the development of a diagnostic impression, they are often devastated at finding out the depth and breadth of this condition, and the torment that their child has been living with for years. This is a condition in which the person’s very nature is attacked by his/her own philosophy in spirit, and he/she will become lost in his/her own rigid and perfectionistic ideas. In treatment, we deal with this paradox of human existence i.e., the brain’s need to gain control and to keep it’s world intact in a world where nothing is perfect and mistakes are made by everyone routinely.

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The first part of assessing someone with this condition is to establish the degree to which the human element has been eradicated by the disorder. By this I mean that there is a potential for someone with this condition to be simultaneously aware that his/her mind is driving him/her to behave in a rigid and inflexible way, and yet one recognizes that this drive, although mysterious and compelling, is alien to what he/she knows in his/her heart to be a more functional way of existing.

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There exists an ongoing process in regard to the degree to which a person with this condition seems capable of working inward in establishing or recognizing an insight into the ability to identify rigid and perfectionistic ideas. It is this degree of insight which acts as a profound determination of one’s prognosis.

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A young woman with this condition, 19 years of age, presented at the Center for Cognitive Behavioral Psychotherapy, consumed by her mind’s perfectionistic guidelines. She came to treatment because her mother clearly recognized that her daughter’s perfectionism had taken her from being an honor student at high school, to now being completely incapacitated and home-bound, performing tidying rituals and obssessing over her speech. Her ritual in this was that everything she said had to be perfect in both form and content.

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Sad to say, this patient reported that her clinical goal was for the therapist to help her be more perfect. She felt confined by her perfectionism, but was more distraught at not being able to perform her rituals more effectively. She was unable to see that her condition was responsible for her life’s deterioration. She was fully willing to sacrifice the diverse life most often associated with a young adolescent, for the goal of getting things exactly right.

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This initial process of evaluating the degree to which a person with OCPD’s condition is consuming him/her, can be a complicated and lengthy process. This condition is also extremely elusive, in that as mentioned previously, society often rewards and compliments the outcome of this condition. Being a straight “A” student, studying for hours and having a perfectly arranged bedroom, are all attributes that most parents would seem to die for. However, although seemingly commendable, these behaviors are far from what is common behavior in adolescents, and therefore, should act as a warning signal for both adolescents and their parents.

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It is also common for adolescents who are developing OCPD to adopt what are considered very rigid and stringent moral guidelines. People with OCPD of this type often eliminate friends for violating strict codes of high moral standards. If a friend were to smoke pot, or cut a class, that could very possibly be justification for ending the relationship. These kids believe that they are the final mediators of morality. They often judge a friend’s character by behaviors that they believe to be a representation of their goodness or depravity. This form of OCPD can be particularly challenging since these strict moral standards can be applied to oneself as well as to the people with which one interacts.

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Profound low self-esteem and depression are often dividends which are derived from these self imposed strict standards. It is perfectly appropriate for an adolescent to live in a world of experimentation and trial and error. For the adolescent with OCPD, failing to meet these standards, which a sufferer imposes on himself/herself, as well as on others, often justifies his/her self-hatred.

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For the overwhelmed and isolated adolescent, this seemingly inescapable situation can lead to suicidal ideation, along with depression and self-loathing. It is important for persons who are having thoughts of harming themselves to notify their parents and/or therapist. Sometimes a person with OCPD can feel the need to be punished for not living up to their own perfectionistic standards.

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The rigidity of ideas regarding right and wrong cannot only crop up in areas of criminal law, but can also be applied to areas such as sexual standards and political ideology. It is during adolescence that many young people start to experiment with their sexual independence. Persons with OCPD often derive a strict code for not only their own sexual practices, but also for the sexual practices of those who are important to them. It is not uncommon that this code is imposed in a harsh and rejected attitude towards people who do not live within that social code. These attitudes not only apply to sex but also to drug use.

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It is during this time in life that adolescents become aware of their potentially independent political views. It is not uncommon that people with obsessive-compulsive personality disorder become more vehement and extremely passionate about their political and religious views. Once again, others can often perceive these qualities as really strong convictions and a strong sense of identity. There exists a clear differentiation between someone who’s passionate about an idea compared to someone who’s rigid and adamant about an idea. Within the home, obsessive-compulsive disorder can manifest itself through obstinate decisiveness and can result in division between parents and child or between siblings. To illustrate, I work with a person whose religion dictated that grown women were not allowed to sing. This person grew up in a household where a younger female family member, enjoyed singing. Although the law allows for children to sing, he held this belief so rigidly, he would become physically violent toward the family member when she would sing.

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Although an almost universal derivative of religion is to provide a sense of meaning to life and guidelines for living a spiritually strong existence, persons with OCPD often take religion and turn it into oppression. Within OCPD, there on occasion exists a manifestation referred to as scrupulosity. Scrupulosity is the unhealthy adherence to a strict moral code, which manifests itself well beyond the intent of the religious practice. Scrupulosity is also a manifestation of obsessive-compulsive disorder, when prayers need to be repeated until they are achieving a perfect soundness or a perfect pronunciation. Scrupulosity also manifests itself in secular law by being overly conscientious and avoiding any behavior which might, in any conceivable way, violate state or federal laws.

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It is very important to recognize the difference between the obsessive compulsive personality disorder and the anxiety disorder of OCD. Although in many ways there are a number of crossovers, the two conditions are distinctly different. A case that comes to mind is a young woman who had cleaned her apartment for hours. Her goal in cleaning was not to protect herself from deadly germs, or to protect others from the harm of disease, but to keep her apartment in absolutely immaculate condition because dirt is “wrong”, and cleanliness is next to “godliness”. On the surface, her cleaning rituals might seem to be a classic form of OCD, but in this case they are not. Just because something involves a cleaning ritual, it does not necessarily imply that it involves the experience of anxiety.

 

There is a tremendous need to differentiate between OCD and OCPD because the treatment for each disorder is extraordinarily distinct and different. As is well-documented, treatment for OCD involves a consistent exposure and response prevention paradigm. Although an exposure-based paradigm for OCPD has been demonstrated to have some benefit on the overall condition, the nature of OCPD is driven by a perfectionistic and rigid style of thinking, and therefore a person’s cognitions are much more paramount to take into consideration.