Obsessive-compulsive personality disorder

Background

• A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency

Clinical Features

• Four (or more) of the following criteria, beginning by early adulthood and present in a variety of contexts:
  • Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
  • 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).
  • Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
  • Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
  • Is unable to discard worn-out or worthless objects even when they have no sentimental value.
  • Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
  • Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
  • Shows rigidity and stubbornness.

Differential Diagnosis

• Obsessive-compulsive disorder
  
• Hoarding disorder
  
• Other personality disorders
  
• Personality change due to another medical condition
  
• Substance use disorders
  

Evaluation

• Clinical diagnosis; however if entertaining other organic causes may initiate workup below

General ED Psychiatric Workup

• Point-of-care glucose
• CBC
• Chem 7
• LFTs
• ECG (for toxicology evaluation)
• ASA level
• Tylenol level
• Urine toxicology screen/Blood toxicology screen
• EtOH
• Urine pregnancy/beta-hCG (if female of childbearing age)
• Consider:
  • Ammonia (see Hepatic encephalopathy)
  • TSH (hypo or hyperthyroidism may mimic mental illness)
  • CXR (for Tb screen or rule-out delirium in older patient)
  • UA (for rule-out delirium in older patients)
  • Head CT (to rule-out ICH in patients with AMS)
  • Lumbar puncture (to rule-out meningitis or encephalitis)

Management

• May need lots of reassurance
• May avoid giving decisive answers
• Try a low-key, casual tone
• Respond with empathy for emotions, but be firm and set boundaries regarding requests for excessive reassurances (e.g. emphasize what is already reassuring about presentation and that additional tests cannot be performed at this time)
• Emphasize follow-up plan and that patient can always return if deteriorates or not getting better
• Referral for outpatient psychiatric treatment, as psychotherapy is the primary treatment.

Disposition

• Discharge

See Also

• Personality disorders