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OBSESSIVE-COMPULSIVE PERSONALITY DISORDER:CASE PRESENTATION AND TREATMENT PLAN
Obsessive-Compulsive Personality Disorder:
Case Presentation and Treatment Plan
Antonio N. Taylor
ORG 7210
Dr. Robert Wolf
8/13/12
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OBSESSIVE-COMPULSIVE PERSONALITY DISORDER:CASE PRESENTATION AND TREATMENT PLAN
Abstract
When treating a client such as an obsessive-compulsive personality disorder (OCPD)
patient, it is the responsibility of the clinician to issue a case presentation and treatment
plan. The client should be aware of expectations, personal responsibilities, and
organizational obligations along with rules and regulations associated with the services.
Establishing a mutual understanding ensures the client’s best interests are regarded.
Additionally, the clinician protects him or herself along with the organization in the
process.
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OBSESSIVE-COMPULSIVE PERSONALITY DISORDER:CASE PRESENTATION AND TREATMENT PLAN
Obsessive-Compulsive Personality Disorder:
Case Presentation and Treatment Plan
Within these United States obsessive-compulsive personality disorder (OCPD)
affects 1% of the populace of which 3%-10% of mental health patients are sufferers
(BrainPsychics.com, 2012). Generally, this condition is described as an Axis II, DSM-
IV-TR mental disorder referring to an obsession with perfection and the overt need to
sustain order and control of people or situations (Butcher, Mineka, & Hooley, 2010).
Although OCPD is commonly confused with obsessive compulsive disorder (OCD) as
the two share a number of like symptoms, the most significant variance is that individuals
afflicted with OCD experience unwanted thoughts whereas OCPD sufferers consider
their thoughts as accurate (Vorick, 2010). Additionally, OCPD symptoms are comprised
of a preoccupation with rules and orderliness, extreme perfectionism, desire to control
situations, inflexibility, miserliness, stubbornness, and the inability to dispose of broken
or useless objects (Butcher et al., 2010). As a practitioner, it is imperative to assess,
diagnose, and treat OCPD patients in an advantageous and proficient manner. In effort to
do so, a combination of psychodynamic psychotherapy, cognitive-behavioral therapy
(CBT), and group therapy are widely employed. Psychodynamic psychotherapy
promotes the comprehension of one’s thoughts and emotions. On the other hand, CBT
enables patients to improve levels of distress, interpersonal relations, and personality
functioning (Ng, 2005). Additionally, group therapy serves as a secondary intervention
enabling sufferers to associate with like-minded individuals in order to alleviate a sense
of isolation (Psych Central, 2012). Hence, the utilization of such methods provides a
comprehensive approach to treating OCPD symptoms, resolving issues, and establishing
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OBSESSIVE-COMPULSIVE PERSONALITY DISORDER:CASE PRESENTATION AND TREATMENT PLAN
functionality and normalcy with potential long term success. In effort to illustrate such
treatment the following hypothetical case describes an adult OCPD patient inclusive of a
detailed description of the case, treatment plan, self-critique, challenges, and ethical
issues.
For these purposes, Janice, a probable OCPD sufferer, has been referred to a
professional psychiatric service by her employer. She is a 37 year old, department store
manager. Additionally, although Janice is stunningly attractive, she is single, never
married, has no children. Also, she maintains very little contact with her extended family
as she has relocated for career purposes, working 55-60 hours per week. With limited
spare time, Janice typically reads romance novels, listens to rhythm and blues and soft
rock, and enjoys watching reality television at her leisure. Most of her companions are
childhood friends which remain in her hometown and she has had difficulty fostering
new relationships as she spends most evenings and off-days at home. According to
reports from her employer, within the past 6 months various employees have repeatedly
expressed concern to the district manager that Janice is indecisive and seemingly lacking
effective leadership skills. From week to week, Janice alters various procedures,
operations, and scheduling, disturbing the continuity from one shift to the next. For
instance, previously, full-time employees were granted two, 15 minute breaks along with
a 30 minute lunch. However, Janice eliminated the 15 minute breaks. Additionally, she
increased the projected sales goal per employee despite the recent decline in store profits.
Most recently, Janice has taken on various responsibilities of the floor supervisors.
Instead of delegating these tasks, she feels as if a hands-on approach ensures the job is
done properly. Furthermore, she has eradicated store sponsored company outings and
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OBSESSIVE-COMPULSIVE PERSONALITY DISORDER:CASE PRESENTATION AND TREATMENT PLAN
holiday parties stating that, “the less time employees spend at leisure, the more time and
dedication they can devote to the company.” However, these actions have inadvertently
compromised employee morale, productivity, and sales.
In consideration of the aforementioned, Janice craves control and perfection
towards her employees and in terms of her position, has difficulty delegating tasks, her
work-life balance is distorted, and she has curtailed the leisure of her employees as well.
In addition, she is stubborn, requiring employees to fully comply or face suspension or
termination. Consequently, numerous employee complaints and the decrease of sales
prompted the employer to refer her to psychiatric assistance or resign. Prior to the initial
therapeutic session, the practitioner read Janice’s file inclusive of employee complaints,
company referral, sales and productivity records, and work history in order to acclimate
himself with her experience and determine his initial approach. However, this
information is insufficient in explicating her condition. Therefore, further inquiries must
be implemented. For the intake session, the practitioner aspired to assess Janice utilizing
a generalized intake assessment, a Conscientiousness-Related Scale, the NEO Personality
Inventory – Revised (NEO-PI-R), and an OCPD Component Scale, the Dimensional
Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ). First, the intake
evaluation provides pertinent data in regards to basic personal information and history,
overview of status and need, authorization and informed consent, confidentiality,
guidelines, and the development of provisional treatment plans (Seligman &
Reichenberg, 2009). Next, the NEO-PI-R evaluates 240 items measuring personality
factors in terms of general and underlying components. These include competence,
order, dutifulness, achievement-striving, self-discipline, and deliberation (Samuel &
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OBSESSIVE-COMPULSIVE PERSONALITY DISORDER:CASE PRESENTATION AND TREATMENT PLAN
Widiger, 2011). Then, the DAPP-BQ utilizes a 290 or 560 item questionnaire in which
the subject responds from strongly agree to strongly disagree in order to assess
personality in regard to affective liability, social avoidance, conduct problems, and
compulsivity (Samuel, Simms, Clark, Livesley, & Widiger, 2010). In short, comparing
Janice’s symptoms along with her life and health history to OCPD characteristics
provides an effective diagnosis. Given the length of these evaluations, the practitioner
designated 6 hours for the intake session, offering 15 minute breaks every 60 minutes.
As the assessments are completed, the practitioner begins to note problematic
concerns regarding Janice’s condition. Prevalent issues include her overwhelming need
to control her environment, the lack of constructive extra-curricular activities, omitting
other individuals from her personal life, and her apparent stinginess and depression.
These factors may indicate Janice’s single status, the reason she does not have children,
and her difficulty fostering new relationships. Additionally, she may have experienced
some traumatic events or damaging relationships in the past which promoted her desire to
maintain organization and power in a detrimental manner.
In effort to assist Janice in overcoming these phenomenon and achieving
favorable, long term success the practitioner may establish long term goals. Such
aspirations include effectively communicating with employees, increasing her confidence
in others, being productive outside of work, and maintaining past relationships while
fostering new relationships. Now, in order to realize such goals, Janice must implement
the following: (1) determine and consistently maintain rules and regulations in the
workplace, (2) assign tasks to employees and create a system of checks and balances, (3)
participate in an outdoor activity at least once per week, (4) enroll in an organizational
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OBSESSIVE-COMPULSIVE PERSONALITY DISORDER:CASE PRESENTATION AND TREATMENT PLAN
activity outside of group therapy at least twice per month, (5) contact a family member or
childhood friend weekly on a designated day, and (6) maintain a journal in which she
illustrates the quality of her interactions throughout the day. Applying these practices
allows Janice to modify her behavior and ultimately her pessimistic thoughts. Over time,
she becomes more aware of how unrealistic her preoccupation with perfectionism, order,
and control has been and her OCPD symptoms should decrease.
Additionally, post-assessment, the practitioner should explicate the treatment
methods and interventions which are to be utilized. Janice should know what to expect as
well as her role and responsibility along with that of the practitioner and the therapeutic
organization. Accordingly, the practitioner has opted to employ psychodynamic
psychotherapy, cognitive-behavioral therapy (CBT), and group therapy. Over the course
of 12 weeks, Janice is to meet with the practitioner every Monday afternoon from 6pm-
7:30pm, 90 minute sessions. The first 5-15 minutes consists of discussion and follow-up
in relation to the past week’s experience. The remaining 75-85 minutes are divided in
half consisting of psychodynamic psychotherapy and CBT. Psychodynamic
psychotherapy, also referred to as insight-oriented therapy, “focuses on unconscious
processes as they are manifested in a person’s present behavior” (Haggerty, 2006). In
addition, this approach enables the client to divulge her emotional expression and
interpersonal relatedness (McKay, 2011). Within this methodology, the client is
encouraged to openly express themselves, self-reflect, and develop patience with the
intent of developing coping skills, internal awareness, personal acceptance, and self-
confidence (Poulsen, Lunn, & Sandros, 2010). The objective of this approach is to
increase the client’s self-awareness and recognizing how their present behavior was
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OBSESSIVE-COMPULSIVE PERSONALITY DISORDER:CASE PRESENTATION AND TREATMENT PLAN
shaped by their past. The second half of the session employs CBT. In general,
“cognitive clinicians believe that thoughts lead to emotions and behaviors and that,
through awareness and modification of their thoughts, people can change their feelings
and actions” (Seligman & Reichenberg, 2010, p. 241). Hence, as Janice becomes more
conscious of her thought process and is persuaded to think differently, in turn she may
alter her behavior and response. Additionally, CBT enables the subject to decrease
psychotic symptoms such as depression, foster hope, and enhance functionality (Lincoln,
Ziegler, Mehl, Kesting, Lüllmann, Westermann, & Rief, 2012). As a secondary
intervention between sessions, Janice is required to attend one hour group sessions once
per week for the duration of the 12 weeks with the option to continue subsequent to one-
on-one therapy as deemed necessary. Furthermore, group therapy is considered a more
advantageous means of dealing with the subject’s resistance, decision making, level of
comfort, and interpersonal proficiency. In addition to these methodologies, a
pharmacological approach may be implemented as needed. Janice’s plausible depression
or anxiety may be treated with antidepressants or betaxolol, respectively. However,
many consider medication an unfavorable method of treatment for OCPD patients as the
drug may stimulate dependency (Ribeiro, 2011).
During the therapeutic process it is imperative to measure the client’s progress
and status. In effort to effectively determine Janice’s progress on a weekly basis, the
practitioner should consider her journal use and content, information from the employer,
feedback from the group therapist, reports from Janice’s organizational activity,
recognize her body language and demeanor as she discloses information concerning her
weekly encounters and endeavors, as well as how she responds to instruction and
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OBSESSIVE-COMPULSIVE PERSONALITY DISORDER:CASE PRESENTATION AND TREATMENT PLAN
criticism. These measures indicate whether or not she is adhering to therapy and actively
incorporating the practices advantageous to realizing her aspirations.
Another critical component of the case presentation is the clinician signature or
policy statement. Typically, this form is employed to protect the practitioner and the
psychiatric staff from prosecution and unwarranted recovery (Porter, 2010).
Accordingly, this itemized listing includes general principles, role implications, use of
colleagues’ names, use of dates, on-call responsibilities, disability documents, forensic
documents, treatment plans, administrative reviews, prescriptions for medications,
prescription privilege, telephone transmissions or prescriptions, billing documents,
treatment authorizations, authorization reviews, managed care contracts, and a conclusion
in which the practitioner signs the document (Glenn, 1997). These factors express the
organizational guidelines, purposes, responsibilities and requirements, practices,
recommendations, expectations, and endorsements.
Although the previously discussed methods and interventions are advantageous
means of treating OCPD, as a practitioner it is imperative to recognize one’s strengths
and weaknesses in relation to the patient. Personally, effective listening, substantial
research, adequate interviewing, self discipline, empathy, reframing and motivational
techniques, and a non-judgmental persona are beneficial skills to possess within the
psychological field. Furthermore, the ability to focus on interests, problem solving,
fulfilling healthy living, assisting those in distress, resilience, gratitude, and cultivating
high quality relationships are advantageous qualities. Embracing and utilizing these traits
and techniques sustains the notion that assisting Janice throughout her therapeutic process
is an attainable personal goal. However, lack of therapeutic experience is a reasonable
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OBSESSIVE-COMPULSIVE PERSONALITY DISORDER:CASE PRESENTATION AND TREATMENT PLAN
issue. Having never dealt with an OCPD patient, or any type of client for that matter,
may pose a concern. Janice may desire to utilize a more experienced professional with
further credentials. Additionally, her symptoms and drive could be considered positive
attributes given they were normalized. Hence, it may be challenging to treat Janice or
modify certain behaviors which could be considered admirable to an extent.
Furthermore, a personal sense of well being or adequacy may impede the process.
Generally, “the less aware we are of our motives, feelings, thoughts, actions, perceptions,
the more they control us and the more we stay stuck in old patterns that don’t work
anymore” (Pologe, 2006). In effort to personally overcome such factors; I must discover
and incorporate into constant, every-day consciousness, that which is being masked,
distracted from, or indirectly acted out. Failure to do so results in the inability to assist
Janice in terms of self-realization and self-awareness.
Other challenges associated with the case are client responsibility, blind spots,
self-disclosure, and ethical issues.
First, as the client, Janice has a responsibility to actively participate and provide
input. Moreover, she must display honesty, open communication, complete external
assignments, maintain appointments, keep me abreast of any changes or progress, assist
in planning goals, follow through, wear appropriate attire, and refrain from overlapping
or visiting multiple clinicians. By fulfilling these obligations and adhering to requests
and requirements, Janice enhances the likelihood of a successful and effective process.
Second, the most significant blind spot in relation to treating Janice is the fact that
some issues have the potential to be more difficult to empathize with from a male versus
female perspective. In effort to conquer this matter I must give consideration to women’s
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OBSESSIVE-COMPULSIVE PERSONALITY DISORDER:CASE PRESENTATION AND TREATMENT PLAN
plight, the Janice’s individual history, and confer with female colleagues and senior
clinicians when applicable.
Third, self-disclosure raises probable concern as well. At times, I may deem it
necessary to disclose personal information which is relevant to Janice’s circumstances in
an attempt to provide helpful information and insight. In addition, self-disclosure fosters
rapport, temporarily removes some of the focus away from the client’s issues, and
conveys empathy. However, the risks of self-disclosure includes the fact it may be
considered narcissistic or disruptive, or that the client may feel obligated to respond in a
similar mode as the clinician. Also, Janice may respond negatively to the information or
gain too much power and information against me. Furthermore, excessive information or
exposure occurring early on in the process may be damaging (Murphy & Dillon, 2011).
Lastly, ethical issues must be upheld. In particular, boundaries may present an
issue. Janice is an attractive, single woman with few interpersonal attachments. From
her perspective she has the potential to become attracted as in certain instances victims
are drawn to the supporter or sponsor. From a personal perspective, Janice is beautiful,
age appropriate, and available. However, I must refrain from abusing the client-clinician
relationship and resist any impending temptations. Additionally, a social relationship
may render Janice ineligible to seek services in the future if needed, cause the her to
consider the treatment as unprofessional or inefficient resulting in a formal complaint or
lawsuit, or simply disregard her best interest, deterring ongoing personal development.
Furthermore, forming a social relationship could “impair the psychologist's objectivity,
competence, or effectiveness in performing his or her functions as a psychologist” (APA,
2002).
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OBSESSIVE-COMPULSIVE PERSONALITY DISORDER:CASE PRESENTATION AND TREATMENT PLAN
In conclusion, in effort to treat a patient suffering from a personality disorder such
as OCPD, the practitioner should provide a case presentation and treatment plan. These
tools enable the practitioner to outline and adequately inform the patient of the process,
responsibilities, guidelines, and objectives. In order to assess, diagnose, and treat an
OCPD sufferer such as Janice, implementing a comprehensive approach is most
advantageous. Thus, the usage of a psychodynamic psychotherapeutic approach,
cognitive behavioral therapy, and group therapy are beneficial and appropriate
methodologies to employ. Such techniques enable Janice to effectively address her past
and emotional welfare, modify her thoughts which ultimately influence her behavior, and
receive support from her peers. As she enthusiastically implements such practices she
increases her potential to realize long term success and maintain functionality.
Additionally, as the practitioner, an awareness of the challenges associated with the case
and the knowledge and ability to overcome them is imperative to the process.
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References
American Psychological Association. (2002). Ethical principles of psychologists and code of
conduct. Retrieved from http://www.apa.org/ethics/code/index.aspx.
Brain Psychics. (2012). Obsessive compulsive personality. Retrieved from
http://www.brainphysics.com/oc-personality.php.
Butcher, J.N., Mineka, S., & Hooley, J.M. (2010). Abnormal psychology (14th ed.).
Boston: Allyn & Bacon.
Glenn, T.J. (1997). Task force on psychiatrists’ signatures. Retrieved from
http://www.familymentalhealth.com/aacapguide.htm.
Haggerty, J. (2006). Psychodynamic Therapy. Retrieved from
http://psychcentral.com/lib/2006/psychodynamic-therapy/.
Lincoln, T.M., Ziegler, M., Mehl, S., Kesting, M., Lüllmann, E., Westermann, S., &
Rief, W. (2012). Moving from efficacy to effectiveness in cognitive behavioral
therapy for psychosis: A randomized clinical practice trial. Journal of Consulting
and Clinical Psychology, 80(4), 674-686.
McKay, D. (2011). Methods and mechanisms in the efficacy of psychodynamic
psychotherapy. American Psychologist, 66(2), 147-148.
Murphy, B. C., & Dillon, C. (2011). Interviewing in action in a multicultural world
(4th ed.). Belmont, CA: Brooks/Cole.
Ng, R.M.K. (2005). Cognitive therapy for obsessive compulsive personality
disorder – A pilot study in Hong Kong Chinese patients. Hong Kong J
Psychiatry, 15, 50-53.
Ribeiro, J.P. (2011). Obsessive-complusive personality disorder treatment. Retrieved
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OBSESSIVE-COMPULSIVE PERSONALITY DISORDER:CASE PRESENTATION AND TREATMENT PLAN
from http://www.health.am/psy/more/ocpd_treatment/.
Pologe, B. (2006). About Psychotherapy. Retrieved from
http://www.aboutpsychotherapy.com/index.html.
Porter, S. (2010). CMS clarifies signature requirements for Medicare participating docs:
AAFP responds with new resources for FPs. Retrieved from
http://www.aafp.org/online/en/home/publications/news/news-now/practice-
management/20100602signaturereqs.html.
Poulsen, S., Lunn, S., & Sandros, C. (2010). Client experience of psychodynamic
psychotherapy for bulimia nervosa: An interview study. Psychotherapy, 47(4),
469-483.
Psych Central. (2012). Obsessive-compulsive disorder treatment. Retrieved from
http://psychcentral.com/disorders/sx26t.htm.
Samuel, D.B., Simms, L.J., Clark, L.A., Livesley, W.J., & Widiger, T.A. (2010).
An Item Response Theory Integration of Normal and Abnormal Personality
Scales. Personal Disord, 1(1), 5-21.
Samuel, D.B. & Widiger, T.A. (2011). Conscientiousness and obsessive-compulsive
personality disorder. Personality Disorders: Theory, Research, and Treatment,
2(3), 161-174.
Seligman, L. W. & Reichenberg, L. W. (2009). Theories of counseling and
psychotherapy: Systems, strategies, and skills. (3rd ed.). Boston: Pearson.
Vorick, L. (2010). Obsessive-compulsive personality disorder. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/000942.htm.
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