OCPD Case Presentation and Treatment Plan

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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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

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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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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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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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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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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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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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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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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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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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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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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http://www.aboutpsychotherapy.com/index.html

OCPD Case Presentation and Treatment Plan

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