Obsessive–compulsive personality disorder
Obsessive–compulsive personality disorder (OCPD) is a personality disorder characterized by a general pattern of concern with orderliness, perfectionism, excessive attention to details, mental and interpersonal control, and a need for control over one's environment, at the expense of flexibility, openness to experience, and efficiency. Workaholism and miserliness are also seen often in those with this personality disorder. Rituals are performed to the point of excluding leisure activities and friendships. Persons affected with this disorder may find it hard to relax, always feeling that time is running out for their activities, and that more effort is needed to achieve their goals. They may plan their activities down to the minute—a manifestation of the compulsive tendency to keep control over their environment and to dislike unpredictable things as things they cannot control.
|Obsessive-compulsive personality disorder|
|Synonyms||anankastic personality disorder|
|Classification and external resources|
The cause of OCPD is unknown. This is a distinct disorder from obsessive–compulsive disorder (OCD), and the relation between the two is contentious. Some (but not all) studies have found high comorbidity rates between the two disorders, and both may share outside similarities – rigid and ritual-like behaviors, for example. Hoarding, orderliness, and a need for symmetry and organization are often seen in people with either disorder. Attitudes toward these behaviors differ between people affected with either of the disorders: for people with OCD, these behaviors are unwanted and seen as unhealthy, being the product of anxiety-inducing and involuntary thoughts, while for people with OCPD they are egosyntonic (that is, they are perceived by the subject as rational and desirable), being the result of, for example, a strong adherence to routines, a natural inclination towards cautiousness, or a desire to achieve perfection.
Signs and symptomsEdit
The main symptoms of OCPD are preoccupation with remembering and paying attention to minute details and facts, following rules and regulations, compulsion to making lists and schedules, and rigidity/inflexibility of beliefs or showing perfectionism that interferes with task completion. Symptoms may cause extreme distress and interfere with a person's occupational and social functioning. Most people spend their early life avoiding symptoms and developing techniques to avoid dealing with these strenuous issues.
Some (but not all) people with OCPD show an obsessive need for cleanliness. This, combined with an obsessive preoccupation with tidiness, might instead make daily life very difficult. Although this kind of obsessive behavior can contribute to a sense of controlling personal anxiety, tension might continue to exist. In contrast, OCPD sufferers might not organize things, and they could become compulsive hoarders because their efforts to clean their homes effectively can be hindered by the amount of clutter that the person still plans to organize at some point. In reality, they might never do it, as they become overwhelmed with the workload, and thus anxious.
Perception of own and others' actions and beliefs tend to be polarised (i.e., "right" or "wrong", with little or no margin between the two) for people with this disorder. As it might be expected, such rigidity places strain on interpersonal relationships, with frustration sometimes turning into anger and even violence. This is known as disinhibition. People with OCPD often tend to general pessimism and/or underlying form(s) of depression. This can at times become so serious that suicide is a risk. Indeed, one study suggests that personality disorders are a substrate to psychiatric morbidity. They may cause more problems in functioning than a major depressive episode.
OCPD is often confused with obsessive–compulsive disorder (OCD). Despite the similar names, they are two distinct disorders—OCD is an anxiety disorder and OCPD is a personality disorder. Some OCPD individuals do have OCD, and the two are sometimes found in the same family, sometimes along with eating disorders. People with OCPD do not generally feel the need to repeatedly perform ritualistic actions—a common symptom of OCD—and usually find pleasure in perfecting a task, whereas people with OCD are often more distressed after their actions.
Some OCPD features are common in those afflicted with OCD. For example, perfectionism, hoarding, and preoccupation in details (which are three characteristics of OCPD) were found in people with OCD and not in people without OCD, showing a particular relationship between these OCPD traits with OCD. The reverse is also true: certain OCD symptoms appear to have close parallels in OCPD ones. This is particularly the case for checking and ordering and symmetry symptoms. OCPD samples who have OCD are particularly likely to endorse obsessions and compulsions regarding symmetry and organization. Washing symptoms, which are among the most common OCD symptoms, don't appear to have much of a link with OCPD, in contrast.
There is significant similarity in the symptoms of OCD and OCPD, which can lead to complexity in distinguishing them clinically. For example, perfectionism is an OCPD criterion and a symptom of OCD if it involves the need for tidiness, symmetry, and organization. Hoarding is also considered both a compulsion found in OCD and a criterion for OCPD in the DSM-IV. Even though OCD and OCPD are seemingly separate disorders there are obvious redundancies between the two concerning several symptoms.
Regardless of similarities between the OCPD criteria and the obsessions and compulsions found in OCD, there are discrete qualitative dissimilarities between these disorders, predominantly in the functional part of symptoms. Unlike OCPD, OCD is described as invasive, stressful, time-consuming obsessions and habits aimed at reducing the obsession related stress. OCD symptoms are at times regarded as ego-dystonic because they are experienced as alien and repulsive to the person. Therefore, there is a greater mental anxiety associated with OCD.
In contrast, the symptoms seen in OCPD, although they are repetitive, are not linked with repulsive thoughts, images, or urges. OCPD characteristics and behaviors are known as ego-syntonic, as people with this disorder view them as suitable and correct. On the other hand, the main features of perfectionism and inflexibility can result in considerable suffering in an individual with OCPD as a result of the associated need for control.
A 2014 study also found a second difference between OCPD and OCD: samples afflicted with OCPD, regardless of the presence of comorbid OCD, are more rigid in behavior and have a greater delayed gratification than either those afflicted with OCD or healthy control samples. Delayed gratification is a measure of self-control; it expresses one's capacity to suppress the impulse to pursue more immediate gratification in order to acquire greater rewards in the future.
Recent studies using DSM-IV criteria have persistently found high rates of OCPD in persons with OCD, with an approximate range of 23% to 32% in persons with OCD. Some data suggest that there may be specificity in the link between OCD and OCPD. OCPD rates are consistently higher in persons with OCD than in healthy population controls using DSM-IV criteria.
There are considerable similarities and overlap between Asperger's syndrome and OCPD, such as list-making, inflexible adherence to rules, and obsessive aspects of Asperger's syndrome, though the former may be distinguished from OCPD especially regarding affective behaviors, worse social skills, difficulties with Theory of Mind and intense intellectual interests e.g. an ability to recall every aspect of a hobby. A 2009 study involving adult autistic people found that 40% of those diagnosed with Asperger's syndrome met the diagnostic requirements for a co-morbid OCPD diagnosis.
Stiff and rigid personalities have been consistently linked with eating disorders, especially with anorexia nervosa. Divergences between different studies as to the incidence of OCPD among anorexics and bulimics has been found, which may in part reflect differences in the methodology chosen in different studies, as well as the difficulties of diagnosing personality disorders. In the table below, results are shown for the frequency of OCPD among anorexics (non-specified subtype, AN), restricting anorexics (RAN), binge/purge anorexics as well as anorexics with a history of bulimia nervosa (BPAN), and normal-weight bulimics (BN).
|Arderluh et al. (2009)||71.4%||46.7%—64%||40%|
|Halmi et al. (2005a)||31%||32%||24%|
|Halmi et al. (2005b)||6%||11-13%||0%|
|Anderluh et al. (2003)||61%||46%|
|Matsunaga et al. (1999)||43.8%||25%||25%|
Regardless of the prevalence of the full-fledged OCPD among eating disordered samples, the presence of this personality disorder and its over-controlled quality has been found to be positively correlated with a range of complications in eating disorders, as opposed to impulsive features—those linked with histrionic personality disorder, for example—which predict better outcome from treatment. OCPD predicts including more severe anorexic symptoms, worse remission rates, and the presence of aggravating behaviors such as compulsive exercising. Compulsive exercising in eating disordered samples, along with smaller lifetime BMI and illness duration among anorexics, also correlates positively and significantly with an important OCPD trait: perfectionism.
Perfectionism has been linked with anorexia nervosa in research for decades. A researcher in 1949 described the behavior of the average anorexic girl as being "rigid" and "hyperconscious", observing also a tendency to "[n]eatness, meticulosity, and a mulish stubbornness not amenable to reason [which] make her a rank perfectionist". Perfectionism is a life enduring trait in the biographies of anorexics. It is felt before the onset of the eating disorder, generally in childhood, during the illness, and also, after remission. The incessant striving for thinness among anorexic women is itself a manifestation of this trait, of an insistence upon meeting unattainably high standards of performance. Because of its chronicity, those with eating disorders also display perfectionistic tendencies in other domains of life than dieting and weight control. Over-achievement at school, for example, has been observed among anorexics, as a result of their over-industrious behavior.
A Swedish study found that hospitalization for eating disorders was around twice more common among girls who took advanced courses and achieved high average grades than among those who had medium or low grades. The link with over-achievement was particularly high among those hospitalized for AN, which was 3.5 times as common among those with high grades as in those with other grade levels. In some individuals with bulimia nervosa, the seemingly conflicting traits of impulsivity and perfectionism are present.
Apart from perfectionism, other OCPD traits have been observed in the childhoods of the eating disordered in much higher frequency than among control samples, including among their unaffected sisters.
|Childhood OCPD trait||AN||RAN||BPAN||BN||OCPD||OCPD+OCD||OCD (without OCPD)||Sisters of anorexics||Control samples|
|Doubt and cautiousness||28%||27.3%||46.7%||21.4%||3%||0—5%|
|Order and symmetry||6%||38.5%||31.3%||10.7%||66.7%||46.4%||17.9%||3%||0—3.6%|
Like those afflicted with OCPD, anorexics and bulimics also tend to have a great need for order and symmetry in their activities and surroundings, something seen in their relationship with a third disorder, OCD. Eating disorders are largely comorbid with OCD; with some studies showing that OCD symptoms are nearly as severe among anorexics as among a classic OCD sample, and that this remains so even after discounting food- and weight-related obsessions and compulsions.
The eating disordered are less likely, however, to develop the multi-object obsessions and compulsions of people with classic OCD, who self-report symptoms related to a multitude of themes such as violence, sex, washing, moral taboos etc. The symptoms of both anorexics and bulimics, however, tend to be more restricted to symmetry and orderliness concerns. The same has been noted in samples afflicted with comorbid OCPD and OCD, who are more likely harbor obsessions and compulsions about symmetry and order than those have OCD only.
At least one paper has made an explicit link between OCPD and the OCD symptoms endorsed by anorexics, noticing that in the samples under study – one with both restrictive anorexia and OCD and another from OCD but no present eating disorder – those with comorbid AN and OCD were more likely to be diagnosed with OCPD than those with OCD only (38.1% vs 8.7%). In a larger sample which included anorexic bingers and normal weight bulimics, it was found that all three eating disordered groups were more likely to develop symptoms about order and symmetry than the OCD-only group. Among women recovered from AN, orderliness concerns remain higher than among control samples without an eating disorder history.
The obsessive compulsive personality traits of over-attention to details and inflexibility have also been found in cognitive testing of anorexics; this group, compared to healthy controls, will display average to above average performance in tests requiring accuracy and the avoiding of errors but poorly on tests requiring mental flexibility and central coherence, i.e., the ability to integrate details of information into a bigger narrative. Over-attention to details among anorexics and weak central coherence are linked with a well-known cognitive failure in this group, that of missing "the big picture", a characteristic also of the cognitive style of those with OCPD.
Both anorexics and non-eating disordered OCPD samples have also been found to share the trait of increased self-control, an above average ability to delay gratification in the name of a greater good to be received in the future. Among anorexics specifically, this trait is manifested in their capacity to repress a key natural urge, that of satisfying hunger, in order to be 'rewarded' with weight loss. In a 2012 paper, it was verified this trait exists among anorexics also beyond food and weight themes. The anorexics, especially those of the restricting type, were observed to save money handled to them by researchers more persistently than a control sample of healthy women.
A similar experiment was tested on four non-eating disordered samples—one with OCPD only, another from OCD only, a third afflicted with both OCPD and OCD, and a sample of healthy controls. Delay gratification was found to be pronounced among those with OCPD but not those with OCD only or the control samples, who had similar performances to one another. Delayed gratification, they found, was highly correlated with the severity of OCPD, i.e., the greater the capacity to delay gratification in a person afflicted with OCPD, the more impairing was the disorder. As the authors noticed, while many psychiatric disorders—substance abuse, for example—may be marked by impulse deregulation, OCPD and anorexia nervosa stand out as the only disorders shown to spring forth from the opposite quality: excessive self-control.
Some family studies have also found a close genetic link between OCPD and anorexia. Lilenfeld et al. 1998, compared for a variety of psychiatric diagnoses three sets of women—one suffering from the restricting type of anorexia nervosa, another from bulimia nervosa, and a group of control women without an eating disorder—plus their respective relatives unaffected by eating disorders. They found a much higher incidence of OCPD among anorexics and their relatives (46% and 19%, respectively) than in the control samples and the latter's own relatives (5% and 6%, respectively). What's more, the rates of OCPD among relatives of Anorexics with that personality disorder and those without it were about the same—evidence, in the authors' words, "suggesting shared familial transmission of AN and OCPD".
In this study, bulimics and their relatives were not found to have elevated rates of OCPD (4% and 7%, respectively). Strober et al. 2007, in a similarly intended study, also found much higher incidence of OCPD among relatives of restrictive anorexics than among relatives of a normal control sample (20.7% vs. 7%). Along with diagnoses of OCD and generalized anxiety disorder, OCPD was the one that best distinguished between the two groups.
The cause of OCPD is unknown. However, it is believed to involve a combination of genetic and environmental factors. Under the genetic theory, people with a form of the DRD3 gene will probably develop OCPD and depression, particularly if they are male. But genetic concomitants may lie dormant until triggered by events in the lives of those who are predisposed to OCPD. These events could include trauma faced during childhood, such as physical, emotional, or sexual abuse, or other psychological trauma. Under the environmental theory, OCPD is a learned behavior.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a widely used manual for diagnosing mental disorders, defines obsessive–compulsive personality disorder (in Axis II Cluster C) as an extensive pattern of preoccupation with perfectionism, orderliness, and interpersonal and mental control, at the cost of efficiency, flexibility and openness. Symptoms must appear by early adulthood and in multiple contexts. At least four of the following should be present:
- 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.
Since the DSM-IV-TR was published in 2000, some studies have found fault with its OCPD coverage. A 2004 study challenged the usefulness of all but three of the criteria: perfectionism, rigidity and stubbornness, and miserliness. A study in 2007 found that OCPD is etiologically distinct from avoidant and dependent personality disorders, suggesting it is incorrectly categorized as a Cluster C disorder.
It is characterized by at least three of the following:
- feelings of excessive doubt and caution;
- preoccupation with details, rules, lists, order, organization, or schedule;
- perfectionism that interferes with task completion;
- excessive conscientiousness, scrupulousness, and undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships;
- excessive pedantry and adherence to social conventions;
- rigidity and stubbornness;
- unreasonable insistence by the individual that others submit exactly to his or her way of doing things or unreasonable reluctance to allow others to do things;
- intrusion of insistent and unwelcome thoughts or impulses.
- compulsive and obsessional personality (disorder)
- obsessive-compulsive personality disorder
Also, it excludes:
- obsessive-compulsive disorder
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
|Subtype||Description||Compulsive personality traits|
|Conscientious||Including dependent features||Rule-bound and duty-bound; earnest, hardworking, meticulous, painstaking; indecisive, inflexible; marked self-doubts; dreads errors and mistakes.|
|Bureaucratic||Including narcissistic, sadistic features||Empowered in formal organizations; rules of group provide identity and security; officious, high-handed, unimaginative, intrusive, nosy, petty-minded, meddlesome, trifling, closed-minded.|
|Puritanical||Including paranoid features||Austere, self-righteous, bigoted, dogmatic, zealous, uncompromising, indignant, and judgmental; grim and prudish morality; must control and counteract own repugnant impulses and fantasies.|
|Parsimonious||Including schizoid, avoidant features||Miserly, tight-fisted, ungiving, hoarding, unsharing; protects self against loss; fears intrusions into vacant inner world; dreads exposure of personal improprieties and contrary impulses.|
|Bedeviled||Including negativistic features||Ambivalences unresolved; feels tormented, muddled, indecisive, befuddled; beset by intrapsychic conflicts, confusions, frustrations; obsessions and compulsions condense and control contradictory emotions.|
||This section's factual accuracy is disputed. (March 2016) (Learn how and when to remove this template message)|
Treatment for OCPD includes psychotherapy, cognitive behavioral therapy, behavior therapy or self-help. Medication may be prescribed. In behavior therapy, a person with OCPD discusses with a psychotherapist ways of changing compulsions into healthier, productive behaviors. Cognitive analytic therapy is an effective form of behavior therapy.
Treatment is complicated if the person does not accept that they have OCPD, or believes that their thoughts or behaviors are in some sense correct and therefore should not be changed. Medication alone is generally not indicated for this personality disorder. Selective serotonin reuptake inhibitors (SSRIs) may be useful in addition to psychotherapy by helping the person with OCPD be less bogged down by minor details, and to lessen how rigid they are.
People with OCPD are three times more likely to receive individual psychotherapy than people with major depressive disorder. There are higher rates of primary care utilization. There are no known properly controlled studies of treatment options for OCPD. More research is needed to explore better treatment options.
Estimates for the prevalence of OCPD in the general population range from 2.1% to 7.9%. A large U.S. study found a prevalence rate of 7.9%, making it the most common personality disorder. Men are diagnosed with OCPD about twice as often as women. It may occur in 8–9% of psychiatric outpatients.
In 1908, Sigmund Freud named what is now known as obsessive–compulsive or anankastic personality disorder "anal retentive character". He identified the main strands of the personality type as a preoccupation with orderliness, parsimony (frugality), and obstinacy (rigidity and stubbornness). The concept fits his theory of psychosexual development.
OCPD was first included in DSM-II, and was largely based on Sigmund Freud's notion of the obsessive personality or anal-erotic character style characterized by orderliness, parsimony, and obstinacy.
The diagnostic criteria for OCPD have gone through considerable changes with each DSM modification. For example, the DSM-IV stopped using two criteria present in the DSM-III-R, constrained expression of affection and indecisiveness, mainly based on reviews of the empirical literature that found these traits did not contain internal consistency. Since the early 1990s, considerable research continues to characterize OCPD and its core features, including the tendency for it to run in families along with eating disorders and even to appear in childhood.
According to the DSM-IV, OCPD is classified as a 'Cluster C' personality disorder. There was a dispute about the categorization of OCPD as an Axis II anxiety disorder. It has been argued that it is more appropriate for OCPD to appear alongside OC spectrum disorders including OCD, body dysmorphic disorder, compulsive hoarding, trichotillomania, compulsive skin-picking, tic disorders, autistic disorders, and eating disorders.
Although the DSM-IV attempted to distinguish between OCPD and OCD by focusing on the absence of obsessions and compulsions in OCPD, OC personality traits are easily mistaken for abnormal cognitions or values considered to underpin OCD. Aspects of self-directed perfectionism, such as believing a perfect solution is commendable, discomfort if things are sensed not to have been done completely, and doubting one's actions were performed correctly, have also been proposed as enduring features of OCD. Moreover, in DSM-IV field trials, a majority of OCD patients reported being unsure whether their OC symptoms really were unreasonable.
- Samuels, Jack; Costa, Paul T. (2012). "Obsessive-Compulsive Personality Disorder". In Widiger, Thomas. The Oxford Handbook of Personality Disorders. Oxford University Press. p. 568. ISBN 978-0-19-973501-3.
- Pinto, Anthon y; Eisen, Jane L.; Mancebo, Maria C.; Rasmussen, Steven A. (2008). "Obsessive-Compulsive Personality Disorder" (PDF). In Abramowitz, Jonathan S.; McKay, Dean; Taylor, Steven. Obsessive-Compulsive Disorder: Subtypes and Spectrum Conditions. Elsevier. pp. 246–263. ISBN 978-0-08-044701-8.
- Murphy, Michael; Cowan, Ronald; Sederer, Lloyd I., eds. (2009). "Personality Disorders". Blueprints Psychiatry (5th ed.). Wolters Kluwer/Lippincott Williams & Wilkins. p. 30. ISBN 978-0-7817-8253-1.
- Cain, Nicole; Ansell, Emily B.; Simpson, H. Blair; Pinto, Anthony (2014). "Interpersonal Functioning in Obsessive–Compulsive Personality Disorder". Journal of Personality Assessment. 97 (1): 1–10. doi:10.1080/00223891.2014.934376.
- "Obsessive–compulsive personality disorder". MedlinePlus. U.S. National Library of Medicine, National Institutes of Health.
- Taber's Cyclopedic Medical Dictionary 18th ed 1968
- Jefferys, Don; Moore, KA (2008). "Pathological hoarding". Australian Family Physician. 37 (4): 237–41. PMID 18398520. Retrieved October 7, 2009.
- Villemarette-Pittman, Nicole R; Matthew Stanford; Kevin Greve; Rebecca Houston; Charles Mathias (2004). "Obsessive-Compulsive Personality Disorder and Behavioral Disinhibition". The Journal of Psychology. 138 (1): 5–22. doi:10.3200/JRLP.138.1.5-22. PMID 15098711.
- Pilkonis PA, Frank E (1988). "Personality pathology in recurrent depression: nature, prevalence, and relationship to treatment response". Am J Psychiatry. 145: 435–41. doi:10.1176/ajp.145.4.435. PMID 3348446.
- Rossi A; et al. (2000). "Pattern of comorbidity among anxious and odd personality disorders: the case of obsessive–compulsive personality disorder". CNS Spectr. 5 (9): 23–6. doi:10.1017/s1092852900021623.
- Shea MT; et al. (1992). "Comorbidity of personality disorders and depression; implications for treatment". J Consult Clin Psychol. 60: 857–68.
- Raja M, Azzoni A (2007). "The impact of obsessive–compulsive personality disorder on the suicidal risk of patients with mood disorders". Psychopathology. 40 (3): 184–90. doi:10.1159/000100366.
- Skodol AE; et al. (2002). "Functional Impairment in Patients With Schizotypal, Borderline, Avoidant, or Obsessive–Compulsive Personality Disorder". Am J Psychiatry. 159: 276–83. doi:10.1176/appi.ajp.159.2.276.
- Samuels J et al. (2000). Personality disorders and normal personality dimensions in obsessive–compulsive disorder. Br J Psychiatry. Nov. 177: 457–62.
- Halmi, KA; et al. (December 2005). "The relation among perfectionism, obsessive–compulsive personality disorder, and obsessive–compulsive disorder in individuals with eating disorders". Int J Eat Disord. 38 (4): 371–4. doi:10.1002/eat.20190. PMID 16231356.
- Calvo, Rosa; Lázaro, Luisa; Castro-Fornieles, Josefina; Fonta, Elena; Moreno, Elena; Toro, J. (April 2009). "Obsessive-compulsive personality disorder traits and personality dimensions in parents of children with obsessive-compulsive disorder". European Psychiatry. 24 (3): 201–206. doi:10.1016/j.eurpsy.2008.11.003.
- Lochner, Christine (2011). "Comorbid obsessive–compulsive personality disorder in obsessive–compulsive disorder (OCD): A marker of severity". Progress in Neuro-Psychopharmacology & Biological Psychiatry.
- Pinto, Anthony (2014). "Capacity to Delay Reward Differentiates Obsessive-Compulsive Disorder and Obsessive-Compulsive Personality Disorder". Biol Psychiatry. 75 (8): 653–659. doi:10.1016/j.biopsych.2013.09.007.
- Gillberg, C.; Billstedt, E. (November 2000). "Autism and Asperger syndrome: coexistence with other clinical disorders". Acta Psychiatrica Scandinavica. 102 (5): 321–330. doi:10.1034/j.1600-0447.2000.102005321.x. PMID 11098802. Retrieved 2014-09-24.
- Fitzgerald, Michael; Aiden Corvin (2001-07-01). "Diagnosis and differential diagnosis of Asperger syndrome". Advances in Psychiatric Treatment. 7 (4): 310–318. doi:10.1192/apt.7.4.310. ISSN 1355-5146. Retrieved 2014-09-24.
- Hofvander, Björn; Delorme, Richard; Chaste, Pauline; Nydén, Agneta; Wentz, Elisabet; Stahlberg, Ola; Herbrecht, Evelyn; Stopin, Astrid; Anckarsäter, Henrik; Gillberg, Christopher; et al. (2009). "Psychiatric and psychosocial problems in adults with normal-intelligence autism spectrum disorders". BMC Psychiatry. 9 (1): 35. doi:10.1186/1471-244x-9-35. Retrieved 2014-09-24.
- DuBois, F.S. (1949). "Compulsion neurosis with cachexia (Anorexia Nervosa)". American Journal of Psychiatry. 106: 107–115. doi:10.1176/ajp.106.2.107. PMID 18135398.
- Halmi, Katherin A (2005). "Obsessive-Compulsive Personality Disorder and Eating Disorders". Eating Disorders. 13 (1): 85–92. doi:10.1080/10640260590893683. PMID 16864333.
- Anderluh, Marija Brecelj; Tchanturia, K; Rabe-Hesketh, S; Collier, D; Treasure, J. (January 2009). "Lifetime course of eating disorders: design and validity testing of a new strategy to define the eating disorders phenotype". Psychological Medicine. 39 (1): 105–114. doi:10.1017/S0033291708003292. PMID 18377676.
- Halmi, Katherin A (2005). "The Relation among Perfectionism, Obsessive-Compulsive Personality Disorder and Obsessive-Compulsive Disorder in Individuals with Eating Disorders". Int J Eat Disord. 38 (4): 371–374. doi:10.1002/eat.20190. PMID 16231356.
- Hisato Matsunaga; et al. (1999). "A Comparison of Clinical Features Among Japanese Eating-Disordered Women With Obsessive-Compulsive Disorder". Comprehensive Psychiatry. 40 (5): 337–342. doi:10.1016/s0010-440x(99)90137-2.
- Lilenfield, LR (2006), "Eating disorders and personality: a methodological and empirical review.", Clin Psychol Rev, 26: 299–320, doi:10.1016/j.cpr.2005.10.003, PMID 16330138
- Crane, Anna (2007). "Are Obsessive-Compulsive Personality Traits Associated with a Poor Outcome in Anorexia Nervosa? A Systematic Review of Randomized Controlled Trials and Naturalistic Outcome Studies". International Journal of Eating Disorders. 40: 581–8. doi:10.1002/eat.20419. PMID 17607713.
- Davis, Caroline (1998). "Obsessionality in Anorexia Nervosa: The Moderating Influence of Exercise". Psychosomatic Medicine. 60 (2): 192–7. doi:10.1097/00006842-199803000-00015. PMID 9560869.
- Halmi, Katherine A. (2000). "Perfectionism in Anorexia Nervosa: Variation by Clinical Subtype, Obsessionality, and Pathological Eating Behavior". Am J Psychiatry. 157: 1799–1805. doi:10.1176/appi.ajp.157.11.1799. PMID 11058477.
- Shroff, Hemal (2006). "Features Associated With Excessive Exercise in Women with Eating Disorders" (PDF). International Journal of Eating Disorders. 39 (6): 454–461. doi:10.1002/eat.20247.
- Srinivasagam (1995). "Persistent perfectionism, symmetry, and exactness after long-term recovery from anorexia nervosa". Am J Psychiatry. 152 (11): 1630–4. doi:10.1176/ajp.152.11.1630. PMID 7485626.
- JR Dura; et al. (1989). "Differences between IQ and school achievement in anorexia nervosa". Journal of Clinical Psychology. 45 (3): 433–5. doi:10.1002/1097-4679(198905)45:3<433::aid-jclp2270450313>3.0.co;2-x. PMID 2745732.
- Michael Strober (1981). "The Significance of Bulimia in Juvenile Anorexia Nervosa: An Exploration of Possible Etiologic Factors". International Journal of Eating Disorders. 1 (1): 28–43. doi:10.1002/1098-108X(198123).
- D. L. NORRIS (1979). "Clinical Diagnostic Criteria for Primary Anorexia Nervosa". South African Medical Journal: 987–93.
- Hilde Bruch (2001). The Golden Cage: The Enigma of Anorexia Nervosa. First Harvard University Press. p. 46.
- Bernard Viallettes (2001). L'anorexie mentale, une déraison philosophique. L'Harmattan. p. 89. ISBN 2-7475-0876-5.
...even in the category of young women with low IQs, some had brilliant school records. This probably is the result of the persistence in work that characterizes anorexic patients.
- Ahre´n-Moonga, Jennie (2009). "Association of Higher Parental and Grandparental Education and Higher School Grades With Risk of Hospitalization for Eating Disorders in Females". American Journal of Epidemiology.
- Degortes, Daniela (2014). "Childhood Obsessive–compulsive Traits in Anorexia Nervosa Patients, Their Unaffected Sisters and Healthy Controls: A Retrospective Study". European Eating Disorders Review. 22: 237–242. doi:10.1002/erv.2295.
- Pinto, Anthony (2014). "Prevalence of childhood obsessive–compulsive personality traits in adults with obsessive compulsive disorder versus obsessive compulsive personality disorder". Journal of Obsessive-Compulsive and Related Disorders. doi:10.1016/j.jocrd.2014.11.002i.
- Masashi Suda; et al. (2014). "Provocation of Symmetry/Ordering Symptoms in Anorexia nervosa: A Functional Neuroimaging Study". PLOS ONE. 9: e97998. doi:10.1371/journal.pone.0097998. PMC . PMID 24844926.
- Serpell, Lucy (2002). "Anorexia nervosa: Obsessive–compulsive disorder, obsessive–compulsive personality disorder, or neither?". Clinical Psychology Review. 22 (5): 647–69. doi:10.1016/S0272-7358(01)00112-X. PMID 12113200.
- Kaye, Walter (1992). "Patients with anorexia nervosa have elevated scores on the Yale-Brown obsessive-compulsive scale". International Journal of Eating Disorders. 12: 57–62. doi:10.1002/1098-108X(199207)12:1<57::AID-EAT2260120108>3.0.CO;2-7.
- Halmi, Katherine (2003). "Obsessions and Compulsions in Anorexia Nervosa Subtypes". Int J Eat Disord.
- H, Matsunaga (1999). "Prevalence and symptomatology of comorbid obsessive-compulsive disorder among bulimic patients". Psychiatry Clin Neurosci.
- Southgate, Laura (2008). "Information processing bias in anorexia nervosa". Psychiatry Research. 160 (2): 221–7. doi:10.1016/j.psychres.2007.07.017. PMID 18579218.
- Van Autreve, Sara (2013). "Do Restrictive and Bingeing/Purging Subtypes of Anorexia Nervosa Differ on Central Coherence and Set Shifting?". Eur. Eat. Disorders Rev. 21 (4): 308–14. doi:10.1002/erv.2233. PMID 23674268.
- Blaney, Paul (2009). Oxford Textbook of Psychopathology, 2nd edition. Oxford University Press. p. 672. ISBN 0195374215.
- Steinglass, Joanna (2012). "Increased Capacity to Delay Reward in Anorexia Nervosa". Journal of the International Neuropsychological Society. 18: 1–8. doi:10.1017/S1355617712000446.
- Lilenfeld, Lisa (1998). "A controlled family study of Anorexia Nervosa and Bulimia Nervosa: psychiatric disorders in first-degree relatives and effects of proband comorbidity.". Arch Gen Psychiatry. 55 (7): 603–10. doi:10.1001/archpsyc.55.7.603. PMID 9672050.
- Strober, Michael (2007). "The Association of Anxiety Disorders and Obsessive Compulsive Personality Disorder with Anorexia Nervosa: Evidence from a Family Study with Discussion of Nosological and Neurodevelopmental Implications". International Journal of Eating Disorders. 40: S46–S51. doi:10.1002/eat.20429.
- Joyce; et al. (2003). "Polymorphisms of DRD4 and DRD3 and risk of avoidant and obsessive personality traits and disorders". Psychiatry Research. 119 (2): 1–10. doi:10.1016/s0165-1781(03)00124-0.
- Light (2006). "Preliminary evidence for an association between a dopamine D3 receptor gene variant and obsessive–compulsive personality disorder in patients with major depression". American Journal of Medical Genetics Part B. 141B: 409–413. doi:10.1002/ajmg.b.30308.
- American Psychiatric Association, ed. (2013). "Obsessive-Compulsive Personality Disorder, 301.4 (F60.5)". Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing. pp. 678–682.
- Grilo CM. (2004). Diagnostic efficiency of DSM-IV criteria for obsessive compulsive personality disorder in patients with binge eating disorder. Behaviour Research and Therapy 42(1) January,57–65.
- Reichborn-Kjennerud T et al. (2007). Genetic and environmental influences on dimensional representations of DSM-IV cluster C personality disorders: a population-based multivariate twin study. Psychol Med. May; 37(5): 645–53
- Anankastic personality disorder. International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)
- Millon, Theodore (2004). Personality Disorders in Modern Life. John Wiley & Sons, Inc., Hoboken, New Jersey. ISBN 0-471-23734-5.
- Millon, Theodore – Personality Subtypes
- Protogerou et al. (2008). Evaluation of Cognitive-Analytic Therapy (CAT) outcome in patients with Obsessive–Compulsive Personality Disorder Annals of General Psychiatry 2008, 7(Suppl 1):S109
- Ryle, A. & Kerr, I. B. (2002) Introducing Cognitive Analytic Therapy: Principles and Practice. Chichester: John Wiley & Sons.
- Bender, D; Dolan R; Skodol A (2001). "Treatment utilization by patients with personality disorders". Am J Psychiatry. 158. 158 (Am J Psychiatry 2001): 295–302. doi:10.1176/appi.ajp.158.2.295.
- Bender, D.; Skodol, A. E.; Pagano, M. E.; Dyck, I. R.; Grilo, C. M.; Shea, M. T.; Sanislow, C. A.; Zanarini, M. C.; Yen, S.; McGlashan, T. H.; Gunderson, J. G. (2006). "Prospective assessment of treatment use by patients with personality disorders". Psychiatr Serv. 57. 2 (Psychiatr Serv): 254–257. doi:10.1176/appi.ps.57.2.254.
- Sansone, R.A.; Hendricks, C. M.; Gaither, G. A.; Reddington, A. (2004). "Prevalence of anxiety symptoms among a sample of outpatients in an internal medicine clinic: a pilot study". Depress Anxiety. 19. 19 (2): 133–136. doi:10.1002/da.10143.
- Sansone, R.A.; Hendricks, C. M.; Sellbom, M.; Reddington, A. (2003). "Anxiety symptoms and healthcare utilization among a sample of outpatients in an internal medicine clinic". Int J Psychiatry Med. 33. 33 (2): 133–139. doi:10.2190/EYJ9-UVF4-RGP8-WK88.
- Bender, Donna S.; Skodol, Andrew E.; Dyck, Ingrid R.; Markowitz, John C.; Shea, M. Tracie; Yen, Shirley; Sanislow, Charles A.; Pinto, Anthony; Zanarini, Mary C.; McGlashan, Thomas H.; Gunderson, John G.; Daversa, Maria T.; Grilo, Carlos M. (2007). "Ethnicity and Mental Health Treatment Utilization by Patients with Personality Disorders". Journal of Consulting and Clinical Psychology. 75 (6): 992–999. doi:10.1037/0022-006X.75.6.992.
- De Reus, Rob J.M.; Paul M.G. Emmelkamp (February 2012). "Obsessive–compulsive personality disorder: A review of current empirical findings". Personality and Mental Health. 6 (1): 1–21. doi:10.1002/pmh.144. Retrieved 14 March 2013.
- Grant, Bridget F.; Hasin, Deborah S.; Stinson, Frederick S.; Dawson, Deborah A.; Chou, S. Patricia; Ruan, W. June; Pickering, Roger P. (2004). "Prevalence, Correlates, and Disability of Personality Disorders in the United States". The Journal of Clinical Psychiatry. 65 (7): 948–58. doi:10.4088/JCP.v65n0711. PMID 15291684.
- Lilenfeld; et al. (1998). "A Controlled Family Study of Anorexia Nervosa and Bulimia Nervosa". Arch Gen Psychiatry. 55 (7): 603–10. doi:10.1001/archpsyc.55.7.603. PMID 9672050.
- Anderluh MB, et al. (2003). "Childhood obsessive–compulsive personality traits in adult women with eating disorders: defining a broader eating disorder phenotype". Am J Psychiatry. 160 (2): 242–47. doi:10.1176/appi.ajp.160.2.242. PMID 12562569.
- Fineberg, N. A., Sharma, P., Sivakumaran, T., Sahakian, B., & Chamberlain, S. (2007). "Does Obsessive-Compulsive Personality Disorder Belong Within the Obsessive-Compulsive Spectrum". CNS Spectrum. 12 (6): 467–474, 477–482.
- Rheaume, J; Freeston, MH; Dugas, MJ; Letarte, H; Ladouceur, R (1995). "Perfectionism, responsibility and obsessive-compulsive symptoms". Behav Res Ther. 33. 33 (7): 785–794. doi:10.1016/0005-7967(95)00017-R. PMID 7677716.
- Foa, EB; Kozak MJ; Goodman WK; Hollander E; Jenike MA; Rasmussen SA (1995). "obsessive-compulsive disorder". DSM-IV field trial. 152 (Am J Psychiatry): 90–96.
- Baer, Lee. (1998). "Personality Disorders in Obsessive–Compulsive Disorder". In Obsessive–Compulsive Disorders: Practical Management. Third edition. Jenike, Michael et al. (eds.). St. Louis: Mosby.
- Cheeseman, Gwyneth D. (2013). "All You Need To Know About OCPD and Perfectionism". Willows Books Publishing. UK. 
- Freud, S. (1959, original work published 1908).Character and Anal Eroticism, in The Standard Edition of the Complete Psychological Works of Sigmund Freud, 9, 170–71. James Strachey, ed. London: Hogarth. ISBN 978-0-7012-0067-1 ISBN 0-7012-0067-7
- Jenike, Michael. (1998). "Psychotherapy of Obsessive–compulsive Personality". In Obsessive–Compulsive Disorders: Practical Management. Third edition. Jenike, Michael et al. (eds.). St. Louis: Mosby.
- Kay, Jerald et al. (2000). "Obsessive–Compulsive Disorder". In Psychiatry: Behavioral Science and Clinical Essentials. Jenike, Michael et al. Philadelphia: W. B. Saunders.
- MacFarlane, Malcolm M. (ed.) (2004). Family Treatment of Personality Disorders. Advances in Clinical Practice. Binghamton, NY: The Haworth Press.
- Penzel, Fred. (2000). Obsessive–Compulsive Disorders: A Complete Guide to Getting Well and Staying Well. Oxford University Press, USA. MPN 0195140923
- Ryle, A. & Kerr, I. B. (2002). Introducing Cognitive Analytic Therapy: Principles and Practice. Chichester: John Wiley & Sons. ISBN 978-0-470-85304-7.
- Salzman, Leon. (1995).Treatment of Obsessive and Compulsive Behaviors, Jason Aronson Publishers. ISBN 1-56821-422-7