Obsessive-compulsive personality disorder and the marital role

Obsessive pathology is an area of major interest in medical literature and clinical practice, both due to its frequency – the fourth position in psychiatric morbidity worldwide, after depression, drug addiction and anxiety disorders – and due to its attributes of severity and persistence. In this context, obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) represent the two dominant forms of obsessional pathology⁽¹⁾.

The characteristic features of OCPD are hyperconscientiousness, assertiveness, meticulousness, perseverance, punctuality, sense of order, discipline, hyperinvolvement in professional activity and the need for performance, as well as a particular sense of justice and moral authority^(1,2).

In adulthood, the moral and axiological inflexibility of OCPD is the foundation of the compulsive triad that integrates insecurity, hyperresponsibility, and guilt. These attributes will have a significant role in interpersonal relationships, including those related to the marital role⁽³⁾.

Among the existential ideals of the contemporary world – a favorable state of health, a safe profession, easy access to the diversity of relaxation offers and moments of happiness –, there is also the harmony of married life^(4,5).

Affective life is the major support of individual identity, and affective values have always motivated human history. Affectivity is the energizing pole of psychism, which makes us feel that we are doing something, not just feeling something, because being human means a way of thinking, acting, feeling and relating⁽⁶⁾.

The fundamental affective experiences, as well as the affective facets of personality dimensions always mark the individual destiny.

The human person is an incomplete being, who is not able to be sufficient by himself and needs – in an affective and relational sense – another being to fulfill himself. Restoring harmony with oneself in this context is tied to the feeling of love, which can also be a source of happiness. In a world that cultivates the true values of humanity, love has always grounded family conjugal relationships^(7,8).

The contemporary Western society has a structure and dynamic that ignores or mystifies traditions and old customs, promotes a culture of compensatory motivations and strategies, protects individual selfish interests, and promotes the motto “everything is possible”, but not everything is allowed. In this framework, marital life and the feelings surrounding it can become vulnerable both due to the social environment and due to the dominant traits of the individual personality⁽⁹⁾.

Scrupulosity, cognitive and behavioral rigidity, along with formalism in relation to social conventions disfavor OCPD in the marital relationship. It always has a formal, polite character, but lacking in empathy, compassion and emotional resonance^(10,11).

The fact of living with another person, even a loved one, represents a major anxiety-provoking element in the case of obsessive-compulsive personality disorder, being considered an invasion or an attack on personal space. Even the thought of being hugged by someone is hard to bear, affecting relational intimacy on all levels, including sexual relationships. This is especially in the presence of obsessive-compulsive phenomena related to hygiene or to the fear of contamination^(12,13).

Marital life is also affected by the fact that the anankastic person is always preoccupied and rigid outside of work hours, preferring to occupy his time with order and cleanliness in the house or with preparations for the next day. He/she focuses on every detail and always feels the need to control the nearby space, always respects symmetry, and any deviation from these strictures can be blamed on the partner^(14,15).

The completion of any tasks – in the vast majority self-assumed – confirms the excessive concern for order and details, the inability to accept chance, randomness and the lack of flexibility and ideational spontaneity that always interferes with the idea of finishing the started things⁽¹⁶⁾.

A whole suite of frustrations accompanies the reference couple due to the mistrust of the subject with obsessive-compulsive personality disorder, who blames the partner for inefficiency or procrastination. In fact, this attitude favors the dilution of the output of the subject with OCPD who always experiences a feeling of chronic fatigue and incompleteness. It is based on an exaggerated sense of responsibility and an inability to relax and have even minor satisfactions^(17,18).

A person with OCPD is hyperinvolved in all roles, but married life can also be affected by the fact that he/she ignores comfort, by stinginess, hoarding behaviors and anxious anticipations related to the immediate future⁽¹⁹⁾.

Other characteristics are the lack of humor, which is always replaced by irony, as well as the capacities for self-transcendence, including those related to the marital relationship. The relationship with the partner is one in which tenderness, delicacy and compliments are missing; as a result, indifference, seriousness and affective coldness are dominant⁽²⁰⁾.

The partner’s needs and feelings are also difficult to perceive and understand. Compared to this, the person with obsessive-compulsive personality disorder, in a partially adaptive variant, chooses to take full responsibility for the relationship, and in a negative variant, he/she claims the unconditional involvement of the other, who is not allowed to escape from control⁽²⁰⁾.

Ambivalence and anxious experiences surrounding the attempt to control negative impulses and thoughts, self-depreciating memory representations and fragile egoism – despite appearances – constantly affect the couple’s relationship⁽²¹⁾.

Further, we describe a variant of destiny from the obsession spectrum, in which traumatic biographical events, generating comorbid conditions, intervene against the background of the anankastic-predisposing terrain. The obsessive-compulsive disorder symptoms were triggered by a global psychotraumatic event – the COVID-19 pandemic – and sustained by its consequences. The depressive symptoms – resistant to treatment in the described context – were triggered by an intense negative experience around family life.

The patient M.N., aged 67 years old, retired, is the only child of a family with an overprotective mother and a rigid, demanding and very authoritarian father, who controlled him until the last days of his life, although the patient had at that time over 60 years old. The patient’s father, with obvious narcissistic traits, whose rigors he also applied to family life, was an army general, and towards the end of his life he was diagnosed with Alzheimer’s dementia. There are no conclusive data about the mother. M.N. had no childhood illnesses or other major health problems. He is currently suffering from prostate adenoma and denies the use of toxic substances. He completed military training, and he is of the Orthodox religion.

In childhood and adolescence, as well as throughout his school years, he was more withdrawn, adapting with difficulty to new or unexpected situations. He never had a close friend or a circle of children or young people to socialize with, but he got involved in the educational process with meritorious results. This is also due to his rigor, meticulousness and sense of order. He meticulously organized the schedule for the day hourly, his space and activities, as well as the equipment he needed. He often suffered when things did not meet his perfectionist expectations.

The subject attended higher studies in environmental engineering. During the period in which he was teaching, he was an affirmatively active person, but with permanent difficulties in relating. The subject describes how difficult it was for him to form teams in which he could trust his co-workers and control what the workers under him were doing, even though some of their activities were not even his concern. No one fulfilled their tasks according to his expectations, he was very demanding and hypercritical, both of himself and of those around him. He strictly followed the work schedule and was sometimes late at home due to exceeding it. He always refused the invitations of some colleagues to socialize outside work hours or on the way home.

Once out of the professional role, where he was used to be in absolute control, he says he was a bit disoriented and could no longer formulate clear goals in life. He is in a close co-dependent relationship with his wife, to whom he has been married for about three decades, without having any children. He takes on the vast majority of family responsibilities – shopping, paying the bills, including preparing meals, which he does with great care. They have a car that he starts at regular intervals to keep it from breaking down because his wife no longer drives and he doesn’t have a driving license.

He is very tidy, and it bothers him that his wife is more “bohemian and messy”. When they come to the medical office – both of them being in evidence –, he has the medical documents in folios by category, although his wife comes with them piled up in a bag. He keeps both health cards in his wallet, as well as both prescriptions, and he also takes care of the note with the date of the next appointment. Every time he comes, he has a bag with multiple pockets, in which each of the items listed above has its place. He is always attentive, formal and polite, he meticulously organizes his schedule and does not accept or ignore the opinions and expectations of those around him.

More detailed clinical and psychometric evaluation develops a conscientious, mannered, rigid and humorless nature, ignoring jokes or only politely smiling. He is dominated by anxiety, insecurity and almost unable to relax. Considering himself a person of superior moral standing, he tries to manipulate and control those around him, being ironic but incapable of self-irony. It always shows emotional instability and difficulty adapting to life changes. He has no hobbies and never really had; it took him a long time to open up to the medical staff, compared to his wife.

They don’t overspend, although their financial situation allows them, they keep up with their bills, they don’t waste money on vacations, which he considers unnecessary. He is very reserved in spending money even for the things necessary for everyday life. He states that he has never been late in paying his bills, and once he even went and paid the amount of a bill again because he was not sure that the employee at the electrical service company had collected the bill correctly. He also states that he avoids going on a vacation if it overlaps with the bill-paying period.

The COVID-19 pandemic has accentuated the obsessive-compulsive features of the subject. Due to the anxious paroxysms, the reduction of prosexic and mnestic capacities against the background of ideational and attitudinal ambivalence and the rarefaction of motivational support, which is associated with insomnia, lack of appetite and disinterest in one’s own person, he was diagnosed with obsessive-compulsive disorder.

A short time later, also after the onset of the pandemic, his father died, and the patient developed symptoms characteristic of a severe depressive episode. Then he was hospitalized for the first time, presenting a psychopathological picture dominated by sadness, anhedonia, pessimism, self-depreciating autobiographical mnestic representations, ideational ambivalence, diffuse anxiety, capacities with reduced affective resonance, irritability, decreased active performance, apathy, and asthenia. He was treated with duloxetine which was progressively supplemented with olanzapine and later the antidepressant was replaced with clomipramine (Anafranil®).

Until that moment, the couple’s relationship was quite good, the wife adapting to the rigorous and somewhat flexible style of the subject, whose feelings towards her were always confirmed. A few months after the initiation of treatment for the previously mentioned pathology, his wife had a fall from the same level in the bathroom of the home which had no particular consequences but which accentuated the obsessive symptomatology.

Thus, for about three years, the subject has been sitting in the bathroom door, guarding his wife whenever she went in to use it. He feared that something would happen to him and he won’t be around, although nothing like that has happened since. For her part, the wife did not leave the home unaccompanied in order not to accentuate the subject’s concern and anxious feelings.

The depressive symptomatology remitted over time, but the obsessive-compulsive manifestations persisted, even though the administered medication also aimed at their remission.

In order to become aware of his obsessive ideas and increase the tolerance to uncertainty, corresponding to cognitive-behavioral therapy, the patient was urged to force himself to stop standing in front of the bathroom, but he did not resist the anxiety and negative anticipations. Exercises were resorted to in order to postpone the moment when he positions himself in front of the door, and the wife, absolutely visibly disturbed by all this control, was urged to leave the house whenever she wanted.

The patient did not react favorably, stating that the situation caused him a state of “discomfort”, but over time he adapted better to the proposed program. In this framework, the obsessive-compulsive symptoms obviously decreased, the subject being more compliant, more relaxed, more functional in the marital role, and more motivated in the formation of life goals. However, the underlying traits from the same spectrum continue to dominate individual destiny.   

Autori pentru corespondenţă: Tudor Nireştean E-mail: tudornirestean@gmail.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

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