The original shadow-syndrome proposal labeled all of these people mentally ill, either mildly (the explorers and the worried parents) or seriously (the addict and the agoraphobe). Today, psychiatry recognizes that although no mental condition is an island—they all sit on continua where the boundaries between pathological and quirky, disordered and eccentric, mad and mundane shift with the fads of medicine and culture—the term “mental disorders” should apply to only a small part of the continuum. Countless common, everyday behaviors tiptoe up to the boundaries between illness and health without crossing them. To argue otherwise is to plunge into the reductio ad absurdum of labeling “mentally ill” a good fraction of the population—people like Bianca and others who have mild compulsions but whose behavior falls well short of a clinical diagnosis.
Numerous studies have shown, for instance, that anxiety can compel people to create a minuscule piece of their world over which they have some control, but let me choose just one. Martin Lang, who at the time of the research was a graduate student in anthropology at the University of Connecticut, and his colleagues told volunteers (students at Masaryk University in the Czech Republic) they had a challenging task ahead of them: give a five-minute speech to a panel of art experts about a decorative metal object sitting on the table in front of them. Other volunteers were instructed to simply look at and think about their objet d’art. Fitted with a heart-rate monitor and an accelerometer (to measure movements of each wrist), the sixty-one participants got to it. After three minutes, the researchers asked everyone to polish their object with a wet cloth until it seemed clean. Finally, the give-a-talk volunteers were let off the (fictitious) hook, with the explanation that the art experts were unavailable.
Volunteers who had anticipated giving a presentation told the researchers they felt more anxious than the just-think-about-it group did, and the heart-rate monitors confirmed that: their pulses had quickened. The accelerometers were even more telling. The most anxious volunteers, those anticipating speaking before a panel of experts, cleaned their object differently than those who felt no such pressure. The former cleaned more repetitively, predictably, meticulously—dare we say compulsively, Lang and his colleagues reported in a 2015 paper in the journal Current Biology. “When facing a complex, uncontrollable, and unpredictable situation,” they wrote, the mind becomes anxious about its inability to know what will unfold. To cope with that fraught mental state, people feel driven to actions that might be completely unrelated to the source of the anxiety yet help them “regain a feeling of control over the situation,” Lang and his colleagues concluded. “[T]his regained sense of control might result in anxiety alleviation.”
You probably haven’t faced an assignment of impressing experts with your understanding of an objet d’art, but perhaps you have felt anxious about an upcoming negotiation—and, since you can’t control that any more than you already have through hours of preparation, you compulsively rearrange your bedroom drawers. Or perhaps you are anxious about meeting your partner’s parents, and you compulsively scrub the bathtub. You likely know people with compulsions like these, for you can find them across the street, in the adjacent cubicle, in your yoga class, on the other side of the bed . . . and probably in the mirror.
Conscientiousness on Steroids
According to psychology’s widely used Five Factor Model, a quintet of traits defines every personality. Larger or smaller doses of agreeableness, openness (to new experiences), neuroticism, extraversion, and conscientiousness combine to form the myriad of personality types that describe the human menagerie. While psychologists debate the validity of the system, it captures the fact that each individual has greater or lesser amounts of each personality ingredient. The ingredient most relevant to compulsions is conscientiousness.
Manifested most clearly by a tendency to be disciplined, deliberate, and dutiful, especially in matters of ethics and responsibility to family and society, conscientiousness is also characterized by a striving for competence, a preference for order, and a drive to achieve. Low conscientiousness, in contrast, is marked by being carefree, impulsive, spontaneous, and hedonistic, as well as irresponsible, uninhibited, and negligent. The highly conscientious among us are dedicated to work and have strong, often unyielding, moral principles and opinions. Those in the middle might step up to register voters for a local election that no one else cares about or finalize a client presentation as everyone else troops off to happy hour. They are the significant others who are adamant about the ideal way to sort the recycling. Toward the more-extreme end of the spectrum, they are people whose preference for order has been ratcheted up into a preoccupation with rules and lists, whose striving for achievement has become the compulsive devotion to career and productivity known as workaholism, and whose drive for competence has hypertrophied into perfectionism. At that extreme, conscientiousness steps over the boundary into obsessive-compulsive personality disorder (OCPD).
Now there’s a discontinuity in the spectrum. Extreme conscientiousness may be OCPD, but extreme OCPD is not obsessive-compulsive disorder. OCPD is not OCD Lite. For one thing, to the surprise of laypeople and experts alike, few people with OCD also have obsessive-compulsive personality disorder or vice versa. That is, few people with OCD are particularly conscientious, disciplined, and dutiful, while few people with OCPD are seized by the throat-gripping anxiety that characterizes OCD. In the early 1980s, research found that fewer than 20 percent of adults with OCD also had OCPD, while barely 20 percent of those with OCPD also had OCD, psychiatrist Steven Rasmussen of Brown University Medical School and colleagues reported. Even when psychiatrists loosened the diagnostic criteria for obsessive-compulsive personality disorder in the late 1980s, only 30 percent of those with OCD also had OCPD. An obsessive-compulsive personality is not even the most common personality diagnosis in people with OCD. As far back as 1993 psychiatrists made the counterintuitive discovery that when people with OCD have a personality disorder, it’s unlikely to be OCPD, researchers led by psychiatrist Donald Black of the University of Iowa Medical School concluded in the American Journal of Psychiatry that August.
In fact, compulsive personality traits are not unique to or even more common in people with obsessive-compulsive personality disorder. Instead, they’re strewn around the population like rice at a wedding. Chronically insisting that people submit to exactly your way of doing things, for instance, characterizes about three-quarters of people diagnosed with OCPD. No surprise there. But that trait is present in an even higher percentage of people diagnosed with narcissism and passive-aggression.
Another distinction shows the disconnect between OCD and OCPD: the compulsions of OCPD are worlds away from those of OCD. With enough effort, you can demonstrate that the fears of someone with OCD are empirically wrong. You can swab her hands and show they are not covered with pathogenic germs. You can have him step on a sidewalk crack and show him that his mother is still quite alive. And of course you can show Shala that Fred is in the living room, not the refrigerator. In contrast, the compulsions of someone with OCPD typically have a firm grounding in reality: hanging up bathmats after they’re used does reduce the chance they’ll get mildewed, turning off lights in unoccupied rooms does reduce energy waste. Heck, you can find virtually all of these “rules” in one or another list of 50 Ways to Save the Planet (run the dishwasher only when it is absolutely full; turn off the faucet while brushing teeth) or 10 Tips for a Germ-Free Home. If an insistence on organic foods, distilled water, careful handling of raw chicken, or fifty minutes of daily exercise is a manifestation of OCPD, then most of upper-middle-class America qualifies.
Most importantly, the compulsions of OCD feel like actions you are executing under the orders of an outside force. The feelings behind the compulsions are ego dystonic. In obsessive-compulsive personality disorder, however, the compulsions are ego syntonic: they feel rational, obvious, and reasonable, an expression of your core beliefs, values, and needs. It’s just the rest of the world that thinks they
’re nuts. Because of the ego-dystonic vs. ego-syntonic distinction, OCD and OCPD (not to mention compulsivity that falls short of OCPD) feel totally different. While people with OCD feel that their compulsions arise from a neural interloper, those with OCPD or extreme conscientiousness feel their compulsions are an expression of their very self.
Liza Jane practically defines herself by her compulsive conscientiousness. If you need a computer repaired, she’s your woman. When a laptop seems shot, she told me, “other people would say, ‘screw it, I’ll just reformat the hard drive.’ ” Reformatting is a quick solution to a machine that seems beyond help—one with the blue screen of death, for instance—but it wipes out saved documents, settings, and programs, leaving the customer to reconstruct his cyberexistence from scratch. “I wouldn’t do that,” Liza Jane said. “It was a source of pride. I couldn’t stop myself. I’d insist on going in there and finding the virus or whatever the problem was. I spent way too much time doing it—I probably wound up making about twenty-five cents an hour—but I never blow things off. I kill myself to get something done, and done the right way.”
That attitude make bosses “love you to pieces,” she said. It also underlines the benefits of a compulsive personality: being meticulous and organized, setting high standards, and striving for excellence. That combination is nevertheless a mixed blessing. “You end up doing a lot of things yourself” because no one lives up to your standards, Liza Jane said. Despite the downside, she can’t dial back a conscientiousness that feels like a well-thought-out, carefully considered expression of her values and intelligence. “It’s hard for me to think this isn’t the right way to be,” she said. The thought of letting her standards slip unleashes the anxiety the compulsions were developed to quash. “It’s so normal to someone like me to live with the constant anxiety. I’m just trying to do things the right way or make things right,” Liza Jane said.
The “Crazy Rules”
While we all have personal preferences and habits, someone with OCPD regards these choices as being the only rational ones and as having the moral, scientific, or logical force of the Ten Commandments and Newton’s laws of motion rolled into one. They are not choices. They are imperatives. Someone with OCPD feels her behavior is not merely justified, but is so hands-down superior to the alternative way of doing even mundane tasks that when someone deviates from her prescription she can neither understand nor tolerate it. A person with OCPD has “extensive intellectual backup for his behavior,” explained the pseudonymous Paul, who runs an online forum about OCPD. It’s the thinking man’s OCD: people with a compulsive personality back up their imperatives with a Ph.D. thesis’s worth of logic, rationalizations, and ethical arguments.
Julie sees that every day. When she dated the man she eventually married, he seemed “very fastidious,” she told me. But after years of marriage, fastidious doesn’t begin to describe him. A technical writer, he has a “system” for everything under the sun: the best way to roll up a towel to block the light from seeping under their daughter’s bedroom door at night; the best way to handle garbage (don’t throw away used tape; it might make the sides of the garbage bag stick together); the best way to tuck away venetian blind cord so as not to strangle anyone. “He says he’s spent forty-five years working out the best way to do things,” Julie said. “When you don’t do it his way you’re an idiot—and, worse, if you don’t do things right he can’t stand it.”
The reason the compulsions of OCPD morph from sensible choice into imperatives is that anxiety is at their root, just as in every compulsive behavior. OCPD sufferers believe there is a clearly right way and an obviously wrong way to do just about everything, and theirs is the right way. Moreover, if they do these things this way, they will be safe, but if they do not then things will go to hell in a handbasket. Following rigid rules offers the halcyon promise of imposing order on the chaos that is rampant in the world, of keeping disaster far from your door. But flouting them triggers throat-constricting anxiety.
People with compulsive personalities fall into either of two camps: those who impose their standards on themselves and leave other people alone, and those who try to make everyone conform to their notions of how to behave. OCPD people call those notions their “crazy rules.” A sampling from Paul’s online forum:
When loading forks and knives into the dishwasher, you must put them point-down.
The remote control must always be put on top of the TV, even though you need it when you’re on the couch.
Never order the same thing at a restaurant as your companions. Doing so robs everyone of the opportunity to sample as many dishes as possible.
The garden hose must be wound up after each use, with the spray handle facing the “correct” direction.
“Straighten out” the curves on the road by crossing over the double yellow line to maintain as direct a line as possible.
Having a few crazy rules doesn’t necessarily qualify someone for a diagnosis of OCPD. Passing the DSM-5’s diagnostic threshold for the disorder requires meeting four of eight criteria: the preoccupation with rules and lists; perfectionism that keeps you from completing tasks; such “excessive” devotion to work that you reject leisure activities and friendships; ethical inflexibility and over-scrupulousness; hoarding; miserly spending; inability to delegate tasks (since no one else can do anything right); and/or general “rigidity and stubbornness.”
Somewhat more user-friendly is the Cammer Test for OCPD, which asks respondents to answer how well twenty-five statements describe them: never, for which you give yourself one point; sometimes, worth two points; often, three points; or almost always, four.
1. I prefer things to be done my way.
2. I am critical of people who don’t live up to my standards or expectations.
3. I stick to my principles, no matter what.
4. I am upset by changes in the environment or the behavior of people.
5. I am meticulous and fussy about my possessions.
6. I get upset if I don’t finish a task.
7. I insist on full value for everything I purchase.
8. I like everything I do to be perfect.
9. I follow an exact routine for everyday tasks.
10. I do things precisely to the last detail.
11. I get tense when my day’s schedule is upset.
12. I plan my time so I won’t be late.
13. It bothers me when my surroundings are not clean and tidy.
14. I make lists for my activities.
15. I worry about minor aches and pains.
16. I like to be prepared for any emergency.
17. I am strict about fulfilling my obligations.
18. I expect worthy moral standards in others.
19. I am badly shaken when someone takes advantage of me.
20. I get upset when people do not replace things exactly as I left them.
21. I keep used or old things because they might still be useful.
22. I am sexually inhibited.
23. I find myself working rather than relaxing.
24. I prefer being a private person.
25. I make a budget and stick to it, not living beyond my means.
If some of these items made you think, Wait, what’s wrong with that? (6, 12, 16, 17, 21, 23, 24, and 25 did that for me), then you see the flaw in the shadow syndromes argument. Just because a long list of symptoms is needed to qualify for a diagnosis of a mental disorder, it doesn’t mean that a few of those symptoms define a milder form of that disorder. Obviously many of the self-descriptions in the Cammer Test are beneficial, even the foundation of a functioning society.
In fact, a score of fifty to seventy is standard. Notice how many things you can be compulsive about and still fall short of obsessive-compulsive personality disorder, which requires a minimum of 75 points: if you answer “always” to, say, 1 through 7 (28 points) and “sometimes” to the other 18 (36 points)—a combination that, to the layperson, sure looks like a compulsive
personality—you fall short. Nevertheless, the National Institute of Health’s 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions, which interviewed 43,093 U.S. adults, found that 7.9 percent (or nearly 15 million people at the time) had obsessive-compulsive personality disorder, making it the most common personality disorder. That estimate held up a decade later, when psychiatrists led by Jon Grant of the University of Minnesota Medical School used face-to-face interviews, also with thousands of adults, and concluded that the lifetime prevalence of OCPD was 7.8 percent. Men and women were about equally likely to develop it. It was less common in younger adults, Asians, and Hispanics, and significantly more common in people with a high school education or less.
My own compulsiveness manifests itself in grocery shopping, where any idiot can see there’s an optimal way to operate. Obviously you buy only items on sale, you buy the size of the item that has the lowest unit cost, you use coupons, and you certainly do not impulsively purchase anything that’s not on the shopping list. On those rare occasions when my husband does the family grocery shopping there is hell to pay, for invariably he violates one of the shopping commandments. My compulsiveness arose from anxiety that we’d run out of money. Logically, I knew an extra seventy-nine cents my husband spent on Swiss cheese because he stupidly bought Kraft rather than the store brand wasn’t going to tip us into foreclosure. But I had convinced myself that unless we watched every penny it was just one short step to eating cat food.
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