Beruflich Dokumente
Kultur Dokumente
Compulsive Personality 28
Disorder
Anthony Pinto
impossibly high standards for the behavior of against internal feelings of insecurity and uncer-
others, difficulty acknowledging differing view- tainty. With this insight, patients then work to
points, and rigidity (Pollak 1987). Millon (1981) change their inflexible patterns of behavior and
also notes that individuals with OCPD may be give up their rigid demands for perfection in
uncompromising and demanding, and OCPD has favor of a more reasonable outlook. One uncon-
been linked with outbursts of anger and hostility, trolled study suggests that supportive-expressive
both at home and at work (Villemarette-Pittman psychodynamic therapy is effective for treating
etal. 2004). In a recent study investigating patients with personality disorders, including
interpersonal functioning in OCPD, Cain etal. OCPD (Barber etal. 1997). This study included
(2015) found that individuals with OCPD re- 14 OCPD patients and found significant improve-
ported hostile-dominant interpersonal problems ment after 52 sessions, but did not include a
and sensitivities with warm-dominant behavior control group. Two subsequent trials found that
by others, as well as less empathic perspective mixed groups of personality disorder patients
taking relative to healthy controls, which may (including some patients with OCPD) treated
underlie some of the interpersonal problems with brief psychodynamic treatments improved
described above. in terms of general functioning relative to wait-
Of the core features of OCPD, research and list control groups (Abbass etal. 2008; Winston
clinical reports have highlighted the importance etal. 1994). However, neither of these two stud-
of perfectionism as a major contributing factor ies specifically investigated improvement among
to life impairment. The belief that anything less those with OCPD, and the study outcomes did
than perfect performance is unacceptable (termed not assess for changes in OCPD symptoms
maladaptive perfectionism) has been linked to specifically. Further research is needed to deter-
the development of depression (Rice and Aldea mine the effectiveness of psychodynamic treat-
2006). Socially prescribed perfectionism (the ments for OCPD.
belief that one will be judged against unrealis-
tic standards by others) has been linked to poorer Cognitive TherapyThe cognitive approach to
relationship adjustment (Haring etal. 2003) as treating OCPD involves identifying and restruc-
well as suicidal ideation (Hewitt etal. 1997). In turing the dysfunctional thoughts underlying
fact, a diagnosis of OCPD may be a risk factor maladaptive behaviors (Bailey 1998; Beck
for suicidality, as Diaconu and Turecki (2009) and Freeman 1990; Beck 1997). For example,
found that among depressed patients, individuals patients would be taught to challenge all-or-
with OCPD reported increased current and life- nothing thinking by considering the range of
time suicidal ideation as well as a greater number possibilities that might be acceptable. Similarly,
of lifetime suicide attempts. Of special clinical therapists might teach patients to recognize
concern, depressed patients with OCPD reported instances in which they overestimate the conse-
fewer reasons for living and less anxiety on the quences of mistakes (catastrophizing) by exam-
fear of death questionnaire, both prognostic indi- ining the realistic significance of minor errors.
cators of suicide. Some approaches also incorporate behavioral
Although there is no empirically validated elements, such as behavioral experiments (e.g.,
gold-standard treatment for OCPD, psychother- purposefully making small mistakes in order to
apy is recommended as the treatment of choice observe the actual consequences; Sperry 2003).
(Sperry 2003). Below is a review of the limited Establishing rapport can be difficult with some
treatment research in OCPD. OCPD patients, due to rigid thinking styles and
difficulty with emotional expression. In light of
Psychodynamic PsychotherapyPsychodynamic this difficulty, Youngs (1999) schema-focused
treatment for OCPD involves an insight-oriented therapy aims to identify and restructure patients
approach that attempts to reveal how the OCPD maladaptive schemas as they are expressed in the
symptoms function to defend the individual therapy process.
28 Treatment of Obsessive-Compulsive Personality Disorder 417
functioning as well as preparing them to fully medical conditions, and his only medical hospi-
utilize the subsequent intervention. CBT for talization was for a tonsillectomy as a child.
clinical perfectionism/rigidity (Egan and Hine When asked to recount the various ways that
2008; Riley etal. 2007; Shafran etal. 2010) is OCPD gets in the way of his life, here is what
a manualized cognitive-behavioral approach that John told me (in his own words, edited for clar-
consists of four aims developed originally by ity):
Fairburn etal. (2003): (1) identifying perfection- I guess as far back as I can remember, perhaps
ism as a problem and understanding maintaining when I was 6 years old, I was preoccupied with
mechanisms, including rigidity, overworking or order, how my room was organized, and how I had
overtraining, behavioral avoidance, dichotomous my toys set up. Thats the way I liked it, and I would
have a problem if my brothers or other people came
thinking, and cognitive biases; (2) conducting into my room, and placed things out of my order,
behavioral experiments to learn more about the the way I liked them. At that point, it was just with
nature of perfectionism and alternative ways my things and that didnt get in the way of my life.
of living; (3) psychoeducation and cognitive However, as I grew up and went to school, I defi-
nitely started to notice that I had a really big prob-
restructuring (in combination with behavioral lem with procrastination on writing assignments.
experiments) to modify personal standards, self- My high standards were getting in the way of com-
criticism, rigid rules and cognitive biases (such pleting assignments. So, procrastination definitely
as selective attention to perceived failures); and started to show itself as I went through school.
The most pervasive part of OCPD for me is the
(4) broadening the individuals scheme for self- perfectionism, and getting bogged down in the
evaluation, by examining existing methods of details of any assignment that Im doing. If I feel
evaluating the self, and identifying and adopting like I am missing one minor detail, it gets in the way
alternative cognitions and behaviors. of completing the particular writing or research
assignment. I really feel like I have to find that one
thing before I can move on. With any paper Im
writing, I find myself stuck on page 1. I am often
Case Study: Presenting Problem trying to get it just perfect, before I can move on to
and Background the rest of the paper. I notice that with readings at
school, it always takes me a lot longer to complete
things than other people. I think I get obsessed
John is a 26-year-old Caucasian male, never mar- with the details of the assignment or trying to
ried, currently in graduate school and working at understand every particular thing that I was deal-
an internship. He lives with two roommates and ing with. One really good example, is that I spend
anywhere from a half hour to an hour writing an
has been in a romantic relationship for the past email that would take most people 5min to write. I
9 months. His presenting problem is preoccupa- make sure that all of my grammar and punctuation
tion with lists, order, and perfectionism, resulting are perfect, that it says exactly what I wanted to say,
in interpersonal problems and compromising his and that it comes off just right. Especially in school,
when working in groups, this has always been a
productivity. He presented with a neat appear- huge problem for me. I never feel comfortable del-
ance, full range of affect, euthymic mood, with egating anything to others, and always think that
normal rate, tone, and volume of speech, linear my idea of how we should do the project is the way
thought process, appropriate thought content, and that it should be done. So naturally, there have been
conflicts with that. Also, procrastination has been
denying suicidal ideation. John is not currently a huge problem for me. With every assignment, I
receiving any psychiatric or psychological treat- say, Ok, this is not going to happen. Im going to
ment. He reports no psychiatric hospitalizations spend a lot of time on it, but Im going to get this
and has never had psychotherapy. His only prior done in time. However, the very last day before the
deadline arrives, Ill be scrambling and doing it all
treatment was the use of a psychostimulant for at once. My goal is to try to make it great by spend-
about 1 year starting at age 25 (he stopped the ing a lot of time on it, and doing it just the way I
medication 2 months prior to this evaluation). want. But instead, I end up pushing it off, and then
The medication was prescribed by a psychia- it would be nowhere near what I want it to be.
I have a lot of extremely high standards and
trist after John described trouble with focusing I often hold my significant other to those high
and completing tasks. John denies any chronic
28 Treatment of Obsessive-Compulsive Personality Disorder 419
way. At school, he resists group projects be- Endicott etal. 1993) is a self-report instrument
cause of his tendency to butt heads with group that assesses quality of life in social, leisure,
members over the quality of the joint product. household, work, emotional well-being, physical,
At home, he takes on most of the chores (e.g., and school domains. The total score is expressed
cleaning, loading dishwasher, caring for the as a percentage of the maximum possible score
dog) because he knows his roommates would of 70. Lower scores on the Q-LES-Q-SF indicate
not do them the way he wants. He often redoes poorer quality of life.
others work which results in confrontations. The Clinical Perfectionism Questionnaire
6. Rigidity and stubbornness: Johns need to (CPQ; Chang and Sanna 2012; Fairburn etal.
be methodical makes him resistant to change. 2003) is a self-report measure designed to as-
He finds comfort in routines (e.g., usually eats sess the current level of clinically dysfunctional
the same foods every day). He often insists on perfectionism. The items assess the cognitive,
being right even in areas in which there is no behavioral, and affective components of setting
right answer. He frequently argues with oth- personally demanding standards of performance
ers about being right (especially in romantic and striving to meet them and the consequences
relationships, and this has contributed to the on the individuals self-evaluation when these
demise of most previous dating relationships). standards are met or not met. Higher scores on
At school, he gets angry/resentful towards the CPQ are indicative of higher clinically sig-
classmates and professors with differing opin- nificant perfectionism.
ions. The Inventory of Interpersonal Problems-
John completed questionnaires about his OCPD Short Circumplex (IIP-SC; Hopwood etal. 2008)
symptoms, quality of life, and interpersonal is a self-report measure of interpersonal prob-
functioning at the orientation visit (week 0), after lems (subscales: domineering, vindictive, cold,
phase I (week 7), after phase II (week 14), and introverted, submissive, exploitable, overly nur-
2 months after acute treatment (week 22; see turing, and intrusive). The total score represents
Table28.1). The following measures were used: an index of interpersonal distress across all types
The Quality of Life Enjoyment and Satisfac- of interpersonal problems, with higher scores
tion QuestionnaireShort Form (Q-LES-Q-SF; indicating greater distress.
Table 28.1 Clinical measures completed by John and percent change by time point
Assessment Baseline After phase I After phase II Two month % Change % Change
measure (week 0) (week 7) (week 14) follow-up week 014 week 022
(week 22)
Q-LES-Q 38.6 71.4 77.1 80.0 99.7 107.2
CPQ 38 27 27 17 28.9 55.3
IIP-SC total 97 64 50 29 48.4 70.1
DERS total 123 91 67 68 45.5 44.7
POPS total 264 221 144 136 45.4 48.4
Difficulty with 47 39 22 24 53.2 48.9
change
Emotional 36 34 20 19 44.4 47.2
overcontrol
Rigidity 76 60 46 39 39.5 48.7
Maladaptive 71 57 34 32 52.1 54.9
perfectionism
Reluctance to 45 38 21 19 53.3 57.8
delegate
Q-LES-Q quality of life enjoyment and satisfaction questionnaire, CPQ clinical perfectionism questionnaire, IIP-SC
inventory of interpersonal problems-short circumplex, DERS difficulties in emotion regulation scale, POPS pathologi-
cal obsessive-compulsive personality scale
28 Treatment of Obsessive-Compulsive Personality Disorder 421
The Difficulties in Emotion Regulation Scale tration of model and Fig.28.2 for its application
(DERS; Gratz and Roemer 2004) assesses emo- to John). In order to bolster Johns response to a
tion regulation via a total score and six sub- targeted perfectionism intervention and strength-
scales: nonacceptance of emotional responses, en his social supports, I decided to precede this
difficulties engaging in goal-directed behavior intervention with a cognitive-behavioral skills
when experiencing negative emotions, difficul- building module (STAIR) that emphasizes in-
ties remaining in control of behavior when ex- creasing emotional awareness and instilling
periencing negative emotions, lack of emotional greater relationship flexibility.
awareness, limited access to emotion regulation
strategies, and lack of emotional clarity. Higher
scores indicate more difficulties with emotion Treatment Course
regulation.
The Pathological Obsessive-Compulsive Per- The 14-week treatment protocol consists of 15
sonality Scale (POPS; Pinto 2011) is a 49-item sessions: an orientation visit, STAIR (phase I;
self-report measure of maladaptive obsessive- six weekly sessions), and CBT for perfectionism/
compulsive personality traits and severity. A bi- rigidity (phase II; eight weekly sessions). Below
factor structure has been identified for this scale, is the session-by-session protocol, including
consisting of five specific trait factors (rigidity, the agenda for each session and notes on Johns
emotional overcontrol, maladaptive perfection- progress in treatment.
ism, reluctance to delegate, and difficulty with
change) and an overall factor (based on all items) Orientation Session (Week 0)Treatment ratio-
that represents obsessive-compulsive personality nale and targets for phase I and II were reviewed
pathology on a continuum of increasing severity as well as psychoeducation about OCPD and
and dysfunction. The POPS has demonstrated related functional impairment.
excellent internal consistency reliability as well
as convergent and discriminant validity. The in-
dividual factors and the overall score are strongly Phase I: STAIR TreatmentSix Sessions
associated with greater psychosocial impairment (Weeks 16)
and poorer quality of life in both community
samples and patient samples with a principal di- The first phase of the treatment consisted of six
agnosis of OCPD. sessions of STAIR (each 50min long). STAIR
Initial impressions of John are that he is an sessions each have essentially the same format:
intelligent, conscientious, yet highly self-critical (1) psychoeducation about relationships and in-
man whose quality of life (Q-LES-Q) and inter- terpersonal skills deficits, (2) identification of
personal relationships (IIP-SC) are being majorly strengths and weaknesses related to a given skill,
impacted by clinically significant perfectionism (3) illustration of new skill, and (4) practice of
and rigidity (POPS, CPQ) as well as his diffi- new skill. John was given a session outline hand-
culties modulating negative emotions (DERS). out at the end of each STAIR session so he could
Shafran etal. (2002) define clinical perfection- review the psychoeducation and skills training
ism as the overdependence of self-evaluation from each session at home. Between-session
on the determined pursuit of personally demand- work was assigned at the end of each session
ing, self-imposed standards in at least one highly and consisted of exercises directly related to the
salient domain, despite adverse consequences content of the given session. Between-session
(p.778). The cycle of clinical perfectionism is work from the previous week was reviewed at
maintained by cognitive biases (e.g., all-or-noth- the beginning of each session, and difficulties in
ing thinking) and performance-related behaviors, implementing new coping skills were addressed.
including checking, being overly thorough, and The six STAIR sessions follow a conceptual pro-
avoidance/procrastination (see Fig.28.1 for illus- gression from a focus on basic identification and
422 A. Pinto
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labeling of emotions to a review of the impor- time in the past week where strong feelings were
tance of emotions in interpersonal relationships triggered. John rated the intensity of the feeling
to a focus on interpersonal flexibility. and identified the situation or trigger. The impor-
tance of self-monitoring throughout phase I of
Session 1 Focus: Introduction this treatment was emphasized. John was given
to Treatment Rationale a list of feelings words to aid in identifying his
During this session, psychoeducation about emo- emotions. Breathing retraining (with empha-
tion regulation was presented. In addition, John sis on slow, rhythmic diaphragmatic breathing)
practiced self-monitoring of feelings and labeling was demonstrated and practiced. Homework 1:
emotions. A self-monitoring form was introduced Breathing retraining practice for 5minutes twice
and demonstrated by asking John to identify a daily and self-monitoring of feelings.
28 Treatment of Obsessive-Compulsive Personality Disorder 423
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Fig. 28.3 The three channels of distress. (Reproduced from Cloitre etal. 2001; adapted for John)
Session 2 Focus: Emotion Regulation balance form). John focused on the pros/cons of
In session 2, we began by reviewing the self- making contact with a former supervisor that he
monitoring form that John completed between worried would be disappointed with him for not
sessions and checked with regard to the breathing meeting a deadline. John concluded that making
exercise he completed. This sessions psycho- the contact would be beneficial for his career,
education covered negative mood regulation, despite the distress/shame he would endure. We
the connection between feelings, thoughts, and also identified pleasurable activities (from a list
behaviors, and a discussion of Johns current of suggestions), including riding his bicycle and
coping skills. John also learned about identifying making plans with friends. Homework 3: Breath-
the three channels of distress: physiological, cog- ing retraining; self-monitoring; assess pros and
nitive, and behavioral (see Fig.28.3) as well as cons of entering one difficult situation and toler-
new coping skills for intervening at each channel. ating distress; use new skills to manage distress;
Homework 2: Breathing retraining; self-moni- engage in pleasurable activities.
toring; practice new coping skills for cognitive
channel (e.g., positive images/self-statements Session 4 Focus: Relationship Between
and shifting attention during stressful events). Affect and Interpersonal Problems
We reviewed the feelings self-monitoring form,
Session 3 Focus: Distress Tolerance emphasizing and reinforcing John for trying
During this session, we reviewed the feelings alternative means of coping with distress, and
self-monitoring form and alternative coping discussed positive activities that he had explored
methods. This weeks psychoeducation explored in the past week. John noted that his former super-
acceptance of feelings/distress tolerance, and to visor was very happy to hear from him and that
illustrate this we completed an exercise on as- she was highly complementary of his work and
sessing pros/cons of an identified goal and coping expressed interest in working with him again. She
with the associated distress (using a decisional made no mention of the missed deadline and may
424 A. Pinto
not have even been aware of it. Psychoeducation to complete interpersonal schema worksheet.
for session 4 focused on interpersonal schemas This sessions psychoeducation was about vari-
(organizing templates/expectations/beliefs about ous types of power balances in relationships
relationships and how they work) and included (equal power relationships, relationships where
an exercise on identifying interpersonal schemas, you have more power than the other, and relation-
using an interpersonal schema worksheet. One ships where you have less power than the other)
of the primary goals of STAIR is helping indi- and the importance of flexibility and adaptabil-
viduals identify the interpersonal schemas that ity in interpersonal situations. To demonstrate
are coming into play in current relationships and this, we conducted role plays for different power
causing problems in their interpersonal function- balances in Johns life. Lastly, we discussed the
ing. John discussed his insistence on doing all transition to Phase II of treatment: CBT for per-
aspects of a job himself (at his internship and at fectionism/rigidity. Homework 6: Self-monitor-
home) and how this view may affect how others ing; interpersonal schema worksheet once daily;
perceive him. Homework 4: Breathing retrain- practice using interpersonal flexibility with dif-
ing; self-monitoring; interpersonal schema work- ferent power differentials; make list of questions/
sheet once daily. concerns regarding transition to phase II.
model of perfectionism and how it is maintained would they spend looking for articles/references
from a case example, and then we drew the vs. writing). Afterwards, we discussed the ratio-
model based on Johns own life (see Fig.28.2). nale for behavioral experiments and discussed a
We also discussed the pros/cons of perfectionism case example. We then set up a behavioral ex-
and making changes and assigned readings for periment (going to work without ironing his shirt
homework. to see if anyone will notice) which John will con-
duct for homework. Setting up the experiment in-
Session 2 Focus: Self-Monitoring cluded specifying the belief/standard to be tested,
and Myths Regarding Perfectionism the prediction, and the approach. John agreed to
We discussed any questions about reading as- note the results and reflect on how they relate to
signments and then reviewed key points about his prediction.
self-monitoring. We generated a list of behaviors
that are contributing to Johns clinical perfection- Session 4 Focus: Dichotomous Thinking:
ism (e.g., list making, checking/going over work Challenging via Behavioral Experiments
mentally, avoidance/procrastination, not deviat- The session began by reviewing the outcomes
ing from routines). John was assigned to monitor of the survey and behavioral experiment. John
specified behaviors for homework. Next, John was fascinated to hear his graduate school peers
identified areas of his life that have been affect- methods for doing research papers. He noted that
ed by his perfectionism, and we practiced self- learning the methods of his most respected peers
monitoring of perfectionism-related thoughts/ gave him further insight on the inefficiency of
standards, emotions, and behaviors. Finally, we his approach to writing papers. John also com-
reviewed a list of myths relevant to perfectionism pleted the behavioral experiment, and, contrary
(e.g., Successful people work harder than less to his prediction, there were no reactions to his
successful people; To get ahead you have to be wrinkled work shirt, and the outcome of his day
single-minded and give up all outside interests.) did not appear to be affected by the shirt. Next,
Besides his reading assignment and self-monitor- I provided psychoeducation about dichotomous
ing, John was asked to complete a questionnaire (all-or-nothing) thinking. To explore this further,
about the frequency of various perfectionism- we set up a behavioral experiment for all or
related behaviors (e.g., How often do you check nothing thinking: John agreed to test his belief
your work for mistakes?) that if he cannot outline all of the assigned chap-
ters for a class, he might as well wait until the
Session 3 Focus: Surveys and Behavioral exam to do it. In this experiment, he agreed to
Experiments outline one chapter. I also introduced continuums
The assigned questionnaire and self-monitoring to emphasize flexible thinking.
forms were reviewed, followed by a discussion
of the rationale for using surveys in this treatment Session 5 Focus: Challenging Cognitive
as a means of learning how others cope with Biases
some of the standards John has been struggling This session focused on cognitive biases such
with. For example, writing research papers is a as selective attention to the negative, discount-
particular challenge for John. Due to his need to ing positive aspects of performance, double
make sure he has done an exhaustive review of standards and accompanying self-criticism, and
the academic literature, he would spend so much overgeneralization. These cognitive maintenance
time researching the topic that he would leave factors of clinical perfectionism and rigidity were
little time for the actual writing. We decided to addressed using behavioral experiments in addi-
create a survey that he would give to graduate tion to cognitive restructuring (using thought
school peers so that he could better understand diaries). John reported on a self-initiated behav-
how much time and effort his colleagues were ioral experiment. On three nights over the last
putting in to their research papers (e.g., how long week, he made a point of going to sleep before
426 A. Pinto
his roommates to test whether they would lock who is more compassionate. We discussed which
up and shut the lights (tasks he usually takes on coach in the analogy would yield better perfor-
himself due to concern that the others will not). mance from athletes. Afterwards, we practiced
Contrary to his prediction, he reported that his thought records for self-critical and compassion-
roommates did take on these tasks when he went ate thoughts, and I explained the concept of treat-
to sleep. Upon reflection, John was relieved that ing yourself as you would treat a friend. Related
he would no longer have to be the last to bed. worksheets were assigned.
I wasnt going to enjoy myself. But I did experi- In fact, he expressed relief after exiting the re-
ments where I went out without a plan, and I
had a wonderful time enjoying myself. Another lationship as he had intended to leave for some
example is with ironing my shirtsI thought that time but was avoiding the uncomfortable con-
if I went to work with a wrinkled shirt, everyone versation. This behavior of persisting in relation-
would think I was a fool, Id be embarrassed, and ships beyond the point of his intended exit was a
it would just be horrible. However, I went to work
with a wrinkled shirt one day, and the world didnt pattern for him in his previous romantic relation-
explode. Everything was great, I had a great day at ships.
work, and nobody seemed to notice. So those are
the biggest things that have been really helpful in
overcoming a lot of this. Im really grateful for this
opportunity. Ive seen a huge improvement. Conclusions and Key Practice Points
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