DSM-IV asserts that individuals with certain personality disorder traits ‘may be especially prone to having explosive outbursts of anger when under stress’ (p. 610). In fact, in a recent double-blind, placebo-controlled phenytoin trial, over half the men self-referred for problems of impulsive physical aggression met the DSM-IV criteria for Obsessive– Compulsive Personality Disorder (OCPD).1 Not all persons with OCPD engage in physical aggression but many are hostile, competitive, and prone to become upset or angry when they are not in control or when others do not meet their standards. It is well established that some anticonvulsant medications have mood stabilizing effects2 and several (i.e., carbamazepine, phenytoin) have been demonstrated to reduce irritability and emotional hyper-responsiveness.2–5 That this type of irritability is responsive to anticonvulsant treatment raises the possibility that persons with OCPD who are hostile and irritable but not physically aggressive may show improvement in these symptoms with anticonvulsant treatment. We present here such a case.
The patient was a 61-year-old Caucasian male who was seen by neurology and subsequently was referred for a psychological evaluation because of complaints of mild cognitive impairment including reduced attention, concentration, and motivation which had become more prevalent in the preceding 3 years. He completed 14 years of education, had been married for 38 years, and had worked in middle management in the same company for 25 years. Medical history was positive for mitral valve prolapse. Computed tomographic imaging showed evidence of clinically silent small vessel disease that was stable over time. His history was negative for diabetes, hypertension, and brain trauma. He had a history of chronic alcoholism (12 years) but had been abstinent for 6 months at the time of this evaluation. Family history was positive for vascular disease.
In interview, he reported a life-long rigid, perfectionistic, and hostile personality style, becoming irritated and agitated easily. He denied ever being physically aggressive but he reported verbal outbursts which, after the fact, he considered excessive. He reported similar impulsivity and hostility at work, often issuing overly strong memoranda to employees who had erred. He also often saw these as inappropriate after the fact. He described himself as a hostile driver. He was compulsive about exercise. He reported difficulty relaxing. He also reported some repetitive, compulsive behavior, and rumination. He reported that he washed his hands as much as six to eight times per day and counted his steps when running. He denied checking behavior. He reported that he had had bouts of depression with racing thoughts in the past, which was treated with paroxetine but he denied current depressed mood. He reported reduced effort and an increased willingness to give up when faced with a challenging task. He had lost interest in sex. He was very self-critical. He denied anorexia and insomnia. He denied fatiguing easily even with exertion but often felt ‘sluggish and sleepy’ in the afternoon. He denied thoughts of death or suicide.
On formal testing he demonstrated average measured intelligence (VIQ = 105; PIQ = 102; FSIQ = 104) with no evidence of decline from likely highest premorbid level. Overall, his cognitive function was intact with performance well above average on some tasks including memory. He performed normally on attentional tasks but impulsive behavior was observed. The MMPI-2 revealed the anxiety, abulia, inertia, and dysphoria of which this patient had complained. He was diagnosed with Obsessive– Compulsive Personality Disorder with features of Obsessive–Compulsive Disorder. His inflexibility contributed to a stable high level of irritability. Dysphoria and, to some extent anxiety, were considered to be secondary to these other conditions.
The patient was started on carbamazepine (100 mg, b.i.d.). At 1 month follow-up he reported feeling considerably calmer and less likely to ‘fly off the handle’. As he noted no side-effects, the dosage was increased to 200 mg (b.i.d.). At follow-up 1 month later he continued to show improvement in his problems in self-regulatory behavior and was tolerating well the stress of having been laid off from his long-held job. Unfortunately, he had also developed an adverse drug reaction (rash) and the drug was discontinued. When seen 8 months later, he had found a new job but reported some return of symptoms including problems with his self-regulatory behavior.
The present case is notable because it demonstrates a reduction in symptoms of OCPD following a trial of carbamazepine. This case suggests the need for further controlled research into the efficacy of carbamazepine and similar medications in alleviating some symptoms associated with OCPD. Blashfield and Intoccia have argued that with the exception of antisocial, borderline, and schizotypal personality disorders, research into personality disorders is either ‘dead or dying’ (p. 473).6 The present case offers one potential avenue of relevant clinical research.