Recently a teenager came into my office complaining about the anxiety they were experiencing from their Obsessive Compulsive Disorder (OCD) parent. They gave me a few examples. The compulsive handwashing that led to dry and sometimes bloody hands were imposed on everyone in the household. There was a sense of superiority that this family did things such as proper cleaning and sterilized laundry better than others. The excessive rituals before and after people would leave the house were designed to impress a magazine decorating editor. Unable to keep up with the expectations of the parent, the teenager felt defeated.
But after meeting the parent, it became apparent that in addition to the OCD they had Narcissistic Personality Disorder (NPD). This changes everything: the approach, the treatment planning, and the management of the OCD because the underlying motive is completely different. A person who has NPD and OCD is not likely to change their behavior but it can be guided so as not to impose destructively it onto others. By contrast, a person with OCD frequently wants their behavior to change and is embarrassed when they impose it onto others.
Here is a chart demonstrating the difference using the characteristics of NPD.
| Characteristic | NPD w/ OCD | OCD |
| Motive | OCD behavior reinforces and justifies NPD behavior | OCD behavior is done as coping mechanism when feeling out of control |
| Superior | OCD behavior is done as a visual demonstration of their superior status (they like being thought of as outdoing their competition) | OCD behavior is done to ease anxiety even though they most likely are doing things a better way |
| Fantasizes | Fantasizes that the OCD behavior proves their worth and desire for power, success, beauty or ideal love | Fantasizes that the OCD behavior is not severe and hides the full extent of their disorder |
| Admiration | Performs OCD behaviors to gain admiration and praise from others | Believes their mild OCD behaviors should be admired but not the severe aspects |
| Special | OCD behavior is a way of further distinguishing an NPD from the pack and placing them in special status | Knows the OCD behavior isolates them; doesn’t like being thought of as special |
| Empathy | No concern or empathy for how their OCD behavior negatively impacts others | Constantly feels bad for how their OCD behavior impacts others |
| Entitled | Demands automatic compliance from others for OCD behaviors regardless of other’s beliefs or the impact | Demands compliance from others to ease anxiety and has a hard time seeing the negative impact on others |
| Exploitative | Exploits other’s lack of OCD behaviors as evidence of perfectionism | Takes advantage of other’s compliance with their behavioral OCD nature to justify their continued behavior |
| Jealous | Believes others are jealous of their OCD behaviors and methods | Is jealous of others who do not have OCD behavior |
| Arrogant | Is proud and boastful of their OCD behaviors, frequently encourages others to be like them | Is prideful of the mild OCD behaviors but shameful of the more severe behaviors |
While cognitive behavioral therapy is highly effective for the treatment of OCD, it is not as efficient when the person is also narcissistic. Rather the underlying narcissistic characteristics need to tackled first before addressing the OCD behaviors.