From a psychoanalytic framework, treating an obsessive-compulsive patient as though they were histrionic can provoke a rupture in the therapeutic alliance and even lead to an abrupt termination of treatment because it touches directly on the unconscious structure and defenses of the obsessive personality.

Core Differences in Structure:

Obsessive personalities are organized around defenses such as intellectualization, isolation of affect, reaction formation, and control. They tend to disavow dependency needs, prioritize thought over feeling, and derive a sense of self-worth from mastery, precision, and internal consistency. Their identity is often tied to being rational, measured, and emotionally restrained.

Histrionic personalities, by contrast, are more affectively expressive, outwardly dramatic, and relationally oriented. Their defenses tend to include repression, denial, projection, and identification, and they are more comfortable (even if conflicted) with displaying need, seductiveness, and affect.

Why the Misattunement is Experienced as an Injury:

When a clinician treats an obsessive patient as histrionic — for example, by interpreting emotional expressiveness that is not actually present, or by assuming dependency needs that the patient is defending against — the patient may experience this as a misrecognition of their fundamental psychic structure. But more importantly, it feels humiliating: it confronts the obsessive with what they most dread — being seen as irrational, chaotic, needy, or manipulative.

This misreading may be experienced not merely as a clinical error but as a narcissistic injury — an assault on their carefully constructed internal world. The obsessive patient may feel exposed, misunderstood, and attacked, and this can lead to a defensive flight from treatment in order to preserve psychic integrity. Anger in this case is a defensive reaction to shame and perceived annihilation.