Clinical perfectionism: a cognitive–behavioural analysis

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Abstract

This paper reviews the characteristics of clinical perfectionism and proposes a new definition of the phenomenon. It is suggested that the defining feature of clinically significant perfectionism is the overdependence of self-evaluation on the determined pursuit (and achievement) of self-imposed personally demanding standards of performance in at least one salient domain, despite the occurrence of adverse consequences.

It is suggested that such clinical perfectionism is maintained by the biased evaluation of the pursuit and achievement of personally demanding standards. Specifically, it is suggested that people with perfectionism react to failure to meet their standards with self-criticism. If they do meet their standards, the standards are re-evaluated as being insufficiently demanding. Anorexia nervosa and bulimia nervosa are considered to have a particular relationship to perfectionism, with both disorders often being direct expressions of perfectionism. Under these circumstances self-evaluation is dependent on the pursuit and attainment of personally demanding standards in the domain of control over eating, shape and weight. The implications of this analysis for research and practice are considered.

Introduction

Perfectionism appears to play an important role in the aetiology, maintenance and course of certain psychopathological states. It has been identified as a specific risk factor for the development of anorexia nervosa (Fairburn, Cooper, Doll, & Welch, 1999, Lilenfeld et al., 1998) and bulimia nervosa (Fairburn et al., 1998, Lilenfeld et al., 2000). There is evidence that it may impede the successful treatment of depression (Blatt, Zuroff, Bondi, Sanislow, & Pilkonis, 1998) and it is a central element of obsessive-compulsive personality disorder (American Psychiatric Association, 1994). Despite this, perfectionism is an ill-defined and poorly understood phenomenon.

As currently used, the construct of perfectionism can be `normal' (Hamachek, 1978) and `positive' (Frost, Heimberg, Holt, Mattia, & Neubauer, 1993) or `neurotic' (Hamachek, 1978) and `dysfunctional' (Frost et al., 1993). When the pursuit of excellence is functional and positive, it has little clinical relevance (Burns, 1980). We consider that it is unhelpful to confuse this functional pursuit of excellence (which may be termed normal `high standards') with dysfunctional perfectionism seen in clinical samples, the crucial distinguishing feature being that in clinical samples, high standards are being pursued despite significant adverse consequences (see later). In order to improve the understanding and treatment of perfectionism in patients, we suggest that the construct should be restricted to phenomena of clinical relevance. For this reason, the remainder of the paper addresses the psychopathological form of perfectionism.

Section snippets

The characteristics of perfectionism

The particular characteristics of perfectionism have been well described by clinicians such as Hamachek (1978). Hamachek observed that people with perfectionism “stew endlessly in emotional juices of their own brewing about whether they're doing it [the task] just right. For stewers, the tasks that they take on do not translate into just doing one's best but, rather, doing better than has ever been done before” (p. 27). These are people “whose efforts—even their best ones—never seem quite good

Definitions of perfectionism

Various attempts have been made to define the construct of perfectionism. It has been defined as “the tyranny of the shoulds” (Horney, 1950) and as “the practice of demanding of oneself or others a higher quality of performance than is required by the situation” (see Hollender, 1965, p. 94). Burns (1980) defines people with perfectionism as “those whose standards are high beyond reach or reason, people who strain compulsively and unremittingly toward impossible goals and who measure their own

A cognitive–behavioural definition of perfectionism

In order to understand clinically-relevant perfectionism, it is necessary to define the construct in a way that captures its core characteristics. We propose that clinically relevant perfectionism be defined as: the overdependence of self-evaluation on the determined pursuit of personally demanding, self-imposed, standards in at least one highly salient domain, despite adverse consequences. What this definition suggests is that people with perfectionism have a scheme for evaluating themselves

The maintenance of perfectionism

A number of processes arise from the core psychopathology of perfectionism and are hypothesised to contribute to the maintenance of perfectionism. These are summarised in Fig. 1.

Clinical perfectionism and comorbidity

It is rare for patients to present with perfectionism as an isolated clinical problem. Rather, it is typically seen in conjunction with an Axis I or Axis II disorder. Perfectionism has been found to predict poor response to treatment for depression, regardless of treatment modality, and it has been suggested that it interferes with the development of the therapeutic alliance (Blatt, Zuroff, Bondi, Sanislow, & Pilkonis, 1998, Zuroff et al., 2000). This finding may also be attributable, in part,

Hypotheses

This analysis is the first cognitive–behavioural account of the maintenance of clinical perfectionism that goes beyond a simple description of phenomenology to identify core maintaining mechanisms. Its main strengths are that it generates testable hypotheses and has specific implications for treatment. Among the hypotheses that may be derived from the analysis are the following:

  • 1.

    Clinical perfectionism is maintained by:

    • ◦

      Biased evaluation of performance

    • ◦

      Re-appraising standards as being

Implications for treatment

Cognitive–behavioural strategies for the treatment of perfectionism (Antony & Swinson, 1998, Burns, 1980, Ferguson & Rodway, 1994) have been described. Based on the present cognitive–behavioural analysis, we suggest that treatment of perfectionism should have four components.

First, it is important to help the patient to identify perfectionism as a problem, and to place it within a cognitive–behavioural formulation that makes sense to the person, and that informs treatment. Within the

Conclusion

A new definition and cognitive–behavioural conceptualisation of clinical perfectionism is proposed. The self-evaluation of people with clinically relevant perfectionism is viewed as overly dependent on the pursuit of personally demanding standards in at least one salient domain, despite adverse consequences. It is suggested that clinical perfectionism is maintained by the setting of dichotomous standards, evaluating the striving and attainment of performance in a biased way, self-criticism if

Acknowledgments

The authors are grateful for the helpful comments of Melanie Fennell, Warren Mansell and the anonymous reviewers. RS is a Wellcome Trust Advanced Training Fellow (055112) and CGF is a Wellcome Trust Principal Research Fellow (046386). ZC is also supported by the Wellcome Trust (046386).

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