Perfectionism and psychopathology: a review of research and treatment

PERFECTIONISM AND PSYCHOPATHOLOGY:A REVIEW OF RESEARCH AND TREATMENT

Roz Shafran and Warren Mansell

University of Oxford

ABSTRACT.

Clinical experience suggests that perfectionism can impede the successful treatment of psychological disorders. This review examines the concept of perfectionism, critically evaluates its assessment, reviews the association between existing measures of perfectionism and psychopathology, and considers the impact of perfectionism on treatment. It is concluded that existing measures do not reflect the original construct of perfectionism and that, consequently,new measures are needed. The evidence reviewed indicates that high personal standards are specifically elevated in patients with eating disorders and beliefs about others’ high standards for the self are associated with a broad range of psychopathology. The importance of examining mean scores across studies (as well as associations between variables within studies) is emphasized.There has been no systematic evaluation of the treatment of perfectionism despite existing cognitive-behavioral treatment protocols.

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KEY WORDS.

Perfectionism, Cognitive therapy, Anxiety, Depression, Eatingdisorders.PERFECTIONISM HAS BEEN described as ‘‘the tyranny of the shoulds’’ (Horney,1950). Its link with psychological problems has been described for many years but more recently a wide range of studies has investigated the specific links betweenperfectionism and psychopathology. The following paper attempts to review thisresearch and draw implications for future research, assessment and treatment.First, definitions of perfectionism are presented and the assessment of perfection-ism is described in some detail, because several different scales of perfectionismare used consistently throughout the literature. Next follows a broad critical review of the theoretical and empirical literature examining perfectionism in depression,suicide attempts, eating disorders, social anxiety, obsessive–compulsive disorder,obsessive–compulsive personality disorder, and somatic disorders. The current

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Correspondence should be addressed to Dr. Roz Shafran, Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford OX3 7JX, UK. Tel.: +44-1865-226479; fax:+1-44-1865-226244; Email: roz.shafran@psychiatry.ox.ac.uk

PII S0272-7358(00)00072-6

Clinical Psychology Review, Vol. 21, No. 6, pp. 879–906, 2001Copyright

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2001 Elsevier Science Ltd.Printed in the USA. All rights reserved0272-7358/01/$–see front matter

treatment of perfectionism is reviewed and, finally, conclusions for conceptualiza-tion, treatment, and research are presented.

THE CONCEPT OF PERFECTIONISM

Hollender (1978) was among the first to define perfectionism, and he considered it as ‘‘the practice of demanding of oneself or others a higher quality of performancethan is required by the situation.’’ Hollender considered perfectionism as a neglectedpersonality trait, yet shortly after this description Burns (1980a) provided a broadanalysis of the concept, describing perfectionism as a ‘‘network of cognitions’’ that included expectations, interpretations of events, and evaluations of oneself andothers. People with perfectionism were described as setting unrealistically highstandards, rigidly adhering to them, and defining their self-worth in terms of theirachieving these standards. Frost and colleagues (Frost, Marten, Lahart, & Rosenblate,1990) defined perfectionism as ‘‘the setting of excessively high standards forperformance accompanied by overly critical self-evaluation.’’ Such high standardsare associated with a fear of failure (Flett, Hewitt, Blankstein, & Mosher, 1991; Flett,Blankstein, Hewitt, & Koledin, 1992; Thompson, Davis, & Davidson, 1998).Fear of failure may motivate the behavioral components of perfectionism that aimto help the person meet his or her unreasonably high standards; for example, carefulchecking, reassurance seeking, correcting others, and excessive consideration beforemaking a decision (Antony & Swinson, 1998). Alternatively, people with dysfunctionalperfectionism are likely to avoid situations that may require the person to try to meet his or her perfectionist standards; for example, procrastination (putting off starting atask because the desire to complete it perfectly will make it hard or unpleasant; Frost et al., 1990) and prematurely ending tasks because perfectionist standards areunlikely to be met (Antony & Swinson, 1998). According to the definitions above, perfectionism is ‘‘neurotic,’’ self-defeating, anddysfunctional. People with ‘‘neurotic’’ or self-defeating perfectionism can never doenoughtofeelsatisfiedwiththeirperformance(Slade&Owens,1998).However,ithasalsobeensuggestedthatperfectionismcanbe‘‘normal’’(Hamachek,1978),thatsomepeoplewithperfectionismcanbe‘‘satisfied’’(Slade,1982),thatthereissome‘‘positivestriving’’ (Frost, Heimberg, Holt, Mattia, & Neubauer, 1993) and that perfectionismcan be divided into categories of ‘‘positive’’ and ‘‘negative’’ (Slade & Owens, 1998) or‘‘passive’’ and ‘‘active’’ (Lynd-Stevenson & Hearne, 1999). The people with normalperfectionism set high standards in a similar way to the person with ‘‘neurotic’’perfectionism but they feel satisfied when the standards have been achieved. Withthe exception of the section on eating disorders, this review focuses principally ondysfunctional, ‘‘neurotic’’ perfectionism because this is the type of perfectionism that is associated with psychopathology, warrants intervention and interferes with treat-ment progress (Blatt, 1995; Lynd-Stevenson & Hearne, 1999; Pacht, 1984).

THE DEVELOPMENT OF PERFECTIONISM

There is some consensus about how perfectionism develops among those who havetheorized about perfection and it is concluded that ‘‘perfectionism has its roots ininteractions with parents who are perfectionistic and demanding’’ (Frost, Lahart, &Rosenblate, 1991, p. 470). A number of different parenting approaches have been

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associated with perfectionism (Hamachek, 1978; Burns, 1980), and these have beendescribed as four types of early experience that contribute to the development of perfectionistic thinking (Barrow & Moore, 1983). These include:1. Overtly critical and demanding parents;2. Parental expectations and standards of performance are excessively high andcriticism is indirect;3. Parental approval is absent, inconsistent or conditional; and4. Perfectionistic parents acting as models for perfectionistic attitudes andbehaviors.Studies of undergraduate students have shown a significant correlation betweenperfectionism among mothers and daughters, but not between fathers and daughters(Frost et al., 1991; Vieth & Trull, 1999). In the Frost et al. study, mothers’, but not fathers’, ratings of harshness were also associated with perfectionism. Perfectionisticmodels and excessive parental demands placed on a daughter by a perfectionist mother may provide a fertile environment for the development of perfectionism. Thegender-specificity of this relationship requires further investigation.It has been suggested that perfectionistic parents withhold approval of their child’sbehavior and instead urge them to do better. Parental criticism and parentalexpectations are considered as important components of perfectionism (Frost et al., 1990). However, there is little evidence for elevation in reports of parentalcriticism or expectations in patient groups and controls (Antony, Purdon, Huta, &Swinson, 1998; see Table 1).It is probable that perfectionism begins as positive and rewarding but becomesexcessive, negative, and destructive for a variety of reasons. First, over time previously positive ‘‘perfectionist’’ behavior may lead to negative effects, such as fatigue and lackof concentration. Second, if a previously positive ‘‘perfectionist’’ behavior fails toachieve a higher goal, such as gaining self-esteem, the individual may choose to raisetheir standard leading to negative effects. Third, circumstances can change making it harder to achieve a previously accessible standard. Finally, one must always considerthat behaviors can be perceived as positive to the self, but that the individual may not be aware of or may not place great importance on the negative effects of theirperfectionism on others and on their own physical health (Slade & Owens, 1998).

ASSESSMENT

Two self-report measures consider perfectionism as multidimensional and both scalesare called the Multidimensional Perfectionism Scale (MPS). These scales were devel-oped by Frost et al. (1990) and by Hewitt and Flett (1991a) and are described below.

Multidimensional Perfectionism Scale (Frost et al., 1990)

The Multidimensional Perfectionism Scale (MPS-F; Frost et al., 1990) includes thefollowing dimensions:1. Concern over Mistakes: Reacting negatively to mistakes and equating them withfailure. For example, ‘‘People will probably think less of me if I make a mistake.’’