pSYCHIATRY When does conscientiousness become perfectionism? Traits, self-presentation styles, and cognitions suggest a persistent psychopathology r. C is a 50-year-old professional® writerDowden who Health Media recently made a serious suicide attempt. At his Minitial session, Mr. C was hesitant to discuss his situation and reason for attending.Copyright He did,For however, personal bring use only a copy of his résumé so the therapist could “get to know him quickly.” He said he had been depressed for a long time, especially since he found an error in one of his published works. His confi dence and writing abilities seemed to decline after this discovery, his career took a downturn, and ultimately he was fi red from his position. He described often being at odds with his supervisors at work, whom he saw as critical and condescending. He was mortifi ed by his job loss and LARDY did not inform his wife or friends of his fi ring. PHILIPPE 2007 Mr. C had always been a bit of a loner, and after losing © his job he further distanced himself from others. He began drinking heavily to avoid the pain of “letting everyone Paul L. Hewitt, PhD, RPsych down.” His wife, family, and friends were shocked at the Professor of psychology University of British Columbia suicide attempt and expressed dismay that Mr. C had not Vancouver confi ded in anyone. Gordon L. Flett, PhD Mr. C describes himself as being perfectionistic Canada Research Chair in Personality and Health throughout his life and never being quite good enough York University Toronto in any of his pursuits. This leads to self-recriminations and persistent feelings of shame. Far from being a positive attribute, perfectionism is a neurotic personality style that can result in serious psychopathology, including relationship problems, depression, anorexia nervosa, and suicide. Determin- ing a patient’s perfectionistic traits is essential when Current Psychiatry evaluating those who seek treatment specifi cally for Vol. 6, No. 7 49 For mass reproduction, content licensing and permissions contact Dowden Health Media. Table 1 How perfectionism diff ers from conscientiousness Perfectionism Achievement striving/conscientiousness Receives no satisfaction from any performance Experiences satisfaction with good performance Experiences no rewards from any performance Rewards self or others for good performance Perfectionism Maintains expectations in the face of failure Alters expectations in the face of failure Is motivated by fear of failure Is motivated by desire for success Shows poor organization Is organized Focuses on fl aws as indication of self-worth Focuses less on fl aws this distressing behavior as well as pa- perfectionism” is more likely a refl ection of tients in treatment for other issues who conscientiousness or achievement striving may have a perfectionistic personality. Ac- (Table 1). Although perfectionism can in- Clinical Point curately assessing perfectionism can help volve rumination, it is much broader than Perfectionism is a you predict and forestall noncompliance, simply having an obsessional cognitive neurotic personality assess suicide risk, determine appropriate style. treatment and identify circumstances un- We defi ne perfectionism as a neurotic per- style involving der which a patient might be particularly sonality style involving perfectionist traits, perfectionistic traits, vulnerable to relapse. self-presentation styles, and cognitions that self-presentation This article describes: is a core vulnerability factor for a variety of styles, and cognitions • 3 traits of perfectionism psychological, physical, achievement, and • 3 dimensions of perfectionistic self- relationship problems (Table 2).1,3 presentation • perfectionistic cognitions 3 traits. Three traits of perfectionism re- • useful self-report tools for clinical fl ect the desire for the self or others to be practice perfect: • effective treatments. • self-oriented perfectionism—a requirement for the self to be perfect • other-oriented perfectionism—a Characteristics of perfectionism requirement for others to be perfect Although perfectionism initially was • socially prescribed perfectionism— viewed as self-related cognitions, recent a perception that others require models suggest it incorporates intraperson- perfection of oneself. al and interpersonal dimensions.1 A person Each of these traits is associated with with perfectionism has a marked need for different Axis I and Axis II disorders, absolute perfection for the self and/or oth- which we outline below.4 In addition to ers in many—if not all—pursuits that is these traits, perfectionism includes inter- strongly rooted in his or her intrapersonal personal and intrapersonal expressions. and interpersonal worlds. Other character- istics of perfectionism include: 3 self-presentational dimensions. The • equating self-worth or esteem with interpersonal expression of perfectionism performance is perfectionistic self-presentation. In our • self-punishment in failure and a lack model, the 3 facets of perfectionistic self- of satisfaction in success presentation are: • maintaining and needing to strive for • perfectionistic self-promotion—overt unrealistic expectations displays and statements of one’s sup- • unrealistic criteria for success and posed “perfection” broad criteria for failure. • nondisplay of imperfections—hiding Some clinicians have suggested that per- any imperfections Current Psychiatry 50 July 2007 fectionism may be adaptive,2 but “adaptive • nondisclosure of imperfections— Table 2 Psychopathologies associated with perfectionism pSYCHIATRY Perfectionism component Description Psychiatric outcomes CurrentPsychiatry.com Perfectionism traits Self-oriented perfectionism Requires self to be perfect Unipolar depression, anorexia nervosa Other-oriented perfectionism Requires others to be perfect Personality disorders (PDs), relationship problems Socially prescribed Perceives that others require Suicidal behavior, general perfectionism one to be perfect distress Perfectionistic self-presentational styles Perfectionistic self-promotion Overtly promotes one’s Narcissistic PD, other dramatic ‘perfection’ cluster PDs Nondisplay of imperfections Avoids demonstrating one’s Poor help seeking, treatment imperfection nonadherence, anxiety in Clinical Point assessment and therapy Individuals with Nondisclosure of imperfections Hides perceived imperfections Poor therapy alliance, from others relationship problems anorexia nervosa appear to have Perfectionistic cognitions Inner dialogue regarding General distress, severity requirement to be perfect of depression, anxiety the highest levels Source: References 1,3,5 of self-oriented perfectionism avoiding disclosure or discussion of It also is elevated in women with an- any imperfection.3 orexia nervosa compared with normal and psychiatric controls.9 Individuals with an- Perfectionistic cognitions. The intraper- orexia nervosa appear to have the highest sonal expression of perfectionism is per- levels of self-oriented perfectionism among fectionistic information processing and clinical groups. ruminative thoughts regarding the need for perfection for the self or others.5 This state Other-oriented perfectionism is associ- component refl ects the self-related inner di- ated with antisocial and narcissistic per- alogue of the patient’s requirement for per- sonality disorders.10,11 It also is related to fection, recriminations, etc. Perfectionistic interpersonal problems and diffi culties with cognitions are associated with state levels marriage and intimate relationships.12 of distress and symptom severity. Socially prescribed perfectionism is highly elevated in patients with social Traits tied to psychopathology phobia13 and narcissistic11 or borderline Each of the 3 traits of perfectionism in our personality disorder.10 It also is associated model has been associated with psychopa- with severity of depression, anxiety, and thology in multiple studies. symptoms of hostility.7 Perhaps most important, determin- Self-oriented perfectionism is often in- ing a patient’s level of socially prescribed volved in Axis I disorders, including unipo- perfectionism can aid in assessing suicide lar depression. This trait is elevated among risk. Socially prescribed perfectionism has adults and children diagnosed with major been shown to be highly relevant in sui- depressive disorder and may be pernicious cide ideation, ratings of suicide risk, and in the presence of stressors, particularly moderate- to high-intent suicide attempts achievement-related ones.6 In other words, in adults,14 adolescents, and children.15 So- self-oriented perfectionism appears to be a cially prescribed perfectionism has been Current Psychiatry risk factor for unipolar depression.7,8 found to be a unique predictor of suicide Vol. 6, No. 7 51 Table 3 In addition, perfectionistic self-presen- Perfectionism self-report tation appears to impair patients’ abil- ity to access and benefit from treatment. assessment tools Researchers (Hewitt PL, Lee-Baggley D, Traits or trait components Sherry SB, et al., unpublished data, 2007) Hewitt and Flett Multidimensional have found that the various dimensions Perfectionism Scale (for adults) of perfectionistic self-presentation are Flett and Hewitt Child and Adolescent Perfectionism Perfectionism Scale associated with: Frost Multidimensional Perfectionism Scale • diffi culty in seeking help for psycho- (for adults) logical problems Perfectionistic self-presentation • increased distress in clinical inter- Hewitt and Flett