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.
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 and Lilenfeld et al., 1998) and bulimia nervosa (Fairburn et al., 1998 and 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.
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 the standards are not met in the salient domain and, if standards are met, re-appraising them as insufficiently demanding. Clinical perfectionism is hypothesised to contribute to the maintenance of comorbid Axis I disorders when the domain in which the perfectionism is expressed overlaps with the domain affected by the psychiatric disorder. It is argued that anorexia nervosa and bulimia nervosa can be the expression of clinical perfectionism in the domain of eating, shape or weight and their control. A series of testable hypotheses are outlined, and implications for treatment discussed. Evaluation of this analysis and its clinical utility is currently underway.
