How is perfectionism linked with youth depression and anxiety?
How is perfectionism linked with youth depression and anxiety?
Perfectionism, defined as the desire to be flawless whilst experiencing unfair self-criticism, flourishes within the Western culture of social media. Using platforms like Instagram preys on people’s insecurities, and carefully manipulated material can create a misperception that ‘perfection’ is achievable. There is a link between perfectionism and experiencing mental health difficulties like depression and anxiety (Egan et al., 2011; Limburg et al., 2017), and experiences of distress are high among young people, negatively impacting adulthood (Copeland et al., 2021). As young people are exposed to contexts that can foster perfectionism, like social media use and academic pressures, effective interventions to support individuals to manage their perfectionistic tendencies are essential.
Cognitive Behavioural Therapy (CBT) for perfectionism is a treatment option that could support individuals. Research has developed a specific therapeutic model that could be targeted using CBT (Egan et al., 2014; Shafran et al., 2018). Although there is some evidence that CBT for perfectionism can reduce depression and anxiety (Suh et al., 2019; Lloyd et al., 2015), the effect sizes are variable, suggesting that treatment could be made more effective. Qualitative studies could provide real value in addressing this gap. This is because qualitative research provides a richer, more in-depth understanding of concepts in comparison to quantitative research. In addition, as young people’s voices are often unheard within research (Bennett et al., 2021), it could provide an understanding of their specific perspectives. Furthermore, this can inform intervention development in the most effective way for clinical practice.
Egan and colleagues (2022) aimed to address this gap in their paper. They aimed to conduct a systematic, meta-synthesis of qualitative literature to:
- Inform our understanding of how perfectionism is associated with negative affect,
- Inform future development of treatment for perfectionism in young people, and make it more effective.
A meta-synthesis of 37 eligible qualitative studies was conducted.
The literature search was carried out by the primary reviewer using six electronic databases. The inclusion criteria were: a qualitative study, investigating perfectionism and depression or anxiety, and English-language and peer-reviewed articles.
Data extraction was conducted by the primary reviewer. The research team was consulted and themes were discussed by the senior authors until a consensus was reached.
The 37 eligible qualitative studies used a variety of analytical methods, including content analysis, interpretative phenomenological analysis, inductive analysis, thematic analysis, and grounded theory. The mean age was 24 years, with 73.5% of the participants being female.
Six main themes related to perfectionism were found.
Association with negative affect
Participants were found to be fixated on their performance and the mistakes they were making, which were related to experiencing distress:
You just feel guilt, like really bad, depressive guilt, like you did something seriously wrong.
Self-worth dependent on achievement
It was highlighted across many individuals that self-esteem and identity were triggered in the process:
I think if I haven’t got something right then I’m a bit of a worthless person.
Cognitive and behavioural maintaining factors
Dichotomous, rigid thinking was the key cognitive component of perfectionism that was maintaining distress. For example, thinking that their performance was a complete failure or complete success.
Behaviours that maintained the cycle of distress included procrastination, avoidance, and excessive time devoted to their performance.
The expectations of others
The pressure of achievement was felt by individuals across different life areas, such as family members, friends and teachers:
My parents put a lot of pressure on me to make good grades like my sister, I know they will be disappointed if I don’t.
Effective elements of interventions
Group treatment was described as the preferable treatment in comparison to self-help. This was because individuals felt that the group environment was positive for normalising their experience:
You always think you are the only person, so it was nice to see that there were other people that felt the same.
Barriers to treatment
A key barrier to engaging in treatment was positive beliefs about perfectionism, such as helping with organisation, achieving goals, and feeling good about accomplishments:
I think there’s quite a lot of advantages because you achieve more just because you don’t accept low standards.
The authors concluded that:
Qualitative literature supports the notion of perfectionism as an important construct to consider in reducing negative affect.
Numerous themes were found across qualitative studies representing the association of perfectionism with anxiety and depression, factors keeping it going, barriers to treatment and potential effective elements of treatment.
Strengths and limitations
The strengths of the study include that this was the first meta-synthesis to the authors’ knowledge in this area. This was important for capturing an in-depth understanding of the construct of perfectionism, to support the development and delivery of clinical interventions.
There are some limitations. Firstly, the study may be at risk of publication bias. This is because only studies published in English and that were peer-reviewed were included. Additionally, grey literature was not included. This may mean that some relevant literature was missed, limiting the validity of the claims. This is an important consideration for designing novel interventions, as a rich understanding of all findings, not just positive findings, could minimise possible barriers to treatment.
Secondly, the age was not specified within the inclusion criteria, and the mean pooled age was 24 years old. As the authors acknowledge, this means that generalisations need to be interpreted with caution, as there were few studies specifically focusing on the target group. This is important for future research, as young people are exposed to multiple, different stressors related to perfectionism. This could mean that there are nuances in the maintenance of perfectionism depending on age, which would be important for practitioners to be aware of for treatment targets.
The research implications of the study highlight the need for co-production with young people when understanding perfectionism. Better understanding the views of young people would help to tailor more effective, relevant interventions.
The clinical implications give insight into the maintaining factors of perfectionism that could be targeted using CBT. For example, targeting dichotomous thinking, or behaviours like avoidance. It also highlighted the value of the group setting. Services should ensure that when offering CBT, a variety of therapeutic modalities are available to individuals.
More widely, the findings call attention to the development and maintenance of perfectionism as a systemic issue. Key social groups and contexts within a young person’s development were mentioned as triggering perfectionism, like families, friends and teachers. This implies that a system-wide approach is required when trying to reduce perfectionism, so that contexts that foster perfectionism have adequate and available support systems to mitigate distress.
Statement of interests
Listen to Prof Roz Shafran, who co-authored this review, talking about perfectionism in our #BABCP2022 podcast:
Egan, S., Wade, T., Fitzallen, G., O’Brien, A., & Shafran, R. (2022). A meta-synthesis of qualitative studies of the link between anxiety, depression and perfectionism: Implications for treatment. Behavioural & Cognitive Psychotherapy, 50, 89-105. https://pubmed.ncbi.nlm.nih.gov/34493352/
Bennett, M., Knight, R., Patel, S., So, T., Dunning, D., Barnhofer, T., Smith, P., Kukyen, W., Ford, T., & Dalgleish, T. (2021). Decentering as a core component in the psychological treatment and prevention of youth anxiety and depression: A narrative review and insight report. Translational Psychiatry, 11, 288. https://pubmed.ncbi.nlm.nih.gov/33990541/
Copeland, W., Alaie, I., Jonsson, U., & Shanahan, L. (2021). Associations of childhood and adolescent depression with adult psychiatric and functional outcomes. Journal of the American Academy of Child and Adolescent Psychiatry, 60, 604–611. https://pubmed.ncbi.nlm.nih.gov/32758528/
Egan, S. J., Wade, T. D., Shafran, R., & Antony, M. (2014). Cognitive-Behavioural Treatment of Perfectionism. NY, USA: Guilford Press.
Egan, S., Wade, T., & Shafran, R. (2011). Perfectionism as a transdiagnostic process: A clinical review. Clinical Psychology Review, 31, 203–212. https://pubmed.ncbi.nlm.nih.gov/20488598/
Limburg, K., Watson, H., Hagger, M., & Egan, S. J. (2017). The relationship between perfectionism and psychopathology: A meta-analysis. Journal of Clinical Psychology, 73, 1301–1326. https://psycnet.apa.org/record/2016-62049-001
Lloyd, S., Schmidt, U., Khondoker, M., & Tchanturia, K. (2015). Can psychological interventions reduce perfectionism? A systematic review and meta-analysis. Behavioural and Cognitive Psychotherapy, 43, 705–731. https://pubmed.ncbi.nlm.nih.gov/26393777/
Shafran, R., Egan, S., & Wade, T. (2018). Overcoming Perfectionism: A Self-Help Guide Using Cognitive Behavioural Techniques (2nd edn). London, UK: Little Brown Book Group.
Shu, C., Watson, H., Anderson, R., Wade, T., Kane, R., & Egan, S. (2019). A randomised controlled trial of unguided internet cognitive behaviour therapy for perfectionism: Impact on risk for eating disorders. Behaviour Research and Therapy, 120, Article 103429. https://psycnet.apa.org/record/2019-53972-001
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