Impact of maladaptive perfectionism on mental health and the role of cognitive behavioral therapy: a narrative review

Impacto do perfeccionismo desadaptativo na saúde mental e o papel da terapia cognitivo-comportamental: uma revisão narrativa

Impacto del perfeccionismo desadaptativo en la salud mental y el papel de la terapia cognitivo-conductual: una revisión narrativa

1. Karen Regina Rosso Schons

2. Alexei Gil

3. Bruna Natalie Dacroce Fasolo

4. Luiza Martins Barbosa

5. Marina Pimentel Beber de Mattos

6. Vinicius Ferreira Lacerda Santos

Affiliation of authors:

1, 3, 4, 5, 6 [Especializandos, Psiquiatria, Fundação Universitária Mario Martins, FUMM, Porto Alegre, RS, Brasil]

2 [Médico Psiquiatra, Preceptor da Residência Médica e Curso de Formação em Psiquiatria da Fundação Universitária Mario Martins, FUMM, Porto Alegre, RS, Brasil]

Chief Editor responsible for the article: César Augusto Trinta Weber

Authors contributions according to the Taxonomia CRediT: Schons KRR [1,5,6,7,13,14], Gil A, Fasolo BND, Barbosa LM, Mattos MPB, Santos VFL [13,14].

Disclosure of potential conflicts of interest: none

Funding: none

Approval Research Ethics Committee (REC): not applicable

Received on: 2025/03/31 | Accepted on: 2025/05/24 | Published on: 2025/06/05

How to cite: Schons KRR, Gil A, Fasolo BND, Barbosa LM, Mattos MPB, Santos VFL. Impact of maladaptive perfectionism on psychiatry and the role of cognitive behavioral therapy: a narrative review. Debates Psiquiatr. 2025;15:1-13 https://doi.org/10.25118/2763-9037.2025.v15.1452

Abstract

Perfectionism is a personality trait that can be strongly valued in many professional environments, such as the medical field. However, when maladaptive, is potentially harmful to the mental and physical health of individuals. In addition, it should be considered that, under a transdiagnostic approach to psychiatry perfectionism can be a factor in psychiatric disorders such as obsessive-compulsive disorder, hoarding disorder and body dysmorphic disorder. In addition, clinical perfectionism correlates with social disconnection, rumination, low levels of self-confidence, depressive and anxious symptoms, as well as self-harm and suicidal ideation. Therefore, identifying maladaptive perfectionist behaviors in psychiatric patients can enable a more comprehensive approach to these patients, ultimately contributing to a reduction in their mental suffering. In this context, cognitive-behavioral psychotherapy has established itself as the main approach for the prevention, early intervention and transdiagnostic treatment of patients affected by maladaptive perfectionism.

Keywords: psychiatry, psychotherapy, cognitive behavioral therapy, mental health, psychological distress, psychological distress, perfectionism.

Resumo

O perfeccionismo é um traço de personalidade que pode ser fortemente valorizado em muitos ambientes profissionais, como no caso da área médica. No entanto, quando desadaptativo, é potencialmente prejudicial à saúde mental e física dos indivíduos. Além disso, deve-se considerar que, sob uma abordagem transdiagnóstica em psiquiatria, o perfeccionismo pode ser um fator presente em transtornos psiquiátricos, como o transtorno obsessivo-compulsivo, transtorno de acumulação e transtorno dismórfico corporal. Além disso, perfeccionismo clinico correlaciona-se com desconexão social, ruminação, baixos níveis de autoconfiança, sintomas depressivos e ansiosos, bem como automutilação e ideação suicida. Portanto, identificar comportamentos perfeccionistas desadaptativos no paciente psiquiátrico pode viabilizar uma abordagem mais compreensiva destes pacientes, contribuindo para redução de seu sofrimento mental. Neste contexto, a psicoterapia cognitivo-comportamental consolidou-se como a principal abordagem para prevenção, intervenção precoce e tratamento transdiagnóstico a pacientes acometidos por perfeccionismo desadaptativo.

Palavras-chave: psiquiatria, psicoterapia, terapia cognitivo-comportamental, saúde mental, angústia psicológica, sofrimento psicológico, perfeccionismo.

Resumen

El perfeccionismo es un rasgo de la personalidad que puede ser muy valorado en muchos entornos profesionales, como el médico. Sin embargo, cuando es desadaptativo, es potencialmente perjudicial para la salud mental y física de los individuos. Además, hay que considerar que, bajo un enfoque transdiagnóstico en psiquiatría, el perfeccionismo puede ser un factor de trastornos psiquiátricos como el trastorno obsesivo-compulsivo, el trastorno de acaparamiento y el trastorno dismórfico corporal. Además, el perfeccionismo clínico se correlaciona con la desconexión social, la rumiación, los bajos niveles de autoconfianza, los síntomas depresivos y de ansiedad, así como con la ideación suicida. Por lo tanto, la identificación de conductas perfeccionistas inadaptadas en pacientes psiquiátricos puede permitir un abordaje más integral de estos pacientes, ayudando a reducir su sufrimiento mental. En este contexto, la psicoterapia cognitivo-conductual se ha consolidado como el principal enfoque para la prevención, la intervención temprana y el tratamiento transdiagnóstico de los pacientes afectados por perfeccionismo desadaptativo.

Palabras clave: psiquiatría, psicoterapia, terapia cognitivo-conductual, salud mental, distrés psicológico, sufrimiento psicológico, perfeccionismo.

Introduction

Perfectionism is a personality trait that, when maladaptive, can be associated with interpersonal difficulties, psychological distress and numerous psychopathologies . In addition, evidence points to the potential harm of perfectionism on the physical health of individuals . In the context of psychotherapy, the pattern of perfectionist behavior employed by the patient (and also the therapist) can strain the therapeutic relationship, causing challenges in building the alliance .

Moreover, maladaptive perfectionism is related to emotion regulation difficulties and ultimately could contribute decisively to increasing the risk of suicidal ideation . The perfectionistic person who is experiencing psychological pain is at a heightened suicide risk as it tends to hide psychache behind a perfect front while also experiencing elevated hopelessness .

As evidence points to an increase in perfectionism levels in society over the last few decades , it is becoming increasingly necessary for psychiatry professionals to adequately understand the different faces of perfectionism linked to negative repercussions in the lives of individuals.

Positively, in recent years the transdiagnostic approach has represented a new paradigm of psychiatry care, where professionals pay attention to psychological factors common to various psychiatric disorders . Thus, perfectionism and its implications for different pathologies and spheres in individuals' lives have received considerable attention from academia .

Precisely as a response to the growing interest in the subject in scientific circles, cognitive behavioral psychotherapy (CBT) for clinical perfectionism has proven to be extremely valuable and effective in prevention, early intervention and transdiagnostic treatment in various age groups, consolidating itself as a relevant modality in supporting these patients .

Thus, in order to better understand the impact of maladaptive perfectionism on mental health and the role of CBT in its treatment, this study was carried out through a narrative review of the literature. To this end, the PubMed database was consulted for encountering articles in English and Portuguese related to the descriptors "perfectionism" and "cognitive behavioral therapy" published between February 2012 and February 2025.

Defining perfectionism

The pursuit of excellence within high and attainable performance standards is a strongly valued behavior in most professional environments, and corresponds to the adaptive side of the perfectionist trait. On the other hand, setting excessively high and unreasonable standards of performance, striving for faultlessness, and rigidly criticizing oneself and others is linked to clinically significant, or maladaptive, perfectionism .

It is suggested that setting high standards of performance has the potential to be adaptive or maladaptive, with the difference lying in the presence or absence of excessive self-criticism. Adaptive perfectionism (with low self-criticism) is often associated with less psychological distress and better well-being .

Maladaptive perfectionism occurs when an individual's sense of worth depends excessively on meeting high personally demanding self-imposed standards in at least one highly salient domain despite adverse consequences .

According to Hewitt and Flett's Multidimensional Perfectionism Scale, perfectionism comes in three forms. In self-oriented perfectionism, the individual rigorously evaluates themselves, setting not only high but unrealistic standards, focusing on failures and generalizing them, presenting an all-or-nothing mentality (results are complete successes or failures). In other-oriented perfectionism, unrealistic expectations and critical evaluation are directed at others. The third subtype, socially prescribed perfectionism, is linked to the need to meet the expectations set by others in order to gain their approval .

The maladaptive perfectionists judge their sense of self-worth as largely dependent on achieving these rigorous standards, and persists in following these demanding standards, despite the enormous cost of the negative consequences of this pursuit .

In addition to a biological vulnerability, early experiences in the family environment and specific psychological vulnerabilities have been identified as etiological components of perfectionism. In this context, high parental expectations and criticism, as well as an insecure bond between the individual and them, play an important etiological role in the development of maladaptive perfectionism .

It is hypothesized that perfectionist thinking and behavior are coping mechanisms used to deal with negative feelings and ideas about the self and maladaptive core beliefs, while information processing occurs through schematic filters of avoidance, compensation or assimilation .

The constant search for success manifests itself in behaviours that are dictated by very rigid rules, from which cognitive biases derive, such as dichotomous thinking, overgeneralization and selective attention .

The relationship between perfectionism and poorer mental health

Data from a study of university students between 1989 and 2016 suggests that perfectionism has increased over time. Recent generations of young people perceive that others are more demanding of them (socially prescribed perfectionism), that they are more demanding of others (other-directed perfectionism) and that they are also more demanding of themselves (self-oriented perfectionism) .

Perfectionism can provoke social disconnection, rumination, difficulties in accepting past negative events, hopelessness and dissatisfaction with one's own body .

Limburg et al. mention that the three pathologies most associated with perfectionism were anxiety disorders, eating disorders and obsessive-compulsive disorder.

In addition, numerous studies point to the transdiagnostic nature of perfectionism, correlating it significantly with mental exhaustion, psychological distress, cynicism, low levels of self-confidence, depressive symptoms, anxiety, suicidal ideation, insomnia and objective markers of sleep disturbances .

Maladaptive perfectionism has the potential to negatively impact individuals' physical health, producing somatic consequences. This occurs because of persistent efforts in pursuit of perfection, despite the warning signals for rest and relaxation emitted and demanded by the body .

Moreover, a systematic review including 15 studies, proposed a clear relationship between non-suicidal self-injury and perfectionism .

A study carried out on a sample of 226 medical students in the United States revealed that maladaptive perfectionists could correlate to an increased risk of feeling like imposters, which in turn would translate into an increased risk for suicidality .

Another study conducted with 246 Israeli physicians identified that maladaptive perfectionism was found to be a risk factor for burnout, depression, and suicidal ideation .

Relevant aspects of CBT in the management of maladaptive perfectionism

Some authors consider perfectionism to be a personality trait that can be changed . However, despite the negative repercussions generated by perfectionism, the self-stigma attached to the individual's own beliefs makes them reluctant to seek treatment .

Historically, research and treatment of psychological disorders prioritized the pathologies contained in the Diagnostic and Statistical Manual of Mental Disorders, resulting in a preponderance of specific treatments for these disorders. Even though changes have occurred more recently, through the promotion of treatments focused on broader transdiagnostic concerns, there are few treatments that specifically target addressing perfectionism . However, CBT for perfectionism has been shown to be a highly accessible and effective program in the prevention, early intervention, and transdiagnostic treatment of maladaptive perfectionism across a range of ages .

As an example of the effectiveness of CBT, a 2021 meta-analysis of randomized clinical trials (N=912 participants) carried out in Australia, the United Kingdom, Canada and Sweden showed a significant reduction in perfectionism as a primary problem or in conjunction with a psychiatric diagnosis (anxiety, depression and eating disorders) . According to this study, the average number of sessions used in treatment, including studies with face-to-face therapy formats, online or via self-help books, was between 3 and 13. Although this meta-analysis does not detail which techniques were used, the authors mention that CBT for clinical perfectionism targets a range of cognitive and behavioral factors, such as repeated performance checking, cognitive biases, self-criticism, procrastination and avoidance .

Regarding the treatment of clinical perfectionism, Shafran, Egan, & Wade mention that the focus is on supporting the patient in re-evaluating their self-worth, which is partially or completely conditioned to meeting self-imposed standards.

As for the content of the CBT sessions for clinical perfectionism, Rozental explains that it encompasses analysis of pros and cons of perfectionism, psychoeducation about the relationship between perfectionism and performance, the use of self-monitoring and it explores the thoughts, emotions and behaviors associated with perfectionism. Moreover, interventions such as behavioral experiments, cognitive restructuring, programming pleasant activities and problem-solving strategies may take place.

A relevant aspect of psychotherapy with perfectionist patients is the impact of the maladaptive pattern on the fulfilment of homework tasks, so often used in CBT and directly related to treatment outcomes. The study by Kobori, Dighton & Hunter , carried out with a sample of 38 patients, found that maladaptive perfectionism correlated significantly with greater procrastination and also with less adherence to carrying out the homework activities proposed by the therapist.

It is worth mentioning that a crucial element of psychotherapeutic treatment, the Therapeutic Alliance, is also influenced by maladaptive perfectionism. Regarding this component, it is important to mention that the expectation of perfection from others strains relationships (perfectionism directed at others) and can predict premature treatment terminations, as well as worse treatment outcomes .

In a review article on the relationship between perfectionism and the Therapeutic Alliance, it is mentioned that patients with high levels of perfectionism perceive their therapist as less empathetic and more critical than other patients. For the authors, the probable cause would be the projection of the individual's own severe self-criticism onto the therapist .

On the other hand, maladaptive perfectionism on the part of the therapist was addressed in a study by Presley et al. It is suggested that depressed clients have better treatment outcomes with CBT with therapists who are not perfectionists. This is because, according to the authors, therapists who set high standards of performance for themselves and others can demotivate clients through rushed interventions or setting unrealistic therapeutic standards. However, the group points out the methodological limitations of their study and suggest further research to confirm their hypothesis .

In any case, the study by Presley et al. reiterates the importance of psychotherapists reflecting on their own perfectionism, which can also benefit from discussion of the issue in personal analysis or supervision.

Final Considerations

This review aimed to address the impact of maladaptive perfectionism on poorer mental health outcomes and the role of CBT interventions for maladaptive perfectionism. According to the content previously exposed, it is possible to conclude that clinical perfectionism is in fact a transdiagnostic problem, for which CBT proves to be a compatible and effective alternative.

The main techniques used in CBT for clinical perfectionism include pros and cons analysis, psychoeducation, self-monitoring, behavioral experiments, programming pleasant activities, problem solving, relaxation techniques, time management, and self-compassion practices

This review also provides evidence of the importance of understanding the dimensions of maladaptive perfectionism and its numerous repercussions on individuals' lives, as well as on the therapeutic relationship.

It is also known that bibliographic reviews such as this one, although they do not test causal associations, raise questions about aspects that have so far been scarcely clarified in the scientific literature. One of these aspects is the influence of perfectionism on the therapeutic alliance, which, although mentioned in this review, still has a very limited number of studies.

The limitations of this study include the fact that articles were searched though a single database.

Finally, as a literature review, this study can help psychiatrists and psychotherapists to familiarize themselves with the possible presentations of perfectionism and to identify relevant therapeutic strategies for the problem.