Perfectionist traits are associated with severe alcohol use disorder (AUD)

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Perfectionist traits – higher self-criticism, and unrealistic standards leading to isolation—are associated with severe alcohol use disorder (AUD), according to the first study directly comparing patients with AUD to a healthy control group.

Perfectionist people strive for unrealistic performance standards and are prone to self-criticism. These goals generate feelings of failure, and—if they can’t attain the standards they believe others expect of them—social disconnection.

Perfectionism is known to increase vulnerability to stress and depression, but its role in severe AUD has not been fully investigated.

Some evidence suggests perfectionist young adults drink less frequently than their peers. Some other studies showed that perfectionism co-occurs with high impulsivity and reduced impulse control, factors involved in AUD, and that perfectionist people may self-medicate with alcohol in an attempt to overcome social anxiety or feelings of inadequacy.

For a study in Alcoholism: Clinical & Experimental Research, researchers in Belgium explored associations between perfectionist traits and severe AUD.

Investigators worked with 65 adults with severe AUD who were undergoing inpatient detoxification and 65 healthy adults matched for sex and age. The participants filled out questionnaires evaluating three dimensions of perfectionism.

Self-oriented perfectionism involves exaggerated performance standards set for oneself (e.g., “One of my goals is to be perfect in everything I do”). Socially-prescribed perfectionism is generated by others’ perceived expectations (e.g., “People expect nothing less than perfection from me”).

Other-oriented perfectionism involves setting high standards for others (e.g., “I have high expectations for the people who are important to me”).

The researchers also evaluated participants’ depressive symptoms, state anxiety (transient anxiety experienced in a specific situation), and trait anxiety (anxiety that generalizes to a person’s broad experience). The researchers used statistical analysis to look for links between these factors.

Patients with severe AUD reported higher depressive symptoms and trait anxiety. They also demonstrated higher self-oriented and socially-oriented perfectionism than the controls, though the two groups were similar in other-oriented perfectionism.

Severe AUD was related to unrealistic personal standards and increased sensitivity to other people’s expectations, even after accounting for the role of depressive symptoms and anxiety, but not to being demanding of others.

This is consistent with what is known about self-related and interpersonal factors in severe AUD, such as reduced self-esteem, a tendency to self-blame, and a divergence between people’s ideal and actual selves.

Perfectionist people might perceive an exaggerated gap between their own high standards and alcohol-related consequences, fearing academic or professional failure.

The study findings also suggest that self-oriented perfectionism in severe AUD is higher among men and people with more education. They also support previous evidence that perfectionism is associated with less daily alcohol consumption in moderate drinkers.

In view of the potential role of perfectionism in developing and maintaining severe AUD, it may be a valuable treatment target, researchers concluded.

They recommend additional investigation of the varying dimensions of perfectionism in AUD, including whether high perfectionism reduces treatment effectiveness, and the causal links between perfectionism, impulsivity, and self-blame.


Perfectionism as a Psychological Construct Historical Definitions of Perfectionism

Early perfectionism researchers conceptualized perfectionism as a unidimensional construct, observable in two forms: normal (also called positive or adaptive) and neurotic (also called negative or maladaptive; Hamachek, 1978). Characteristics of adaptive perfectionism include one’s ability to set reasonable and attainable goals, accept personal limitations and environmental constraints on performance, enjoy the freedom to “be less precise” (Hamachek, 1978, p. 27), and derive pleasure from the challenges faced when striving for excellence (Burns, 1980; Hamachek, 1978; Pacht, 1984). In his seminal article on the differences between normal and neurotic perfectionism, Hamachek (1978) noted that normal perfectionists value praise and approval received from others; however,

the sense of validation experienced from such accolades is considered an “additional good feeling” (p. 27), secondary to their own sense of achievement. Further, adaptive perfectionists are encouraged by such praise and are further compelled to engage in challenges that serve to hone their abilities and advance their capabilities (Blatt, 1995; Burns, 1980; Hamachek, 1978; Pacht, 1984).

Conversely, neurotic, or maladaptive, perfectionists are said to be those who unremittingly strive to meet their own high and exacting personal standards, set goals that are impossible from the outset, and are seemingly unable to feel satisfied with their achievements or believe themselves capable of being “good enough” (Burns, 1980; Frost et al., 1990; Hamachek, 1978; Hewitt & Flett, 1991). Whereas adaptive perfectionists feel free to be less exacting and precise in their efforts, maladaptive perfectionists hold a view that is considerably more black-and-white. There is research to indicate both cognitive rigidity and dichotomous thinking are associated with negative perfectionism such that, for these individuals, to not reach a goal perfectly and in-full marks them as failures, regardless of other achievements. The same cognitive pattern does not appear to hold true for positive perfectionists (Egan, Piek, Dyck, & Rees, 2007; Egan, Piek, Dyck, Rees, & Hagger, 2013). The behavior of the maladaptive perfectionist may also be viewed as compulsive in nature, as those endorsing these traits appear unwilling to modify their goals to better suit their abilities or create satisfactory milestones in pursuit of the greater goal (Blatt, 1995; Flett, Hewitt, & Heisel, 2014; Hewitt & Flett, 2002; Hewitt et al., 2006); as such, a relationship between obsessive-compulsive disorder and maladaptive perfectionism is widely documented within the current perfectionism literature (Martinelli, Chasson, Wetterneck, Hart, & Bjorgvinsson, 2014). Further, maladaptive

perfectionists perceive their worth as being inherently tied to their accomplishments, productivity, and the achievement of a self-set standard of flawlessness (Blatt, 1995; Flett et al., 2014; Hamachek, 1978). Early perfectionism researchers posited that the relationship between perfectionism and self-worth is indicative of the relationship between maladaptive perfectionists and their parents, beginning in childhood.

Researchers theorized that children who experience love and approval as conditional are likely to form the maladaptive belief that “to feel love and approval, they must perform at ever increasing levels of perfection. Any failure or mistake risks rejection by the parents and a loss of love” (Frost et al., 1990, p. 451). Finally, researchers posit that neurotic perfectionism is the result of disparity between one’s perceived self and high personal standards surrounding their conception of the ideal self (Hewitt & Flett, 1991; Slaney et al., 2001).

Expanding to a Multidimensional Perspective

Observing that the historic definition of perfectionism provided a limited understanding of this phenomenon, and seeking to explore the factors underlying maladaptive perfectionism, researchers in the early 1990s began to investigate perfectionism as a multidimensional construct. From this research, two prominent multidimensional models of perfectionism emerged, in which the traditional, unidimensional definition of perfectionism was expanded to include both intra- and interpersonal factors. The multidimensional perfectionism models put forth by both Frost, Marten, Lahart, and Rosenblate (1990) and Hewitt and Flett (1991) remain in wide use today.

Derived from their observations of common themes found within the limited body of existing perfectionism and obsessional thinking research, Frost et al. (1990) hypothesized that maladaptive perfectionism consists of multiple underlying factors that drive perfectionistic thinking and behavior. Frost and colleagues (1990) noted earlier researchers’ belief that the origins of maladaptive perfectionism were, in part, rooted in familial influence; thus, the authors sought to expand the unidimensional understanding of perfectionism to include an interpersonal component centered on familial relationships. Specifically, the Frost Multidimensional Perfectionism Scale (FMPS; Frost et al., 1990), which is discussed in greater detail later in the chapter, expanded the historical definition of perfectionism to include the impact of both parental criticism and expectations. The measure also incorporates additional characteristics observed to be associated with maladaptive perfectionism, including maladaptive perfectionists’ ruminative focus on mistakes and concerns regarding the sufficiency of one’s actions (Frost et al., 1990).

Also conceptualizing perfectionism as multidimensional, Hewitt and Flett (1991) put forth a model comprised of both intra- and interpersonal dimensions of perfectionism, similar to that of Frost and colleagues (1990). Unlike the FMPS, however, Hewitt and Flett’s (1991) perfectionism model extends the influence of interpersonal relationships and perceived social expectations beyond the scope of familial relationships, broadening the existing definition to include three new dimensions. Self-oriented perfectionism is associated with an internal locus of control and a “discrepancy between actual and ideal self” (p. 457, Hewitt & Flett, 1991). Accordingly, it is defined as the tendency to hold oneself to exacting and impossible standards, set exceedingly high goals, and engage in

self-blame. Hewitt and Flett (1991) purport that self-oriented perfectionists are motivated by a desire to reach perfection in both work and personal endeavors, as well as a desire to avoid failure. Such individuals are likely to engage in all-or-nothing thinking, holding to the belief that success and failure exist as absolutes. Shifting focus, other-oriented perfectionism centers on the expectations maladaptive perfectionists hold for others.

Whereas the self-oriented perfectionist places high expectations and performance demands on the self, the other-oriented perfectionist turns those demands outward, believing others should adhere to standards set by the other-oriented perfectionist. Rather than engaging in self-blame when faced with disappointment, other-oriented perfectionists blame their failings on those around them (Hewitt & Flett, 1991).

With the inclusion of socially prescribed perfectionism, Hewitt and Flett (1991) extend the impact of interpersonal associations beyond the parental relations addressed by the FMPS (Frost et al., 1990) to include significant others with whom the maladaptive perfectionist interacts (e.g., intimate partner, co-workers, friends, family, and perceived authority figures). Rather than demanding perfection from others, the socially prescribed perfectionist perceives others as holding unrealistic expectations and setting standards for the individual that are unattainable. This dimension is associated with a high degree of emphasis on an external locus of control, which often leads to feelings of helplessness, hopelessness, and depression. Further, the socially prescribed perfectionist is one who seeks approval from others while simultaneously believing they will never be “good enough,” feel they are disappointing those around them, and perceive themselves a failure (Hewitt & Flett, 1991). Taken together, this lack of control, as well as the belief that one will never reach the goals set by others, lends itself to a lack of motivation and the

development of a defeatist attitude (Blatt, 1995; Flett, Hewitt, Blankstein, & O’Brien, 1991). Expanding on Hewitt and Flett’s (1991) original research, Hewitt, Flett, Sherry, and Caelian (2006) developed the Social Disconnection Model, in which they posit that socially prescribed perfectionists create the conditions for social disconnection through interpersonal sensitivity. The authors state that the insecure attachments, high degree of neediness, and fear of negative appraisal experienced by socially prescribed perfectionists leads to perceptions and feelings of loneliness and rejection. Consequently, this results in subjective feelings of isolation and disconnection (Hewitt et al., 2006).

Perfectionism and Alcohol Use Disorder

With a clearer understanding of the ways in which perfectionism is defined and measured, it is now possible to return to a discussion of the relationship between maladaptive perfectionism and alcohol use disorder. As noted, evidence of this association can be gleaned from a variety of sources, including non-academic, anecdotal sources that allow alcoholics to give voice to their common experiences; the broader body of perfectionism literature; and the more limited body of research specific to the prevalence of perfectionism among those diagnosed with AUD.

AA’s Big Book provides insight into the alcoholic mind as told by recovering alcoholics. The common maxim, “Progress not perfection,” is derived from a passage in this text, which reads: “We claim spiritual progress, not spiritual perfection,” (AA, 2001,

p. 60). This axiom makes salient the black-and-white, or dichotomous thinking, common to those suffering from alcohol and substance addiction, wherein both an individual’s successes and perceived failures are viewed as absolute, rather than arrived at incrementally (Flores, 2007; Gibson, 2010). Similarly, all-or-nothing thinking again

arises as a defining factor of alcoholism in AA’s second leading text, The Twelve Steps and Twelve Traditions (colloquially, the “12 & 12”; AA, 1981), wherein Tradition Six reads: “Nearly every one of us had wished to do great good, perform great deeds, and embody great ideals. We are all perfectionists who, failing perfectionism, have gone to the other extreme and settled for the bottle and the blackout” (p. 156). As noted, this cognitive distortion, anchored in extremes, is also among the cognitive processes observed among maladaptive perfectionists (Flett et al., 1998; Hamachek, 1978; Hewitt & Flett, 1991). Of perfectionism, the Big Book further notes: “I was always able to see the flaw in every person, every situation. And I was always glad to point it out, because I knew you wanted perfection, just as I did” (AA, 2001, p. 417). This passage highlights the internalized demand for perfection of both self and others, common to those with alcohol dependence (Hagedorn & Hartwig Moorhead, 2010); further, these beliefs align with the intra- and interpersonal dimensions of self- and other-oriented perfectionism, as put forth within Hewitt and Flett’s (1991) multidimensional model.

Of the demand for perfection of self, the 12 & 12 (AA, 1981) posits fear as an underlying factor driving the pursuit of perfectionism. In particular, the text makes note of perfectionism as a tool for impression management used to mask a deeper sense of insecurity: “false pride became the reverse side of a coin marked ‘Fear.’ We simply had to be number one people to cover up our deep-lying inferiorities. In fitful successes we boasted of greater feats to be done; in defeat we were bitter” (AA, 1981, p. 123). Like socially-oriented perfectionism, this passage makes salient the drive to appear perfect in the eyes of others by both meeting and exceeding social expectations and perceived standards of perfection. Moreover, this passage clearly illustrates that, among

maladaptive perfectionists, achieving success is not met with a sense of accomplishment, but only with the need to continue striving.

reference link: https://etd.ohiolink.edu/apexprod/rws_etd/send_file/send?accession=akron1561997957994848&disposition=inline


Original Research: Closed access.
Greater self‐oriented and socially prescribed perfectionism in severe alcohol use disorder” by Pierre Maurage et al. Alcoholism: Clinical and Experimental Research

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