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Perfectionism and clinical disorders among employees
Personality and Individual Differences 50 (2011) 1126–1130
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Perfectionism and clinical disorders among employees Nico W. Van Yperen a,⇑, Marc Verbraak b, Ellen Spoor c a
University of Groningen, The Netherlands Behavioral Science Institute, Radboud University Nijmegen, The Netherlands, and HSK Group, Arnhem, The Netherlands c Eindhoven University of Technology, The Netherlands b
a r t i c l e
i n f o
Article history: Received 5 November 2010 Received in revised form 12 January 2011 Accepted 29 January 2011 Available online 19 February 2011 Keywords: Perfectionism Achievement Burnout Depression Anxiety Comorbidity
a b s t r a c t We examined differences in perfectionism between burned-out employees (n = 77), depressed employees (n = 29), anxiety-disordered employees (n = 31), employees with comorbid disorders, that is, a combination of clinical burnout, depression, or anxiety disorder (n = 28), and individuals without clinical burnout, depression disorder, or anxiety disorder (clinical control group; n = 110). The results suggest that setting high personal standards per se is not associated with clinical disorders. In contrast, maladaptive aspects of perfectionism, including perceived discrepancy between standards and performance and socially prescribed perfectionism, were related to clinical disorders, and in particular to comorbidity. Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction Although no definition of perfectionism has been formally agreed upon, the centrality of high personal standards is evident (Flett & Hewitt, 2002; Slaney, Rice, & Ashby, 2002). Several researchers have demonstrated that setting high personal standards (Slaney et al., 2002) or self-oriented perfectionism (Flett & Hewitt, 2002), was positively associated with positively valenced variables such as self-esteem, problem-focused coping, career satisfaction, and physical health (e.g., Bieling, Israeli, & Antony, 2004; Enns & Cox, 2002; Slaney et al., 2002; Stoeber, Feast, & Hayward, 2009). Similarly, in goal-setting research, high standards of performance have typically been found to be associated with focused attention, effort, and persistence, all of which are likely to enhance work motivation and job performance (Locke & Latham, 1990). Therefore, we argue and will demonstrate that, relative to their occurrence in a clinical control group, only maladaptive characteristics of perfectionism are prevalent among employees diagnosed with clinical disorders, and in particular among individuals with comorbid disorders. Specifically, not high standards per se, but individuals’ perceptions that they consistently fail to meet their personal standards, ⇑ Corresponding author. Address: University of Groningen, Department of Psychology, Grote Kruisstraat 2/I, 9712 TS Groningen, The Netherlands. Tel.: +31 50 363 63 32; fax: +31 50 363 45 81. E-mail address: [email protected] (N.W. Van Yperen). 0191-8869/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2011.01.040
henceforth referred to as perceived discrepancy (Slaney et al., 2002), may elevate levels of distress, and lead to the development of clinical disorders. Several studies consistently report that perceived discrepancy is associated with negative adjustment indicators such as lack of self-esteem, worry, and psychological distress (e.g., Slaney, Rice, Mobley, Trippi, & Ashby, 2001; Van Yperen & Hagedoorn, 2008). A perceived discrepancy between standards and criteria of success in meeting those standards is distressing because it interferes with people’s basic need for competence and the need to actually succeed in getting what they want (Ellis, 2002; Ryan & Deci, 2002). Similarly, the perception that others are imposing high standards on the self (i.e., socially prescribed perfectionism) has typically been found to be associated with a variety of negative outcomes, including depressive symptomatology, fear of negative evaluation, and negative affect (e.g., Flett & Hewitt, 2002; Stoeber et al., 2009). In contrast to personally adopted high standards, socially imposed high standards create concerns about others’ criticism and expectations (Clara, Cox, & Enns, 2007; O’Connor, O’Connor, & Marshall, 2007). Focusing on others’ high standards tends to raise a want to a necessity which is irrational and self-defeating, and accordingly, may decrease one’s sense of self-efficacy and self-esteem, increase psychological distress, and, ultimately, leads to clinical disorders (cf., Ellis, 2002). The assumed links between clinical disorders, including comorbidity, on the one hand, and maladaptive characteristics of perfectionism, on the other, are discussed below.
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dards are typically perceived as uncontrollable (Blatt, 1995; O’Connor et al., 2007).
1.1. Burnout From the beginning, burnout (for the five common elements of burnout, see Table 1) was associated with perfectionism (Freudenberger, 1974). However, to our knowledge, there are no studies among employees that link dimensions of perfectionism to clinical burnout. Maladaptive aspects of perfectionism, including the perception of consistently failing to meet one’s own standards and a chronic concern about others’ criticism and expectations, may however lead to the development of severe burnout symptoms (Clara et al., 2007; Stoeber & Otto, 2006). Employees with a clinical burnout meet the criteria of the ICD-10 (i.e., the 10th revision of the International Statistical Classification of Diseases and Related Health Problems) equivalent of job- or work-related neurasthenia (Schaufeli, Bakker, Schaap, Kladler, & Hoogduin, 2001). That is, for the diagnosis clinical burnout, the listed symptoms (see Table 1) have to be present each day for at least 6 months. Table 1 also shows that the elements of burnout are very similar to the criteria for neurasthenia in ICD-10 and those for an undifferentiated somatoform disorder. In the DSM-IV (i.e., Diagnostic and Statistical Manual of Mental Disorders, 4th edition), undifferentiated somatoform disorder includes neurasthenia, which was abandoned as a separate category (Hickie, Hadzi-Pavlovic, & Ricci, 1997). 1.2. Depression According to the criteria of the DSM-IV, the symptoms of a major depressive episode include persistent sad mood, feelings of hopelessness or worthlessness, loss of interest in activities that were once enjoyed, and thoughts of death or suicide. Individuals may be more likely to develop depressive symptomatology, and in the long term, clinical depression when they are high in perceived discrepancy (e.g., Bieling, Israeli, & Antony, 2004; Clara et al., 2007). Such individuals are too critical of their own achievements, making them vulnerable to experiences of failure and the development of depressive symptomatology. Also, individuals who consistently feel that others are imposing high standards on them develop these symptoms because externally imposed stan-
1.3. Anxiety Several researchers have reported a robust link between perceived discrepancy and anxiety, suggesting that people’s perceptions that they consistently fail to meet their personal standards lead to the development of an anxiety disorder (Slaney et al., 2001). Similarly, the perception that one must meet others’ high expectations may be perceived as being excessive and uncontrollable, and ultimately, lead to the development of an anxiety disorder. For example, Hewitt and Flett (1991) found higher levels of socially prescribed perfectionism in a group of patients with anxiety disorders than in healthy respondents. Hence, Hypothesis 1 was that, relative to the individuals in the control group, burned-out individuals, depressed individuals, and anxiety-disordered individuals would be higher in perceived discrepancy and socially prescribed perfectionism. Comorbidity may be associated with even higher levels of perceived discrepancy and socially prescribed perfectionism; this is discussed in the following paragraph. 1.4. Comorbidity In the present research, comorbidity refers to the co-occurrence of clinical burnout, depression, or anxiety disorders within the same individual. Assuming that socially prescribed perfectionism and perceived discrepancy are related to one of these mental disorders (see Hypothesis 1), the most severe and maladaptive forms of perfectionism may be associated with comorbidity (cf., Bieling, Summerfeldt, Israeli, & Antony, 2004). For example, individuals who score high on socially prescribed perfectionism and perceived discrepancy feel chronically anxious because they feel that they typically do not meet others’ high standards and their own high standards, respectively. This may make them feel depressed and less energetic, making it difficult for them to work harder. In turn, this increases their feeling of falling short of the socially imposed or personally adopted standards, which is likely to elevate anxiety
Table 1 Comparison of the five common burnout elements as identified by Maslach and Schaufeli (1993), the criteria for neurasthenia (ICD-10), and the criteria for an undifferentiated somatoform disorder (DSM-IV). Common elements of burnout as identified by Maslach and Schaufeli (1993)
Job or work-related neurasthenia (ICD-10)
Undifferentiated somatoform disorder (DSM-IV)
1.
A predominance of fatigue symptoms such as mental or emotional exhaustion, tiredness, and depression
The feeling of either mental or physical fatigue or weakness and exhaustion after minimal effort
The presence of one or more physical complaints persisting for 6 months or longer. The most frequent complaints are chronic fatigue, loss of appetite, or gastrointestinal or genito-urinary symptoms
2.
Various atypical physical symptoms of distress may occur
3.
These symptoms are work-related
4.
The symptoms manifest themselves in ‘normal’ persons who did not suffer from psychopathology before Decreased effectiveness and impaired work performance occurs because of negative attitudes and behaviors
At least two out of seven symptoms should be present: i.e., muscular aches and pain, dizziness, tension headaches, sleep disturbance, inability to relax, irritability, and dyspepsia The life-management difficulty criterion put forward in ICD-10’s definition of burnout corresponds to workrelatedness These symptoms should not better be accounted for by the presence of a depression or anxiety disorder, or any other of the more specific disorders in the ICD-10 classification In the clarification of neurasthenia the association of the disorder with impaired occupational performance or reduced coping efficiency in daily tasks is made explicitly
5.
The complaints are not better accounted for by another mental disorder, or are not intentionally produced or feigned The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning The complaints cannot be fully explained by a known general medical condition or by the direct effects of a substance. When there is a related general medical condition the physical complaints or resultant impairment are grossly in excess of what could be expected from the history, physical examination, or laboratory findings
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and fatigue to even higher levels. Hence, these individuals develop subsequently, or simultaneously, a burnout syndrome, depression, or an anxiety disorder. Therefore, Hypothesis 2 stated that, relative to burned-out individuals, depressed individuals, anxiety-disordered individuals, and individuals in the control group, individuals with comorbid disorders would be higher in perceived discrepancy and socially prescribed perfectionism. In sum, we expected that only maladaptive characteristics of perfectionism are prevalent among employees diagnosed with clinical disorders, and in particular among individuals with comorbid disorders. No differences between the groups were anticipated with regard to high standards and self-oriented perfectionism. 2. Method 2.1. Participants Complete datasets were available from 275 participants (56.4% men, 98.1% Caucasian) who represented a broad range of industries. They were consecutive clients of a Dutch mental health care institute specialized in diagnosing and treating people with workrelated psychological problems. The participants were referred by their occupational physician, which is common practice in the Netherlands. The average age was 42 years (SD = 9.1), ranging from 22 to 59. Relative to the general Dutch population, the level of education was quite high: 43.3% had a BSc degree or higher, 47.0% had completed high school or had had technical or vocational training at an intermediate level, and the remaining 9.7% had had technical or vocational training at the lowest level. 2.2. Procedure As part of the standardized intake procedure at the institute, all participants were routinely subjected to a standardized clinical semi-structured interview (the Mini-International Neuropsychiatric Interview, or MINI) in order to arrive at one or more DSM-IV classifications describing their complaints (Sheehan et al., 1998). The interviews were conducted by, approximately, 30 different, welltrained and licensed psychologists. The interviews were rated in pairs, one was the assessor at the first (intake) assessment, the other the psychologist at the second (intake feedback and treatment allocation) assessment. Classification was reached by means of consensus. The overall percentage of agreement before consensus was high (i.e., between 79% and 98%; Verbraak et al., submitted). After the intake, clients diagnosed as burned-out (n = 77), depressed (n = 29), anxiety-disordered (n = 31), or with comorbidity of two or more of the aforementioned disorders (n = 28), were asked to participate in the research project on ‘work-related psychological problems’. Furthermore, clients with minor workrelated complaints without mention of clinical burnout, depression, or anxiety disorders anywhere in their clinical profile (mostly adaptation disorders, V-codes, disorders of impulse control) were asked to participate (clinical control group; n = 110). All the participants were told that participation was completely voluntary and that the data would be treated confidentially and anonymously. Almost all eligible clients (91%) were willing to participate. Before the second visit to the institute, the participants had completed and returned (to the secretary’s office) the completed questionnaire, including a signed informed consent. 2.3. Measures Emotional exhaustion. This core symptom of burnout (Maslach & Schaufeli, 1993) was measured using the corresponding scale of
the widely used and validated Maslach Burnout Inventory-General Survey (MBI-GS; Schaufeli, Leiter, Maslach, & Jackson, 1996). This scale consists of five items, including ‘‘I feel emotionally drained from my work.’’ Each item was followed by a seven-point Likert Scale, ranging from 0 (never) to 6 (every day). The Dutch version, the Utrecht Burnout Scale-A (UBOS-A), was developed and validated by Schaufeli and Van Dierendonck (2000). They found internal consistency reliabilities between .84 and .90 among eight samples representing different occupations, and high correlations with indicators of fatigue and psychological complaints. In the current sample, Cronbach’s alpha was .92. Self-reported depressive symptomatology was assessed using the 16-item subscale ‘Depression’ of the Symptom CheckList-90 (SCL90, Derogatis & Cleary, 1977). Cronbach’s alpha was .91. Self-reported anxiety was assessed by the 10-item subscale ‘Anxiety’ of the SCL-90. Cronbach’s alpha was .88. The SCL-90 items ask respondents to indicate the amount to which they were bothered by symptoms of depression, anxiety, etc. during the previous week on a five-point Likert scale, ranging from 1 (not at all) to 5 (very much). The SCL-90 depression and anxiety subscales (both the English and the Dutch versions) showed good convergent and divergent validity, and high internal consistencies (Arrindell & Ettema, 2003; Derogatis & Cleary, 1977; Koeter, 1992; Morgan, Wiederman, & Magnus, 1998). High standards was measured with the seven-items subscale from the Almost Perfect Scale Revised (APS-R; Slaney et al., 2001). A sample item is: ‘‘I have high expectations of myself.’’ Cronbach’s alpha was .82. Perceived Discrepancy was measured with the 12-items subscale from the APS-R, for example, ‘‘I hardly ever feel that what I’ve done is good enough.’’ Cronbach’s alpha was .94. Self-oriented Perfectionism was assessed by the 15-items subscale from the Multidimensional Perfectionism Scale (MPS; Hewitt & Flett, 1991). A sample item is: ‘‘I strive to be as perfect as I can be.’’ Cronbach’s alpha was .74. Socially Prescribed Perfectionism was assessed by the 15-items subscale from MPS, and comprises items such as ‘‘People expect nothing less than perfection from me’’. Cronbach’s alpha was .70. For all APS-R scales and MPS scales, participants responded on a 7-point Likert-scale from 1 (strongly disagree) to 7 (strongly agree). All subscales (both the English and the Dutch versions) showed good convergent and divergent validity, and high internal consistencies (e.g., Hewitt & Flett, 1991; Slaney et al., 2002; Van Yperen & Hagedoorn, 2008). Occupational context. Because work-related psychological problems usually result from both the characteristics of the employee and the nature of the work situation, we assessed three key work characteristics (Karasek & Theorell, 1990) in order to statistically control for the potential impact of occupational context. The measures of Job Demands (11 items) and Lack of Job Control (11 items) were developed and validated by Van Veldhoven and Meijman (1994). Cronbach’s alpha was .74 for Job Demands, and .86 for Lack of Job Control. The Job Social Support measure (four items) was adopted from Van Yperen and Hagedoorn (2003). Cronbach’s alpha was .87. All items were followed by a four-point scale, ranging from 0 (never) to 3 (always).
3. Results We conducted a multivariate analysis of covariance (MANCOVA) with emotional exhaustion, SCL depression, SCL anxiety, high standards, perceived discrepancy, self-oriented perfectionism, and socially prescribed perfectionism as the dependent variables. The covariates were age, educational level, job demands, lack of job control, and job social support. At the multivariate level, the differ-
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ences between the five groups were significant, F(28,1048) = 5.92, p < .001, Np = .14). Sex differences were examined in preliminary analyses, but no significant results were obtained (ps > .22). Hence, sex was omitted from further consideration. Our primary objective was to demonstrate that various classifications of clinical disorder were associated with varying profiles of perfectionistic characteristics. Therefore, it is important to validate clinician’s consensus diagnoses first, that is, to examine for differences between the five diagnostic groups in emotional exhaustion, depression, and anxiety. In line with the diagnoses, the findings at the univariate level and the results of the follow-up analyses (LSD contrasts), presented in Table 2, show that both burned-out individuals and individuals with comorbid disorders scored higher on emotional exhaustion relative to the other three groups. Furthermore, both the depressed individuals and the individuals with comorbid disorders scored higher on the depression scale than the other three groups. With regard to the anxiety scale, the picture was somewhat less straightforward. As expected, the anxiety-disordered individuals were higher in anxiety than the burned-out individuals and the individuals in the control group, but they were not higher relative to the depressed individuals. Individuals with comorbid disorders reported the highest levels of anxiety. All together, these findings indicate high validity of clinicians’ diagnoses.
and depressed individuals were higher in socially prescribed perfectionism. Secondly, relative to the other four groups, individuals with comorbid disorders more strongly perceived a discrepancy between their own high standards and their performances. In addition, they more strongly felt that they had to live up to the high standards presumably imposed by others. Their probably too critical attitudes towards their own achievements may have made them vulnerable to experiences of failure and the development of depressive symptomatology. Similarly, the perception that one must meet others’ high expectations tends to be perceived as being excessive and uncontrollable, eliciting anxiety, strain, and fatigue (cf., Blatt, 1995; Crocker & Wolfe, 2001). This may have caused these individuals to feel depressed and lacking in energy to work harder, which, in turn, increased their feeling of falling short of the imposed or personally adopted standards, elevating anxiety and fatigue to even higher levels, etc. In contrast, no differences between the groups of employees were observed with regard to the tendency to set high personal standards, or self-oriented perfectionism. This supports previous findings indicating that setting high personal standards of performance per se may not be considered as a maladaptive aspect of perfectionism (e.g., Enns & Cox, 2002; Flett & Hewitt, 2002; Slaney et al., 2002; Stoeber & Otto, 2006). 4.1. Strengths and limitations
3.1. Hypotheses testing The univariate results and the follow-up analyses (LSD contrasts) indicated that Hypothesis 1 was partially supported (see Table 2). That is, relative to the individuals in the control group, burned-out individuals and depressed individuals, but not anxiety-disordered individuals, were higher in socially prescribed perfectionism. Furthermore, relative to the other four groups, individuals with comorbid disorders were higher in perceived discrepancy (see Table 2), so that support was obtained for Hypothesis 2. Individuals with comorbid disorders were also higher in socially prescribed perfectionism, but only relative to the anxiety-disordered individuals and the individuals in the control group. The differences with the burned-out individuals and the depressed individuals were in the expected direction, but lacked significance. Table 2 also shows that – as expected – no differences between the groups were observed with regard to high standards and selforiented perfectionism. 4. Discussion The present study extends previous research by showing differences in maladaptive characteristics of perfectionism between groups of employees with distinct clinical profiles. First, relative to the individuals in the control group, burned-out individuals
A strength of our research is the nature and the size of the sample, and the distinctive clinical profiles of the five groups. Apparently, clinicians can reliably differentiate burned-out individuals from depressed individuals (cf., Brenninkmeijer, Van Yperen, & Buunk, 2001). Burned-out individuals are particularly high in emotional exhaustion, whereas depressed individuals are high in depressive symptomatology. Similarly, anxiety-disordered individuals were higher in anxiety than burned-out individuals and individuals in the control group. However, anxiety-disordered individuals and depressed individuals were equally high in anxiety, which is in line with the extant literature showing that depressed individuals are typically high in anxiety as well (e.g., Brown, Campbell, Lehman, Grisham, & Mancill, 2001). Furthermore, individuals with comorbid disorders were highest in emotional exhaustion, depression, and anxiety. In contrast, the lowest scores on these symptoms were observed among the individuals in the clinical control group. A limitation of this initial exploration of the relationships between clinical disorders and perfectionism, is the absence of ethnic and nationality diversity within the sample (98.1% Dutch Caucasian). Also, highly educated people were overrepresented. Although we statistically controlled for demographic variables (e.g., age and educational level), and found no sex differences, generalization to another context is possible only with great caution. Furthermore, we cannot make causal inferences on the basis of
Table 2 Differences between diagnostic groups (n = 275)1.
Emotional exhaustion SCL-depression SCL-anxiety High standards Perceived discrepancy Self-oriented perfectionism Socially prescribed perfectionism 1
Clinical burnout (n = 77)
Depression (n = 29)
Anxiety (n = 31)
Comorbidity (n = 28)
Control (n = 110)
M
SD
M
SD
M
SD
M
SD
M
SD
21.51a 36.38a 19.39a 35.85 42.91a 65.75 58.41ab
5.92 9.54 6.22 7.28 13.91 14.40 9.23
15.24b 48.93b 24.48bc 35.94 43.38a 66.83 58.21ab
8.00 10.89 8.40 7.49 15.55 14.10 12.09
12.87b 35.58a 22.55b 33.77 42.77a 64.40 56.44ac
8.53 12.39 8.02 7.94 17.25 14.54 8.80
23.32a 47.61b 26.50c 37.71 51.68b 68.36 61.70b
5.52 12.22 8.23 5.80 13.42 12.32 12.13
13.66b 34.82a 18.72a 35.58 40.11a 65.00 53.78c
7.60 12.10 7.60 6.67 14.77 14.68 10.91
Within each row, initial sample means that do not share a common subscript differ at p < .05 minimally. p < .05 ⁄⁄p < .01 ⁄⁄⁄ p < .001.
2⁄
F(4265)2
Np
20.45⁄⁄⁄ 13.71⁄⁄⁄ 8.95⁄⁄⁄ 1.83 4.19⁄⁄ .69 2.66⁄
.24 .17 .12 .03 .06 .01 .04
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the present data. That is, perfectionism may lead to distress and clinical disorders, but clinical disorders may elicit or strengthen maladaptive forms of perfectionism. Indeed, rather than a unidirectional link, a reciprocal link between perfectionism and clinical disorders is most likely. Furthermore, work-related clinical disorders may be associated with other dispositional variables than maladaptive forms of perfectionism, such as neuroticism (Roelofs, Huibers, Peeters, & Arntz, 2008) and self-efficacy (Murris, 2002). In this regard, it is important to note that exclusive use of dispositional arguments in order to gain an understanding of and explain the development of work-related psychological problems is undesirable: these may raise difficult ethical and political questions since these arguments imply that employers should select employees with the ‘‘appropriate’’ dispositions (cf., Newton & Keenan, 1991). Work-related psychological problems usually result from both the characteristics of the employee and the nature of the work situation. When examining the role of personality factors, it is therefore important to statistically control for the potential impact of the occupational context. 4.2. Practical implications Socially prescribed perfectionism may interfere with people’s basic need for autonomy, which refers to the need to be the perceived origin or source of one’s own behavior (Ryan & Deci, 2002). Moreover, the perception that one consistently fails to meet one’s own standards may decrease one’s sense of self-efficacy (Van Yperen & Hagedoorn, 2008). These two maladaptive aspects of perfectionism tend to raise a want to a necessity which is irrational and self-defeating (Ellis, 2002). To relieve the psychological distress that accompanies maladaptive perfectionism, cognitive interventions and stress management training courses should address the following questions: (1) Can the self-critical perceptions of the discrepancy between personal standards of performance and criteria of success in meeting those standards be changed? Related to this, are people able to discriminate between standards and discrepancy? (2) Is there a fit between personally adopted high standards and the standards perceived to be imposed by others? If the supposedly imposed standards are clearly higher, why is that? And why is it important for individuals to meet these imposed high standards? (3) Is the wish to achieve the high standards a desire (‘‘preference’’) or is it perceived as an absolute need (‘‘demand’’)? The present findings suggest that in treatment, these so-called self-critical evaluative concerns of perfectionism as perceiving greater discrepancies between standards and performance, and the perception that others are imposing unrealistic high demands on the self, warrant the clinician’s attention more than does simply addressing the level, quantity, and quality of individuals high standards. References Arrindell, W. A., & Ettema, J. H. M. (2003). SCL-90. Handleiding bij een multidimensionele psychopathologie-indicator. [SCL-90. Manual of a multidimensional psychopathology indicator.] Lisse: Swets & Zeitlinger. Bieling, P. J., Israeli, A. L., & Antony, M. A. (2004a). Is perfectionism good, bad, or both? Examining models of the perfectionism construct. Personality and Individual Differences, 36, 1373–1385. Bieling, P. J., Summerfeldt, L. J., Israeli, A. L., & Antony, M. M. (2004b). Perfectionism as an explanatory construct in comorbidity of Axis I disorders. Journal of Psychopathology and Behavioral Assessment, 26, 193–201. Blatt, S. J. (1995). The destructiveness of perfectionism: Implications for the treatment of depression. American Psychologist, 50, 1003–1020. Brenninkmeijer, V., Van Yperen, N. W., & Buunk, A. P. (2001). Burnout and depression are not identical twins: Is decline of superiority a distinguishing feature? Personality and Individual Differences, 30, 873–880.
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Personality and Individual Differences, 47, 423–428. Stoeber, J., & Otto, K. (2006). Positive conceptions of perfectionism: Approaches, evidence, challenges. Personality and Social Psychology Review, 10, 295–319. Van Yperen, N. W., & Hagedoorn, M. (2003). Do high job demands increase intrinsic motivation or job strain or both? The role of job control and social support. Academy of Management Journal, 46, 339–348. Van Yperen, N. W., & Hagedoorn, M. (2008). Living up to high standards and psychological distress. European Journal of Personality, 22, 337–346. Veldhoven, M., & Meijman, T. (1994). Het meten van psychosociale arbeidsbelasting met een vragenlijst: De vragenlijst Beleving en Beoordeling van de Arbeid (VBBA) [Measuring psychosocial workload with a questionnaire: The questionnaire on Experiences and Assessment of Work]. Amsterdam: NIA. Verbraak, M. J. P. M., Keijsers, G. P. J., Kleyweg, J., & Hoogduin, C.A.L. (submitted for publication). On the clinical diagnosis of burnout.
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Perfectionism and clinical disorders among employees Nico W. Van Yperen a,⇑, Marc Verbraak b, Ellen Spoor c a
University of Groningen, The Netherlands Behavioral Science Institute, Radboud University Nijmegen, The Netherlands, and HSK Group, Arnhem, The Netherlands c Eindhoven University of Technology, The Netherlands b
a r t i c l e
i n f o
Article history: Received 5 November 2010 Received in revised form 12 January 2011 Accepted 29 January 2011 Available online 19 February 2011 Keywords: Perfectionism Achievement Burnout Depression Anxiety Comorbidity
a b s t r a c t We examined differences in perfectionism between burned-out employees (n = 77), depressed employees (n = 29), anxiety-disordered employees (n = 31), employees with comorbid disorders, that is, a combination of clinical burnout, depression, or anxiety disorder (n = 28), and individuals without clinical burnout, depression disorder, or anxiety disorder (clinical control group; n = 110). The results suggest that setting high personal standards per se is not associated with clinical disorders. In contrast, maladaptive aspects of perfectionism, including perceived discrepancy between standards and performance and socially prescribed perfectionism, were related to clinical disorders, and in particular to comorbidity. Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction Although no definition of perfectionism has been formally agreed upon, the centrality of high personal standards is evident (Flett & Hewitt, 2002; Slaney, Rice, & Ashby, 2002). Several researchers have demonstrated that setting high personal standards (Slaney et al., 2002) or self-oriented perfectionism (Flett & Hewitt, 2002), was positively associated with positively valenced variables such as self-esteem, problem-focused coping, career satisfaction, and physical health (e.g., Bieling, Israeli, & Antony, 2004; Enns & Cox, 2002; Slaney et al., 2002; Stoeber, Feast, & Hayward, 2009). Similarly, in goal-setting research, high standards of performance have typically been found to be associated with focused attention, effort, and persistence, all of which are likely to enhance work motivation and job performance (Locke & Latham, 1990). Therefore, we argue and will demonstrate that, relative to their occurrence in a clinical control group, only maladaptive characteristics of perfectionism are prevalent among employees diagnosed with clinical disorders, and in particular among individuals with comorbid disorders. Specifically, not high standards per se, but individuals’ perceptions that they consistently fail to meet their personal standards, ⇑ Corresponding author. Address: University of Groningen, Department of Psychology, Grote Kruisstraat 2/I, 9712 TS Groningen, The Netherlands. Tel.: +31 50 363 63 32; fax: +31 50 363 45 81. E-mail address: [email protected] (N.W. Van Yperen). 0191-8869/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2011.01.040
henceforth referred to as perceived discrepancy (Slaney et al., 2002), may elevate levels of distress, and lead to the development of clinical disorders. Several studies consistently report that perceived discrepancy is associated with negative adjustment indicators such as lack of self-esteem, worry, and psychological distress (e.g., Slaney, Rice, Mobley, Trippi, & Ashby, 2001; Van Yperen & Hagedoorn, 2008). A perceived discrepancy between standards and criteria of success in meeting those standards is distressing because it interferes with people’s basic need for competence and the need to actually succeed in getting what they want (Ellis, 2002; Ryan & Deci, 2002). Similarly, the perception that others are imposing high standards on the self (i.e., socially prescribed perfectionism) has typically been found to be associated with a variety of negative outcomes, including depressive symptomatology, fear of negative evaluation, and negative affect (e.g., Flett & Hewitt, 2002; Stoeber et al., 2009). In contrast to personally adopted high standards, socially imposed high standards create concerns about others’ criticism and expectations (Clara, Cox, & Enns, 2007; O’Connor, O’Connor, & Marshall, 2007). Focusing on others’ high standards tends to raise a want to a necessity which is irrational and self-defeating, and accordingly, may decrease one’s sense of self-efficacy and self-esteem, increase psychological distress, and, ultimately, leads to clinical disorders (cf., Ellis, 2002). The assumed links between clinical disorders, including comorbidity, on the one hand, and maladaptive characteristics of perfectionism, on the other, are discussed below.
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dards are typically perceived as uncontrollable (Blatt, 1995; O’Connor et al., 2007).
1.1. Burnout From the beginning, burnout (for the five common elements of burnout, see Table 1) was associated with perfectionism (Freudenberger, 1974). However, to our knowledge, there are no studies among employees that link dimensions of perfectionism to clinical burnout. Maladaptive aspects of perfectionism, including the perception of consistently failing to meet one’s own standards and a chronic concern about others’ criticism and expectations, may however lead to the development of severe burnout symptoms (Clara et al., 2007; Stoeber & Otto, 2006). Employees with a clinical burnout meet the criteria of the ICD-10 (i.e., the 10th revision of the International Statistical Classification of Diseases and Related Health Problems) equivalent of job- or work-related neurasthenia (Schaufeli, Bakker, Schaap, Kladler, & Hoogduin, 2001). That is, for the diagnosis clinical burnout, the listed symptoms (see Table 1) have to be present each day for at least 6 months. Table 1 also shows that the elements of burnout are very similar to the criteria for neurasthenia in ICD-10 and those for an undifferentiated somatoform disorder. In the DSM-IV (i.e., Diagnostic and Statistical Manual of Mental Disorders, 4th edition), undifferentiated somatoform disorder includes neurasthenia, which was abandoned as a separate category (Hickie, Hadzi-Pavlovic, & Ricci, 1997). 1.2. Depression According to the criteria of the DSM-IV, the symptoms of a major depressive episode include persistent sad mood, feelings of hopelessness or worthlessness, loss of interest in activities that were once enjoyed, and thoughts of death or suicide. Individuals may be more likely to develop depressive symptomatology, and in the long term, clinical depression when they are high in perceived discrepancy (e.g., Bieling, Israeli, & Antony, 2004; Clara et al., 2007). Such individuals are too critical of their own achievements, making them vulnerable to experiences of failure and the development of depressive symptomatology. Also, individuals who consistently feel that others are imposing high standards on them develop these symptoms because externally imposed stan-
1.3. Anxiety Several researchers have reported a robust link between perceived discrepancy and anxiety, suggesting that people’s perceptions that they consistently fail to meet their personal standards lead to the development of an anxiety disorder (Slaney et al., 2001). Similarly, the perception that one must meet others’ high expectations may be perceived as being excessive and uncontrollable, and ultimately, lead to the development of an anxiety disorder. For example, Hewitt and Flett (1991) found higher levels of socially prescribed perfectionism in a group of patients with anxiety disorders than in healthy respondents. Hence, Hypothesis 1 was that, relative to the individuals in the control group, burned-out individuals, depressed individuals, and anxiety-disordered individuals would be higher in perceived discrepancy and socially prescribed perfectionism. Comorbidity may be associated with even higher levels of perceived discrepancy and socially prescribed perfectionism; this is discussed in the following paragraph. 1.4. Comorbidity In the present research, comorbidity refers to the co-occurrence of clinical burnout, depression, or anxiety disorders within the same individual. Assuming that socially prescribed perfectionism and perceived discrepancy are related to one of these mental disorders (see Hypothesis 1), the most severe and maladaptive forms of perfectionism may be associated with comorbidity (cf., Bieling, Summerfeldt, Israeli, & Antony, 2004). For example, individuals who score high on socially prescribed perfectionism and perceived discrepancy feel chronically anxious because they feel that they typically do not meet others’ high standards and their own high standards, respectively. This may make them feel depressed and less energetic, making it difficult for them to work harder. In turn, this increases their feeling of falling short of the socially imposed or personally adopted standards, which is likely to elevate anxiety
Table 1 Comparison of the five common burnout elements as identified by Maslach and Schaufeli (1993), the criteria for neurasthenia (ICD-10), and the criteria for an undifferentiated somatoform disorder (DSM-IV). Common elements of burnout as identified by Maslach and Schaufeli (1993)
Job or work-related neurasthenia (ICD-10)
Undifferentiated somatoform disorder (DSM-IV)
1.
A predominance of fatigue symptoms such as mental or emotional exhaustion, tiredness, and depression
The feeling of either mental or physical fatigue or weakness and exhaustion after minimal effort
The presence of one or more physical complaints persisting for 6 months or longer. The most frequent complaints are chronic fatigue, loss of appetite, or gastrointestinal or genito-urinary symptoms
2.
Various atypical physical symptoms of distress may occur
3.
These symptoms are work-related
4.
The symptoms manifest themselves in ‘normal’ persons who did not suffer from psychopathology before Decreased effectiveness and impaired work performance occurs because of negative attitudes and behaviors
At least two out of seven symptoms should be present: i.e., muscular aches and pain, dizziness, tension headaches, sleep disturbance, inability to relax, irritability, and dyspepsia The life-management difficulty criterion put forward in ICD-10’s definition of burnout corresponds to workrelatedness These symptoms should not better be accounted for by the presence of a depression or anxiety disorder, or any other of the more specific disorders in the ICD-10 classification In the clarification of neurasthenia the association of the disorder with impaired occupational performance or reduced coping efficiency in daily tasks is made explicitly
5.
The complaints are not better accounted for by another mental disorder, or are not intentionally produced or feigned The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning The complaints cannot be fully explained by a known general medical condition or by the direct effects of a substance. When there is a related general medical condition the physical complaints or resultant impairment are grossly in excess of what could be expected from the history, physical examination, or laboratory findings
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and fatigue to even higher levels. Hence, these individuals develop subsequently, or simultaneously, a burnout syndrome, depression, or an anxiety disorder. Therefore, Hypothesis 2 stated that, relative to burned-out individuals, depressed individuals, anxiety-disordered individuals, and individuals in the control group, individuals with comorbid disorders would be higher in perceived discrepancy and socially prescribed perfectionism. In sum, we expected that only maladaptive characteristics of perfectionism are prevalent among employees diagnosed with clinical disorders, and in particular among individuals with comorbid disorders. No differences between the groups were anticipated with regard to high standards and self-oriented perfectionism. 2. Method 2.1. Participants Complete datasets were available from 275 participants (56.4% men, 98.1% Caucasian) who represented a broad range of industries. They were consecutive clients of a Dutch mental health care institute specialized in diagnosing and treating people with workrelated psychological problems. The participants were referred by their occupational physician, which is common practice in the Netherlands. The average age was 42 years (SD = 9.1), ranging from 22 to 59. Relative to the general Dutch population, the level of education was quite high: 43.3% had a BSc degree or higher, 47.0% had completed high school or had had technical or vocational training at an intermediate level, and the remaining 9.7% had had technical or vocational training at the lowest level. 2.2. Procedure As part of the standardized intake procedure at the institute, all participants were routinely subjected to a standardized clinical semi-structured interview (the Mini-International Neuropsychiatric Interview, or MINI) in order to arrive at one or more DSM-IV classifications describing their complaints (Sheehan et al., 1998). The interviews were conducted by, approximately, 30 different, welltrained and licensed psychologists. The interviews were rated in pairs, one was the assessor at the first (intake) assessment, the other the psychologist at the second (intake feedback and treatment allocation) assessment. Classification was reached by means of consensus. The overall percentage of agreement before consensus was high (i.e., between 79% and 98%; Verbraak et al., submitted). After the intake, clients diagnosed as burned-out (n = 77), depressed (n = 29), anxiety-disordered (n = 31), or with comorbidity of two or more of the aforementioned disorders (n = 28), were asked to participate in the research project on ‘work-related psychological problems’. Furthermore, clients with minor workrelated complaints without mention of clinical burnout, depression, or anxiety disorders anywhere in their clinical profile (mostly adaptation disorders, V-codes, disorders of impulse control) were asked to participate (clinical control group; n = 110). All the participants were told that participation was completely voluntary and that the data would be treated confidentially and anonymously. Almost all eligible clients (91%) were willing to participate. Before the second visit to the institute, the participants had completed and returned (to the secretary’s office) the completed questionnaire, including a signed informed consent. 2.3. Measures Emotional exhaustion. This core symptom of burnout (Maslach & Schaufeli, 1993) was measured using the corresponding scale of
the widely used and validated Maslach Burnout Inventory-General Survey (MBI-GS; Schaufeli, Leiter, Maslach, & Jackson, 1996). This scale consists of five items, including ‘‘I feel emotionally drained from my work.’’ Each item was followed by a seven-point Likert Scale, ranging from 0 (never) to 6 (every day). The Dutch version, the Utrecht Burnout Scale-A (UBOS-A), was developed and validated by Schaufeli and Van Dierendonck (2000). They found internal consistency reliabilities between .84 and .90 among eight samples representing different occupations, and high correlations with indicators of fatigue and psychological complaints. In the current sample, Cronbach’s alpha was .92. Self-reported depressive symptomatology was assessed using the 16-item subscale ‘Depression’ of the Symptom CheckList-90 (SCL90, Derogatis & Cleary, 1977). Cronbach’s alpha was .91. Self-reported anxiety was assessed by the 10-item subscale ‘Anxiety’ of the SCL-90. Cronbach’s alpha was .88. The SCL-90 items ask respondents to indicate the amount to which they were bothered by symptoms of depression, anxiety, etc. during the previous week on a five-point Likert scale, ranging from 1 (not at all) to 5 (very much). The SCL-90 depression and anxiety subscales (both the English and the Dutch versions) showed good convergent and divergent validity, and high internal consistencies (Arrindell & Ettema, 2003; Derogatis & Cleary, 1977; Koeter, 1992; Morgan, Wiederman, & Magnus, 1998). High standards was measured with the seven-items subscale from the Almost Perfect Scale Revised (APS-R; Slaney et al., 2001). A sample item is: ‘‘I have high expectations of myself.’’ Cronbach’s alpha was .82. Perceived Discrepancy was measured with the 12-items subscale from the APS-R, for example, ‘‘I hardly ever feel that what I’ve done is good enough.’’ Cronbach’s alpha was .94. Self-oriented Perfectionism was assessed by the 15-items subscale from the Multidimensional Perfectionism Scale (MPS; Hewitt & Flett, 1991). A sample item is: ‘‘I strive to be as perfect as I can be.’’ Cronbach’s alpha was .74. Socially Prescribed Perfectionism was assessed by the 15-items subscale from MPS, and comprises items such as ‘‘People expect nothing less than perfection from me’’. Cronbach’s alpha was .70. For all APS-R scales and MPS scales, participants responded on a 7-point Likert-scale from 1 (strongly disagree) to 7 (strongly agree). All subscales (both the English and the Dutch versions) showed good convergent and divergent validity, and high internal consistencies (e.g., Hewitt & Flett, 1991; Slaney et al., 2002; Van Yperen & Hagedoorn, 2008). Occupational context. Because work-related psychological problems usually result from both the characteristics of the employee and the nature of the work situation, we assessed three key work characteristics (Karasek & Theorell, 1990) in order to statistically control for the potential impact of occupational context. The measures of Job Demands (11 items) and Lack of Job Control (11 items) were developed and validated by Van Veldhoven and Meijman (1994). Cronbach’s alpha was .74 for Job Demands, and .86 for Lack of Job Control. The Job Social Support measure (four items) was adopted from Van Yperen and Hagedoorn (2003). Cronbach’s alpha was .87. All items were followed by a four-point scale, ranging from 0 (never) to 3 (always).
3. Results We conducted a multivariate analysis of covariance (MANCOVA) with emotional exhaustion, SCL depression, SCL anxiety, high standards, perceived discrepancy, self-oriented perfectionism, and socially prescribed perfectionism as the dependent variables. The covariates were age, educational level, job demands, lack of job control, and job social support. At the multivariate level, the differ-
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ences between the five groups were significant, F(28,1048) = 5.92, p < .001, Np = .14). Sex differences were examined in preliminary analyses, but no significant results were obtained (ps > .22). Hence, sex was omitted from further consideration. Our primary objective was to demonstrate that various classifications of clinical disorder were associated with varying profiles of perfectionistic characteristics. Therefore, it is important to validate clinician’s consensus diagnoses first, that is, to examine for differences between the five diagnostic groups in emotional exhaustion, depression, and anxiety. In line with the diagnoses, the findings at the univariate level and the results of the follow-up analyses (LSD contrasts), presented in Table 2, show that both burned-out individuals and individuals with comorbid disorders scored higher on emotional exhaustion relative to the other three groups. Furthermore, both the depressed individuals and the individuals with comorbid disorders scored higher on the depression scale than the other three groups. With regard to the anxiety scale, the picture was somewhat less straightforward. As expected, the anxiety-disordered individuals were higher in anxiety than the burned-out individuals and the individuals in the control group, but they were not higher relative to the depressed individuals. Individuals with comorbid disorders reported the highest levels of anxiety. All together, these findings indicate high validity of clinicians’ diagnoses.
and depressed individuals were higher in socially prescribed perfectionism. Secondly, relative to the other four groups, individuals with comorbid disorders more strongly perceived a discrepancy between their own high standards and their performances. In addition, they more strongly felt that they had to live up to the high standards presumably imposed by others. Their probably too critical attitudes towards their own achievements may have made them vulnerable to experiences of failure and the development of depressive symptomatology. Similarly, the perception that one must meet others’ high expectations tends to be perceived as being excessive and uncontrollable, eliciting anxiety, strain, and fatigue (cf., Blatt, 1995; Crocker & Wolfe, 2001). This may have caused these individuals to feel depressed and lacking in energy to work harder, which, in turn, increased their feeling of falling short of the imposed or personally adopted standards, elevating anxiety and fatigue to even higher levels, etc. In contrast, no differences between the groups of employees were observed with regard to the tendency to set high personal standards, or self-oriented perfectionism. This supports previous findings indicating that setting high personal standards of performance per se may not be considered as a maladaptive aspect of perfectionism (e.g., Enns & Cox, 2002; Flett & Hewitt, 2002; Slaney et al., 2002; Stoeber & Otto, 2006). 4.1. Strengths and limitations
3.1. Hypotheses testing The univariate results and the follow-up analyses (LSD contrasts) indicated that Hypothesis 1 was partially supported (see Table 2). That is, relative to the individuals in the control group, burned-out individuals and depressed individuals, but not anxiety-disordered individuals, were higher in socially prescribed perfectionism. Furthermore, relative to the other four groups, individuals with comorbid disorders were higher in perceived discrepancy (see Table 2), so that support was obtained for Hypothesis 2. Individuals with comorbid disorders were also higher in socially prescribed perfectionism, but only relative to the anxiety-disordered individuals and the individuals in the control group. The differences with the burned-out individuals and the depressed individuals were in the expected direction, but lacked significance. Table 2 also shows that – as expected – no differences between the groups were observed with regard to high standards and selforiented perfectionism. 4. Discussion The present study extends previous research by showing differences in maladaptive characteristics of perfectionism between groups of employees with distinct clinical profiles. First, relative to the individuals in the control group, burned-out individuals
A strength of our research is the nature and the size of the sample, and the distinctive clinical profiles of the five groups. Apparently, clinicians can reliably differentiate burned-out individuals from depressed individuals (cf., Brenninkmeijer, Van Yperen, & Buunk, 2001). Burned-out individuals are particularly high in emotional exhaustion, whereas depressed individuals are high in depressive symptomatology. Similarly, anxiety-disordered individuals were higher in anxiety than burned-out individuals and individuals in the control group. However, anxiety-disordered individuals and depressed individuals were equally high in anxiety, which is in line with the extant literature showing that depressed individuals are typically high in anxiety as well (e.g., Brown, Campbell, Lehman, Grisham, & Mancill, 2001). Furthermore, individuals with comorbid disorders were highest in emotional exhaustion, depression, and anxiety. In contrast, the lowest scores on these symptoms were observed among the individuals in the clinical control group. A limitation of this initial exploration of the relationships between clinical disorders and perfectionism, is the absence of ethnic and nationality diversity within the sample (98.1% Dutch Caucasian). Also, highly educated people were overrepresented. Although we statistically controlled for demographic variables (e.g., age and educational level), and found no sex differences, generalization to another context is possible only with great caution. Furthermore, we cannot make causal inferences on the basis of
Table 2 Differences between diagnostic groups (n = 275)1.
Emotional exhaustion SCL-depression SCL-anxiety High standards Perceived discrepancy Self-oriented perfectionism Socially prescribed perfectionism 1
Clinical burnout (n = 77)
Depression (n = 29)
Anxiety (n = 31)
Comorbidity (n = 28)
Control (n = 110)
M
SD
M
SD
M
SD
M
SD
M
SD
21.51a 36.38a 19.39a 35.85 42.91a 65.75 58.41ab
5.92 9.54 6.22 7.28 13.91 14.40 9.23
15.24b 48.93b 24.48bc 35.94 43.38a 66.83 58.21ab
8.00 10.89 8.40 7.49 15.55 14.10 12.09
12.87b 35.58a 22.55b 33.77 42.77a 64.40 56.44ac
8.53 12.39 8.02 7.94 17.25 14.54 8.80
23.32a 47.61b 26.50c 37.71 51.68b 68.36 61.70b
5.52 12.22 8.23 5.80 13.42 12.32 12.13
13.66b 34.82a 18.72a 35.58 40.11a 65.00 53.78c
7.60 12.10 7.60 6.67 14.77 14.68 10.91
Within each row, initial sample means that do not share a common subscript differ at p < .05 minimally. p < .05 ⁄⁄p < .01 ⁄⁄⁄ p < .001.
2⁄
F(4265)2
Np
20.45⁄⁄⁄ 13.71⁄⁄⁄ 8.95⁄⁄⁄ 1.83 4.19⁄⁄ .69 2.66⁄
.24 .17 .12 .03 .06 .01 .04
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the present data. That is, perfectionism may lead to distress and clinical disorders, but clinical disorders may elicit or strengthen maladaptive forms of perfectionism. Indeed, rather than a unidirectional link, a reciprocal link between perfectionism and clinical disorders is most likely. Furthermore, work-related clinical disorders may be associated with other dispositional variables than maladaptive forms of perfectionism, such as neuroticism (Roelofs, Huibers, Peeters, & Arntz, 2008) and self-efficacy (Murris, 2002). In this regard, it is important to note that exclusive use of dispositional arguments in order to gain an understanding of and explain the development of work-related psychological problems is undesirable: these may raise difficult ethical and political questions since these arguments imply that employers should select employees with the ‘‘appropriate’’ dispositions (cf., Newton & Keenan, 1991). Work-related psychological problems usually result from both the characteristics of the employee and the nature of the work situation. When examining the role of personality factors, it is therefore important to statistically control for the potential impact of the occupational context. 4.2. Practical implications Socially prescribed perfectionism may interfere with people’s basic need for autonomy, which refers to the need to be the perceived origin or source of one’s own behavior (Ryan & Deci, 2002). Moreover, the perception that one consistently fails to meet one’s own standards may decrease one’s sense of self-efficacy (Van Yperen & Hagedoorn, 2008). These two maladaptive aspects of perfectionism tend to raise a want to a necessity which is irrational and self-defeating (Ellis, 2002). To relieve the psychological distress that accompanies maladaptive perfectionism, cognitive interventions and stress management training courses should address the following questions: (1) Can the self-critical perceptions of the discrepancy between personal standards of performance and criteria of success in meeting those standards be changed? Related to this, are people able to discriminate between standards and discrepancy? (2) Is there a fit between personally adopted high standards and the standards perceived to be imposed by others? If the supposedly imposed standards are clearly higher, why is that? And why is it important for individuals to meet these imposed high standards? (3) Is the wish to achieve the high standards a desire (‘‘preference’’) or is it perceived as an absolute need (‘‘demand’’)? The present findings suggest that in treatment, these so-called self-critical evaluative concerns of perfectionism as perceiving greater discrepancies between standards and performance, and the perception that others are imposing unrealistic high demands on the self, warrant the clinician’s attention more than does simply addressing the level, quantity, and quality of individuals high standards. References Arrindell, W. A., & Ettema, J. H. M. (2003). SCL-90. Handleiding bij een multidimensionele psychopathologie-indicator. [SCL-90. Manual of a multidimensional psychopathology indicator.] Lisse: Swets & Zeitlinger. Bieling, P. J., Israeli, A. L., & Antony, M. A. (2004a). Is perfectionism good, bad, or both? Examining models of the perfectionism construct. Personality and Individual Differences, 36, 1373–1385. Bieling, P. J., Summerfeldt, L. J., Israeli, A. L., & Antony, M. M. (2004b). Perfectionism as an explanatory construct in comorbidity of Axis I disorders. Journal of Psychopathology and Behavioral Assessment, 26, 193–201. Blatt, S. J. (1995). The destructiveness of perfectionism: Implications for the treatment of depression. American Psychologist, 50, 1003–1020. Brenninkmeijer, V., Van Yperen, N. W., & Buunk, A. P. (2001). Burnout and depression are not identical twins: Is decline of superiority a distinguishing feature? Personality and Individual Differences, 30, 873–880.
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