ANXIETY & DEPRESSION DUE TO CLINICAL PERFECTIONISM

CLINICAL PERFECTIONISM:

Perfectionism says:

“I must achieve the highest standards in all that I do.”

Clinical Perfectionism says:

“I must achieve the highest standards in all that I do and if I don’t, then I am not good enough.”

Clinical perfectionists lose confidence in their ability to deliver worthwhile outcomes, whether in work, social situations, leisure pursuits, sport, study or appearance. It leads to self-criticism, lowered self-esteem and impaired performance.

Overcoming clinical perfectionism is not about lowering standards but changing core beliefs related to the consequences of not meeting high standards and strengthening impulse control.

CASE STUDY: Perfectionism in academic performance and employment.

This section is based on the theory of Cognitive Principle Therapy [CPT-developed by the author of this article.] However, the case study uses Cognitive Behaviour Therapy [CBT]

The author believes the combined use of CPT & CBT is the most effective and fastest way to overcome the anxiety-depression combination of clinical perfectionism.

There are many different types of behaviours resulting from perfectionism. In the following case study we look at perfectionism related to academic performance and work performance. We also, look at one particular personality type which can lead to anxiety and depression. The personality type, which is genetic at its base, but developed to a higher or lower level based on environmental factors.

The following chart shows 16 types of dysfunctional personality styles developed due to negative environmental factors.

The one we will choose in this case study into clinical perfectionism is:

Body Energy                                             - Overly Negative & low levels of energy.

Autonomic Nervous System  [ANS]     - Overly Responsible-Escape leading to Overly Avoidant-Avoid

Brain                                                          - Left brain-Overly logical.

Notes:

  1. Body energy can be at high levels or low levels. Lower levels lead more easily into giving up and avoidance.
  2. The ANS has a response to stress, then a back-up response under extreme stress. In the case study the client is overly responsible, but avoidant under excessive stress.
  3. The overly left brain client uses too much logic and has under developed their feelings, which can result in procrastination and avoidance from negative emotions.

The following chart provides more detail on the types of dysfunctional response.

In the case study the client follows the following pathway, using the above chart.

  1. ANXIETY PATHWAY: Initially feels “I can get away” “using FLIGHT-fix by escape”, “feeling anxious or panic” thinking “I must get away”. If they cannot get away then they may go into a FREEZE state and have a panic attack, which feels like you can’t breathe or will have that you are having a heart attack. The head thinks “I’m going to die”.

2. DEPRESSION PATHWAY: Initially feels “I can get away” “using FLIGHT-fix by avoidance”, “feeling confused ” thinking “I must do something else”. If they cannot do something else, then they may procrastinate for long periods then go into a FREEZE state and feel helpless, experiencing numbness in the body and shut down. The head stops thinking, they are depressed.

The following chart looks deeper into the drivers of perfectionism and provides us with the place to start to overcome clinical perfectionism.

During childhood or teenage years the person with high standards [clinical perfectionism], becomes overly responsible due to developing false negative core beliefs and looses impulse control which turns on anxiety and could lead to panic attacks. After failing to achieve perfectionism the nervous system eventually slow down with procrastination and  then shuts down with depression.

In CPT [incorporating Polyvagal Theory] the external or internal triggers will set off the ANS down one of 3 pathways which lead to a dysfunctional emotional response:

  1. Sympathetic nervous system-FIGHT: Typically over controlling with anger or range
  2. Sympathetic nervous system-FLIGHT: Typically overly responsible with anxiety
  3. Dorsal Vagal Response -FREEZE: Typically overly avoidance with procrastination or depression.

Note: Engagement response: This is an appropriate response.

In CPT [incorporating Polyvagal theory] we would use principles related to the Head brain, the Heart brain, the Gut Brain and the Spiritual Brain to overcome anxiety and depression. In CPT we would start with the Gut Brain because that is where the negative core beliefs are [senses in the body] and impulse control  [shut down of the nervous system in the body]. These are the two drivers of clinical perfectionism.

In this case study we will look at two other resources, namely:

  1. Jeffrey Young’s “Schema therapy”
  2. “Overcoming Perfectionism” 2nd Edition [2018] by Roz Shafran, Sarah Egan & Tracey Wade

Jeffrey Young’s “Schema therapy”

Young states that a schema is a structure, framework or outline. It is a pattern imposed on reality or experience to help individuals mediate their perception and guide their responses. Young states “Many schemas are formed early in life, continue to be elaborated and then imposed on later life experiences , even when they are no longer applicable.” Young identified 18 maladaptive schemas of which four are relevant to this case study:

  • Unrelenting standards/hypercriticalness: The underlying belief that one must meet very high internalized standards of behaviour and performance, usually to avoid criticism. Must involve significant impairment in pleasure, relaxation, health, self-esteem, sense of accomplishment or satisfying relationships.
  • Punitiveness: The belief that people [usually oneself] should be harshly punished for making mistakes. Usually includes difficulty in forgiving mistakes in oneself.
  • Approval seeking: Excessive emphasis on gaining approval at the expense of developing a true sense of self.
  • Insufficient self-control/self discipline: Pervasive difficulty or refusal to exercise sufficient self-control and frustration tolerance to achieve one’s goals. Over emphasis on avoidance at the expense of commitment and personal fulfillment.

“Overcoming Perfectionism” 2nd Edition [2018] by Roz Shafran, Sarah Egan & Tracey Wade

The book is based on Cognitive Behaviour Therapy techniques. It uses surveys, worksheets and education as a self-help guide.

  1. Self-Assessment
  • Box 5.1 [page 82] Example of concerns about lowering standards:

-If I lower my standards I will let myself completely slip and not perform at all.

-If I lower my standards, others will not praise me for doing well anymore.

-If I lower my standards I will be overwhelmed with anxiety.

-If I lower my standards I will not achieve.

-If I lower my standards I will be average.

 

  • Worksheet 5.1 [ page 93-94] Questions to draw a diagram of what is keeping your perfectionism going.

Q1. Is how you think about yourself, feel about yourself or judge yourself dependent on achievement or striving? Is it too dependent? Would you feel bad about yourself as a person if you did not achieve or strive to achieve high standards?

Q2. Do you have excessively high standards?

Q3. Do you have rules to help you achieve your high standards?

Q4. Does “all or nothing” thinking mean that you feel you often don’t meet your standards and that you perceive yourself as a failure as a result?

Q5. Do you react to the perceived failure with self-criticism?

Q6. Do you use “counterproductive” behaviour such as avoidance, procrastination or repeated checking? Is it self-criticism? Is it anxiety? Is it low mood or stress?

 

  • Worksheet 6.1 [ page 99-10] Consider the importance of changing perfectionism and your confidence that you can make changes:
  • What score would you give yourself out of 10. With 0 being not important to change your perfectionism and 10 very important to change.
  • What score would you give yourself out of 10. With 0 being no confidence in in changing your perfectionism and 10 being very confident of changing.
  • Worksheet 6.2 [ page 101] Consider the pros and cons changing perfectionism.
  • Worksheet 6.3 [ page 103 ] Consider the long term costs and benefits of perfectionism.
  • Worksheet 7.1.1 Which areas of perfectionism apply to me? Areas, Thoughts & Behaviours.

 

  • Worksheet 7.1.2 [page 121] Self-monitoring areas of perfectionism.
  • Over the next week identify examples of when your perfectionism is a problem.
  • Record the area of perfectionism and the particular situation.
  • Record your and rate your thoughts.
  • Record your behaviour.
  • Record your feelings.
  • What did you learn over the week?

 

  • Worksheet 7.1.3 [page 123] Examples of specific behaviour associated with perfectionism.
  • Avoidance
  • Procrastination

 

  • Worksheet 7.2 [page 123 onwards] Psychoeducation
  • Fact versus fiction.
  • Facts about perfectionism and performance
  • Facts about efficiency.
  • Facts about risk

 

  • Worksheet 7.3 [page 149 onwards] Surveys.
  • Constructing your own survey to test beliefs. Eg. Avoidance/procrastination
  • What beliefs can be tested by surveys? Eg. “I am a fraud and will be discovered”

 

  • Worksheet 7.4 [page 161 onwards] Behavioural experiments.
  • Testing that repeated checking helps memory and reduces anxiety.
  • Testing that procrastination helps reduce anxiety.

 

  • Worksheet 7.5 [page 179 onwards] All or nothing thinking.
  • Examples of all or nothing thinking in perfectionism
  • Using a continuum to challenge all or nothing thinking.

 

  • Worksheet 7.6 [page 211 onwards] Learning to notice the positive.
  • Noticing negative aspects of performance.
  • Noticing negative and broadening attention.
  • Diary of positive comments and lack of negative comments.

 

  • Worksheet 7.7 [page 225 onwards] Changing thinking styles.
  • The impact of thinking on feelings and behaviour.
  • Common thinking styles in perfectionism. Eg. Over generalisations and “should” statements.
  • Examples of cognitive restructuring.

 

  • Worksheet 7.8 [page 245 onwards] Procrastination, problem-solving and pleasant events.
  • In which areas of my life do I procrastinate?
  • Worksheet-Self monitoring procrastination
  • How procrastination is maintained by increasing belief in perfectionist predictions.
  • Behavioural experiment to overcome procrastination.

 

  • Worksheet 8.1 [page 298 onwards] Am I Self-Critical?
  • I often find I don’t live up to my own standards or ideals.
  • I tend to devalue or undersell myself.
  • I have a difficult time accepting weaknesses in myself.
  • I tend to be very critical of myself.

 

  • Worksheet 8.1 [page 306] Diary to help identify the self-critical thoughts.

Covers: triggering events, Self-critical thoughts and associated feelings.

 

  • Worksheet 8.2 [page 307] What values are important to you in your friendships?

Covers: Acceptance, Caring, Hope, Justice, Service, Respect etc.

 

  • Worksheet 8.3 [page 308] Applying the same values to yourself that you apply to your friends.

Covers: Acceptance-To accept myself as being intrinsically worthwhile no matter what I achieve. Respect-To treat myself with respect and not run myself down. Forgiveness- To be forgiving of myself.

 

  • Worksheet 8.4 [page 310] Diary to help identify the compassionate thoughts.

Covers: Triggers, Self-critical thoughts, Associated feelings, What does the compassionate voice say?, What has happened to your first feelings when you think this?

The Book “Overcoming Perfectionism” is a self-help book.

The author states that if you are struggling to work through the exercises or are overwhelmed by them, then you should consult a psychologist or counsellor to help you work through the tasks.  If you score under “5” to question 6.1 (ii) then you may need assistance with overcoming perfectionism.

 

 

 

 

 

 

 

 

 

 

 

 

 

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