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Personality and perfectionism in chronic fatigue syndrome: A closer look
Vincent Dearya; Trudie Chalderb
a
Institute of Health and Society, Newcastle University, UK b Department of Psychological Medicine,
and Psychiatry, King's College, London, UK
First published on: 17 November 2008
To cite this Article Deary, Vincent and Chalder, Trudie(2010) 'Personality and perfectionism in chronic fatigue syndrome:
A closer look', Psychology & Health, 25: 4, 465 — 475, First published on: 17 November 2008 (iFirst)
To link to this Article: DOI: 10.1080/08870440802403863
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Psychology and Health
Vol. 25, No. 4, April 2010, 465–475
Personality and perfectionism in chronic fatigue syndrome: A closer look
Vincent Dearya* and Trudie Chalderb
a
Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK;
Department of Psychological Medicine, and Psychiatry, King’s College, London, UK
b
Downloaded By: [Chalder, Trudie][King's College London] At: 12:53 19 May 2011
(Received 29 November 2007; final version received 12 August 2008)
Objective: To test the hypothesis that people with chronic fatigue syndrome (CFS)
would differ significantly from a healthy control group on measures of general
personality and perfectionism, specifically on measures of neuroticism and
unhealthy perfectionism. Method: A total of 27 female CFS outpatients and 30
female healthy controls completed questionnaires, including the NEO Personality
Inventory-Revised, the Multi-dimensional Perfectionism Scale and measures of
anxiety and depression. Results: The CFS group was significantly more fatigued,
anxious and depressed than healthy controls. They scored significantly higher on
neuroticism and unhealthy perfectionism. Healthy and unhealthy perfectionism
were positively correlated in the CFS group, but not in the control group.
Conclusion: The present study confirms the link between neuroticism and fatigue
and finds a link between unhealthy perfectionism and fatigue. A ‘healthy trait’,
such as healthy perfectionism, when coupled with evaluative concerns is not
necessarily healthy in a fatigued population. Researchers and clinicians should
note the context in which apparently benign traits are expressed, and how they
interact with other traits.
Keywords: chronic fatigue syndrome; personality; perfectionism; neuroticism
Introduction
There is increasing evidence that chronic fatigue syndrome (CFS) is unlikely to be caused
or maintained by a single agent and is probably the result of an interplay of several factors.
This evidence is operationalised in the cognitive behavioural model of CFS which
distinguishes between predisposing, precipitating and maintaining factors (Deary,
Chalder, & Sharpe, 2007). Among factors that have been identified as potential
predisposing factors are a history of depression, somatisation and lack of social support
(Addington, Gallo, Ford, & Eaton, 2001; Chalder, 1998). Stressful life events and more
severe viral infections are common precipitants (Hatcher & House, 2003; Hotopf, Noah, &
Wessely, 1996; White et al., 2001). In terms of maintenance, alteration of the functioning
of the hypothalamus pituitary adrenal axis; avoidance of activity, driven by beliefs that
activity is harmful; physical illness attributions and symptom focussing are implicated
(Deale, Chalder, & Wessely, 1998; Gaab et al., 2005; Ray, Jefferies, & Weir, 1997).
*Corresponding author. Email: vincent.deary@ncl.ac.uk
ISSN 0887–0446 print/ISSN 1476–8321 online
ß 2010 Taylor & Francis
DOI: 10.1080/08870440802403863
http://www.informaworld.com
466
V. Deary and T. Chalder
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Neuroticism
Personality traits may be additional predisposing factors. Neuroticism has been widely
implicated in a variety of medically unexplained symptoms (MUS): high levels of neuroticism
have been associated with functional dysphonia and a history of MUS (Deary, Scott, &
Wilson, 1997), with irritable bowel syndrome (Hazlett-Stevens, Craske, Mayer, Chang, &
Naliboff, 2003) and with general MUS (Costa & McCrae, 1987; Kirmayer, Robbins & Paris,
1994). Watson and Pennebaker (1989) suggest that the trait of neuroticism can be seen as
predisposing to somatopsychic distress in general. Recent integrative overviews agree that a
general tendency to physical and emotional distress contributes to the likelihood of
experiencing a range of medically unexplained disorders (De Gucht, Fischler, & Heiser, 2004;
Henningsen, Zimmermann, & Sattel, 2003). CFS groups have higher neuroticism and lower
extraversion than controls in some studies (Blakely et al., 1991; Buckley et al., 1999; Taillefer,
Kirmayer, Robbins, & Lasry, 2003). Others have questioned whether this apparent between
group difference is an artefact of comorbid depression (Johnson, De Lucas, & Natelson,
1996). Most of these studies have been cross-sectional. Kato, Sullivan, Evengard, and
Pedersen (2006) conducted one of the few prospective population-based studies, and showed
that emotional instability (aka neuroticism) predicted chronic fatigue 25 years later. Most of
these studies of neuroticism and CFS have utilised overall neuroticism measures, whereas it is
known that neuroticism comprises a number of sub-factors (Costa & McCrae, 1992), only
some of which might relate to CFS.
Perfectionism
In addition to neuroticism, a recurring hypothesis is that perfectionism is a pre-disposing
factor to fatigue and CFS. Several mechanisms have been proposed to explain how they
might be associated. One of the prevailing stereotypes of CFS patients is that of the ‘burnt
out’ high achieving perfectionist. There is some evidence for this. Ware and Kleinman
(1992) report that CFS patients report themselves as having excessively high standards and
working hard to achieve them, whilst Van Houdenhove and Neerinckx (1999) propose that
overactivity predicts and perpetuates fatigue. Thus the striving for perfection may drive
physical overexertion which could, over time, have physical consequences. Another
potentially deleterious aspect of perfectionism is the associated thinking style, specifically
self-doubt, self-criticism and all or nothing thinking (Arpin-Cribbie & Cribbie, 2007).
These more obviously negative aspects of perfectionism are associated with anxiety,
depression and general distress, which are in themselves associated with fatigue, and may
also contribute to fatiguing patterns of behaviour such as overstriving to reach
unreachable standards (see Arpin-Cribbie & Cribbie, 2007, for a fuller discussion of
this). These different facets of perfectionism, and the ways in which they may relate to
fatigue, bring us to the issue of what perfectionism actually is, and what the ‘active
ingredient’ might be in distress and fatigue proneness.
The nature and effect of perfectionism has been the subject of some debate in recent
years. Shafran, Cooper, and Fairburn (2002) propose that the pathogenic core feature of
what they call clinical perfectionism is a uni-dimensional construct characterised by ‘the
overdependence of self-evaluation on the determined pursuit of personally demanding,
self-imposed standards in at least one highly salient domain, despite adverse consequences.’ (p. 778). Against this proposal Hewitt, Flett, Besser, Sherry, and McGee (2003)
have asserted the multi-dimensional nature of perfectionism which in their model
comprises high self-standards, critical self-evaluation, standards imposed on other people
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Psychology and Health
467
and standards perceived to be imposed by others. They place particular emphasis on these
latter interpersonal dimensions as being important in the production of distress. In a reply
to both these papers, Dunkley, Blankstein, Masheb, and Grilo (2006) in an analysis of
existing studies and through analysis of novel data, conclude that perfectionism comprises
two related but independent factors. These are ‘personal standards’, characterised by high
self-standards and achievement striving, and ‘evaluative concerns’ characterised by selfdoubt and self-criticism. They propose that the self-criticism of evaluative concerns
accounts for the relationship between perfectionism and distress. As they observe, there is
considerable empirical and theoretical precedent for this two-factor model, and it is closely
related to the concepts of healthy and unhealthy perfectionism, proposed by Stumpf and
Parker (2000), which we will discuss below.
Empirically, the association between perfectionism and fatigue has some support from
a study of fatigability in a non-CFS sample (Magnusson, Nias, & White, 1996). Attempts
to test it in relation to CFS have been less conclusive, with some studies showing no
association (Blenikorn, Edwards, & Lynch, 1999; Woods & Wessely, 1999), whilst White
and Schweitzer (2000) found that people with chronic fatigue were more likely to report
negative aspects of perfectionism, such as evaluative concerns. In their recent review of this
field, Geelen, Sinnema, Hermans, and Kuis (2007) comment that this lack of consensus is
remarkable, given that the same instruments are being used. In fact, this is not the case.
Their confusion has arisen because there are two scales which carry the title Multidimensional Perfectionism Scale (MPS). These have different psychometric properties
which emerge when they are compared to standardised personality measures. The
currently most statistically robust model of personality is the so-called five-factor model,
which comprises traits of neuroticism, extraversion, openness, agreeableness and
conscientiousness (Costa & McCrae, 1992). Hewitt and Flett’s (1991) perfectionism
measure (used in the studies by Blenikorn et al. (1999), and Woods & Wessely, (1999)
which found no relation with fatigue) has three dimensions, two of which have significant
correlations with the five-factor model. The ‘self-oriented’ perfectionism subscale
correlates significantly with conscientiousness and also has small correlations with
agreeableness and neuroticism. Socially prescribed perfectionism had correlations with the
depression subscale of neuroticism (Hill & McIntire, 1997).
The other MPS is by Frost, Marten, Lahart, and Rosenblate (1990) and it has six
dimensions. This measure was used by White and Schweitzer (2000). They did find a
correlation with CFS and the negative aspects of perfectionism, such as ‘concern over
mistakes’ and ‘doubts about actions’ (see method: personality measures below for a full list
of sub-factors). A subsequent factor analysis of this questionnaire reduced it to two
‘superfactors’ of healthy perfectionism, to do with standards and organisation, and
unhealthy perfectionism to do with doubts and concerns (Stumpf & Parker, 2000).
Dunkley et al. (2006), in distinguishing personal standards and evaluative concerns find
their distinction supported by data from both Multi-dimensional Perfectionism
Questionnaires, and their distinction is essentially identical to Stumpf and Parker’s
(2000), with personal standards corresponding to healthy perfectionism, and evaluative
concerns corresponding to unhealthy perfectionism. Both papers report that unhealthy
perfectionism/evaluative concerns correlates positively with neuroticism, whilst healthy
perfectionism/personal standards correlates positively with conscientiousness. Both sets of
authors suggest that unhealthy perfectionism/evaluative concerns is the key factor linking
perfectionism with distress.
This work on general personality factors and fatigue, and on perfectionism and fatigue
forms the background to the present study. Our first aim was to further test the hypothesis
468
V. Deary and T. Chalder
that neuroticism was linked to fatigue, and to do so using a measure which would access
the subcomponents of neuroticism. With regard to perfectionism our aim was to further
investigate the relationship between the negative aspects of perfectionism and fatigue.
To do so, we chose to utilise Frost et al.’s (1990) MPS in the light Stumpf and Parker’s
(2000) analysis of it into the two dimensions of healthy and unhealthy perfectionism. It
was hypothesised that compared to a normal population, a chronically fatigued
population would score higher on measures of unhealthily perfectionism and neuroticism.
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Method
Subjects
A case control design was employed, and only women were recruited. CFS is 2–3 times
more common in women (Chalder, 1998); therefore even with a relatively large sample size,
there would still be a statistically negligible male group. Since there are well-replicated sex
differences in personality (Costa & McCrae, 1992) and perfectionism measures (Blenikorn
et al., 1999; White & Schweitzer, 2000), sex differences could confound between group
differences. Following ethical approval, subjects were drawn from the current waiting list
of the CFS Research and Treatment Unit, Kings College Hospital, London. They were
assessed by a qualified psychiatrist prior to entry into the study and they were also
clinically evaluated to establish that they fulfilled either the Centre for Disease Control
(Fukuda et al., 1994) or the Oxford (Sharpe, Archard, & Banatvala, 1991) criteria for CFS.
50 patients were approached; 33 agreed to take part; and 27 completed and returned
the study questionnaires. All but four fulfilled both criteria for CFS and those four
fulfilled the Oxford criteria. From their clinical letters, none was clinically depressed,
though, as usual in this patient group, there was some low mood attributable to the illness.
The control group of 30 women was selected by a process of interpersonal
dissemination in which friends and colleagues of the authors were asked to recruit friends
and colleagues of their own. This approach successfully produced a group matched on age
and education to the CFS group.
Measures
Hospital anxiety and depression measure
This was employed to measure anxiety and depression in both groups (Zigmond & Snaith,
1983). The two subscales are scored from 0–21. Scores of 0–7 indicate no significant
anxiety/depression; scores of 8–10 indicate possible cases; and scores of 11 and above
indicate probable cases.
Chalder fatigue scale
Fatigue severity was assessed in both groups on this questionnaire with a possible score
range from 0 to 33 (Chalder, Berelowitz, & Pawlikoska, 1993). This questionnaire has been
well validated for use in people with CFS.
Level of education
Subjects were asked for their highest level of education reached, and this was then given a
categorical score. No qualifications ¼ 0; GSCE’s or O Grades ¼ 1; A levels or Higher
Grades ¼ 2; Degree ¼ 3; Post-Graduate Degree ¼ 4.
Psychology and Health
469
Personality measures
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NEO personality inventory-revised
This is a 240 item questionnaire which measures the five broad personality dimensions of
Extraversion (E), Neuroticism (N), Openness to experience (O), Agreeableness (A), and
Conscientiousness (C) (Costa & McCrae, 1992). In this detailed version of the
questionnaire, each dimension is further divided into six facets, each of which is assessed
by 8 questions. Each individual question is scored by the respondent reading a sentence
and reflecting on how well it describes their own personality on a scale from ‘strongly
agree’ (4) to ‘strongly disagree (0).
Multi-dimensional perfectionism scale
This is a 35-item measure of 6 different subscales of perfectionism (Frost et al., 1990).
It assesses doubts about actions; concern over mistakes; parental criticism; parental
expectations, organisation and personal standards. Questions are scored on a likert scale
from 0 ¼ strongly disagree, to 5 ¼ strongly agree. According to the analysis of Stumpf and
Parker, concern over mistakes, doubts about actions, parental expectations and parental
criticism constitute the superfactor of Unhealthy Perfectionism. Personal standards and
organisation constitute Healthy Perfectionism. They report congruence coefficients for
these factors in excess of 0.95 (Stumpf & Parker, 2000).
Analyses
Two-tailed independent t-tests were used to compare means on all baseline variables, other
than level of education which was coded categorically and analysed using a Chi-square
test. A multivariate analysis of variance (MANOVA) was used to examine whether there
were significant between group differences on the NEO-Personality Inventory and the
MPS. If the overall MANOVA proved significant then a univariate analysis, with
Bonferroni correction, was performed on each of the questionnaires dimensions. Post hoc
analyses of dimension sub-facets were then performed on the dimensions that differed
significantly between groups. All calculations were performed using the SPSS 15.0
package, except differences between correlations which were examined for significance
using the ‘indepcorr’ programme.
Results
Mean differences between CFS and control groups
Table 1 shows the demographic and baseline data. The groups are similar in age and
educational experience. Both groups were well educated. As expected, the CFS group
were significantly more fatigued than the control group (p50.01) with a mean fatigue
score of 24.2 (SD ¼ 6.7) out of a possible maximum of 33. The CFS group, in
accordance with previous findings, were also significantly more anxious and depressed
(p50.01 in both cases). Mean duration was 6.5 years (SD ¼ 4.90) and mean onset was
35.3 (SD ¼ 8.6).
There were significant associations among personality trait scales in the NEO-PI-R,
and the two aspects of perfectionism were significantly correlated. Therefore, MANOVA
was conducted using the scales of the respective questionnaires as the dependent variables
and group status (fatigue versus control) as the independent variable.
470
V. Deary and T. Chalder
Table 1. Demographics and baseline data for CFS and control groups.
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Age
Education (mode)c
Duration (years)
Onset (years)
Disability
Fatigue
HAD depression
HAD anxiety
ta
CFS mean
SD
Control mean
SD
p
41.2
3
6.5
35.3
25.5
24.2
7.8
9.2
8.9
37.68
3.4
7.75
0.12
0.08
1.55
8.79b
11.9
2.0
4.8
3.0
1.9
2.8
0.000**
0.000**
0.000**
9.03
5.03
7.96
4.9
8.6
6.8
6.7
3.4
3.6
HAD – Hospital Anxiety and Depression Measure.
Notes: ad.f. ¼ 55 for all t-test comparisons; bFor Chi-square test, d.f. ¼ 1; cSee ‘Measures’ for coding.
*p50.05; **p50.01.
Table 2. Personality in CFS and control groups.
Neo-PI-R
dimensions
Neuroticism
Extraversion
Openness
Agreeableness
Conscientiousness
CFS mean
n ¼ 27
SD
Control
mean n ¼ 30
SD
p
ta
100.2
103.6
122.7
127.5
113.6
18.9
22.0
15.7
14.0
14.3
85.5
115.8
120.8
129.0
118.7
20.5
21.6
19.5
13.5
17.3
0.007**
0.04*
0.67
0.67
0.24
2.81
2.11
0.40
0.43
1.20
Notes: ad.f. ¼ 55 for all comparisons. *p50.05; **p50.01.
For the NEO-PI-R the multivariate test (Wilks’ lambda) was of borderline significance
(F ¼ 2.73, d.f. ¼ 5,51, p ¼ 0.061). Univariate tests (with Bonferroni correction) of the
individual personality trait scales within the Neo-PI-R revealed significant differences for
the Neuroticism (F ¼ 7.90, d.f. ¼ 1,55, p ¼ 0.007) and Extraversion (F ¼ 4.44, d.f. ¼ 1,55,
p ¼ 0.040) scales (Table 2). Overall, the fatigue group had significantly higher neuroticism
and lower extraversion scores. Post hoc analyses of individual facets of Neuroticism
revealed that the fatigue group scored significantly higher on four out of the six facets:
Anxiety (p ¼ 0.036), Hostility (p ¼ 0.044), Depression (p ¼ 0.001), and Self-consciousness
(p ¼ 0.013). Post hoc analyses of individual facets of Extraversion revealed that the fatigue
group scored significantly lower on two out of the six facets: Gregariousness (p ¼ 0.014)
and Activity (p ¼ 0.034). The control group mean score for Neuroticism (85.47,
SD ¼ 20.48) corresponded closely to the published population norms (83.1, SD ¼ 21.7),
as did their Extraversion score (115.77, SD ¼ 21.57 for this population, 110.3, SD ¼ 18.4
for population norms) (Costa & McCrae, 1992).
For the overall MPS score, the multivariate test (Wilks’ lambda) was significant
(F ¼ 4.53, d.f. ¼ 2,54, p ¼ 0.015). In accordance with the literature cited in the introduction,
the MPS was then analysed at the level of the two factors of Healthy and Unhealthy
Perfectionism (Table 3). Univariate tests of these factors (with Bonferroni correction)
within the MPS revealed a significant between-group difference for Unhealthy
Perfectionism (F ¼ 9.13, d.f. ¼ 1,55, p ¼ 0.004), but not for Healthy Perfectionism
(F ¼ 1.66, d.f. ¼ 1,55, p ¼ 0.20). Overall, the fatigue group had significantly higher scores
471
Psychology and Health
Table 3. Perfectionism in CFS and control groups.
MPS factors
Healthy perfectionism (HP)
Unhealthy perfectionism (UP)
Concern about mistakes (UP)
Doubts about actions (UP)
Parental expectations (UP)
Parental criticism (UP)
Personal standards (HP)
Organisation (HP)
CFS mean
n ¼ 27
SD
Control
mean n ¼ 30
SD
p
ta
42.7
60.1
25.63
11.63
11.20
10.26
24.48
18.19
9.3
19.3
9.77
3.99
6.77
4.65
6.77
4.31
40.1
47.1
20.10
8.77
11.20
7.00
21.73
18.33
5.7
13.1
7.20
3.05
4.20
3.14
3.91
3.40
0.20
0.004**
0.018*
0.003**
0.337
0.003**
0.063
0.885
1.29
3.02
2.50
3.06
0.97
3.061
1.90
0.145
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Notes: ad.f. ¼ 55 for all comparisons. *p50.05; **p50.01.
on Unhealthy Perfectionism. Post hoc analyses of individual facets of the MPS revealed
that the fatigue group scored significantly higher on three out of the six facets, all of which
were facets of Unhealthy Perfectionism: Concern Over Mistakes (F ¼ 5.99, d.f ¼ 1,55,
p ¼ 0.018); Doubts About Actions (F ¼ 9.730, d.f. ¼ 1,55, p ¼ 0.003) and Parental Criticism
(F ¼ 9.78, d.f. ¼ 1,55, p ¼ 0.003).
Finally, we looked at the associations between Healthy and Unhealthy Perfectionism in
the fatigued and in the control population. In the CFS group, there was a positive
correlation of Healthy and Unhealthy Perfectionism (0.5, p50.01); these dimensions were
uncorrelated in the normal population. This difference between correlations was
significant (p50.05).
Discussion
Main findings
The main findings of the study were the following: the chronic fatigue population showed
significantly higher neuroticism than the normal population on most of its subdimensions; they were significantly less extraverted but only on two of its sub-dimensions,
gregariousness and activity; they scored higher on unhealthy perfectionism. Finally,
healthy perfectionism and unhealthy perfectionism were positively correlated in the CFS
population but uncorrelated in the controls.
Personality, perfectionism and fatigue
Unlike previous studies, the present one looked at the sub-dimensions of the NEO-PI-R.
Perhaps the most telling finding here is extraversion. It is unsurprising that someone with
fatigue would be both less gregarious and less active than someone less fatigued. These
were the only significant extraversion factors, so perhaps we should look with more
caution at studies which implicate introversion in CFS susceptibility as this personality
difference, on closer inspection, could equally likely be an illness artefact. The neuroticism
finding is more robust across most of its sub-dimensions and less easily dismissed as an
illness artefact. However it could still be argued that the higher anxiety, depression,
hostility and self-consciousness were the consequence rather than the cause of fatigue.
The distinction between healthy perfectionism and unhealthy perfectionism that
has been noted in the literature is borne out by the present study. Some authors
472
V. Deary and T. Chalder
(Frost et al., 1990; Hewitt & Flett, 1991) have noted the relationship between the negative
side of perfectionism – or what Hamachek (1978) calls neurotic perfectionism – and
various markers of ill health and distress: suicidal ideation, procrastination, compulsivity
and low self-esteem to name a few. Burns (1980) defines neurotic perfectionism as the
dependence of self-worth on the attainment of impossible goals. Some items from the MPS
give a flavour of this:
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‘I should be upset if I made a mistake’.
‘People will probably think less of me if I made a mistake’
‘Even when I have done something carefully, I feel that it is not quite right.’
In contrast, healthy perfectionism, as defined by Hamachek (1978), is characterised by
pleasure in achievement, goal directedness and organisation, with self-esteem being less
dependent on task outcomes.
The present study shows that there is a significant tendency for people with CFS to
report more unhealthy perfectionism. Indeed, Hamachek’s (1978) term neurotic
perfectionism emerges as a singularly appropriate label, for, in line with previous studies,
the present studies showed a high correlation between unhealthy perfectionism and
neuroticism. This, then, offers a fairly straightforward conclusion: unhealthy perfectionism
as a trait is associated with CFS.
However the picture may be slightly more complicated. Healthy perfectionism and
unhealthy perfectionism were uncorrelated in the normal sample but positively correlated
in the CFS group. In the fatigued group the higher self-standards and organisation of
healthy perfectionism are matched by the doubts, concerns and self-criticism of unhealthy
perfectionism. It may not be either trait in itself, but their interaction that is important.
Attempting to maintain the high standards associated with healthy perfectionism in the
face of the worry, doubt and self-criticism of unhealthy perfectionism may be both a
predisposing and a perpetuating factor of fatigue. Dunkley et al. (2006) propose a similar
interaction in eating disorder patients. As one of the CFS respondents put it:
‘Not only do I have to climb Mount Everest, I also have to do it with a piano on my back’
This throws further light on the model sketched by White and Schweitzer (2000). They
suggest that the negative factors of perfectionism, coupled with high environmental
demand, create an impossible problem for the individual that is, in a way, ‘solved’ by
becoming ill. They predict that chronicity of fatigue will be predicted by maintenance of
these standards despite illness, and continued attempts to implement them in periods of
remission, leading to further relapse. Whether this picture is valid or not must be tested by
further research, but we can now add further specification to this model.
The ‘unhealthiness’ of perfectionism may be an interactional term rather than an
independent factor. In a relatively low-neuroticism, unfatigued population, where the
standards of healthy perfectionism are unrelated to the concerns of unhealthy
perfectionism, overall perfectionism may be a benign or useful trait. On the other hand,
in a population where the standards of healthy perfectionism are matched by the doubts of
unhealthy perfectionism, the same level of ‘healthy perfectionism’ may become unhealthy,
as in the current study. It is worth emphasising that in our study the CFS population had
the same level of self-standards and organisation (healthy perfectionism) as the control
population. Where they differed was as to their self-doubt, concern over mistakes and past
experience of criticism about maintaining these standards. In terms of the current debate
on the nature of perfectionism and its pathogenic ingredient(s), the current study would
tend to support the position of Dunkley et al. (2006), that perfectionism should be
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Psychology and Health
473
considered as two dimensional. Further it suggests that it is not just the absolute level of
evaluative concerns (aka unhealthy perfectionism) that is the determinant of distress, but
also its interaction with personal standards (aka healthy perfectionism).
How might unhealthy perfectionism be linked to distress and fatigue? Combining this
study with previous work in both perfectionism and fatigue a tentative model could be
sketched. The unhealthy/evaluative concerns dimension of perfectionism is experienced
and embodied in the individual as physiological arousal, emotional distress, cognitive
activation and behavioural striving to eliminate or perfect the stimuli causing this
experience of distress. With relatively more self-doubt and self-criticism as to the success
of this striving, this process will continue for longer. If this process was continued for a
long enough period of time, in a phase of high demand, and if the person was further
impacted by life events, then the ongoing physiological arousal, emotional distress and
cognitive and behavioural activation could result in the kind of physiological ‘burn out’
response, specifically alteration of the hypothalamus-pituitary adrenal axis function, that
appears to be at work in CFS. Whilst the parts of this picture fit with the multi-factorial
evidence base of CFS, the systemic links and mechanisms are far from being elucidated
and tested.
A more parsimonious account of the extant data, the current study included, needs also
to be considered. In the present study, as in previous studies, unhealthy perfectionism
correlated significantly and positively with measures of neuroticism. It could be that the
evaluative concerns of unhealthy perfectionism are merely the expression of a more general
tendency to somatopsychic distress. This latter may be the underlying factor determining
the association between levels of physical symptoms, emotional distress and evaluative
concerns. Further work needs to be done to tease out the specific contribution, of
unhealthy perfectionism to fatigue. Either way one could argue, along with Dunkley et al.
(2006), that the clinical implications are the same. It may not be so important to tackle
and reduce high standards as it is to target the self-doubt and the self-criticism associated
with them.
This study obviously has the limitations of all cross-sectional studies in that it is
impossible to infer causality in any of these factors. It uses a normal rather than an illness
control group, and it restricts itself to a female population with a high degree of education.
Whilst this latter demographic reflects the reality of the secondary and tertiary care
demographics of CFS, it is not necessarily representative of the CFS population at large.
Acknowledgements
We thank Ian Deary at Edinburgh University for advice on personality and on statistical analysis.
Differences between correlations were examined for difference using the ‘indepcorr’ program
provided by John Crawford of Aberdeen University. Vincent Deary acknowledges the support of the
Medical Research Council who are funding his research fellowship at Newcastle University.
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