Perfectionism, Health and Preventive
Health Behaviours
by
Charlotte Williams
Submitted for the Degree of Doctor of Philosophy
School of Psychology
Faculty of Arts and Human Sciences
University of Surrey
Supervisor: Professor Mark Cropley
©Charlotte Williams, 2015
Declaration of originality
This thesis and the work to which it refers are the results of my own efforts. Any ideas,
data, images or text resulting from the work of others (whether published or unpublished)
are fully identified as such within the work and attributed to their originator in the text,
bibliography or in footnotes. This thesis has not been submitted in whole or in part for any
other academic degree or professional qualification. I agree that the University has the
right to submit my work to the plagiarism detection service TurnitinUK for originality
checks. Whether or not drafts have been so-assessed, the University reserves the right to
require an electronic version of the final document (as submitted) for assessment as above.
Signature: ___________________________________________
Date: ______________________________________________
Abstract
The perfectionism and health literature suggests that maladaptive perfectionism is
associated with a plethora of negative health outcomes and adaptive perfectionism with
both favourable and unfavourable health outcomes. Additionally, a small amount of
research has proposed maladaptive perfectionists may refrain from engaging in preventive
health behaviours whilst adaptive perfectionists may engage more readily. This thesis
explored the differences between adaptive and maladaptive perfectionism in relation to
engagement in preventive health behaviours as well as addressing possible intervening
variables in the perfectionism, engagement relationship (e.g. self-presentation, perceived
stress, self-efficacy and affect).
Four studies were carried out. In study 1, (N=370), using a sample of university
students, results identified maladaptive perfectionism to be associated with decreased
engagement in preventive health behaviours and adaptive perfectionism with increased
engagement. Self-concealment (a self-presentational strategy) was found to partially
mediate the perfectionism, engagement relationship for maladaptive perfectionists. In
study 2, (N= 875), again with university students, (using a different conceptualisation of
perfectionism), results showed that although ‘type’ of perfectionism did not interact with
perceived stress to influence engagement, significant differences were identified between
type of perfectionism and a number of health related variables. In study 3, results from a
qualitative study involving university students showed that factors inherent in the
university environment as well as factors characteristic of perfectionism prohibited
engagement in preventive health behaviours. In study 4, using a general population
sample, adaptive perfectionism was associated with greater engagement but no relationship
was found for maladaptive perfectionism. Various factors were found to moderate and
mediate the perfectionism, engagement relationship for adaptive perfectionism and
adaptive perfectionism was associated with more benefits to engagement and maladaptive
perfectionism with more barriers to engagement in preventive health behaviours.
In summary, the results from this thesis suggest there are differences between the
two perfectionism dimensions in relation to engagement and other health variables,
although this may be dependent on the population/context being studied. More research is
warranted to explore the perfectionism, engagement relationship specifically looking at
different populations to establish whether maladaptive perfectionists in a university
environment represent a particularly vulnerable group.
i
Acknowledgements
Anyone who knows me will be aware of what a long journey this has been. There have
been many times when the self-doubt has been overpowering and I have wondered how I
could ever finish this thesis. Writing a thesis about perfectionism when you are highly
perfectionistic yourself has probably added another level of difficulty to the process;
something I didn’t really think about when I started. Thank you to my supervisor Professor
Mark Cropley for all your help and support and for giving me the space to develop my
own ideas and do things in my own time.
One thing is certain, I could never have got this far, had it not been for the support of my
wonderful family. My husband Paul who has supported me throughout all of my academic
pursuits (since A Levels); I just can’t thank you enough for everything you’ve done. My
children; Jake, Beth and Sam; thank you for allowing me time away from being a Mum to
be able to pursue this. My Mum; thank you for always believing that I had it in me, and
Dad, I’m so sorry that you didn’t get to see me finish, but I know you would be so proud
of me.
ii
Table of Contents
Page
Abstract………………………………………………………………………….. i
List of tables……………………………………………………………………... vi
List of figures……………………………………………………………………. vii
List of charts…………………………………………………………………….. viii
List of appendices……………………………………………………………….. ix
Chapter 1. Introduction
1
1.1 Background to the current research…………………………………………. 1
1.2 Main aims of the thesis……………………………………………………… 4
1.3 Thesis outline………………………………………………………………... 6
Chapter 2. Review of the literature
10
2.1 Definitions and conceptualisation……………………………........................
2.1.1 Early conceptualisations……………………………………................
2.1.2 The multidimensional perspective………………………….................
2.1.3 Definitional issues and controversies…………………………………
2.1.4 Current conceptualisations…………………………………................
The 2 x 2 Model of Dispositional Perfectionism…………….........
Cognitive Behavioural Model of Clinical Perfectionism………….
The Transdiagnostic Model………………………………………..
2.1.5 Conclusion to part 1…………………………………………...............
2.2 The relationship between perfectionism, health and health behaviours……...
2.2.1 Perfectionism and psychopathology…………………………..............
Depressive disorders………………………………….....................
Anxiety disorders…………………………………………………..
Eating disorders……………………………………………………
Suicide…………………………………………………………......
2.2.2 Perfectionism and physical health……………………………….........
Chronic Fatigue Syndrome…………………………………...........
Perfectionism and the personal experience of illness………...........
2.2.3 Perfectionism and stress……………………………………….............
2.2.4 Perfectionistic self-presentation and health……………………………
2.2.5 Perfectionism and health behaviours…………………………………..
Potential intervening variables…………………………………….
2.2.6 Treating perfectionists……………………………………………........
2.2.7 Can perfectionism be beneficial to health and wellbeing?.....................
2.2.8 Conclusion to part 2……………………………………………............
10
10
13
17
22
22
26
28
30
31
31
32
33
35
36
39
41
43
45
48
50
53
59
62
64
Chapter 3 The relationship between perfectionism and engagement in
preventive health behaviours: The mediating role of
self-concealment (study 1)
66
iii
3.1 Introduction…………………………………………………………..............
3.1.1 Hypotheses……………………………………………………............
3.2 Methods………………………………………………………………………
3.2.2 Measures………………………………………………………...........
3.2.3 Data analysis………………………………………………………….
3.3 Results……………………………………………………………….............
3.4 Discussion…………………………………………………………………....
3.5 Conclusion……………………………………………………………………
66
70
71
71
74
75
82
85
Chapter 4 The relationship between perfectionism and engagement in
Preventive health behaviours: The role of perceived stress
(study 2)
87
4.1 Introduction…………………………………………………………………..
4.1.1 Hypotheses……………………………………………………………
4.2 Methods………………………………………………………………...........
4.2.1 Measures……………………………………………………………...
4.2.2 Data Analysis…………………………………………………………
4.3 Results……………………………………………………………………......
4.4 Discussion……………………………………………………………………
4.5 Conclusion……………………………………………………………….......
87
91
92
92
96
97
104
108
Chapter 5 A qualitative study exploring engagement in preventive health
behaviours and obstacles to engagement in adaptive and
maladaptive perfectionists: An interpretative phenomenological
analysis (study 3)
109
5.1 Introduction………………………………………………………………….. 110
5.2 Methods…………………………………………………………………....... 112
5.2.1 Data analysis……………………………………………...………...... 114
5.3 Results……………………………………………………………………….. 115
5.3.1 Taking personal responsibility for health………………………......... 116
5.3.2 Lack of awareness of limitations…………………………………….. 124
5.3.3 Control over health and wellbeing…………………………………... 131
5.4 Discussion…………………………………………………………………... 142
5.4 Conclusion………………………………………………………………….. 151
Chapter 6 Moderators and mediators in the relationship between
perfectionism and engagement in preventive health
behaviours (study 4)
152
6.1 Introduction………………………………………………………….............
6.1.1 Hypotheses……………………………………………………….......
6.2 Methods……………………………………………………………………..
6.2.1 Measures……………………………………………………………..
6.2.2 Data analysis………………………………………………………....
6.3 Results………………………………………………………………….........
6.4 Discussion……………………………………………………………………
6.5 Conclusion……………………………………………………………….......
152
158
160
161
166
167
175
182
iv
Chapter 7 General discussion
184
7.1
7.2
7.3
7.4
7.5
7.6
186
189
202
206
208
211
Summary of findings…………………………………………………………
Contribution of research……………………………………………………...
Limitations of research…………………………………………………….....
Future research……………………………………………………………….
Implications for Interventions………………………………………………...
Overall conclusions…………………………………………………………..
References………………………………………………………………………... 212
Appendices………………………………………………………………………... 253
v
List of tables
Page
Chapter 2
2.1 The differences between adaptive (“normal”) and maladaptive…………..
13
(“neurotic”) perfectionism (taken from Hewitt & Flett, 2002)
2.2 The key features of the two multidimensional perfectionism scales……...
14
2.3 The tripartite model of perfectionism (Stoeber & Otto, 2006)……………. 19
2.4 The 2 x 2 model of dispositional perfectionism…………………………… 23
(Gaudreau & Thompson, 2010)
Chapter 3
3.1 Sample demographics, means, standard deviations and reliabilities for all….. 76
variables
3.2 Correlation matrix for all major variables…………………………………… 78
3.3 Summary of the regression analysis for the variables: Maladaptive………… 80
Perfectionism, self-concealment and engagement in preventive health
behaviours
3.4 Summary of the regression analysis for the variables: Maladaptive………… 81
Perfectionism, self-concealment and psychological distress
Chapter 4
4.1 The four perfectionism groups formulated for the study………………......... 94
4.2 Sample demographics, means, standard deviations and reliabilities for…..... 98
all variables
4.3 Participant characteristics by perfectionism group………………………...... 99
4.4 Correlation matrix for all major variables………………………………....... 100
Chapter 5
5.1 Interview participants……………………………………………………….. 113
5.2 The three superordinate themes……………………………………………... 115
5.3 Possible obstacles to engagement…………………………………………… 149
Chapter 6
6.1 The scales and subscales of the Exercise Benefits/Barriers questionnaire….. 163
6.2 Sample demographics, means, standards deviations and reliabilities for........ 167
all variables
6.3 Correlation matrix for all major variables………………………………....... 170
6.4 Table showing predictors of engagement in preventive health behaviours.... 172
vi
List of figures
Page
Chapter 1
1.1 Possible reasons why maladaptive perfectionists may represent a………..... 3
“high risk” group in terms of health and wellbeing
Chapter 3
3.1 Testing the indirect effect using the method outlined by Sobel (1982)……... 75
3.2 The mediating role of self-concealment in the relationship between……….. 79
maladaptive perfectionism and engagement in preventive health
behaviours
3.3 The mediating role of self-concealment in the relationship between………... 81
maladaptive perfectionism and psychological distress
Chapter 6
6.1 Model of adaptive perfectionism as a predictor of engagement in…………… 174
preventive health behaviours mediated by exercise self-efficacy
6.2 Model of adaptive perfectionism as a predictor of engagement in………….. 175
preventive health behaviours, mediated by self-presentational
efficacy expectancy
Chapter 7
7.1 Possible reasons why maladaptive perfectionists may represent a………….. 198
high risk group in terms of health and wellbeing
vii
List of charts
Page
Chapter 2
4.1 Engagement in preventive health behaviours by perfectionism group……..
and stress group
101
4.2 Reporting of physical symptoms by perfectionism group and stress………. 102
group
4.3 State anxiety by perfectionism group and stress group…………………….. 103
4.4 Trait anxiety by perfectionism group and stress group……………………..
104
viii
List of appendices
Appendix
A
Page
Unpublished version of article submitted to the Journal……….... 253
of Health Psychology (Williams and Cropley, 2014)
B
Interview schedule for study 3……………………………………. 277
C
The Frost Multidimensional Perfectionism Scale………………… 278
D
Self-Concealment Scale…………………………………………… 279
E
Preventive Health Behaviours Questionnaire……………………... 280
F
The Hopkins Symptom Checklist-21……………………………… 281
G
Satisfaction with Life Scale……………………………………….. 282
H
Perceived Stress Scale…………………………………………….. 283
I
The Pennebaker Inventory of Limbic Languidness……………….. 284
J
The State-Trait Anxiety Inventory………………………………… 286
K
The Godin Leisure-Time Exercise Questionnaire…………………. 288
L
The Exercise Benefits/Barriers Scale……………………………… 289
M
The WHO-5 Wellbeing Index……………………………………... 291
N
Self-Presentational Efficacy Scale…………………………………. 292
O
Physical Activity Motivation Scale………………………………... 293
P
Exercise Self-Efficacy Scale………………………………………. 295
Q
The Positive and Negative Affect Schedule………………………. 296
ix
Chapter 1
Introduction
1.1 Background to the current research
For some, the pursuit of excellence may be a positive experience that energizes and
challenges them to achieve greatness. For others, the drive to achieve excellence may
represent a negative experience; an unremitting struggle to achieve perfection whatever the
cost to health and wellbeing. Perfectionism has been described as a fairly stable
personality trait characterised by the setting of and striving towards unreasonably high
standards of performance. Often it is believed to be accompanied by self-criticism and
doubts about the quality of one’s actions (Frost, Marten, Lahart & Rosenblate, 1990).
Perfectionism represents for many, a double edged sword. A highly sought after quality in
certain circles, for example by employers and academics but not necessarily the case for
those whose lives are affected by the darker side of perfectionism. For some individuals
the desire to achieve perfection may have severe consequences in terms of their health and
wellbeing.
Recent research has highlighted how this often praised and valued personality trait can
shorten life expectancy (Fry & Debats, 2009), markedly increase the risk of suicide (Flett,
Hewitt & Heisel, 2014) and lead to lower levels of life-satisfaction and wellbeing (Park
and Jeong, 2015). The problem is exacerbated by the fact that many perfectionists try and
conceal the extent of their difficulties and distress from others in an attempt to project a
perfect and flawless persona (Hewitt, Flett, Besser, Sherry & McGee, 2003). It is therefore
difficult to gauge the extent of the problem and the result of this may be a controlled and
measured outward expression to the rest of the world but one which masks the inner
turmoil and distress that is experienced by the perfectionist.
A further complication of the situation is that many perfectionists seem to be reluctant to
ask for help or utilise social support networks (Crăciun & Dudău, 2013; Flett, Baricza,
Gupta, Hewitt & Endler, 2011) perhaps this is based on a fear that such actions will expose
a flaw or potential weakness and make them vulnerable to criticism. Perfectionists,
according to health professions also represent a particularly difficult client group to treat
(Blatt & Zuroff, 2002; Scott, 2001). Research has identified that perfectionistic beliefs are
fairly resistant to change and that perfectionists may sabotage the therapy process by using
1
it as yet another opportunity to set unrealistically high standards and then push themselves
relentlessly to try and achieve them.
Unfortunately, it would appear that we live in a perfectionistic society where turbulent
economic conditions have put increased pressure on us to achieve and continue pushing
ourselves to meet higher and higher standards (Greenspon, 2014). Young people are likely
to be aware of these pressures from a young age and as a result are being socialised into a
world where they have to set their sights high and compete to be the best. The result of
which, aside from the health implications, is that we develop a perception of ourselves,
where we can only be accepted and valued for what we can achieve, rather than who we
are as people.
The present thesis sits within the wider field of perfectionism and health and an abundance
of research points to the existence of a maladaptive side to the perfectionism construct that
has been linked to a multitude of physical and psychological health problems (e.g. Fry and
Debats, 2009; Egan, Wade & Shafran, 2011). Well established links have been made
between the maladaptive dimensions of perfectionism and a wide array of health issues
such as depression, anxiety, eating disorders, chronic pain, Chronic Fatigue Syndrome,
Irritable Bowel Disease etc. The situation is further exacerbated by the fact that
perfectionists seem to find it harder than non-perfectionists to deal with stress (Flett &
Hewitt, 2002).
Researchers have also explored and identified what they believe to be an adaptive
dimension to the perfectionism construct (Hamachek, 1978; Slade & Owens, 1998). This
positive personality dimension is considered to embody the positive qualities associated
with perfectionism, (e.g. high levels of organisation, conscientiousness, a desire to
approach challenges and experiencing satisfaction when a job has been completed) without
all of the negative connotations that appear to accompany the maladaptive dimension (e.g.
doubting the qualities of one’s actions, a desire to avoid challenges and lack of satisfaction
when a job is completed). Unfortunately, the evidence to support this premise has not been
consistent, with some authors wholeheartedly supporting the existence of an adaptive
form of perfectionism (Slade & Owens, 1998) and others suggesting that even taking the
positive characteristics into account, perfectionism is, and always will be, inherently
dysfunctional (Flett & Hewitt, 2006).
2
Although there is a well-established body of literature addressing the psychopathological
correlates of perfectionism and, to a lesser extent, a number of studies looking at the
relationship between perfectionism and physical health variables, there is limited research
that has touched on whether perfectionists actively engage in activities that may safeguard
and protect their health and wellbeing (preventive health behaviours) from the potential
risks associated with being highly perfectionistic (e.g. Longbottom, Grove & Dimmock,
2010; Williams & Cropley, 2014). It has not been established empirically whether
perfectionists regularly engage in preventive health behaviours. The small body of
literature that is available points to a reduced level of engagement, particularly for
maladaptive perfectionists. If it is found that maladaptive perfectionists refrain from
engaging in preventive health behaviours, and also show no let-up in term of pushing
themselves to meet their exceptionally high standards, then there may be a very real danger
that they will eventually push themselves to the point where they have nothing left to give,
and their health and wellbeing may suffer as a result. When you also consider the vast
body of research linking the maladaptive dimension of perfectionism with unfavourable
health outcomes then it seems logical to assume that maladaptive perfectionists may
represent a ‘high risk’ group in terms of their health and wellbeing, (see figure 1.1).
Figure 1.1
Possible reasons why maladaptive perfectionists may represent a “high
risk” group in terms of health and wellbeing
Difficult
client group
to treat
Reluctance
to seek
help
Lower levels of
life satisfaction
and wellbeing
Increased risk of
suicide
Maladaptive
Perfectionists: A
“high risk” group?
Linked to
psychopathology
Increased risk of
mortality
Linked to
physical health
problems
Stress
Conceal personal
difficulties
3
1.2 Research aims
The purpose of the present thesis was to address a gap in the literature within the broad
area of perfectionism and health. What is known from previous research is that
perfectionism, particularly the maladaptive dimension is associated with both
psychological and physical health difficulties. Perfectionism is also known to have a
complicated relationship with stress whereby stress has been implicated in the generation
and maintenance of various psychopathological states (Flett & Hewitt, 2002). We also
know that perfectionists tend to conceal the extent of their difficulties from others,
reportedly to preserve a perfect and flawless persona. What is not known, however, in the
research literature is whether perfectionists actively engage in behaviours that may
safeguard or protect them from the pressures and problems that seem to accompany
perfectionism as well as the type of factors that may interfere with their ability to maintain
such behaviours.
The main aims of the thesis are as follows;
1. To explore engagement in preventive health behaviours (such as exercise, physical
activity, diet and looking after their emotional wellbeing) for both adaptive and
maladaptive perfectionists and try and establish if there are any differences
between the two perfectionism dimensions in terms of engagement.
2. To explore two key areas; self-presentation and perceived stress, that are
considered to play an important role in the relationship between perfectionism and
health outcomes and on the basis of this are predicted to influence the relationship
between perfectionism and engagement in preventive health behaviours
3. To explore the possible benefits and barriers to engagement, i.e. the factors that
might intervene in the relationship between perfectionism and engagement that
either encourage or discourage engagement.
4. To generate support for the possibility that maladaptive perfectionists may
represent a high risk group in terms of health and wellbeing.
5. To support a distinction between the two dimensions of perfectionism: a
maladaptive type of perfectionism related to maladjustment and an adaptive type of
perfectionism associated with potential benefits to health and wellbeing.
4
By concentrating on these specific areas, the intention is to further research in this field by
moving beyond what is currently known about the relationships between perfectionism and
health and develop a deeper understanding of the decisions perfectionists (adaptive and
maladaptive) make in relation to how well they look after their health and wellbeing and
gain a deeper understanding of factors that may interfere with perfectionists’ ability to look
after themselves.
One of the difficulties associated with conducting perfectionism research, is despite an
increase in research interest in this area over the past few decades; there is still no
universally accepted definition. A variety of ways of conceptualising the construct have
been developed with the majority of these acknowledging that perfectionism consists of
both positive/adaptive qualities as well as negative/maladaptive features. The two
conceptualisations that have received the most interest as evidenced by their extensive
usage within the perfectionism and health literature are those developed by Frost and
colleagues (1990) and Hewitt & Flett (1991b). The conceptualisation that has been chosen
for the present thesis follows and supports the work of Frost and Colleagues (1990) and
utilises their Multidimensional Perfectionism Scale as a means of establishing a measure
of both adaptive and maladaptive perfectionism, for the four studies contained within this
thesis. The reason for choosing this particular conceptualisation, over other methods was
based primarily on the flexibility of the scale in being able to differentiate between the
constructs of adaptive and maladaptive perfectionism and it was also considered to be the
most appropriate method to explore the main aims of the thesis.
The added difficulty with conceptualisations and definitions is the unresolved debate over
the potential “adaptiveness” of the perfectionism construct. Most would agree that
perfectionism consists of both adaptive and maladaptive qualities; however, what has not
been established is whether the potentially adaptive features (such as high personal
standards, organisation, and conscientiousness) are able to bring associated benefits to
health and wellbeing. From a health perspective, the downside of having multiple
definitions and multiple assessment methods means that there may be problems with the
diagnosis and treatment of individuals struggling with the consequences of extreme forms
of maladaptive perfectionism. If it were possible to categorically identify the existence of a
positive and adaptive form of perfectionism (that would bring with it associated health
benefits) then this would influence the way in which perfectionism could and should be
defined. Additionally from the point of view of health and wellbeing, the existence of an
5
adaptive and potentially healthy form of perfectionism may provide answers about how
best to help individuals struggling to deal with the maladaptive and potentially destructive
side of perfectionism.
1.3 Thesis outline
Chapter 2 (part 1). The issue of multiple conceptualisations/definitions continues to be a
fiercely debated subject in the perfectionism field and a problem that has infiltrated the
perfectionism and health literature. In addition, there are no reviews to date that have
provided an overview of past and present approaches taking into consideration the most
recent conceptualisations in the perfectionism literature. On the basis of this, it was felt
that before embarking on reviewing the area of perfectionism and health, it would be
beneficial to first begin with a detailed and up to date review of the available literature on
definitions/conceptualisations. As well as a discussion of the available approaches, the first
part of this chapter also discusses some of the specific definitional issues and controversies
that have arisen over the past few decades.
Chapter 2 (part 2). Provides a detailed review of the literature exploring the subject of
perfectionism and health. To begin with, the relationships between perfectionism and
psychopathology and perfectionism and physical health are discussed, highlighting some
of the specific conditions that have been associated with the maladaptive dimension of
perfectionism, such as depression, anxiety, eating disorders, suicide and Chronic Fatigue
Syndrome. It is important to note that this review was not intended to present an
exhaustive list of conditions associated with perfectionism, rather, a selection have been
carefully chosen to present an overview. Following on from this, the relationships between
perfectionism and two specific areas are discussed; stress and self-presentation. Towards
the end of the review the focus shifts to address the relationship between perfectionism and
health behaviours. Consideration is then given to factors that may influence engagement in
preventive health behaviours such as self-handicapping behaviours, physical activity
motivation, perceived stress and self-efficacy. Treatment issues are considered as the
penultimate element of the literature review and the final section is devoted to a discussion
of the available literature concerning the potentially adaptive dimension of perfectionism.
The relevance of chapter 2 is, firstly to explore the concept of perfectionism (part 1) and
secondly to discuss the potential health implications of this personality construct (part 2).
Establishing the potential health consequences of being a perfectionist seems to be an
6
essential first step in supporting one of the basic premises of the thesis; to generate support
for the possibility that maladaptive perfectionists may represent a high risk group in terms
of health and wellbeing as well as identifying whether the so called ‘adaptive’ dimension
of perfectionism is really worthy of its name; in providing potential benefits to health and
wellbeing. The next step was to gather empirical evidence to support the aims of the thesis.
It is important to note that the focus of the present thesis was intentionally wide to
encompass an expansive area of research. Due to the limited availability of research
specifically addressing perfectionism and engagement in preventive health behaviours, it
was necessary to draw on a large number of areas within the field of perfectionism and
health to try and address the main aims of the thesis.
Chapter 3. The area of self-presentation was highlighted in the literature review as
permeating various aspects of the perfectionism, health relationship; therefore this chapter
presents the results of a cross-sectional study exploring self-concealment (a selfpresentational strategy) as a potential mediator in the relationship between perfectionism
and engagement in preventive health behaviours. Self-concealment involves the need to
withhold personal and sensitive information from others and it was hypothesised that
maladaptive perfectionists would engage less than adaptive perfectionists in preventive
health behaviours. Research has suggested that perfectionists, particularly maladaptive
perfectionists may have a strong desire to hide their imperfections from others (Hewitt et
al, 2003) and therefore engaging in preventive health behaviours, such as exercise classes
or going to the gym (where there is an element of public exposure) may be more of a
challenge to them because they don’t want to expose a less than perfect image. The
associations between adaptive and maladaptive perfectionism and a number of other health
related variables were also considered such as psychological distress, wellbeing and lifesatisfaction. As discussed in the chapter, one of the limitations of the study involved the
conceptualisation of perfectionism that was employed. To address this, a different
conceptualisation was utilised in the next study.
Chapter 4. As well as identifying self-presentation as a key area that may influence
decisions to engage in preventive health behaviours, the literature review also highlighted
perceived stress to be an important area that has been shown to have associations with both
perfectionism and engagement in preventive health behaviours. In study 2, the relationship
between perfectionism and perceived stress was explored to determine if type of
perfectionism interacted with level of perceived stress to predict engagement in preventive
7
health behaviours. Using a slightly different conceptualisation; four groups of perfectionist
were considered; non-perfectionists, adaptive perfectionists and two types of maladaptive
perfectionist (based on their coexisting levels of adaptive and maladaptive perfectionism
traits). The main effects of perfectionism and perceived stress were also considered in
relation to a number of other health related variables such as physical symptom reporting,
perception of general health and level of anxiety. After addressing these two key areas;
self-presentation and perceived stress, the next logical step was to look more closely at
factors that may intervene in the relationship between perfectionism and engagement.
Chapter 5. In this chapter, the focus of the thesis moves on to address intervening factors
that may influence decisions to engage in preventive health behaviours. The chapter
presents the results of a qualitative study which explored the area of engagement in
preventive health behaviours in a group of university students and attempted to identify
potential obstacles to engagement. There are very few studies that have addressed
perfectionism from a qualitative perspective and none that have looked specifically at
engagement in preventive health behaviours, therefore this study was considered to
address a gap in the research literature. Using Interpretative phenomenological analysis,
the intention was to discover a number of key themes that may help explain which factors
influence engagement and how individuals’ manage to maintain their engagement when
there are other pressures and distractions. Furthermore the intention was to build up a more
detailed representation of how type of perfectionism (adaptive/maladaptive) may affect the
engagement process as well as identify any differences between the two perfectionism
dimensions. After providing a qualitative explanation of the potential obstacles to
engagement in preventive health behaviours, it was felt necessary to explore this area in
more detail from a quantitative perspective; looking at both barriers and benefits to
engagement.
Chapter 6. To extend the findings of study 3, This chapter presents the results of a crosssectional study exploring a range of potential mediators and moderators in the relationship
between adaptive and maladaptive perfectionism and two types of engagement;
engagement in general preventive health behaviours (as in studies 1 and 2) as well as the
specific area of physical activity/exercise behaviour. Potential intervening variables that
were considered included; adaptive/maladaptive cognitions and behaviours towards
exercise/physical activity, perceived stress, specific benefits/barriers to exercise, selfpresentational efficacy and exercise self-efficacy. The focus of the study was to try and
8
identify the possible reasons why perfectionists may choose to engage/not engage in
preventive health behaviours and attempt to identify any differences between the two
perfectionism dimensions.
Chapter 7. This final chapter presents a general overview and discussion of the thesis.
This includes a summary of the four studies and the main findings, a discussion of the
contribution of the research to the wider field of perfectionism and health, with specific
attention to whether the main aims of the thesis have been achieved. General limitations
are discussed as well as ideas for future research. Finally an overall conclusion is
presented.
9
Chapter 2:
Review of the literature
2.1 Definitions and Conceptualisations
2.1.1 Early conceptualisations
Despite the vast increase in perfectionism research over the past few years, there still
remains a lack of consensus about how to conceptualise and define this personality trait.
As a result, conducting research in this field can be problematic because there is no single
definition to adhere to. For this part of the review, the main conceptualisations will be
introduced and the most recent formulations discussed along with a number of definitional
issues and controversies that have dominated in the research literature.
Early writers viewed perfectionism as a predominantly maladaptive unidimensional
personality construct, almost always associated with psychopathology (e.g. Burns, 1980).
Definitions of perfectionism encompassed various attributes such as excessively high
standards (Horney, 1950; Ellis, 1962), a lack of flexibility in ideas (Ellis, 2002),
dichotomous thinking (Ellis, 2002; Burns, 1980), poor self-esteem/self-acceptance
(Horney, 1950; Missildine, 1963), hypersensitivity to criticism (Horney, 1950), overgeneralisation (Beck, 1976; Burns, 1980), being ruled by “should” statements (Horney,
1950; Burns, 1980) and an inability to gain satisfaction from one’s own accomplishments
(Missildine, 1963; Weisinger & Lobsenz, 1981). Many of these attributes are still
considered relevant to the most recent formulations that now dominate in the perfectionism
literature.
Early definitions often focussed on a dysfunctional cognitive style that was present in the
dialogue of many highly perfectionistic individuals. Horney (1950) maintained that
perfectionists were driven by an inner narrative that dictated what they ‘should’ and
‘should not’ do in a given situation. This harsh self-talk was purported to lead
perfectionists to set themselves unrealistic and impossible standards, without considering
the internal or external factors that may influence their achievement of such goals (Horney,
1950). An example of the all-encompassing and biased cognitions present in the inner
dialogue of the perfectionist has been described by Ellis (2002);
10
“A person should be thoroughly competent, adequate and intelligent in all possible
respects; the main goal and purpose of life is achievement and success; incompetence in
anything whatsoever is an indication that a person is inadequate or valueless” (Ellis,
1962).
Burns (1980) identified multiple cognitive distortions in perfectionism such as the
presence of ‘all or nothing’ thinking, over-generalisations and frequent use of punishing
‘should’ statements. Burns (1980) suggested that individuals who were driven to pursue
excellence were locked in an unhealthy and self-defeating cycle whereby they were prone
to gauge their own self-worth according to their ability to achieve impossibly high
standards of performance. The unhealthy tendencies of perfectionists were also identified
by Pacht (1984) who questioned whether the concept of perfection could ever really exist.
He suggested that striving for perfection was akin to striving for the impossible and
therefore psychological problems were to be an expected consequence.
For many years, the unidimensional view dominated and gave the impression that being a
perfectionist was fraught with harmful and damaging consequences which would
inevitably lead the individual into a downward spiral towards psychopathology.
Unfortunately this view was not able to account for any of the positive attributes that had
been noted in some perfectionistic individuals, such as being highly organised,
conscientious and effective in meeting high standards. Following these observations, it
became necessary to consider the possibility that there might also be individuals who were
driven by high standards but who did not develop the problems that were experienced by
some of the more extreme perfectionists.
Although the setting of high standards was considered to be one of the fundamental traits
characterising highly perfectionistic individuals (Burns, 1980; Hollender, 1965;
Hamachek, 1978; Pacht, 1984), authors gradually realised that it wasn’t the setting of the
high standards that was the problem, rather the tendency to make overly critical
evaluations of ones’ performance in relation to these high standards (Frost et al, 1990).
Frost and colleagues proclaimed that the associations between perfectionism and
psychopathology were a product of the harsh evaluative tendencies that coincided with the
setting of exceptionally high standards and that not all perfectionists reacted to these in the
same manner.
11
A seminal article by Hamachek (1978) represented a significant shift in the way that
perfectionism would come to be conceptualised and defined. This article suggested that it
was possible to view perfectionism as embodying both maladaptive and adaptive traits. In
his article, Hamachek identified two types of perfectionism that he termed; ‘normal’ and
‘neurotic’. He described normal perfectionists as “those who derive a real sense of
pleasure from the labours of painstaking effort and who feel free to be less precise as the
situation permits” (p.27) and conversely, neurotic perfectionists as “the sort of people
whose efforts, even their best ones never seem quite good enough” and who “are unable to
feel satisfaction because in their own eyes they never seem to do things good enough to
warrant that feeling” (Hamachek, 1978,p.27).
One of the key differences between these two conceptualisations and a factor that set
adaptive and maladaptive perfectionists apart was identified as; possessing the flexibility
to adjust ones’ standards depending on the situation and being able to express a sense of
satisfaction form ones’ efforts. This was in stark contrast to neurotic perfectionists who
seemed to possess an absence of such flexibility and derived little satisfaction from their
endeavours. Adaptive perfectionism, in contrast to maladaptive perfectionism was believed
to be driven by a desire for success (Hamachek, 1978) and was believed to be associated
with characteristics such as; high personal standards, a high level of organisation, a desire
to achieve personal goals (Slade & Owens, 1998), greater life satisfaction, positive affect
(Chang, Watkins & Banks, 2004), conscientiousness (Cox, Enns & Clara, 2002; Enns,
Cox, Sareen & Freeman, 2001) and higher academic attainment (Bieling, Israeli, Smith &
Antony, 2003). When compared to maladaptive perfectionists, adaptive perfectionists were
believed to ruminate less, be less susceptible to negative affectivity and engage in fewer
self-critical evaluations in appraisal situations (Beiling, Summerfeldt, Israeli & Antony,
2004; Enns et al, 2001; Rhéaume, Freeston, Ladouceur, Bouchard, Gallant, Talbot, et al,
2000), see table 2.1.
With the emergence of studies focussing on the adaptive/positive side of perfectionism, the
research field grew and findings began to dispel the negative bias that had dominated the
perfectionism literature for many years. Research focussing on the possibility of
understanding and explaining perfectionism from a more positive perspective began to
12
emerge and the multidimensional perspective became recognised (Frost et al, 1990; Hewitt
& Flett, 1991a, 1991b).
The Differences between Adaptive (“Normal”) and Maladaptive
Table 2.1
(“Neurotic”) Perfectionism taken from Hewitt and Flett (2002).
Adaptive Perfectionism

Able to experience satisfaction from
Maladaptive Perfectionism

ones’ endeavours
Unable to experience pleasure from
ones’ endeavours

Flexibility to adjust standards

Inflexibly to adjust standards

Set achievable standards that are

Sets unrealistically high standards that
matched to strengths/limitations of the
are not matched to strengths/limitation
person
of the person

Focus is on striving for success

Focus is on a fear of failure

Attitude that is relaxed but careful

Attitude that is tense/anxious

Sense of self, not tied to the successful

Sense of self-worth highly dependent
completion of tasks
on performance

Timely completion of tasks

Associated with procrastination

Motivation to gain positive

Motivation to avoid negative
feedback/rewards
consequences

Failure associated with renewed efforts


Balanced thinking

Desire to excel

A reasonable level of certainty about
white thinking: perfectionism versus
actions
failure
Failure associated with harsh selfcriticism


Distorted cognitions e.g. black and
Belief that one should excel
Note. Table derived from Burns (1980), Hamachek (1978) and Pacht (1984) (Hewitt & Flett, 2002)
2.1.2 The multidimensional perspective
The move towards a multidimensional perspective was one of the most significant
developments in the perfectionism field. This perspective recognised both the personal and
interpersonal dimensions of perfectionism as well as acknowledging both the
13
adaptive/positive and maladaptive/negative attributes. The early 1990s marked the arrival
of two new methods of assessing perfectionism both named the Multidimensional
Perfectionism Scale (Frost, et al, 1990; Hewitt & Flett, 1991a).
Table 2.2
The key features of the two Multidimensional Perfectionism Scales
Frost Multidimensional Perfectionism Scale
Hewitt and Flett Multidimensional
(MPS-F)
Perfectionism
Scale (MPS-HF)
Authors
Authors
Frost, Marten, Lahart and Rosenblate (1990)
Hewitt and Flett (1991b)
Purpose/Focus
Purpose/Focus
Focusses on self-directed cognitions
Focusses on interpersonal aspects
associated with perfectionism
as well as self-directed cognitions
associated with perfectionism
Measures six subscales/dimensions
Measures three dimensions
Personal Standards (PS)
Self-Oriented Perfectionism (SOP)
Concern over Mistakes (CM)
Socially-Prescribed Perfectionism (SPP)
Doubts about Actions (DA)
Other-Oriented Perfectionism (OOP)
Organisation (O)
Parental Criticism (PC)
Parental Expectations (PE)
Number of items
Number of items
35 items to measure the six subscales
45 items to measure the three
Dimensions
Scoring
Scoring
A total score can be derived from
Scores are derived by totalling the
Summing five out of the six subscales*. An
responses for each of the three
Adaptive perfectionism score can be
dimensions, producing a score for each of the
derived from summing PS and O** and a
dimensions of perfectionism
Maladaptive perfectionism score
obtained from summing CM and DA or
CM, DA, PC and PE***
* The Organisation subscale was found to have weak correlations with the other subscales and as such was excluded from the total perfectionism score (Frost et al, 1990)** This
method of obtaining a measure of Adaptive Perfectionism has been supported by research (e.g. Harris, Pepper & Mack, 2008)*** This method of obtaining a measure of Maladaptive
Perfectionism has been supported by previous research (e.g. Dunn, Gotwals, Dunn & Syrotuick, 2006; Frost et al, 1990; Harris et al, 2008; Wei, Mallinckrodt, Russell & Abraham
2004)
14
In developing their scale, Frost et al (1990) honed in on a number of key features that they
felt typified the perfectionism construct. These included; the setting of excessively high
standards, having doubts about the quality of one’s actions, an excessive concern over
making mistakes, the influence of parents with regards to expectations and evaluations and
finally a fixation on organisation and order. Frost and colleagues generated many new
items for their scale as well as utilising items from two existing measures; the Burns
Perfectionism Scale (BPS; Burns, 1983) and the Eating Disorders Inventory (EDI-P;
Garner, Olmsted & Polivy, 1983). Sixty seven items were reduced down to thirty five
statements and factor analyses resulted in the identification of six subscales; Personal
Standards (PS), Concern over Mistakes (CM), Doubts about Actions (DA), Organisation
(O) and finally two subscales relating to parental involvement – Parental Criticism (PC),
and Parental Expectations (PE). To provide a separate scale of adaptive and maladaptive
perfectionism, studies have typically combined the PS and the O subscales (adaptive
perfectionism) and the CM and DA subscales (maladaptive perfectionism), (Dunn et al,
2006; Frost et al, 1990; Harris et al, 2008; Wei et al, 2004). The Frost Multidimensional
Perfectionism Scale has been used extensively to study a diverse range of
psychopathological indicators, such as Obsessive Compulsive Disorder symptoms,
Chronic fatigue syndrome, suicidal ideation, indecisiveness, erectile dysfunction and social
phobia (Enns & Cox, 2002).
The Hewitt and Flett Multidimensional scale (Hewitt & Flett, 1991a) differed from the
Frost scale in that it focussed on the interpersonal aspects of perfectionism as well as selfdirected cognitions. These authors described three distinct dimensions; Self Oriented
Perfectionism (SOP) which referred to the setting of exceptionally high standards for
oneself, Socially Prescribed Perfectionism (SPP) which related to the perception of others
having exceptionally high standards of oneself and the third dimension, Other-Oriented
Perfectionism (OOP) which referred to an individual having exceptionally high standards
for others and expecting perfection from them. From a total of one hundred and twenty
two potential items, forty five items were chosen to assess the three dimensions. Initial
testing of the MPS-HF provided good measures of reliability and validity (Hewitt & Flett,
1991b). Since its development the Hewitt & Flett Multidimensional Perfectionism Scale
has been extensively used with a variety of clinical groups and a wide range of
psychopathological indicators (Hewitt & Flett, 2002) e.g. depression, anxiety, suicidal
ideation, self-esteem, obsessional symptoms and social adjustment difficulties (Enns &
15
Cox, 2002). It is now generally accepted that the socially prescribed dimension of
perfectionism represents a maladaptive type of perfectionism that has been related to
depression, anxiety and suicidal ideation (Enns & Cox, 2002). A lack of consensus
surrounds how to categorise the self-oriented dimension proposed by Hewitt and Flett
(1991a) with some authors supporting its association with positive personal attributes such
as achievement in academic settings and elevated levels of positive affect (e.g. Molnar,
Reker, Culp, Sadava & DeCourville, 2006) and other authors advocating an association
with maladjustment (Hewitt and Flett, 2004).
Although sharing the same name, the two Multidimensional Perfectionism Scales were
developed from somewhat different perspectives; the MPS-F (Frost et al, 1990) focussing
on self-directed intrapersonal perfectionism and the MPS-HF (Hewitt & Flett, 1991a)
placing more emphasis on interpersonal elements of the perfectionism construct (Parker &
Adkins, 1995b). Despite their differences, Frost, Heimberg, Holt, Mattia & Neubauer
(1993) considered there to be a considerable degree of overlap between the two scales.
These authors found that the nine dimensions (six from the MPS-F and three from the
MPS-HF) could be reduced to a two factor solution which they labelled; “Maladaptive
Evaluative Concerns” which was identified as reflecting the negative/maladaptive traits of
perfectionism and “Positive Strivings” which reflected the positive/adaptive traits.
Considerable empirical investigations examining the possible correlates of both types of
perfectionism have been carried over out over the years in an attempt to validate the
perfectionism construct as both adaptive and maladaptive. Although different labels
(positive/negative, functional/dysfunctional, active/passive, normal/neurotic and
healthy/unhealthy) have been used to refer to the two types of perfectionism, the majority
of studies have utilised a combination of the original facets identified by Frost et al (1993),
(Bieling, Israeli & Antony, 2004; Beiling et al, 2003; Chang et al, 2004; Cox et al, 2002;
Dunkley, Blankstein, Masheb & Grillo, 2006; Dunkley, Zuroff & Blankstein, 2003; Enns
et al, 2001; Hill, Huelsman, Furr et al, 2004; Lynd-Stevenson & Hearne, 1999; Parker &
Stumpf, 1995; Rice, Ashby & Slaney, 1998; Suddarth & Slaney, 2001).
Slade and Owens’ (1998) Dual Process Model has provided a theoretical explanation for
the distinction between the dimensions of adaptive and maladaptive perfectionism. The
model was based on Skinner’s (1968) theories of positive and negative reinforcement.
Slade and Owens focussed on the motivational tendencies driving the perfectionistic
16
behaviours and suggested that there were fundamental differences in the way that
perfectionists approached tasks. Positive or adaptive perfectionists possessed a desire to
‘approach’ (pursue) situations or challenges whereas negative perfectionists were
motivated to “avoid” (escape) situations. Positive perfectionists were believed to gain
satisfaction, gratification and even elation in response to success whereas negative
perfectionists were seen to be reluctant to ‘let themselves go’ possibly due to an awareness
that “failure could be just around the corner” (Slade & Owens, 1998). Slade and Owens
even went as far as to say that positive perfectionism was considered to be healthy and
advantageous for the individual and therefore should be encouraged and promoted.
Negative perfectionism, on the other hand, was viewed as unhealthy personality trait and
something that should definitely be eluded and remedied. Within the model, individuals
were considered to be jointly motivated by both the positive and negative aspects of
perfectionism. Much of the support for this model was derived from the literature on eating
disorders and field of sport psychology (e.g. Frost & Henderson, 1991; Terry-Short,
Owens, Slade & Dewey, 1995).
The multidimensional approach has not been received without criticism. The factor
structure of the Frost et al (1990) MPS has been repeatedly questioned (Parker & Adkins,
1995; Rhéaume, Freeston, Ladouceur et al, 1995; Stober, 1998) and various suggestions
have been made to adjust the number of factors (e.g. Stober, 1998; Stumpf & Parker,
2000). In terms of the Hewitt and Flett (1991a) MPS, the main criticism has been that
some of the dimensions are not relevant in a clinical setting, specifically when considering
the associations between perfectionism and psychopathology (Shafran, Cooper & Fairburn,
2002). Despite the criticisms, these two conceptualisations represent two of the most
widely utilised perfectionism scales in both clinical and non-clinical settings.
2.1.3 Definitional Issues and Controversies
There is no doubt that the two multidimensional perfectionism scales have been
instrumental in generating considerable research in the perfectionism field, however, the
absence of a universally accepted conceptualisation/definition has led to some confusion
and inconsistency in the research literature and has meant that researchers have needed to
be very clear about the specific conceptualisations and methods that they are utilising so
that the results of studies can be interpreted correctly. Two particular concerns have arisen
in the research field; firstly, what is gained from subdividing perfectionism into its two
17
component parts (adaptive and maladaptive)? And secondly, can perfectionism ever really
be described as a positive construct? These two themes have infiltrated the perfectionism
literature over the past few decades and despite the emergence of yet more
conceptualisations in recent years, still continue to be debated.
To subdivide perfectionism the majority of studies have used either a dimensional or group
based approach. The dimensional approach has been described as one where the facets of
perfectionism have been amalgamated to produce two independent dimensions e.g.
labelled ‘perfectionistic strivings’ (positive features of perfectionism such as high personal
standards and self-oriented perfectionism) and ‘perfectionistic concerns’ (maladaptive
features of perfectionism such as concern over mistakes, doubts about actions, perceived
discrepancy between high expectations and actual achievements and socially prescribed
perfectionism). The group based approach involves combining the elements of
perfectionism to produce two groups of perfectionists e.g. labelled healthy and unhealthy
perfectionists (Stoeber & Otto, 2006).
Stoeber and Otto (2006) conducted an extensive review of thirty five studies that followed
either a dimensional or group based approach and on the basis of their findings developed
a further conceptual framework for defining and conceptualising perfectionism. The
Tripartite Model was based on an amalgamation of elements from both the dimensional
and group based approaches. Three groups were identified; ‘healthy perfectionists’ who
were identified as having “high perfectionistic strivings” and “low perfectionistic
concerns”; ‘unhealthy perfectionists’ who were identified as possessing “high
perfectionistic strivings” and “high perfectionistic concerns” and ‘non-perfectionists’ who
were identified as having “low perfectionistic strivings” and “low perfectionistic
concerns”. Stoeber and Otto (2006) felt that ‘perfectionistic concerns’ may be the crucial
factor differentiating a healthy pursuit of high standards from the clinical forms of
perfectionism.
18
Table 2.1.3 The Tripartite Model of Perfectionism (Stoeber & Otto, 2006)
Subtype of perfectionism
Perfectionistic
Perfectionistic concerns**
strivings*
Non-perfectionism1
Low
Low
Healthy perfectionism
High
Low
Unhealthy perfectionism
High
High
*Perfectionistic Strivings – positive features of perfectionism
**Perfectionistic Concerns – negative features of perfectionism
The motivations behind the need to subdivide perfectionism appear to be related to the
desire to find out if there is a healthy type of perfectionism that has the potential to bring
with it particular benefits to health and wellbeing (this will be discussed in more detail in
part 2 of this chapter). Unfortunately it would appear that a lack of consensus in the
literature has made it difficult to say with any certainty that there may be a positive and
healthy form of perfectionism. In discussing their theoretical framework, Stoeber and Otto
(2006) felt that despite incorporating aspects of the adaptive perfectionism traits into their
model, that it would be too early (due to the lack of consensus in the research literature) to
describe perfectionism as adaptive or functional and felt the terms ‘healthy’ and
‘unhealthy’ were more appropriate.
The work of Stoeber and Otto (2006) represented a tangible method of amalgamating some
of the existing conceptualisations to produce a new formulation for explaining the
dimensions of perfectionism, however, as more methods continue to emerge (e.g. Egan et
al, 2011; Gaudreau & Thompson, 2010) it has yet to be established whether have added
clarity to the situation or further complicate matters by providing yet more ways of
defining and subdividing the perfectionism construct.
From a treatment perspective, being able to subdivide perfectionism to be able to identify
the relative levels of adaptive and maladaptive dimensions within an individual may have
important implications. Flett & Hewitt (2006) suggest that some perfectionists may have
specific difficulties that stem from the competing tendencies associated with the desire to
both approach and avoid situations, therefore it could be argued that finding out the
1
Although not made explicit in their model, Stoeber and Otto also identified individuals with low levels of perfectionistic strivings
(adaptive traits) and high levels of perfectionistic concerns (maladaptive traits) to fall within the category of non-perfectionism
19
relative contribution of each type of perfectionism be particularly important. The need to
gauge the relative contribution of both adaptive and maladaptive tendencies has been
supported by Sorotzkin (1998) who identified the coexistence of both depressive and
narcissistic tendencies in many perfectionists and suggested that individuals may struggle
from a treatment point of view because they are likely to have cognitive and behavioural
conflicts that result from the two competing tendencies.
The second issue of whether perfectionism can justifiably be classified as an adaptive or
healthy trait has not been resolved and therefore remains a potential problem from both a
theoretical and practical standpoint. From a personality perspective, adaptive perfectionism
has been associated with the personality dimensions of conscientiousness (Hill, McIntire &
Bacharach, 1997; Stumpf & Parker, 2000), extraversion and openness (Ulu & Tezer,
2010). This has led to the suggestion that what has been described as adaptive or positive
perfectionism is simply just a type of conscientiousness of an achievement striving
dimension of personality (e.g. Flett & Hewitt, 2006). Flett and Hewitt have questioned
whether perfectionism can ever be considered healthy as they have failed to identify any
empirical evidence that has convinced them that the adaptive dimension of perfectionism
may be related to positive emotions such as fulfilment, elation and contentment. Similar
inconsistencies have been noted when looking at research that has explored the
relationship between perfectionism and life-satisfaction (Enns et al, 2001; Mitchelson &
Burns, 1998).
In support of a healthy and adaptive subtype of perfectionism, Slade and Owens (1998)
have provided suggestions for the motivations behind the different perfectionism
dimensions. Adaptive perfectionists, they argue, are motivated to act and behave in
particular ways because they are driven by a desire for success. Flett and Hewitt (2006)
have argued against this suggestion, claiming that Slade & Owens’ explanation
oversimplifies the underlying thought processes of adaptive perfectionists. Their belief
(Flett and Hewitt) is that if an adaptive or positive type of perfectionism exists, then the
underlying motivations are fuelled jointly by “a desire for success and a fear of failure”, (p.
481). Slade and Owens (1998) have also maintained that adaptive perfectionists are able to
deal with setbacks and achievement failures, however, Flett and Hewitt (2006) have also
disputed this suggestion, stating, from their own research that self-oriented perfectionists
(often considered to represent a more adaptive form of perfectionism) may be at risk of
20
developing depression when they experience achievement setbacks of failures (Hewitt and
Flett, 2002).
There is a considerable body of research that has found associations between the adaptive
dimension of perfectionism and negative outcomes such as higher levels of perceived
hassles (Dunkley, Blankstein, Halsall et al, 2000), decreased levels of wellbeing and
perceived social support networks (Hill et al, 2004) as well as negative affect, experienced
as depression, neuroticism and anxiety (Bieling et al, 2004; Cox et al, 2002; Enns et al,
2001). After a critical review of the literature looking at whether perfectionism can bring
with it benefits to health, Greenspon (2000) concluded there to be “no factual or theoretical
basis for such a claim” (p.197). He went on to assert that
“the recent broad acceptance of the term healthy perfectionism is based neither on logical
argument nor on scientific reasoning, but rather on uncritical acceptance of assertions
made in the literature on perfectionism” (p. 202).
Stoeber and Otto (2006) suggest that the situation of whether perfectionism can be
considered healthy and adaptive cannot be resolved because of a number of ambiguities in
the research literature all of which all point to a lack of consistency across studies; firstly,
studies have utilised a multitude of different labels, features and combinations of features
to define and conceptualise perfectionism. Secondly, studies have used either a group
based or dimensional approach to subdividing perfectionism into adaptive/healthy and
maladaptive/unhealthy components and finally, not all studies have found an association
between the adaptive/healthy dimension of perfectionism and positive characteristics and
there are some studies that have achieved mixed results, i.e. an association with both
positive and negative characteristics, (e.g. Bieling et al, 2003; Cox et al, 2002; Dunkley et
al 2000; Enns et al, 2001).
It has been generally accepted that research linking the adaptive/positive forms of
perfectionism with potentially positive outcomes has not been as consistent as research
that has linked the maladaptive/negative forms of perfectionism with various negative
outcomes (see part 2 of the present chapter). Some believe that this may be due to the
possible overlap between the dimensions of positive and negative perfectionism¸ for
example Stoeber and Otto (2006) have highlighted the fact that research focussing on the
adaptive form of perfectionism may be compromised by a coexisting level of maladaptive
21
perfectionism and therefore correlations between adaptive perfectionism and negative
outcome may become over inflated.
Clearly a resolution of whether a healthy form of perfectionism really exists needs to be
reached. The implications of identifying a so called adaptive/positive/healthy/functional
form of perfectionism leading to positive outcomes for the individual may have positive
implications in the management and treatment of extreme forms of perfectionism and
accompanying psychopathology (Flett & Hewitt, 2006). Before we can fully accept that an
adaptive form of perfectionism exists it seems that we would need to be able to say
unequivocally that what has been described as ‘adaptive perfectionism’ constitutes a
distinct subtype of the perfectionism construct and not simply an extreme form of
achievement striving or conscientiousness. On the positive side, the lack of consensus in
the research literature has led to the development of a number of recent conceptualisations
that may have helped to shed some light on these definitional issues and controversies.
2.1.4 Current conceptualisations
On the positive side, the lack of consensus in the research literature has led to the
development of a number of conceptualisations that have gained popularity in recent years.
At present, three of the most utilised conceptualisations in the research literature are the 2
x 2 model (Gaudreau and Thompson, 2010), a Cognitive Behavioural Model of Clinical
Perfectionism (Shafran, Cooper & Fairburn, 2002) and the Transdiagnostic Model
(Shafran, Egan & Wade, 2010).
The 2 x 2 Model of Dispositional Perfectionism
In developing their model, Gaudreau and Thompson (2010) felt that previous approaches
had focussed solely on the associated outcomes of the core facets of perfectionism rather
than how the dimensions were structured and additionally how these two dimensions
might be integrated within each individual. To address this shortfall, Gaudreau and
Thompson formulated a model that focussed on the potential integration of the core
dimensions of perfectionism. Conceptually the model was similar to the Tripartite Model
of Perfectionism (Stoeber & Otto, 2006) in that it recognised and supported a need to
address the interactive effects of the two dimensions of perfectionism (adaptive and
maladaptive) rather than concentrate on the core facets on perfectionism individually. Two
general dimensions were identified; Evaluative Concerns Perfectionism (ECP) and
22
Personal Standards Perfectionism (PSP). ECP has been described as “a socially prescribed
tendency to perceive that others are exerting pressure to be perfect, combined with a
propensity to evaluate oneself harshly and to doubt one’s capacity to progress towards
elevated standards” and PSP has been described as “the self-oriented tendency to set
highly demanding standards and to consciously strive for their attainment”, (Gaudreau &
Thompson p. 532). The focus of the model was on the within-person combinations of these
two broad dimensions.
Table 2.4
The 2 x 2 Model of Dispositional Perfectionism (Gaudreau & Thompson,
2010)
EVALUATIVE CONCERNS PERFECTIONISM **
LOW
HIGH
HIGH
STANDARDS
MIXED PERFECTIONISM
PERFECTIONISM
PURE EVALUATIVE
LOW
PERSONAL STANDARDS
PERFECTIONISM *
PURE PERSONAL
NON-PERFECTIONISM
CONCERNS
PERFECTIONISM
*Personal Standards Perfectionism – encompasses more of the adaptive traits of perfectionism
**Evaluative Concerns Perfectionism – encompasses more of the maladaptive traits of perfectionism
The model has proposed four subtypes of dispositional perfectionism; the first, nonperfectionism, refers to individuals who possess low levels of both personal standards
perfectionism and evaluative concerns perfectionism. Such individuals have been
described as not being directed by perfectionistic strivings and do not feel that significant
others and expecting them to meet high standards. The second subtype, pure personal
standards perfectionism, refers to an internally regulated subtype of perfectionism which
according to Gaudreau and Thompson (2010) is (the category) “at the heart of the debate
23
about the healthy or unhealthy nature of perfectionism” (p. 533), where individuals possess
high levels of personal standards perfectionism but low levels of evaluative concerns
perfectionism. The third category, pure evaluative concerns perfectionism, describes
individuals who have a type of externally driven perfectionism whereby the individual is
primarily influenced by pressures inherent in the social environment (low personal
standards perfectionism/high evaluative concerns perfectionism). The final category,
mixed perfectionism refers to a partially internally regulated category of perfectionism
which is characterised by individuals who have high levels of both evaluative concerns
perfectionism and personal standards perfectionism. These individuals are influenced
jointly by the perceived pressure from others as well as the need to strive and achieve for
themselves.
Although sharing a number of similarities with the tripartite model of perfectionism
(Stoeber & Otto, 2006), the Gaudreau and Thompson (2010) model does have one
fundamental difference which concerns the dimension of non-perfectionism; in the
tripartite model there are two formulations for non-perfectionism; firstly an amalgamation
of low levels of both ECP and PSP (similar to the 2 x 2 model) but also a combination of
low PSP and high ECP (which Gaudreau and Thompson have labelled “pure evaluative
concerns perfectionism”). Gaudreau and Thompson suggest that it is impossible to label
the second category as non-perfectionism because the “two subtypes are etiologically and
functionally distinct” (p. 533).
Testing of the 2 x 2 model (by Gaudreau & Thompson, 2010) has revealed that the subtype
of pure evaluative concerns perfectionism was associated with lower general positive
affect, lower academic self-determination, lower academic goal progress, lower academic
satisfaction and higher negative affect when compared to the subtype of nonperfectionism. Further to this, the subtype of pure evaluative concerns perfectionism
produced the most negative outcomes when compared to all the other subtype of
perfectionism. These findings are contrary to the findings of Stoeber and Otto (2006) who
identified a subtype possessing high levels of both perfectionistic striving and
perfectionistic concerns to (which matches the Gaudreau and Thompson category of mixed
perfectionism) to be the most unhealthy and maladaptive type of perfectionism.
A potential rational for the category of ‘pure evaluative concerns’ being more maladaptive
and unhealthy than the category of ‘mixed perfectionism’ has been proposed by recent
24
research (Altstötter-Gleich, Gerstenberg & Brand, 2012) that has explored the underlying
functions of the ‘perfectionistic strivings’ and ‘perfectionistic concerns’ dimensions of
perfectionism. Findings indicated that whilst ‘perfectionistic concerns’ represented an
inherent vulnerability factor due to an underlying relationship with stress related processes,
‘perfectionistic strivings’ was found to have a potentially protective or buffering effect. If
this is true, then it makes sense that possessing high levels of both evaluative concerns
perfectionism and personal standards perfectionism (Gaudreau and Thompson, 2010)
would be considered more adaptive overall, because the high levels of the adaptive
perfectionism traits could potentially or neutralise of cancel out the deleterious effects of
the maladaptive dimensions. It then follows, as Gaudreau and Thompson’s model has
supported, that the category of pure evaluative concerns perfectionism (low PSP, high
ECP) would be more maladaptive as the negative consequences of the high levels of
maladaptive perfectionism are not buffered by any of the adaptive traits.
Focussing on the potential adaptiveness of perfectionism, Gaudreau and Thompson (2010)
found the subtype of pure personal standards perfectionism (high PSP/low ECP) to be
associated with the most favourable outcomes (when compared with non-perfectionists)
which included higher levels of; self-determination, academic satisfaction, academic goal
progress and general positive affect. These results support the association between positive
perfectionism and possible benefits to psychological wellbeing. These results also support
the dualistic model proposed by Slade and Owens (1998) purporting a positive type of
perfectionism being associated with a willingness to approach challenges and
responsibilities.
A small number of studies, predominantly in the sport domain, have tested and supported
the 2 x 2 model of dispositional perfectionism (Cumming & Duda, 2012; Gaudreau &
Verner-Filon, 2012; Hill, 2013). The 2 x 2 conceptualisation, focussing on both the
adaptive and maladaptive domains of the perfectionism construct appear to have proved
beneficial in this context because there seems to have been a maladaptive bias when
addressing many of the difficulties concerning perfectionism in sport (Stoeber, 2014).
Although some authors have only provided partial support for the model (e.g. Hill &
Davis, 2014) most would agree that it represents a useful framework through which to
understand and explain the interactive effects of the different components of
perfectionism.
25
Cognitive Behavioural Model of Clinical Perfectionism
Broadening and supporting the area of clinical perfectionism, Shafran et al, (2002) have
developed a conceptualisation of clinical perfectionism encompassing a cognitive
behavioural framework. According to these authors, clinical perfectionism within a
cognitive behavioural perspective represents a unidimensional construct focussing on;
“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”, (Shafran et al, 2002).
Although it has been suggested that at least one domain may be affected, Shafran et al
(2002) state that clinical perfectionism has the potential to affect multiple life domains.
With clinical perfectionism the main focus has been concerned with the distorted way that
individuals evaluate their personal standards and associated performance. If self-imposed
standards are not achieved, this is interpreted as a personal failure with harsh self-criticism
likely to ensue. If on the other hand, standards are achieved, the individual is likely to reevaluate them as not being demanding enough in the first instance. Perfectionists are
considered to spend a disproportionate amount of time attending to their failures and not
really noticing or congratulating themselves when they have done a good job or been
successful at their endeavours (Shafran et al, 2002). According to Shafran and colleagues
the dysfunctional consequences of clinical perfectionism are endured because “the
person’s self-evaluation is contingent on the pursuit of attainment of their goals” (p. 778).
This suggests that an individuals’ self-belief and self-worth are inextricably linked to their
achievement of their goals. The unpleasant consequences, according to Shafran et al are
tolerated because they provide feedback and confirmation to the perfectionist that they are
continuing to push themselves (Shafran et al, 2002).
Within the clinical conceptualisation, Shafran et al (2002) have focussed on a number of
cognitive processes that they consider contribute to the maintenance of perfectionism e.g. a
morbid fear of failure, dichotomous thinking, the need for self-control, harsh evaluation of
performance (negative self-evaluation), discounting of successes and the reappraisal of
standards as being too low if they are reached. Historically, cognitive processes have been
implicated in the maintenance of perfectionism. Hollender (1965), for example, observed
26
that perfectionists were prone to selectively attend to certain features of their surroundings.
He stated that the individual is
“constantly on the alert for what is wrong and seldom focuses on what is right. He looks
so intently for defects or flaws that he lives his life as though he were an inspector at the
end of a production line” (p. 95).
In developing their model, Shafran et al (2002) noted the role of perfectionism in the
aetiology, continuation and development of certain psychopathological states such as
anorexia nervosa and bulimia nervosa (Fairburn, Cooper, Doll & Welch, 1999; Lilenfeld,
Stein, Bulik, Strober, Plotnicov, Pollice, et al, 2000). The coexistence of perfectionism
with various Axis I and Axis II disorders such as eating disorders, depression and
obsessive-compulsive personality disorder have also been identified within the cognitive
behavioural model of clinical perfectionism (Shafran et al, 2002; Shafran et al, 2003). In
terms of treatment outcomes, these authors have noted there to be evidence of
perfectionism being counterproductive in relation to the effective management and
treatment of depression (Blatt, Zuroff, Bondi, Sanislow & Pilkonis, 1998). Treatment
issues will be discussed further in chapter 2, part 2.
Shafran et al (2002) have taken issue with the multidimensional approach to measuring
and conceptualising perfectionism. These authors feel that perfectionism as defined by the
multidimensional methods presents a conceptualisation that measures too broad a range of
features than those realistically encountered by clinicians. According to Shafran and
colleagues, only some of the dimensions have relevance in a clinical setting such as “selforiented perfectionism” (from the MPS-HF), the “personal standards” subscale and some,
though not all items of the “concern over mistakes” subscale (of the MPS-F). The other
dimensions are considered by these authors to detract from the clinical picture.
Although noting their contribution to the literature on perfectionism, Hewitt et al (2003)
have criticised the definition of clinical perfectionism put forth by Shafran et al (2002).
These authors (Hewitt et al, 2003) have identified a number of concerns with the clinical
approach; Firstly they take issue with Shafran and colleagues’ suggestion that the
interpersonal dimensions of perfectionism are not relevant to clinical perfectionism, Hewitt
et al (2003) have argued that the multidimensional orientation can help to understand
concepts such as “fear of failure”, something that is central to the clinical model of
perfectionism proposed by Shafran et al (2002). Secondly, Hewitt et al (2003) argue that
27
the clinical model makes only limited references to cognitive processes despite presenting
a cognitive framework for conceptualising perfectionism. They have argued that the model
has not taken into consideration other relevant research focussing on cognitive processes
such as rumination (Frost & Henderson, 1991; Frost, Trepanier, Brown, Heimberg, Juster,
Makris, & Leung, 1997) and the individual differences in automatic thoughts (Flett,
Hewitt, Blankstein & Gray, 1998). Finally Hewitt et al (2003) have suggested that the
clinical model should not place its focus on only one significant life domain,
“although concerns about being imperfect in just one life domain can be quite distressing
for individuals, we believe that even greater dysfunction is likely among people who strive
for perfection in multiple domains, despite negative consequences” (Hewitt et al, 2003, p.
1228-1229), and “by definition, the study of perfectionism as a personality trait implies
generalisation across situations and life domains” (p. 1229).
In response to the criticisms, a revised version of the cognitive-behavioural model
(Shafran, Egan & Wade, 2010) considered the role of performance related behaviours and
their function in the maintenance cycle of clinical perfectionism. Such behaviours have
been identified as procrastination, avoidance and excessive checking of performance.
The Transdiagnostic Model
The cognitive behavioural model of clinical perfectionism (Shafran et al, 2002; Shafran et
al, 2010) paved the way for understanding perfectionism from a transdiagnostic
perspective. Over the past two decades perfectionism has repeatedly been associated with
the cause, maintenance and progression of various adjustment difficulties such as anxiety,
depression and eating disorders (e.g. Antony, Purdon, Huta & Swinson, 1998; Flett,
Besser, Davis & Hewitt, 2003; Shafran et al, 2002; Sutander-Pinnock, Woodside, Carter et
al, 2003). Based on an extensive review of the available literature, Egan, Wade and
Shafran (2011) formulated the conceptualisation of perfectionism as a transdiagnostic
process. Transdiagnostic literally means “across diagnosis” and translates as an approach
that concentrates on several symptoms and trends that seem to occur across several
diagnostic classifications. Their formulation has gone beyond the basic definition (of a
transdiagnostic process) to also incorporate risk and maintaining factors.
Egan and colleagues have identified a number of important factors that provide support for
their formulation of perfectionism. Firstly perfectionism has been found to be elevated
28
across a variety of disorders including depression (e.g. Blatt, 1995; Hewitt and Flett,
1991), eating disorders (e.g. Lilenfeld et al, 2000; Sassaroli, Lauro, Ruggiero, Mauri,
Vinai, & Frost, 2008), obsessive compulsive disorder (e.g. Frost, Novara & Rhéaume,
2002), panic disorder (e.g. Antony et al, 1998), anxiety disorders (e.g. Frost & Dibartolo,
2002) and personality disorders (e.g. Halmi, Tozzi, Thornton, et al, 2005). Secondly,
perfectionism has been identified as being an explanatory and underlying factor for the cooccurrence of various disorders. This has been supported by research looking at
perfectionism, anxiety and mood disorders (Bieling et al, 2004). Thirdly, perfectionism has
been identified as a maintaining factor in the cognitive conceptualisations of various
disorders such as eating disorders (Fairburn, Cooper & Shafran, 2003) and social phobia
(Heimberg, Juster, Hope & Mattia, 1995). This is also supported by the model of “Clinical
Perfectionism” (Shafran et al, 2002) which identifies perfectionism as a maintaining factor
for a wide variety of psychopathologies. Finally, evidence from studies addressing the
impact of perfectionism on treatment outcomes has found that perfectionism can have a
negative impact on treatment outcomes e.g. in the case of eating disorders, raised
perfectionism scores have been related to a worse prognosis after admission (Bizuel,
Sadowsky & Rigaud, 2001) and treatment drop-out rate (Sutandar-Pinnock et al, 2003). In
relation to treatment for depression, data from the National Institute of Mental Health,
Treatment of Depression Collaborative Research Program identified perfectionism to
predict a worse response to treatment across all patient groups when tested post treatment
and at follow up (NIMH, Elkin, Shea, Watkins, Imber, Sotsky, Collins et al, 1989).
According to Macedo, Marques & Pereira (2014), viewing perfectionism as a
transdiagnostic process has implications in terms of helping individuals who are suffering
from the extreme or maladaptive consequences of being highly perfectionistic. The result
of treating one area of dysfunction is likely to have a knock on effect in relieving
symptoms in multiple areas of an individuals’ life. A treatment approach that embodies
multiple domains rather than focusing on a single disorder has been identified as being a
promising avenue for the treatment of perfectionism (Egan, Shafran & Wade, 2010) and
has also been highlighted as a more flexible and transferable approach (McHugh, Murray
& Barlow, 2009).
29
2.1.5 Conclusion to part 1
The way that perfectionism has been defined and conceptualised has been debated
considerably over the past few decades. The major shift in the 1990s was a move from a
predominantly negatively oriented unidimensional perspective to a more balanced view;
identifying and supporting both the adaptive and maladaptive facets of the perfectionism
construct within a multidimensional framework. Other ways of defining and
conceptualising perfectionism have emerged in recent years and there are currently a
number of dominant conceptualisations that are represented within the research literature,
predominantly focussed on viewing perfectionism in a clinical context. On the positive
side, the plethora of conceptualisations/definitions has meant a huge increase in this
research area and led to multiple studies purporting to add clarity and support for the
existing formulations as well as studies that have led to the development of yet more
methods of defining perfectionism. The downside of this, however, has been a level of
confusion for researchers concerning which definitions and formulations to choose.
Perhaps it is the case that the multiplicity of conceptualisations has resulted in further
confusion and actually diverted attention away from reaching a universally accepted
definition? From a practical point of view, considering health and treatment implications,
the particular definition or conceptualisation employed can have profound consequences
for treating individuals who are struggling to deal with clinical perfectionism or extreme
levels of maladaptive perfectionism. The problem has been compounded by the fact that
there is also no recognised and accepted method of subdividing the construct in terms of
the trait dimensions of adaptive and maladaptive perfectionism and still no agreement
reached over the possible adaptiveness of the perfectionism construct. With the clinical
and transdiagnostic approaches gaining prominence, and the suggestion that there may be
fundamentally distinct cognitive and behavioural processes that underlie the two
dimensions of perfectionism (adaptive and maladaptive), perhaps we are at last getting
closer to reaching an agreement about the most comprehensive approach to defining the
personality construct of perfectionism.
30
2.2 The Relationship between Perfectionism, Health and Health Behaviours
The research area concerning perfectionism and health has been dominated by studies that
have supported the association between the maladaptive dimensions of perfectionism and
negative health outcomes (both psychological and physical). This review intends to
provide a synopsis of these areas as well as bring together a number of other research areas
that may have implications for the perfectionism – health relationship, these include; a
summary of the relationship between perfectionism and stress, the self-presentational
aspect of perfectionism in relation to health, perfectionism and health behaviours, treating
perfectionists and finally a return to the debate over whether there is an adaptive type of
perfectionism that can be beneficial to health and wellbeing. The intended purpose of this
literature review is to bring together a number of carefully selected strands of research that
have not been brought together before, to answer two main questions;
1. Do maladaptive perfectionists represent a high risk group in terms of health and
wellbeing?
2.
Is there an adaptive type of perfectionism that is beneficial to health and
wellbeing?
By providing answers to these questions, the intention is to identify a potential gap in the
research literature and provide justification for exploring whether perfectionists actively
take steps to look after their health and wellbeing as well as the types of factors that may
interfere with their ability to do so. Additionally by providing support for there being a
potentially adaptive or protective aspect to the perfectionism construct, this will provide
valuable information concerning how these specific traits can be fostered and nurtured to
help maladaptive perfectionists take better care of themselves.
2.2.1 Perfectionism and Psychopathology
There is a well-established relationship between the maladaptive elements of the
perfectionism construct and negative psychological functioning (see Blatt, 1995; Chang,
2003; Pacht, 1985; Flett & Hewitt, 2002; Shafran & Mansell, 2001). Perfectionism has
been identified as playing a pivotal role in the aetiology, continuation and progression of a
range of psychopathological disorders such as depression, anxiety and eating disorders
(Shafran & Mansell, 2001; Shafran et al, 2002).
31
The transdiagnostic model of perfectionism (Egan et al, 2011) described earlier in this
chapter has identified an increase in perfectionism across a range of disorders and has
identified that perfectionism increases susceptibility to certain conditions such as eating
disorders. Perfectionism has been found to predict treatment outcomes for a range of
disorders including depression, social anxiety and Obsessive Compulsive Disorder (for a
review see Egan et al, 2011). Perfectionism has also been identified as a potential amplifier
of suicide risk (see Flett et al, 2014) and furthermore, it has been identified that in an
attempt to self-present a perfect and flawless persona, perfectionists often conceal the
extent of their difficulties from others which makes it difficult to gauge the extent of the
problem (Flett et al, 2014).
Depressive disorders
Blatt (1995) was one of the early researchers to acknowledge the potentially harmful role
of perfectionism in depression. One of the main problems for perfectionists seems to be
that they become embroiled in a self-defeating cycle of pushing themselves continually to
achieve impossible standards, whilst never really acknowledging their successes or feeling
any sense of satisfaction from their efforts (Blatt, 1995). As a result, perfectionists become
burdened with the constant pressure of trying to avoid failure, which according to Blatt,
will inevitably lead to increases in negative affect and distress and make them vulnerable
to depression. Enns & Cox (2002) have also identified the presence of exceptionally high
standards to affect the quantity and intensity of perceived failures with in turn often leads
to depression.
A more recent examination of the relationship between perfectionism and depression has
identified that the two dimensions of perfectionism may be differentially related to
depressive symptoms (Flett, Hewitt, Blankstein & Mosher, 1995). The strongest
association between perfectionism and depression has been demonstrated for the
dimension of socially prescribed perfectionism2. Socially prescribed perfectionists feel that
standards and expectations are being imposed upon them by external sources (Hewitt &
Flett, 1990, 1991a, 1991b). Such is the need for these perfectionists to gain the esteem and
acceptance of others, that they often feel the only course of action is to push themselves
harder and harder to meet these high standards. Individuals who experience this type of
2
Socially prescribed perfectionism is one of the perfectionism dimensions formulated by Hewitt and Flett, 1991a. This perfectionism
dimension is considered to represent a maladaptive type of perfectionism.
32
perfectionism often have the perception that these external expectations are out of their
control and as a consequence seem more likely to experience feelings of helplessness and
hopelessness which are often related to depression and suicidal ideation. Research
supporting this notion has been demonstrated using both clinical and non-clinical samples
(Enns & Cox, 1999; Hewitt & Flett, 1991a; Hewitt, Flett & Ediger, 1996).
Self-oriented perfectionism, (involving individuals’ imposing unrealistically high
standards and expectations upon themselves) is a type of perfectionism that has been
associated with both positive and negative outcomes. Although this dimension of
perfectionism has been associated with improved psychological functioning (Frost et al,
1993), there has also been the suggestion that under certain circumstances, (i.e. the
presence of negative life events) this type of perfectionism can become maladaptive
(Hewitt & Flett, 1991b). The diathesis-stress model of perfectionism and depression has
been proposed as a potential explanation for the disparity in findings concerning the
dimension of self-oriented perfectionism (Hewitt & Flett, 1993) and depression. According
to the model, when perfectionism combines with life stress, it has the potential to become
maladaptive, leading to depressive symptomatology (Hewitt & Flett, 1991b). There has
been considerable support for the model (e.g. Hewitt & Flett, 1993; Flett et al, 1995) and
findings suggest that self-oriented perfectionism may have adaptive health enhancing
qualities up to a point (when daily stress levels are at a minimum), however, if stress levels
increase for any reason, this may increase the risk of developing depressive symptoms or
enhancing existing psychopathology (Hewitt & Flett, 1993; Flett et al, 1995).
2.6.2: Anxiety Disorders
There is a considerable amount of research that has explored the relationship between
perfectionism and anxiety disorders such as Obsessive Compulsive Disorder (OCD) and
social phobia (Antony et al, 1998). Perfectionism has been identified as a risk factor in the
development of OCD (The Obsessive Compulsive Cognitions Working Group, 2003) and
as levels of OCD increase, researchers have identified an associated rise in levels of
perfectionism (Reuther, Davis, Rudy et al, 2013). It would appear that OCD sufferers may
find themselves in a vicious cycle where the desire for perfectionism and certainty in their
actions leads them to have increased doubts about their actions, which leads to a rise in
uncertainty and then more checking behaviours. Frost & Steketee, (1997) have stated that
“doubting the quality of one’s actions has been a hallmark of OCD and indeed may reflect
33
symptoms of patients checking rituals”, (p. 294). A similar pattern is evident for social
anxiety. The primary insecurity behind social anxiety is that social situations have the
potential to be unsafe and therefore individuals rationalise that the only way to stay safe
and to avoid social humiliation is to set very high standards of performance to work
towards (Heimberg et al, 1995). Unfortunately for these individuals, the standards set are
often completely out of reach and this often results in an increase in worry about achieving
the expected standard, which in turn reinforces the core beliefs that are driving the disorder
(Shafran & Mansell, 2002).
In terms of addressing how the adaptive and maladaptive dimensions of perfectionism are
related to anxiety disorders, research has supported the presence of high levels of the
maladaptive perfectionism traits in both social anxiety (Juster, Heimberg, Frost et al, 1996;
Faccenda 1996; Saboonchi & Lundh, 1997) and OCD (Bardone-Cone, Wonderlich, Frost,
Bulik, Mitchell, Uppala et al, 2007. One of the most significant findings for anxiety
disorders is that they appear to show little elevation in the achievement striving/positive
dimension of perfectionism when compared to individuals with depressive disorders
(Bardone- Cone et al, 2007). A number of studies have specifically addressed this by
comparing groups of individuals with anxiety and depressive disorders. Results have
indicated that both groups show similarities on the maladaptive dimensions of
perfectionism but when compared on the achievement striving/positive dimension,
individuals with depressive disorders had much higher scores than the anxiety disorders
group (Hewitt & Flett, 1991b; Norman, Davies, Nicholson, Cortese & Malla, 1998).
Referring back to the conceptualisations and definitions of perfectionism discussed earlier
and specifically the formulations that have considered the interactive and within-person
combinations of both adaptive and maladaptive dimensions (Gaudreau & Thompson,
2010; Stoeber & Otto, 2006), it may be that the psychological burden of anxiety disorders
is greater than for depressive disorders because of the interactive combination of high
levels of the maladaptive dimension accompanied by low levels of the adaptive dimension.
For depressive disorders perhaps there is some compensation to having high levels of both
adaptive and maladaptive dimensions of perfectionism.
34
Eating disorders
There is a long history of perfectionism being implicated as an important factor in the
eating disorders literature from both a theoretical and phenomenological perspective
(Shafran & Mansell, 2001). Perfectionism has been related to the onset, continuation and
progression of both anorexia nervosa (AN) and bulimia nervosa (BN), (Bardone-Cone et
al, 2007; Bieling et al, 2004; Fairburn et al, 2003) and has repeatedly been identified as a
key influence for individuals trying to attain the ideal body weight (Goldner, Cockell, &
Srikameswaran, 2002). Research involving both clinical and non-clinical samples has
identified AN sufferers to have elevated perfectionism scores compared to healthy controls
(Bastiani, Rao, Weltzin & Kaye, 1995; Slade & Dewey, 1986) and both the adaptive and
maladaptive dimensions of perfectionism have been implicated with respect to eating
disorder symptoms (Hewitt et al, 1995; Minarik & Ahrens, 1996).
In an extensive review of the literature concerning the relationship between perfectionism,
eating disorders and other psychopathology, Bardone-Cone et al (2007) identified a
number of important factors concerning both AN and BN sufferers; firstly, Individuals
with AN and BN presented with higher mean levels of perfectionism (as measured by the
EDI – Eating Disorders Inventory, Olmsted et al, 1983) when compared to healthy controls
(e.g. Halmi, Sunday, Thornton, Crow, Fichter, Kaplan et al, 2000; Lilenfeld et al, 2000;
Sutander-Pinnock et al, 2003; Tachikawa, Yamaguchi, Hatanaka et al, 2004). Secondly,
when compared to other psychiatric groups, AN sufferers (and to a lesser extent BN
sufferers) presented with higher mean levels of perfectionism over and above other
disorders such as OCD, depressive disorders, social phobia and panic, and, finally, the
elevations in mean perfectionism scores for AN sufferers were maintained for both
maladaptive and adaptive dimensions of perfectionism.
Research addressing the role of perfectionism in eating disorders appears to have
progressed further than research focussing on the role of perfectionism in depression and
anxiety disorders (Bardone-Cone et al, 2007). This is evidenced by research that addressed
both premorbid and hereditary patterns of perfectionism in relation to both AN and BN
(e.g. Fairburn et al, 1999; Lilenfeld et al, 2000). For AN sufferers there is evidence that
elevated perfectionism levels pre-treatment have been associated with poorer prognosis for
anorexia nervosa sufferers at long term follow ups (Bizeul et al, 2001) and greater drop-out
35
rate before the completion of treatment (Sutander-Pinnock et al, 2003). There is also
evidence that perfectionism levels remain elevated in eating disorder sufferers even after
successful treatment (e.g. Bastiani et al, 1995; Kaye, Strober & Jimerson, 2004;
Srinivasagam, Kaye, Plotnikov et al, 1995).
Suicide
Blatt (1995) in his descriptive accounts of a number of high profile suicides drew attention
to the relationship between perfectionism and suicide. Attributes highlighted by Blatt as
being consistent across cases included a compulsion towards perfection whilst being
tortured by extreme self-doubt and self-criticism. Blatt noted how the self-presentational
needs of such perfectionists contributed to their vulnerability and would propel them to
extreme lengths to avoid public criticism and maintain a flawless persona. Added to this, a
lack of satisfaction when a task was completed, markedly increased feelings of selfscrutiny and susceptibility to depression and suicide. More recent case accounts continue
to demonstrate the association between perfectionism and suicide (e.g. Bialosky, 2011;
Hyatt, 2010).
The strongest evidence for the link between perfectionism and suicide points to the
involvement of two of the trait dimensions of perfectionism identified by Hewitt & Flett
(1991a). Shafran & Mansell (2001) in a review of the literature concerning perfectionism
and psychopathology, identified a significant relationship between both self-oriented and
socially prescribed perfectionism in relation to suicidal ideation in both clinical and nonclinical samples. The dimensions of self-oriented and socially prescribed perfectionism
have both been identified as being relevant to suicidal behaviour although sociallyprescribed perfectionism appears to show the closest relationship with both suicide
ideation and actual suicide attempts (Dean & Range, 1996; Dean, Range & Goggin, 1996;
Enns et al, 2001; Hamilton & Schweitzer, 2000; Hewitt, Flett & Turnball-Donovan, 1992;
Hewitt, Norton, Flett, Callender & Cowan, 1998).
A number of authors have proposed possible mechanisms and models to help explain the
perfectionism-suicide link; these include Hewitt and Flett’s (2002) explanation of the role
of stress in the relationship between perfectionism and suicide, the Escape Theory of
36
Sucide (Baumeister, 1990) and the Perfectionism Social Disconnection Model (Hewitt,
Flett, Sherry & Caelian, 2006). Each of which will be discussed briefly.
Hewitt & Flett (1993, 2002) have suggested that specific aspects of the stressperfectionism relationship have the potential to produce suicidal potential in certain
individuals. These authors believe that perfectionistic behaviour has the capacity to
influence both the frequency and intensity of certain stressors and in doing so, increases
vulnerability to suicide ideation and suicide attempts. Additionally, Hewitt & Flett suggest
that the aversiveness of the stressor may be elevated when the type of stress interacts with
the particular perfectionism dimension involved e.g. self-oriented perfectionists are
thought to find failures associated with achievement more difficult to deal with because
their primary focus is on achievement and the attainment of high standards. In a similar
way, socially prescribed perfectionists are believed to find it more difficult to deal with
social stressors because their focus is primarily concerned with the interpersonal aspects of
feeling approved of and fitting in with society. Recent research by Hewitt, Caelian, Chen
& Flett (2014) examined the diathesis stress model of perfectionism and suicide and found
that socially prescribed perfectionism interacted with daily hassles to predict suicide
potential in adolescent psychiatric patients diagnosed with depression even after
controlling for previous suicide attempt, level of depression and hopelessness.
The Escape Theory of Suicide (Baumeister, 1990) proposes that in some cases individuals
who attempt suicide have a powerful desire or motivation to escape from their own painful
awareness that they have flaws and imperfections. A central component of the theory is
how the individual deals with expectations either from the self or from others. It is
believed that much distress is generated from a perceived inability to meet unrealistically
high standards and in particular, how the individual deals with the discrepancy between the
idealised view of how they would like their life to be and the reality of potentially falling
short of such stringent standards. Many authors have considered how individuals react to a
perceived or actual failure to meet unrealistically high standards. Hamachek (1978)
believed this to be one of the central facets differentiating adaptive and maladaptive
perfectionists, with adaptive perfectionists being able to rationalise achievement failures as
being acceptable, whereas maladaptive perfectionists internalising the failure as
unacceptable. Maladaptive perfectionists are believed to rate highly in terms of
discrepancy (see Slaney, Rice, Mobley et al, 2001; Almost Perfect Scale-Revised).
37
According to the Escape Theory, suicide is viewed as the final step to flee from the
discrepancy within the self and from the world.
The Perfectionism Social Disconnection Model (PSDM; Hewitt et al, 2006) proposes that
much of the distress associated with perfectionism stems from a thwarted need to feel
accepted and connected to others. The model focuses on the role of perfectionistic selfpresentation and its associated influences on interpersonal relationships and behaviour. As
a result of the interplay between type of perfectionism (socially prescribed) and the
perfectionist’s self-presentational need to feel accepted and connected to the social
environment, diminished social relationships and psychological maladjustment can result.
Further problems have been identified as being associated with the sustained role of selfpresentation in perfectionism with interpersonal difficulties such as hostility and
hypersensitivity (Habke & Flynn, 2002) making social disconnection more likely.
According to the model, social disconnection has been related to various adverse
consequences that include suicide ideation and attempted suicide (Hewitt et al, 2006).
Recent research by Flett et al, (2014) suggests that the role of perfectionism in suicide has
been seriously underestimated. These authors call for a re-evaluation of the perfectionism
construct on the basis of the potential risk to both the individual and the wider society.
Specifically, rather than studying individual variables as potential risk factors, Flett et al
(2014) believe there is a need to focus on the whole person and take into consideration
accumulative risk factors. One of the fundamental problems and reasons for playing down
the perfectionism-suicide link, according to these authors, is the widespread view that
perfectionism in society is often considered a positive and adaptive personality attribute
that is highly valued and praised in work and educational settings. Another problem
appears to concern the self-presentational desires of perfectionists, specifically the
tendency of many perfectionists to hide or conceal their flaws and imperfections behind a
mask of apparent invulnerability (Blatt, 1995; Flett et al, 2014; Friedlander, Nazem, Fiske,
Nadoff & Smith, 2012) which suggests that many individuals do not let on to others about
the extent of their difficulties.
The role of self-concealment in suicide behaviour has been supported by a number of
authors (see Friedlander et al, 2012). Flett & Hewitt (2013) believe that particularly in
children and adolescents, there is a high proportion of individuals who are “flying under
38
the radar” whereby their psychological problems are seriously underestimated due to the
presence of a personality style that is motivated to keep psychological distress hidden or
disguised. Flett et al (2014) propose that self-concealment becomes deeply ingrained into
the persona of some perfectionists to the extent that serious psychological problems may
be overlooked and underestimated. It has been suggested that self-presentational
tendencies, specifically self-concealment may help explain the lack of warning that often
accompanies the suicide of seemingly high functioning individuals (Flett et al, 2014).
2.2.2 Perfectionism and Physical Health
Compared to the area of perfectionism and psychopathology, the area of perfectionism and
physical health has received only a modest amount of research attention (Molnar, Reker,
Culp, Sadava & DeCourville, 2006). This is also in direct comparison to the much vaster
research field addressing the relationships between personality and physical health. The
importance of studying the long-term effects of how perfectionists cope with physical
health symptoms has been exemplified by Fry & Debats (2009) who, over the course of six
years, and after controlling for the effects of neuroticism and conscientiousness identified
perfectionism to be associated with early all-cause mortality.
Personality factors have been explored as risk factors for the onset and development of
physical illness with well-established links being identified between neuroticism and
conditions such as Irritable Bowel Syndrome (Hazlett-Stevens, Craske, Mayer et al, 2003),
Chronic Fatigue Syndrome (Buckley, MacHale, Cavanagh et al, 1999; Taillefer, Kirmayer,
Robbins & Lasry, 2003) and medically unexplained symptoms (McCrae & Costa, 1987;
Kirmayer, Robbins & Paris, 1994). Conversely, conscientiousness has been identified as
having a potential protective or buffering effect on health and longevity (Carver & ConnerSmith, 2010) with high levels of this personality trait linked to greater perceived health,
life satisfaction (Roesch, Aldridge, Vickers, & Helvig, 2009), and an increased tendency to
follow treatment regimens (Christenson & Smith, 1995). Highly conscientious individuals
may experience more positive health outcomes due to their engagement in behaviours that
have been identified as either promoting or impeding good health. Indeed research by
Bogg & Roberts, (2004) identified conscientious individuals to engage more readily in
health protective behaviours (such as having a good diet and exercising regularly) and less
39
likely to engage in unsafe health behaviours (such as risky sexual practices and excessive
alcohol, tobacco or drug use).
Much of the early work addressing the relationship between perfectionism and physical
health utilised a unidimensional perspective of the perfectionism construct, focussing
solely on the negative/maladaptive perfectionism traits and negative health outcomes. Such
research found associations between perfectionism and various physical
difficulties/disorders such as chronic pain (Van Houdenhove, 1986), asthma (Morris,
1961), migraine (Burns, 1980), Irritable Bowel Syndrome (IBS) and Ulcerative Colitis
(Pacht, 1984).
More recent research, embracing a multidimensional view of perfectionism (e.g. Martin,
Flett, Hewitt, Krames & Szanto, 1996) has supported some of these associations and new
connections have been identified between perfectionism and various other health
conditions such as Chronic Fatigue Syndrome (White & Schweitzer, 2000), fibromyalgia
(Sansone, Levengood & Sellbom, 2004), Crohns Disease, Ulcerative Colitis (Flett et al,
2011) and general somatic health problems e.g. daytime sleepiness, tension, insomnia and
headaches (Saboonchi & Lundh, 2003). Relationships between perfectionism and health
symptoms have been studied in both student samples (Bottos & Dewey, 2004; Martin,
Flett, Hewitt, Krames & Szanto, 1996) and general population samples (e.g. Molnar et al,
2006; Saboonchi & Lundh, 2003).
Recognising both the adaptive and maladaptive perfectionism dimensions has meant that it
has been possible to explore whether the specific dimensions of perfectionism are
differentially allied to physical health variables. The result of which has enabled
researchers to further explore and understand the possible “adaptiveness” of the
perfectionism construct and try and establish whether there are positive qualities that could
have a beneficial or protective impact on health and wellbeing. Other authors using a
multidimensional perspective have supported the association between the maladaptive
dimensions of perfectionism and physical health (e.g. White & Schweitzer, 2000).
Additional research has identified that both adaptive and maladaptive dimensions may be
associated with poorer health outcomes (Saboonchi & Lundh, 2003), with this result found
even after controlling for the personality dimensions of conscientiousness, extraversion
and neuroticism (Molnar et al, 2006).
40
The relationship between adaptive perfectionism and physical health outcomes appears to
be less clear cut. Exploring the role of affect in the relationship between perfectionism and
physical health, a study by Molnar et al (2006) identified perfectionism to represent a
“double edged sword” in terms of its association with physical health. Using the
multidimensional framework put forth by Hewitt & Flett (1991b), these authors have
supported the association between the maladaptive dimension of perfectionism and poorer
health outcomes as well as giving credence to the notion that the adaptive dimension of
perfectionism may be associated with some benefits to health and wellbeing (Frost et al,
1993; Slade & Owens, 1998). Perhaps it is the case that in certain situations and under
certain conditions the adaptive perfectionistic traits may provide some advantages as far
as health and wellbeing are concerned, indeed, Molnar and colleagues, identified the
relationship between self-oriented perfectionism and physical health to be much more
complex than first thought. When looking at the role of perfectionism in fibromyalgia, a
moderate or optimal level of self-oriented perfectionism was identified as being potentially
adaptive to health, however, too much or too little of this type of perfectionism was found
to be associated with considerable reductions in physical health functioning (Molnar, Flett,
Sadava, & Collautti, 2012)
Chronic Fatigue Syndrome
Studying the relationship between perfectionism and Chronic Fatigue Syndrome has
become increasingly popular in the last decade. Addressing this research field is proving to
be important because there is the possibility that it may hold the key to our understanding
of how perfectionism may be related to physical health as well as informing the literature
about how the dimensions of perfectionism may be differentially related to health
outcomes.
There has been a long standing association between perfectionism and fatigue, indeed,
Freudenberger (1974) first noted burn out and exhaustion to be more prevalent in
perfectionists. Fatigue was seen to be part of a vicious circle where the perfectionist’s need
to strive endlessly and relentlessly to meet their own prescribed standards would lead to
distress and ultimately fatigue. Chronic Fatigue Syndrome (CFS) has been described as
consisting of a sustained period of fatigue accompanied by other symptoms such as
headaches, muscle pain and tiredness after physical exertion (Fukuda, Strauss, Hickie,
Sharp, Dobbins & Komaroff, 1994). Commonly, individuals suffering from CFS also
41
endure chronic pain (Kanaan, Lepine & Wessely, 2007; VanHoudenhove, Kempe &
Luyten, 2010) and associations have been found between CFS and fibromyalgia syndrome
(Yunus, 2007; Van Houdenhove & Luyten, 2009). CFS has also been associated with
depression (Arnold, 2008; Kempke, Goossens, Luyten et al, 2010).
Individuals with CFS have been found to demonstrate elevated levels of perfectionism
when compared to healthy controls (White and Schweitzer, 2000; Deary & Chalder, 2010)
with maladaptive perfectionism (i.e. Concern over Mistakes and Doubts about Actions)
being most consistently associated with CFS (Kempke et al, 2011; Luyten, Van
Houdenhove, Cosyns & Van den Broeck, 2006; Magnusson, Nias & White, 1996; White
& Schweitzer, 2000). Recent research has identified that on a daily basis, the maladaptive
dimension of perfectionism is predictive of both fatigue and pain in CFS sufferers
(Kempke, Luyten, Claes et al, 2013). In terms of the role of adaptive perfectionism in CFS
(although research has been limited in this area) Deary & Chalder (2010) found a positive
correlation between the adaptive and maladaptive dimensions of perfectionism (in CFS
patients) and as such suggested the CFS profile be typified by high personal standards and
organisation as well as doubts about the quality of one’s actions and concern over
mistakes. One could therefore argue that if this client group have a similarly high level of
both maladaptive and adaptive perfectionism traits then the adaptive traits may provide
some sort of protective buffer against the potentially serious consequences of the
maladaptive traits. Unfortunately when compared to a control group, the CFS group
possessed significantly elevated levels of fatigue, depression and anxiety which has led
some authors to question whether a high combination of both adaptive and maladaptive
traits is a healthy combination for individuals suffering from CFS (Deary & Chalder, 2010;
Kempke, Van Houdenhove, Luytens et al, 2011).
Research of this nature is important as it has focussed on the differential contribution of
both the maladaptive and adaptive dimensions of perfectionism in relation to health
outcomes, as well as contributing to the ongoing debate over whether there really is a
subtype of perfectionism that can be regarded as positive or healthy. In the CFS literature,
results have demonstrated that by itself, adaptive perfectionism has not been linked
directly with negative health outcomes (Deary & Chalder, 2010) and the considerable
overlap between the dimensions has made it difficult to pinpoint the unique contribution of
adaptive perfectionism.
42
Research that has addressed the relationship between perfectionism and CFS is also
important because it has generated interest in the potential mediators in the relationship
between perfectionism and health. Research by Kempke et al (2011) using the Frost MPS,
investigated the role of depression as a potential mediator. These authors found depression
to fully mediate the relationship between the maladaptive dimension of perfectionism and
fatigue which exemplifies the importance of looking at both the personal experience of
perfectionism and any coexisting conditions which may jointly exacerbate and perpetuate a
condition such as CFS.
Perfectionism and the personal experience of illness
The role that perfectionism may play in the personal experience of illness is a relatively
new area of research. There are a number of factors that appear to feature highly when
perfectionists are faced with the challenge of having to live with health problems of a
predominantly physical nature. These include; dealing with perfectionistic automatic
thoughts and cognitive distortions, utilising different coping mechanisms, difficulties when
a health problem interferes with achievement goals and problems associated with the selfpresentational nature of perfectionism.
Research has identified that perfectionistic automatic thoughts and other cognitive
distortions/biases may alter the personal experience of illness for the individual (e.g. Flett
et al, 2011). Cognitive distortions accompanied by being highly perfectionistic are likely to
exacerbate an already difficult and stressful situation (Hewitt & Flett, 1991) such as having
to deal with having health problems, a chronic condition or disease. Blatt (1995) proposed
the combination of cognitive distortion and perfectionism to be devastating in terms of
decreasing quality of life. Recent research focussing on the relationship between
perfectionistic automatic thoughts and psychosomatic symptoms has proposed that the
potential cognitive preoccupation in perfectionism may lay the foundations for future
health difficulties (Flett et al, 2011). In describing the potentially debilitating role of
perfectionistic thoughts in this process, these authors suggest
“Chronic awareness of not being perfect while still feeling compelled and needing to
achieve this essential personal goal should be a chronic source of stress and distress for
certain perfectionists that should be reflected eventually by a heightened experience of
psychosomatic symptoms” (page 566).
43
One of the main difficulties appears to be an inability on the part of the perfectionist to
disengage cognitively from the need to keep pushing towards the achievement of
perfection (Flett et al, 2011). This is likely to use up valuable resources and unsurprisingly
may interfere and hinder the successful management of an illness.
There may be clear differences in the coping mechanisms utilised by perfectionists,
specifically with regard to coping style. Perfectionistic individuals appear to rely more on
avoidant or emotion focussed coping in response to stressful situations such as dealing
with the burden of a health difficulty (Flett et al, 2011). Such strategies, although
providing short-term relief, may not be beneficial in the long-term as they do not address
the source of the stress. Research on coping mechanisms by Epping-Jordan, Compas &
Howell, (1994) identified a faster rate of physical deterioration in cancer patients who used
avoidance strategies. Looking specifically at the research literature concerning
perfectionism and chronic conditions such as Cardiovascular disease (CVD) and Irritable
Bowel Disease (IBD), perfectionism has been associated with maladaptive coping styles,
poor rehabilitation prospects (Shanmugasegaram, Flett, Madan, Oh, Marzolini, Reitav,
Hewitt & Sturman, 2014) and a tendency to amplify the impact of a chronic condition
(Flett, et al, 2011). What may exacerbate the situation further is the fact that there seems to
be reluctance for perfectionists to utilise social support networks (Crăciun & Dudău, 2013;
Flett et al, 2011). There is a robust relationship in the research literature linking the
availability of social support with improved physical health outcomes (for reviews please
refer to Berkman, Glass, Brissette & Seeman, 2000; Uchino, 2004) and individuals with
low levels of social support have been found to have higher rates of mortality especially
from conditions such as cardiovascular disease (Berkman et al, 2000; Lespérance, FrasureSmith, Juneau et al, 2000).
Perfectionists appear to have specific difficulties dealing with health problems when they
interfere with the achievement of their goals (Flett et al, 2011). This seems logical when
you consider the importance that perfectionists place on the achievement of personal
standards and expectations. Highly perfectionistic individuals have been found to
experience increased amounts of stress when they experience achievement failures and
when they feel they have not achieved the expected standard of performance (Hewitt &
Flett, 2002). It may be particularly stressful for perfectionists when health difficulties
interfere with their ability to pursue and achieve their goals or perhaps when treatment
interferes with the achievement of goals and standards. This was found for cardiac
44
rehabilitation patients where the rehabilitation itself was identified as an additional stressor
that further burdened the individual and represented yet another impossible standard to
work towards (Medved & Brockmeier, 2011).
The self-presentational nature of perfectionism has been described by Hewitt et al, (2003)
as a dual drive towards wanting to appear perfect at all times accompanied by attempts to
minimize or prohibit the public display/disclosure of imperfections. Research addressing
the area of perfectionism and physical health has identified that certain physical conditions
may be particularly difficult for perfectionists to cope with because they interfere with the
self-presentational drive towards wanting to portray the perfect public image. Flett et al
(2011) explored the relationship between perfectionism and living with two chronic bowel
conditions; Crohn’s Disease and Ulcerative Colitis. Both conditions consist of a variety of
symptoms (e.g. diarrhoea, abdominal pain, rectal bleeding, inflammation, fatigue and
nausea) that have been described by sufferers as being embarrassing and misunderstood by
others (Hall, Rubin, Dougall et al, 2005). Flett et al (2011) have suggested that it is
particularly important to consider perfectionism in relation to understanding the reactions
of individuals living with irritable bowel disease (IBD) “given the emphasis that patients
have on maintaining the appearance of normality to others”, (p. 562). The resulting
research identified perfectionism to be associated with a greater psychosocial awareness of
the impact of living with the disease, greater physical impact and an elevated level of
preoccupation coping which has been identified as a style of coping thought to have
negative consequences in a chronically ill population ( Macrodimitris & Endler, 2001).
2.2.3 Perfectionism and Stress
Stress has been implicated as both a moderating and mediating variable in the relationship
between perfectionism and psychological health, specifically in the generation or
maintenance of psychopathological states. According to Hewitt & Flett (2002), when
compared to non-perfectionists, perfectionists are more likely to have an increased
exposure to stress from two sources; firstly in the form of daily hassles and secondly from
the constant unremitting burden to achieve exceptionally high standards. Such high levels
of stress exposure as well as maladaptive ways of coping with stress are likely, according
to these authors, to lead to a greater chance of experiencing psychological distress. In
addressing the precise way that stress is involved, the relationship between perfectionism,
45
stress and psychopathology appears to be a complex one with perfectionism implicated in
the generation, anticipation and perpetuation of stress in relation to psychopathology
(Hewitt & Flett, 2002).
Certain individuals may be more vulnerable to developing psychological difficulties
because they have a personality style that means they are more likely to place themselves
in situations, engage in particular behaviours or ways of thinking that increase their
exposure to stress. Hewitt & Flett (2002) believe that perfectionists are more likely to fall
into this category because “of their unrealistic approach to life” (p. 259). Such an approach
according to these authors, involves the setting of unrealistically high standards for
performance, a cognitive style that involves focussing predominantly on the negative
aspects of performance as well as experiencing only minimal satisfaction from their
efforts. The generation of stress is likely to be influenced in part by a lack of flexibility by
perfectionists to lower their standards or adjust their goals. Research has identified such
attitudinal inflexibility to be a pervasive characteristic present in both the adaptive and
maladaptive dimensions of the perfectionism construct (Ferrari & Mautz, 1997).
Focussing on only the negative elements of a situation means that perfectionists are likely
to interpret even innocuous events as representing serious threats (Dunkley, et al, 2003).
Hewitt and Flett (2003) have elaborated on this by suggesting that even minor shortfalls in
performance can represent major failings for self-oriented perfectionists. In a test of the
diathesis-stress model of perfectionism and depression, where self-oriented perfectionism
interacted with achievement hassles of predict depression, Hewitt & Flett (2003) felt that
minor achievement hassles were particularly significant for self-oriented perfectionists as
they may serve to activate much deeper beliefs concerning personal failings and
imperfections of the self.
In terms of the anticipation of stress, research has shown that perfectionists tend to become
preoccupied with the fact that stressful events may occur in the future, for example
worrying that they may fail at a particular task that has yet to occur. Evidence of a failure
orientation in perfectionism has been supported by a number of research studies (e.g. Flett,
Hewitt, Blankstein & O’Brien, 1991; Frost & Henderson, 1991). Research by Flaxman and
colleagues, addressing the psychological benefits of taking time off from work, found that
self-critical perfectionists were more inclined than non-perfectionists to worry about ‘what
might happen’ whilst away from work which appeared to have a detrimental effect on their
46
health and wellbeing when they returned to work (e.g. higher levels of fatigue, exhaustion
and anxiety), (Flaxman, Ménard, Bond & Kinman, 2012). There also seems to be a
perception that there is nothing that can be done to avert the stressful events form
occurring, (Hewitt & Flett 2002). This has been confirmed by a study by Martin, et al,
(1996) who identified self-reported depressive symptoms to be greater for socially
prescribed (maladaptive) perfectionists when they held the belief that they do not have
control over the major outcomes in their life (low self-efficacy).
Hewitt & Flett (2002) suggest that perfectionists’ anticipation of stressful events occurring
in the future accompanied by a lack of desire to address this in advance, can be explained
as a type of hopelessness response that has been identified in various models of depression
(Brown & Harris, 1978; Abraham, Metalsky & Alloy, 1989). Research has confirmed the
link between perfectionism and depression in both student samples (e.g. Flett et al, 1991;
Hewitt & Flett, 1991) and clinical samples (Hewitt & Flett, 1993). Furthermore, feelings of
hopelessness and helplessness seem to be an integral part of the maladaptive
perfectionistic profile (e.g. Hewitt & Flett, 1991a, 1991b) e.g. socially prescribed
perfectionists have been identified as having an inherent worry about the likelihood of
stressful events happening and it has been the certainty of their convictions that appears to
exacerbate the stress associated with these events (Hewitt & Flett, 2002).
In terms of perpetuating the stress response, it would appear that perfectionists have a
tendency to draw on maladaptive tendencies that keep a stressful experience going for
longer than is required. Such maladaptive tendencies have been described by Hewitt &
Flett (2002) as falling into three categories of interrelated cognitive tendencies; a
preoccupation with self-blame coupled with a failure orientation which make the
possibility of rationally dealing with a stressful episode highly unlikely, secondly a
propensity to experience frequent negative automatic thoughts concerning the negative
aspects of perfectionism which have been found to be associated with psychological
distress and finally, having a ruminative response orientation whereby perfectionists worry
specifically about failing to meet their expected standards. Not being able to achieve the
expected standard is likely to create a discrepancy for the perfectionist between their actual
and ideal self. Furthermore, once a stressful event has occurred, the perfectionist is likely
to ruminate, and it is this rumination that will act as a reminder about the discrepancy
between their actual and ideal self, which may lead to further psychological distress
(Strauman, 1989).
47
A further area contributing to the perpetuation of stress in perfectionism may be associated
with how perfectionists utilise social support networks when they are feeling vulnerable or
in need of help. Hewitt & Flett (2002) have identified a significant factor contributing to
the perpetuation of the stress response to be reluctance on the part of the perfectionist to
admit to other people that they are having personal problems. This seems to be linked to
the self-presentational aspect of the perfectionism construct where perfectionists, in their
attempts to appear flawless and avoid potential negative evaluation from others, resort to
concealing negative information about themselves. It is likely that the desire to keep such
personal information concealed from others is a block to such individuals seeking or
asking help from other people. Perfectionists, it would seem, often have difficulty asking
for help because they seem to perceive this as an admission of failure to cope, which may
have the effect of displaying to the outside world that they are not perfect. Hewitt & Flett
(2002) have identified that not utilising social support networks seems to be a key factor in
prolonging or exacerbating the stressful experience and the accompanying psychological
distress.
2.2.4 Perfectionistic Self-Presentation and Health
The self-presentational aspect of the perfectionism, according to Hewitt et al (2003)
encompasses two specific motivational components; the desire to demonstrate one’s
perfection to the world (self-promotion) and the desire to conceal one’s imperfections from
others (self-concealment). Hewitt et al (2003) proposed that perfectionists differ not only
in their level of trait perfectionism but also in terms of their levels of self-presentation.
Self-presentational aspects of perfectionism have already been discussed briefly in the
context of a number of health related areas, specifically; in relation to masking the extent
of both psychological and physical health difficulties, creating problems when dealing
with certain physical health conditions such as irritable bowel disease and affecting the
likelihood that perfectionists will seek help or support for health related problems.
In terms of its relationship with health and wellbeing, the self-concealment aspect of selfpresentation has received considerable research attention, specifically, its proposed
relationship with psychological distress (Cepida Benito & Short, 1998; Kawamura &
Frost, 2004). Withholding personally distressing information has been associated with
greater depression (Kelly & Achter, 1995) and more interpersonal conflict (Straits-Tröster,
48
Patterson, Semple, et al, 1994). Despite the health implications, for certain individuals, it
would appear, the desire to self-conceal outweighs and justifies the potential health
difficulties that may accompany such a personality trait (Flett & Hewitt, 2013). The
resulting problem, however, is the likelihood that certain individuals are suffering in
silence, not willing to accept or reveal either the psychological distress they are
experiencing or the flaws and imperfections that are fuelling such distress.
Perfectionistic self-presentation is considered to be a problematic and unhealthy strategy
for a number of reasons; firstly it is unlikely that the individual will be able to conceal their
personal flaws and imperfections indefinitely (Hewitt et al, 2003, Leary, Tchividijian &
Kraxberger, 1994), secondly there may be a reluctance on the part of the individual to take
risks because at any point the individual may let their guard down and this could invalidate
the façade that they are trying so hard to maintain, and thirdly a tendency to self-conceal
can cause problems in the development and maintenance of intimate relationships because
a desire to self-conceal can be interpreted by others to represent a lack of authenticity.
Research has shown that individuals who freely express their flaws are more successful in
developing successful close relationships (Derlaga, Metts, Petronio & Margulis, 1993).
Self-presentational strategies specifically self-concealment have also associated lower
levels of help seeking for psychological or physical health problems, specifically high selfconcealers are less likely to seek help for their difficulties either in the form of personal
requests for help or acceptance of help from external sources (Hewitt et al, 2003). Cepida
Benito & Short (1998) identified an avoidance on the part of high self-concealers, to seek
counselling, despite individuals’ expressing a need for such psychological interventions.
Research has attempted to address why self-presentational strategies, specifically selfconcealment may be detrimental for health. Consistent with Bem’s (1972) Self Perception
Theory, the active concealment of personal information may signify to the individual that
they have been acting in a shameful or inappropriate manner and consequently interfere
with their core perception of themselves (Kelly, 2002) thus leading to psychological
difficulties. Additionally there is the suggestion that the additional effort and self-control
involved in hiding potentially sensitive and personal information from others may itself
cause psychological and physiological symptoms (Kelly, 2002). There may also be an
indirect pathway whereby self-concealment leads to psychological and physical health
difficulties because of a lack of engagement in preventive health behaviours. Recent
49
research has identified an inverse relationship between self-concealment and engagement
in such behaviours (Williams & Cropley, 2014).
Exploring the subject of self-presentation in perfectionism and how this is related to health
seems to be an essential step in furthering our understanding of the perfectionism-health
relationship. Perfectionists may be avoiding admitting to health difficulties, seeking help
or engaging in preventive health behaviours for fear of being judged negatively and they
may engage in further impeding behaviours so as to justify their lack of engagement in
their health and wellbeing, such as self-handicapping behaviours. These types of
behaviours appear to come about from trying to conceal personal imperfections.
2.2.5 Perfectionism and Health Behaviours
Gochman (1982) described health behaviours as
“those personal attributes such as beliefs, expectations, motives, values, perceptions and
other cognitive elements; personality characteristics, including affective and emotional
states and traits; and overt behaviour patterns, actions and habits that relate to health
maintenance, to health restoration, and to health improvement”.
Such behaviours have frequently been subdivided into health protective (preventive health
behaviours) and health risk behaviours. Health protective behaviours have the effect of
enhancing health and include such behaviours as eating a healthy balanced diet, exercising
regularly and reducing stress. Health risk behaviours have the effect of impairing health
such as excessive smoking and alcohol use, risky sexual behaviours and eating a poor diet.
Research has identified clear evidence that engaging in preventive behaviours such as
exercise/physical activity are beneficial to health, both psychologically and physically. The
psychological benefits include reduced levels of depression, improvements to mood,
altering an individuals’ appraisal of a stressful situation, improving ability to cope with
stress and improving self-esteem and body image e.g. Biddle, Gorely & Stensel, 2004;
Bouchard, Blair & Haskell, 2007; Fox, Stathi, McKenna & Davis, 2007; Netz, Wu, Becker
& Tennenbaum, 2005. Physical benefits include improving levels of longevity, mortality,
preventing many chronic illnesses (particularly in relation to cardiovascular disease) as
50
well as improving treatment outcomes for a number of acute and chronic conditions (e.g.
Biddle et al, 2004; Bouchard et al, 2007; Fox et al, 2006; Netz et al, 2005). Conversely,
not engaging in such behaviours has been found to increase vulnerability to acute and short
term health problems as well as increasing the likelihood of long term health difficulties
such as chronic illnesses. McGinnis & Foege (1993) have suggested that health behaviours
represent the most significant contribution to unfavourable health outcomes and according
to Roberts and colleagues, are important to long term health because of their association
with chronic conditions such as cancer, cardiovascular disease and accidental death
(Roberts, Currie, Samdal et al, 2007). Despite clear evidence of the benefits of engaging in
regular physical activity, it seems that many people do not appear to be engaging in the
recommended amount (UK Department of Health, 2004).
Research has supported the link between specific personality styles and engagement in
preventive health behaviours (e.g. Sirois & Voth, 2007; Caspi, Begg, Dickson et al, 1997)
with certain personality types associated with increased amounts of engagement in such
behaviours. The Five Factor model of personality has often been used as a framework for
researching the interrelations between personality dimensions and health behaviours (e.g.
Booth-Kewley & Vickers, 1994) with two of the five factors; conscientiousness and
neuroticism emerging as the most significant predictors. High levels of conscientiousness
have been associated with increased health promotion activities such as diet, exercise, less
risk taking and more accident control (Bogg & Roberts, 2004; Booth-Kewley & Vickers,
1994) and low levels of conscientiousness have been linked to increased health risk
behaviours (Bogg & Roberts, 2004) such as sexual risk taking (Hoyle, Fejfar & Miller,
2000) and an inability to restrict alcohol consumption (Loukas, Krull, Chassin & Carle,
2000). Conscientiousness is believed, by a number of authors to have protective qualities
in terms of health and wellbeing (e.g. Carver & Conner-Smith, 2010). Specifically it has
been associated with a reduced desire to engage in activities or health practices that detract
from good health as well as often being accompanied by health promoting activities
(Roberts & Bogg, 2004). Neuroticism, on the other hand has been associated with less
wellness behaviours, less accident control, more risk taking (Booth-Kewley & Vickers,
(1994), greater alcohol consumption and riskier sexual behaviours (Trobst, Herbst, Masters
& Costa, (2002).
51
Research has supported the association between the two major perfectionism dimensions
and the two personality dimensions of conscientiousness and neuroticism (Hamachek,
1978; Stoeber & Otto, 2006) with the maladaptive, socially prescribed perfectionism
dimension being associated with neuroticism and self-oriented (often viewed as the most
adaptive dimension) perfectionism associated with conscientiousness. In the light of this
evidence one could assume that adaptive perfectionists may engage more readily in
preventive health behaviours because of the high levels of conscientiousness and
maladaptive perfectionists engage less frequently due to the association between this
dimension of perfectionism and neuroticism.
Molnar et al (2006) proposed two health behaviour pathways that could potentially help
explain the relationship between perfectionism and physical health outcomes, specifically
how the behaviours of certain perfectionists may adversely affect their health. The first
pathway was identified as a greater propensity to engage in health risk behaviours and the
second pathway described as a lack of engagement in behaviours that are likely to have a
positive impact on short and long-term health (health protective behaviours or preventive
health behaviours). Socially prescribed perfectionism (maladaptive) was predicted to be
associated with more health risk behaviours and self-oriented (adaptive) with more health
promoting behaviours. Unfortunately equivocal results were obtained from this research
with neither perfectionism dimension being related to health promoting behaviours and
contrary to the proposed hypotheses, self-oriented perfectionism was associated with less
engagement in health risk behaviours, Molnar et al (2012).
Unfortunately there is a lack of research specifically addressing the relationship between
perfectionism and engagement in health behaviours (health promoting and health risk). A
recent study by Williams & Cropley (2014) focussed on the differences between adaptive
and maladaptive perfectionism and their association with health behaviours. These authors
found maladaptive perfectionism to be associated with decreased levels of engagement and
increased levels of psychological distress and adaptive perfectionism related to higher
levels of engagement in preventive health behaviours. Recent research by Longbottom et
al (2010) has proposed that the cognitive and behavioural motivations underlying the two
dimensions of perfectionism (adaptive and maladaptive) are fundamentally distinct and
have proposed that adaptive perfectionism may be associated with positive motivational
tendencies e.g. higher levels of self-efficacy and perseverance when engaging in physical
52
activity/exercise and maladaptive perfectionism associated with negative motivational
tendencies that reflect a fear of failure and a desire to avoid engaging in such activities.
Such results provide support for the fact that maladaptive perfectionists may be putting
their long-term health and wellbeing at risk by not engaging in such behaviours,
particularly considering the well evidenced association between maladaptive perfectionism
and psychological distress. Furthermore the fact that adaptive perfectionism has been
linked to greater engagement may point to some potential health benefits attached to being
an adaptive perfectionist, which adds more weight to the debate over whether there may be
a type of perfectionism that is health promoting. Clearly more research investigating the
potential factors that may influence perfectionist’s engagement in health behaviours is
required.
Potential intervening variables
There are many factors that may influence the relationship between perfectionism and
engagement in health behaviours in that they may consciously or unconsciously present
themselves as possible barriers and benefits to engagement. Although the present review
cannot do justice to all of these factors, five possible intervening variables are discussed
that are considered to fit most appropriately with the specific research questions that are
addressed within the present thesis these are; self-presentation, self-handicapping,
perceived stress, physical activity motivation and self-efficacy.
The self-presentational aspect of perfectionism, encompassing the desire to self-conceal
has already been addressed in the preceding section and is considered an integral
component of the perfectionism construct, particularly concerning maladaptive
perfectionism. Considering self-presentation in direct relation to engagement in preventive
health behaviours may provide important information relating to the decisions
perfectionists make concerning how they look after their health and wellbeing.
Self-presentation has been described as a method employed by individuals to attempt to
control other peoples’ impressions of them and therefore it is likely that individuals will do
what they can, in a situation, to try and create the best possible impression to others. To be
able to do this they may feel that they only want to present the information that will show
53
them in a favourable light, whilst leaving out information that could jeopardise the desired
ideal image. Research addressing self-presentational processes in relation to exercise
behaviour (see Hausenblas, Brewer & Van Raalte, 2004) has identified self-presentation to
be an important factor influencing decision to engage in physical activity and selfpresentational concerns have been found to have the potential to either encourage or deter
exercise behaviour. Self-presentation is considered to be related to exercise in a
multifaceted way having the power to influence individuals’ thoughts, feelings and
behaviours related to exercise (Hausenblas et al, 2004). Motivation to engage may be
influenced by a complex process of considering the likelihood of being able to self-present
oneself favourably in an exercise context. If an individual feels they have the confidence to
self-present as someone who appears to be fit, healthy and toned they may experience
greater motivation to engage in exercise behaviour. If, on the other hand there are any
doubts about the ability to self-present in this way they may feel discouraged from
engaging (Leary, 1992).
Empirical research has suggested that individuals displaying more of the maladaptive
dimensions of perfectionism are more likely to use self-presentational strategies (Hewitt et
al, 2003). In an exercise setting maladaptive perfectionists may find it particularly
challenging because of a heightened awareness of the need to self-present a favourable
public image. There is no doubt that attending an exercise class or going to the gym
involves a certain amount of personal exposure in terms of displaying one’s abilities to the
outside world. Maladaptive perfectionists may have a heightened fear of negative
evaluation and fear of making a mistake in front of others. There is the possibility that their
need for positive approval may lead them to believe that such situations are too difficult
for them to endure and therefore avoidance may seem like a logical option.
The term self-handicapping was first discussed by Jones & Berglas (1978) to refer to the
tendency for individuals to create barriers to their achievement of success with the
intention of not having to take responsibility for failure or having a reason to explain away
a failure should it occur.
“By finding or creating impediments that make good performance less likely, the strategist
nicely protects his sense of self-competence. If the person does poorly, the source of failure
is externalised in the impediment. If the person does well, then he or she has done well in
spite of less than optimal conditions”. (Jones & Berglas, p. 201)
54
In essence, what someone is trying to do when they engage in self-handicapping
behaviours is trying to distance themself from the potential failure of a task and in doing
so, protect their self-esteem if something doesn’t work out as planned (Prapavessis &
Grove, 1998). Examples of self-handicapping behaviours include; procrastination, overcommitting, avoidance, adopting a “sick role”, utilising alcohol, lack of effort, not taking
time to practise, not putting effort in and avoiding challenges (Kearns, Forbes, Gardiner &
Marshall, 2007). Self-handicapping has been linked to poor adjustment (Zuckerman,
Kieffer, & Knee, 1998), higher levels of depression, reduced self-esteem and anxiety in
both student and clinical samples (Lay & Silverman, 1996; Saddler & Sacks, 1993).
Procrastination has probably received the most interest in the research literature as it is
considered one of the most common forms of self-handicapping (Ellis & Knaus (1977).
Procrastination has been associated with a reduced intention to engage in health
behaviours (Sirois, 2004) and fewer wellness behaviours such as exercise and healthy
eating (Sirois, Melia-Gordon & Pychyl, 2003). Procrastination has also been associated to
higher stress levels and poor general health (Tice & Baumeister, 1997). According to
Sirois (2007);
“people who chronically procrastinate tend to not practice health protective behaviours,
delay seeking care for their health problems, have higher stress levels, and report a
greater number of acute health problems” (p. 2)
Higher levels of perfectionism have been associated with a greater propensity to use selfhandicapping behaviours (Frost et al, 1990; Hobden & Pliner, 1995). These behaviours
may be particularly attractive to perfectionists because these individuals may feel that they
have a lot to lose in evaluative situations. Previous research has supported these findings
identifying a propensity towards self-handicapping in people who have a high level of
uncertainty about their skills and capabilities (Snyder & Smith, 1982). In recognising the
close associations between perfectionism and self-handicapping, Kearns et al, (2007)
proposed a model linking the two. They proposed self-handicapping behaviours may occur
(although not always) in response to the flawed and biased cognitions that tend to be
inherent in perfectionists. Although noting that both perfectionism and self-handicapping
often appear to coincide with each other, these authors do suggest that the two do not
always coexist, although, the close relationship between perfectionism and selfhandicapping may mean that perfectionists are more likely to utilise such strategies as an
55
excuse for not engaging in preventive health behaviours such as exercise and physical
activity.
Clear associations have been found between perceived stress and poor health outcomes
(see section 3.4). There are many proposed ways that stress may influence health but one
route may be through health behaviours. Research has provided evidence for an
association between perceived stress and engagement in health risk behaviours such as
smoking, alcohol consumption, and eating high fat foods (Abbey, Smith & Scott, 1993;
Macht & Simons, 2000) suggesting that engaging in such behaviours can be a pleasurable
experience (Zillman & Bryant, 1985) and help manage mood (Ng & Jeffery, 2003). Adler
and Matthews (1994) have suggested that engaging in health risk behaviours acts as a
means of offsetting the stress that one is dealing with.
Although most studies have found a positive association between perceived stress and
health behaviours such as following an unhealthy diet (Hellerstedt & Jeffery, 1997; Pak,
Olsen & Mahoney, 2000), there have been less consistent results for studies that have
addressed the relationship between stress and physical activity. Some studies have
identified a relationship between reduced physical activity and stress (Heslop, Smith,
Carroll et al, 2001; Stetson, Rahn, Dubbert, Wilner & Mercury, 1997) whilst some
research has identified that adults increased physical activity when they experienced high
levels of stress (Spillman, 1990).
Adler and Matthews (1994) suggest engagement in health promoting behaviours is likely
to be compromised in times of high stress. This has been supported by research looking at
the effects of academic stress on health behaviours in young adults. Studies have identified
that during periods of high stress (i.e. when academic demands were high) engagement in
certain health behaviours was reduced. Specifically behaviours that required effort on the
part of the individual were found to be diminished such as following a healthy diet or
engaging in regular exercise whereas those behaviours requiring little effort (e.g. personal
hygiene and keeping oneself safe) tended to be unaffected (Weidner, Kohlmann, Dotzauer
& Burns, 1996). Adler and Matthews (1994) have suggested that the act of engaging in
health promoting activities, at times of stress, may evoke certain behavioural demands on
the individual that are simply too overwhelming for them to deal with.
Research has shown that there is a well-established relationship between perfectionism and
stress and research by Molnar et al (2012) has identified perceived stress to be one of the
56
key processes connecting perfectionism to indices of health. For maladaptive perfectionists
where the pressure to meet high standards is already high, coupled with the presence of
higher than normal levels of stress, the likelihood of having the resources to engage in
preventive health behaviours may be compromised.
Another factor potentially affecting engagement are motivational tendencies. Selfdetermined motivation has been consistently linked with the maintenance and
perseverance of exercise and physical activity behaviours (Huberty, Ransdell, Sidman, et
al, 2008; Wang & Biddle, 2001). A specific multidimensional framework for exploring
motivation in an exercise/physical activity setting has been developed by Martin, Tipler,
Marsh, Richards & Williams (2006). The model encompasses adaptive and maladaptive
cognitions and behaviours that are considered to influence physical activity levels.
Adaptive cognitions and behaviours are proposed to relate to factors that facilitate physical
activity such as; the value individuals’ place on physical activity, beliefs that the desired
levels of activity can be achieved as well as planning and maintaining regular activities.
Maladaptive cognitions and behaviours are believed to encompass factors that may
obstruct the engagement process such as; fear of negative evaluation, uncertainty, selfhandicapping behaviours, aversion to physical activity and withdrawal (Martin et al,
2006). The model has received support with the four factors being related to physical
activity levels and the maintenance of physical activity and exercise (e.g. Marsh, Richards,
Johnson et al (1994).
Perfectionism has been considered as one of a number of variables that may underpin the
motivational desires of individuals in an exercise and physical activity context
(Longbottom et al, 2010). The adaptive and maladaptive aspects of perfectionism have
been found to relate to the adaptive and maladaptive facets of physical activity motivation
proposed by Martin et al (2006); specifically a positive association has been identified
between the adaptive dimension of perfectionism and adaptive motivational cognitions and
behaviours (such as confidence, self-efficacy and a proactive attitude) and the maladaptive
dimensions of perfectionism related to maladaptive cognitions and behaviours (such as
self-handicapping and avoidance), (Longbottom et al, 2010). These findings are supported
by Slade & Owens’ dual process model of perfectionism (Slade & Owens, 1998), detailing
a fundamental distinction between the two dimensions of perfectionism in relation to their
behaviour; with adaptive perfectionists motivated to ‘approach’ situations and maladaptive
perfectionists likely to ‘avoid’ situations. As well as identifying a potential barrier or
57
obstacle to engagement in preventive health behaviours, addressing the role of physical
activity motivation in relation to the adaptive and maladaptive dimensions of perfectionism
may add further support for the potential adaptiveness of the perfectionism construct.
Another factor that may influence engagement in preventive health behaviours is selfefficacy. This concept refers to an individuals’ belief that they have the personal resources
to carry out a desired behaviour in a particular context and the likelihood that it will be
sustained in the event of potential barriers and setbacks. Self-efficacy, according to
Bandura is not a global trait, rather, it can be described as “a differentiated set of selfbeliefs linked to distinct realms of functioning” (Bandura, 2006, p. 307). Bandura uses the
example of a business executive who may possess a high level of efficacy in a work
domain but low self-efficacy in terms of their beliefs about their parenting abilities. There
is a considerable amount of research supporting the fact that self-efficacy is an important
predictor and correlate of physical activity participation (e.g. Sallis & Hovell, 1990; Sallis,
Hovell, Hofstetter et al, 1989). Individuals with high self-efficacy have been found to exert
greater effort to conquer health promoting behaviours and persevere longer when there
may be obstacles threatening to get in the way of their engagement in such behaviours
(Laffrey, 2000). In contrast, low self-efficacy has been associated with a greater tendency
to self-handicap, which in turn may affect engagement.
In terms of the relationship between perfectionism and self-efficacy, Burns (1980)
identified the two to be linked on a theoretical basis, predominantly due to the fact that
both perfectionism and self-efficacy appear to be concerned with the setting and
achievement of goals and standards. Perfectionists, according to Burns (1980) are likely to
have low self-efficacy because of the unrealistically high standards they often set
themselves, “Stated simply, the higher the standard of success, the less likely it is that a
successful result will be perceived as a probable outcome. Thus, the perfectionist
minimizes outcome efficacy by setting over-ambitious and nearly inaccessible goals”
(Burns, 1980, p. 38)
Research investigating the relationship between perfectionism and self-efficacy has
identified the possibility that the two dimensions of perfectionism (adaptive and
maladaptive) may be differentially related to self-efficacy, (Dunkley et al, 2003; Hart,
Gilner, Handal & Gfeller, 1998; Stoeber & Otto, 2006). As both perfectionism and selfefficacy are concerned with the setting of personal goals and standards, a factor that is
58
considered to distinguish adaptive and maladaptive perfectionists, (and that may help
explain the link with self-efficacy) is the way that adaptive and maladaptive perfectionists
cope with failing to meet their expected standards of performance. Adaptive perfectionists,
in contrast to maladaptive perfectionists, are considered to have more tolerance and be
more accepting of themselves when their expected standards are not achieved. Another
common theme between perfectionism and self-efficacy appears to relate to the way that
an individual may deal with a task or potential challenge. According to Slade & Owens
(1998), adaptive perfectionists are more likely to ‘approach’ challenges with a positive
focus whereas maladaptive perfectionists will be more likely to ‘avoid’ situations for fear
of negative evaluation and fear of failure. Similarly, self-efficacy research has identified
that individuals with high self-efficacy tend to adopt a ‘performance-approach orientation’
and individuals with low self-efficacy possess a ’performance-avoidance orientation’
(Wolters, Yu, & Pintrich, 1996). Self-efficacy research has generally identified higher
levels of self-efficacy for adaptive perfectionists compared to maladaptive or nonperfectionists (Locicero & Ashby, 2000) which as well as confirming the link between
perfectionism and self-efficacy, could suggest a potential health benefit associated with
being an adaptive perfectionist.
2.2.6 Treating perfectionists
As discussed in the preceding subsections of this chapter, perfectionism has been viewed
by many to be a maladaptive personality style that has the potential to bring with it various
problems and difficulties for the individual, specifically with respect to their health and
wellbeing. Following on from this, it would appear that if perfectionists are to be
considered to be an “at risk” group then it is vitally important to consider how
perfectionists respond to treatment for both physical and psychological problems. If
perfectionists represent a client group that are difficult to treat then the health implications
of this personality dimension may be more significant than first anticipated.
Evidence suggests that across a multitude of different therapeutic modalities, perfectionists
have particular problems that tend to impede the successful course of therapy and
treatment. Examples of such problems include difficulties forming a good therapeutic
relationship/working alliance with their therapist (Blatt & Zuroff, 2002), difficulties
59
adhering to treatment guidelines (e.g. regarding taking medications, Scott, 2001) and selfreports of disappointing treatment outcomes (Blatt & Zuroff, 2002; Scott, 2001).
Some authors have tried to formulate possible explanations for the potential difficulties
treating perfectionists. Problems associated with forming a successful therapeutic
relationship have been hypothesised as being associated with an unwillingness to reveal
intimate details of personal difficulties to another individual for fear that such selfdisclosure may be perceived as a personal weakness or as an admission of failure (Habke,
1997; Nadler, 1983). The self-presentational aspect of the perfectionism construct has been
discussed in the preceding sections of this chapter and the desire to self-present a flawless
image, whilst trying at all costs to conceal any negative personal information is more likely
to lead to a reluctance to ask for/seek help for personal difficulties (Flett & Hewitt, 2002).
Such reluctance has been identified as leading to an increase in levels of psychological
distress a well as having the potential to undermine the entire treatment process (Habke¸
Hewitt, & Flett, 2001). It may also be the case that perfectionists have unrealistic
expectations about wanting to create the perfect environment in therapy i.e. to be the
perfect client or by placing excessive and unrealistic demands on the therapist to embody
the characteristics of the perfect therapist (Flett & Hewitt, 2002). Sorotzkin (1998) has
addressed the desire for perfectionists to try and achieve perfection in the treatment
process;
“as they become more knowledgeable about psychological issues, they may also become
perfectionistic in the process of therapy, by trying to become the perfect emotional
specimen (i.e. by not having any anxieties, conflicts or fears)” (p. 92).
Research has also examined how well perfectionists adhere to treatment plans and
medication regimens. Flett et al, (1995) have highlighted that perfectionists generally have
an elevated need for control and such adherence to treatment plans is likely to interfere
with their need for personal regulation. Length of treatment has also been considered as an
important factor influencing the success of therapy. Some would argue that only long-term
therapeutic interventions are likely to be beneficial due to the deep rooted nature of many
perfectionistic traits (e.g. Blatt, Quinlan, Pilkoms & Shea, 1995) and that short term
therapies may simply not be enough to address the core beliefs associated with the
perfectionism construct.
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Specific cognitive biases that have been associated with perfectionism may also hinder
successful treatment. Selectively attending to the possibility of failure as well as a
compulsion to monitor performance have been identified as two cognitive biases that may
interfere with the treatment process (Shafran & Mansell, 2001). Additionally the
dichotomous thinking style that is common to perfectionism may interfere with treatment
outcomes. All or nothing thinking can make it difficult for perfectionists to notice and
appreciate small improvements in therapy and attribute these to a successful outcome
(Sorotzkin, 1998).
An additional problem seems to be reluctance on the part of the perfectionist to let go of
unrealistically high standards during the treatment process. Despite having information to
suggest that pushing oneself towards such unrealistically high standards may be
detrimental for health, individuals may still find it hard to let go of them. There may be a
number of possible explanations for this; firstly individuals may perceive that their high
standards have for the most part served them well e.g. in a work setting this may have
contributed to them reaching a high position with high earnings, secondly, perfectionistic
beliefs have often had their origins in childhood and therefore such ingrained personality
traits are difficult to change and finally, according to Greenspon (2014) we live in a
society where perfectionistic traits are necessary to deal with the fierce competition that
exists in the workplace. In western society, particularly, there are clear and often tangible
rewards attached to pushing oneself to reach high standards and such traits are often
praised and rewarded, therefore it may be almost inconceivable for some perfectionists to
consider adjusting their standards.
Being aware of how perfectionists react to treatment and how perfectionism may interfere
with the treatment process may be helpful for health professionals in developing more
appropriate treatment programs that can be specifically directed towards helping
individuals who suffer from the maladaptive traits of the perfectionism construct.
Additionally knowing levels of perfectionism (i.e. adaptive and maladaptive traits) pretreatment via effective assessment and screening methods may help more accurately match
individuals to the most effective treatment modalities.
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2.2.7 Can perfectionism be beneficial to health and wellbeing?
As discussed in the previous chapter, there has been considerable debate over the issue of
whether or not there is an adaptive side to the perfectionism construct, which may bring
potential benefits to health and wellbeing (e.g. Slade & Owens, 1998). This issue has
already been discussed from a theoretical and conceptual viewpoint earlier in the present
chapter and now consideration is given to the practical implications of there being an
adaptive and healthy type of perfectionism.
Research addressing the relationship between the maladaptive aspects of perfectionism and
dysfunction has been more consistent than research that has addressed the relationship
between adaptive perfectionism and healthy functioning. Indeed for the adaptive
dimension there has been equivocal findings with some authors supporting healthy and
positive associations (e.g. Frost et al, 1993) and others providing evidence to suggest that
the so called adaptive dimension may lead to various levels of maladjustment and poor
physical health outcomes too (Saboonchi & Lundh, 2003; Molnar et al, 2006). There is
also evidence to suggest, according to the perfectionism diathesis stress model proposed by
Hewitt & Flett, (1993; 2002) that under certain circumstances the apparently higher
functioning perfectionists (those demonstrating higher levels of the more adaptive selforiented perfectionism) may be vulnerable to increased depressive symptomatology and
suicide potential when stress interferes or blocks their attempts to meet their high
standards.
According to Stoeber & Otto (2006) the equivocal findings concerning the existence of a
positive and healthy side to perfectionism rest upon several inconsistencies in the research
literature, including the use of a variety of different labels, features and combinations of
these components that researchers have utilised to formulate their conceptualisations. A
further problem may be derived from difficulties associated with trying to accurately
identify the influence of one or other of the two perfectionism dimensions. Perfectionism
has been found to be characterised by coexisting levels of both the adaptive and
maladaptive traits and therefore it may be difficult to accurately extrapolate the unique
effect of each of the dimensions and their relative associations with health and wellbeing.
Being able to say, unequivocally, that a healthy type of perfectionism exists would have
implications for the assessment and treatment of individuals presenting with problems
associated with perfectionism. Similar to the views of Slade & Owens (1998) a positive
62
form of perfectionism could be considered advantageous for the individual and could be
nurtured and encouraged. Also knowing how the different dimensions of perfectionism are
related to different problems could aid our understanding of particular conditions and
disorders and knowing levels of perfectionism (i.e. adaptive and maladaptive traits) pretreatment via effective assessment and screening methods may help more accurately match
individuals to the most effective treatment modalities.
Research exploring the relative contribution of the dimensions of perfectionism, in relation
to health outcomes, may be a promising area of research. It has already been recognised
that there are differences between various conditions and disorders with respect to their
associated levels of the adaptive and maladaptive dimensions. Although demonstrating
similar levels of the maladaptive dimensions, individuals with depression and anxiety have
been found to differ on the achievement striving or adaptive dimension of perfectionism
(Bardone-Cone et al, 2007) with individuals suffering from depression possessing higher
levels of the adaptive traits than anxiety sufferers (Hewitt & Flett, 1991b; Norman et al,
1998). Similar results have been found for Anorexia Nervosa (Bardone-Cone et al, 2007)
and Chronic Fatigue Syndrome (Deary & Chalder, 2010) with both being identified as
showing high levels of both the adaptive and maladaptive traits. Perhaps it is the case that
the dysfunction associated with high levels of maladaptive perfectionism is somehow
offset by the accompanying high levels of the adaptive perfectionism dimension, thus
neutralising the level of dysfunction and offering some type of psychological buffer as has
been suggested for conscientiousness (Carver & Conner-Smith, 2010). It is difficult,
however, to make such inferences (i.e. suggesting there may be some benefits to health and
wellbeing) when discussing conditions that are unquestionably inherently dysfunctional.
Personality research may have added some clarity to the situation; conscientiousness, a
personality trait that has been thought to have considerable overlap with perfectionism has
been identified as having an “enabling” function (Weiss & Costa, 2005) with regards to
protecting against the effects of stress (McCrae & Costa 1987). The “protective or
buffering effect” of conscientiousness with regard to longevity has also received much
support in the literature (e.g. Friedman, Tucker, Tomlinson-Keasy et al, 1993; Kern &
Friedman, 2008; Roberts et al, 2007) and higher levels of conscientiousness have also been
associated with greater engagement in positive health behaviours (Bogg & Roberts, 2004).
There appear to be clear associations between conscientious related traits and positive
health outcomes.
63
There is clearly a bias in the research literature focussing on studies that have addressed
the relationship between the maladaptive dimensions of perfectionism and various health
related problems and with the more recent conceptualisations focussing on the clinical
manifestations of perfectionistic traits, this disparity is likely to increase. There is no doubt
that addressing the needs of individuals struggling to deal with the consequences of the
more extreme and dysfunctional forms of perfectionism has to take priority, however,
there would also seem to be a need for more research addressing the potentially protective
aspects of perfectionism. Such findings may provide insights that could be refined in such
a way as to help vulnerable individuals suffering from the negative effects of high levels of
maladaptive perfectionism.
2.2.8 Conclusion to part 2
The main objective of the present literature review was to bring together some of the key
research areas within the field of perfectionism and health with the intention of answering
two key questions; do maladaptive perfectionists represent a high risk group in terms of
health and wellbeing? And, is there an adaptive type of perfectionism that is beneficial to
health and wellbeing? It would seem that taking into account the different research areas
that have been discussed in this literature review and which fall within the field of
perfectionism and health; there is a considerable amount of research suggesting that
maladaptive perfectionists may represent a high risk group in terms of health and
wellbeing. With this in mind, it seems reasonable to suggest that a justifiable avenue of
research is to address whether maladaptive perfectionists (and adaptive perfectionists)
actively take steps to look after their health and wellbeing by engaging in preventive health
behaviours as well as identify any intervening variables in the relationship. When
addressing the second question regarding the potential adaptiveness of the perfectionism
construct, the answers are not so clear. Equivocal findings within the research domains
discussed in the present chapter have not been able to provide a definite answer of whether
or not there is an adaptive form of perfectionism that may be beneficial to health and
wellbeing. Further research in this field is clearly required. This thesis aims to look at the
64
potential differences between the adaptive and maladaptive dimensions of perfectionism to
attempt to add support for their being a potentially adaptive and health enhancing form of
perfectionism.
65
Chapter 3
Study 1
The Relationship between Perfectionism and Engagement in Preventive health Behaviours:
The Mediating Role of Self-Concealment3
The previous chapter provided a review of the literature concerning two areas of
perfectionism; part 1 was a review of the conceptualisations/definitions and formulations
of perfectionism and part 2 was a review of the area of perfectionism, health and health
behaviours. The available literature points unequivocally to a well-established relationship
between perfectionism and unfavourable health outcomes. Having established that
maladaptive perfectionists may already be at risk from a health point of view, the next step
was to address whether perfectionists look after their health and wellbeing by engaging in
preventive health behaviours. The first study addressed the area of perfectionism and a
sub-type of self-presentation; self-concealment, in relation to engagement in preventive
health behaviours.
3.1 Introduction
Both perfectionism and the self-presentational traits allied with perfectionism have been
linked to a wide range of unfavourable health outcomes. These include difficulties of both
a psychological and physical nature and are discussed in detail in chapter 2 (part 2). The
significance of the problem has been exemplified by recent research suggesting that the
suicide risk in perfectionists has been gravely underestimated due to the self-presentational
need of many perfectionists to keep their difficulties concealed in order to maintain the
appearance of a perfect and flawless image (Flett et al, 2014).
The maladaptive aspects of the perfectionism construct have been associated with a
multitude of different health concerns including; anxiety (Antony et al, 1998; Shafran &
Mansell, 2001), substance abuse (Pacht, 1984), chronic pain (Liebman, 1978), coronary
heart disease (Pacht, 1984), stress (Hewitt & Flett, 2002), depression (Blatt, 1995; Chang,
2000; Enns & Cox, 1999; Frost et al, 1990; Frost et al, 1993; Hewitt & Flett, 1991;
Kawamura, Hunt & Frost, 2001; Pacht, 1984), eating disorders (Bardone-Cone et al, 2007;
3
This chapter represents an earlier version of a published study: Williams, C., & Cropley, M. (2014). The relationship between
perfectionism and engagement in preventive health behaviours: The mediating role of self-concealment. Journal of Health Psychology,
19(10) 1211-1221.
66
Bieling et al, 2004; Fairburn, et al, 2003), Obsessive Compulsive Disorder (Bardone-Cone
et al, 2007), Chronic Fatigue Syndrome (Deary & Chalder, 2010) and suicide (Flett et al,
2014). Although some authors have suggested that the adaptive dimensions of
perfectionism may be associated with noticeable benefits to health and wellbeing
(specifically in the form of improvements in psychological functioning, Frost et al, 1993),
this has remained a contentious issue in the research literature with some authors arguing
(from a health perspective) that perfectionism can only be viewed as negative and
maladaptive, (Flett et al, 1991). For a full discussion of this topic please refer chapter 2,
part 2.
The self-presentational desires of perfectionists have been identified as consisting of a dual
need to project and display a flawless image (self-promotion) coupled with a simultaneous
desire to conceal and withhold personally sensitive information (self-concealment),
(Hewitt et al, 2003). The use of self-presentational strategies by perfectionists seems to be
concerned with the need to manage and control the social impressions of others. Sorotzkin
(1985) believed that the need for admiration and approval from others leads the
perfectionist to attempt to create a socially acceptable persona that will protect them from
the potential rejection of others.
Research has identified that trying to both present and protect a flawless image may place
considerable strain on an individuals’ health and wellbeing and the self-concealment
dimension of self-presentation has been identified as having the closest relationship to
maladjustment (Kelly, 2002). Elevated levels of self-concealment have been associated
with a range of negative health related outcomes including anxiety, depression (Kahn &
Hessling, 2001), symptoms of illness (Larson & Chastain, 1990) and self-reported distress
(Cepeda-Benito & Short, 1998). Additionally the need to conceal one’s imperfections has
been related to; a diminished desire to seek help (Hewitt et al, 2003), less of an inclination
to pursue counselling (Cepeda-Benito & Short, 1998), difficulties forming lasting and
trusting relationships with other people (Derlaga, et al, 1993), lower levels of seeking out
and utilising social support networks (Kawamura and Frost, 2004) and decreased
motivation to engage in physical activity and exercise behaviour (Leary, 1992).
One possible reason for the negative associations with self-concealment may be due to the
additional effort and self-control required on the part of the individual to hide potentially
sensitive and personal information from others, which may lead to an increase in
67
psychological and physiological symptoms (Kahn & Hessling, 2001). Unfortunately, it
would appear that actively concealing negative information relating to the self (Larson &
Chastain, 1990) is not a long-term healthy strategy for living; at some point it is likely that
the individual will either be required to demonstrate their perceived inadequacies and
flaws to others or may accidentally let their guard down and expose their imperfections.
Either way, additional psychological pressure is likely to be involved in the maintenance
of such a false persona. Hewitt and Flett (2002) have suggested that high levels of selfconcealment may be detrimental to health because of an association with increased levels
of perceived stress. The relationship between perfectionism, stress and health has been
discussed in chapter 2 (part 2).
Although there is only a small amount of research that has focussed specifically on
perfectionism and engagement in preventive health behaviours (Longbottom et al, 2010;
2012), a small body of research has looked at the association between self-presentation and
exercise behaviour/physical activity. Research by Hausenblas, et al, (2004) has identified
self-presentation to be an important factor influencing decision to engage in physical
activity behaviour. In an exercise context, self-presentational concerns have been found to
have the potential to either encourage or deter exercise behaviour, for example a person
may be motivated to engage due to a desire to self-present themselves as someone who is
healthy, fit and toned. However, if there is any doubt about one’s ability to do this (e.g.
they are worried about revealing their imperfections and being perceived as unhealthy,
unfit and uncoordinated) then these self-presentational concerns may deter them from
engaging (Leary, 1992). In the perfectionism literature this finding has been supported by
research by Hewitt et al, (2003) who have suggested that perfectionists may avoid
situations that risk exposing a less than perfect image. Furthermore, when investigating the
role of perfectionism in eating disturbances, Chang, Ivezaj, Downey et al, 2008 identified
an association between perfectionism and poor uptake of health behaviours.
The purpose of the present study was to concentrate on the potential role of selfconcealment in the relationship between perfectionism (adaptive and maladaptive) and
engagement in preventive health behaviours. There is certainly evidence to suggest that
type of perfectionism may influence the motivation to engage in certain preventive health
behaviours, such as exercise and physical activity (Longbottom et al, 2010; 2012) and
there is also research that has considered the negative implications of high levels of selfconcealment (e.g. increased levels of psychopathology, higher levels of stress and
68
decreased motivation to engage in physical activity and exercise behaviour). It may be the
case that self-concealment when coupled with the maladaptive dimensions of
perfectionism has the potential to add to the vulnerability of perfectionists and further
reduce their desire to engage in preventive health behaviours. The self-presentational need
to self-conceal negative personal information relating to the self may lead to an avoidance
of engagement in such behaviours, particularly those involving a public display of one’s
abilities (e.g. exercise classes and physical activity behaviours) for fear of exposing a less
than perfect persona. Previous research has investigated the role of self-concealment as a
potential mediator in the relationship between maladaptive perfectionism and
psychological distress (Kawamura & Frost, 2004). On this occasion, self-concealment was
found to fully mediate the relationship, suggesting that the desire to withhold personally
relevant information may be instrumental to the psychological distress experienced by
perfectionists.
Life-satisfaction and wellbeing were also addressed in the present study. Previous research
has identified a negative association between the maladaptive aspect of perfectionism and
both life-satisfaction and wellbeing (Park & Jeong, 2015; Greblo, Zrinka, Bosnar &
Ksenija, 2008) suggesting that individuals possessing more of the maladaptive
perfectionistic traits tend to experience a poorer quality of life and a diminished sense of
wellbeing. The adaptive perfectionism dimensions, in contrast, have been associated with
higher levels of life-satisfaction (Chang, 2000; Chang et al, 2004; Gilman, Ashby, Sverko,
et al, 2005; Greblo et al, 2008). Recent research has identified adaptive perfectionists to
possess higher levels of life satisfaction than maladaptive perfectionists and higher levels
of psychological wellbeing than both maladaptive and non-perfectionists (Park & Jeong,
2015). The identification of the adaptive perfectionism dimension being related to higher
levels of wellbeing than non-perfectionists suggests the possibility of there being some
positive and enhancing qualities inherent in adaptive perfectionists.
As identified in chapter 2 (part 2), despite the wealth of research linking the
negative/maladaptive aspects of the perfectionism construct with various psychological
difficulties, and the identification of an association between the self-presentational
dimensions of perfectionism and poor health outcomes, there has been little research to
establish how well perfectionists look after their health and wellbeing. This study is an
attempt to address a gap in the literature concerning the relationships between
perfectionism, self-concealment and engagement in preventive health behaviours. The
69
intention is to further research in the area by addressing the mediating role of selfconcealment in the relationship between maladaptive perfectionism and engagement in
preventive health behaviours.
Whilst supporting previous research that has been instrumental in linking the maladaptive
dimension of perfectionism with psychopathology and poor physical health outcomes, the
present study does also supports the potentially adaptive side of the perfectionism
construct. The positive premise of the thesis postulates (in accordance with previous
research) that there may be some inherent advantages to being an adaptive perfectionist in
terms of health and wellbeing and therefore the hypotheses reflect a positive bias whereby
adaptive perfectionism (when compared to maladaptive perfectionism) is predicted to be
associated with more engagement in preventive health behaviours, lower levels of
psychological distress and noticeable psychological benefits such as greater satisfaction
with life and a greater sense of psychological wellbeing.
3.1.1 Hypotheses
1.
Maladaptive perfectionism is predicted to be associated with lower levels of
engagement in preventive health behaviours and adaptive perfectionism associated
with higher levels of engagement
2.
Maladaptive perfectionism is predicted to be positively associated with selfconcealment and self-concealment is proposed to be associated with lower levels of
engagement in preventive health behaviours.
3.
Both maladaptive perfectionism and self-concealment are predicted to be
associated with elevated levels of psychological distress and reduced levels of both
life-satisfaction and wellbeing. Adaptive perfectionism is predicted to be associated
with lower levels of psychological distress and higher levels of both lifesatisfaction and wellbeing.
4.
Self-concealment will be identified as a mediator in the relationships between;
maladaptive perfectionism and engagement in preventive health behaviours and
self-concealment and psychological distress.
70
3.2 Method
Participants and Procedure
Participants were students at the University of Surrey, recruited through an email
advertisement circulated to all students. Of the final sample (N=370), 287 (77%) were
women and 83 were men (23%). Their mean age was 26.72 years (SD = 9.4). Of the
sample, 44% were undergraduate students (n = 164) and 51% were postgraduate students
(n = 188), the remaining 5% (n = 18) did not specify level of study. Participants
completed an online questionnaire that was designed to find out about various aspects of
health and wellbeing as well as engagement in preventive health behaviours.
3.2.1 Measures
Perfectionism
To assess adaptive and maladaptive perfectionism, four of the subscales of the Frost
Multidimensional Perfectionism Scale (FMPS, Frost et al, 1990) were used (this scale has
been summarised in chapter 2, part 1). For adaptive perfectionism, the subscales of
Personal Standards (7 items) and Organisation (6 items) were summed to form a total
adaptive perfectionism score (Adaptive Perf.). Examples of questions encompassing the
adaptive dimension of perfectionism included “I expect higher performance in my
everyday tasks than most people” and “Neatness is very important for me”. A high score
indicates a higher level of adaptive perfectionism. The use of these two subscales to
represent a measure of adaptive perfectionism has been supported by previous research,
showing good internal reliability, Cronbach’s alpha, 0.88 (Chang et al, 2004; Harris et al,
2008). For maladaptive perfectionism, the Concern over Mistakes (CM) and Doubts about
Actions (DA) subscales of the Frost et al scale were utilised and summed to form a
measure of maladaptive perfectionism (Maladaptive Perf.). Examples of questions to
assess the maladaptive dimension of the perfectionism construct included, “If I fail partly,
it is as bad as being a complete failure” and “I tend to get behind on my work because I
repeat things over and over”. A high score denoted a higher level of maladaptive
perfectionism. The use of these two subscales to represent a measure of maladaptive
perfectionism has been utilised and supported in the research literature (Dunn et al, 2006;
71
Frost et al, 1990; Harris et al, 2008; Wei et al, 2004). Cronbach’s alpha for the two
subscales combines has been found to be 0.87 (Harris et al, 2008).
Self-Concealment
The Self-Concealment Scale (SCS; Larson & Chastain, 1990) was used to assess selfconcealment. The scale consists of ten items addressing an individual’s desire to conceal
negative personal information. Examples of questions included; “When something bad
happens to me, I tend to keep it to myself” and “I have negative thoughts about myself that
I never share with anyone”. Participants are asked to rate their agreement with the various
statements on a five point Likert scale ranging from strongly disagree (1) to strongly agree
(5). A total score is then derived, with high scores denoting a greater tendency to selfconceal. The scale has been shown to be reliable, with favourable test-retest and interim
reliability. Internal consistency has been reported to be good, α = 0.83 (Larson & Chastain,
1990). The scale is generally considered to be a valid means of assessing the tendency to
conceal personal information.
Engagement in Preventive Health Behaviours
This questionnaire was designed for the present study and was an adaptation of the
General Preventive Behaviours Checklist (Amir, 1987). It required respondents to rate on a
three point scale the frequency with which they carry out a range of preventive health
behaviours. Areas addressed included diet, exercise, physical activity, avoidance of
cigarettes and alcohol, social interaction, work, and emotional well-being. Examples of
questions included; “I eat a balanced diet”, “I do regular aerobic or strenuous exercise”, “I
avoid overworking” and “I avoid too much emotional distress”. Responses were summed
to form a total engagement score with higher scores indicating a greater amount of
engagement in preventive health behaviours. An acceptable level of internal reliability was
found for scale in the present study (Chronbach’s alpha, .84).
72
Psychological Distress
The Hopkins Symptom Checklist-21 was utilised (HSCL-21; Green, Walkey, McCormick
& Taylor, 1988) as a measure of general psychological and symptom distress. This
measure gauges the respondent’s current experience of somatic, performance and general
distress by asking individuals to indicate how much they have been affected by these types
of symptoms in “the past seven days, including today”. The scale consists of 21 items
scored on a four point Likert scale ranging from 1 (strongly disagree) to 4 (strongly
agree). A high score overall, denotes a higher degree of psychological distress. The scale
has good internal reliability (α = 0.90; Green, et al, 1988) and has adequate test-retest
reliability, construct and concurrent validity (Deane, Leathern & Spicer, 1992). The use of
this scale as a valid and reliable method of assessing psychological distress has been
supported in the research literature (Harari, Waehler & Rogers, 2005; Komiya, Good &
Sherrod, 2000).
Life satisfaction
To assess life satisfaction, the Satisfaction with Life Scale (SWLS; Diener, Emmons,
Larson et al, 1985) was used. This consists of five items rated on a seven point Likert scale
ranging from 1 (strongly disagree) to 7 (strongly agree). Higher scores denote greater life
satisfaction. An encouraging level of reliability and internal consistency has been found,
Cronbach’s alpha, 0.87 (Diener et al, 1985). In terms of validity, the scale correlates
moderately well with other subjective well-being scales (Pavot, Diener, Colvin & Sandvik,
1991).
Wellbeing
To provide a measure of general well-being the WHO-5 WellBeing index (Bech, Gudex &
Johansen, 1996) was employed. It covers the following areas; positive mood, vitality and
general interest. Each of the five items is rated on a six point Likert scale from 0 (not
present) to 5 (constantly present). A total score is derived from summing the five items,
with higher scores corresponding to a greater sense of wellbeing. Findings suggest good
reliability and validity, Cronbach’s alpha = 0.82, (Bech, Olsen, Kjoller & Rasmussen,
2003; De Wit, Pouwer, Gemke et al, 2007).
73
3.2.2 Data Analysis
The research design for the present study was primarily correlational. Mediation analyses
were also carried out to determine the importance of self-concealment in the relationship
between maladaptive perfectionism and engagement in preventive health behaviours and
maladaptive perfectionism and psychological distress.
To test for mediation, there needs to be the suggestion of a causal sequence between three
variables, i.e. that one variable affects the second variable which will in turn affect a third
variable. There are a number of different ways of testing for mediation; one accepted
method is to follow the steps proposed by Baron & Kenny (1986) that utilises a series of
regression equations. According to these authors, for a variable to be considered a
mediator, a number of conditions need to be satisfied; firstly the independent variable must
significantly predict the dependent variable, secondly the independent variable must
significantly predict the mediator, and thirdly the mediator must significantly predict the
dependent variable whilst controlling for the independent variable. The final step is to
check for mediation. Full or complete mediation is suggested if the effect of the
independent variable on the dependent variable falls close to zero once the mediator has
been introduced into the prediction. If the effect of the independent variable on the
dependent variable is reduced, but not to zero, partial mediation is indicated. No reduction
in the effect of the independent variable on the dependent variable with the addition of the
mediator indicates that there is no mediation. The majority of research studies adhere to
the Baron and Kenny (1986) steps to establish whether mediation has occurred and do not
take this one step further and test the significance of the indirect effect. Such a procedure is
considered to be a more stringent test of mediation (Sobel, 1982). In a review of fourteen
methods to assess mediation, Mackinnon, Lockwood, Hoffman et al, (2002) have
suggested the Sobel test (and its variants) to be superior with respect to power and ease of
application.
74
Figure 3.1
Testing the indirect effect using the method outlined by Sobel (1982)
M
(Sa)
(Sb)
a
IV
b
c
DV
To establish mediation using the Sobel Test (1982) you need to find the standard error of a
and b (Fig.1). This can be done by performing two steps; firstly carrying out a regression
analysis with the independent variable predicting the mediator to give you the
unstandardised regression coefficient (a) and the standard error of a (Sa), secondly
performing a regression analysis with both the independent variable and the mediator
predicting the dependent variable, which will give you the unstandardised regression
coefficient of b and the standard error of b (Sb). Finally, the resulting Z value is calculated
by performing the following equation;
a*b
Z=
(b2 *Sa 2 + a2 *Sb2 )
Assuming you have a fairly sizable sample, minimal measurement error in the mediator
and the dependent variable does not significantly predict the mediator, a result of +/- 1.96
will be considered significant at the 0.05 level.
3.3 Results
Analyses are separated into three sections. The first section comprises the preliminary
analysis consisting of sample demographics, means (M), standard deviations (SDs) and
reliabilities (Cronbach’s alpha α) for all the major variables (Table 3.1). Secondly the
results of the correlational analyses are presented in Table 3.2. The results from the
mediation analyses are displayed diagrammatically and regression coefficients presented in
Table 3.3.
75
Sample Demographics
Table 3.1: Sample Demographics; means, standard deviations and reliabilities for all
variables
n
Age
18-29
30-39
40-49
50-59
60+
Level of Study
Undergraduate
Postgraduate
Not specified
Variables
Adaptive Perf.
(PS and O)
Maladaptive Perf.
(CM and DA)
Self-Concealment
(SCS)
Engagement in
Preventive Health
Behaviour
Psychological Distress
(HSCL-21)
Wellbeing
(WHO-5)
Life-Satisfaction
(SWLS)
(%)
267
56
33
11
3
(72.2)
(15.1)
(8.9)
(3)
(0.8)
164
188
18
(44)
(51)
(5)
(M)
(SD)
(α)
45.42
8.41
0.88
34.90
9.12
0.89
27.96
8.74
0.89
31.9
8.30
0.84
37.55
9.88
0.90
12.55
6.96
0.87
22.14
6.96
0.88
Adaptive Perf = adaptive perfectionism, PS= personal standards, O= organisation, Maladaptive Perf=maladaptive perfectionism, CM=
concern over mistakes, DA= doubts about actions
Correlational Analyses
As predicted a significant negative association was found between maladaptive
perfectionism and engagement in preventive health behaviours (r = -0.330, p<0.01)
76
suggesting that those participants scoring highly on the negative aspects of perfectionism
engaged less in behaviours that could potentially benefit their health. A small yet
significant correlation was found for adaptive perfectionism and engagement in preventive
health behaviours (r = 0.254, p<0.01) suggesting those participants scoring highly on the
more adaptive elements of perfectionism may be more inclined to take preventive steps as
far as health behaviours are concerned (hypothesis 1).
For perfectionism and self-concealment, a positive association was observed between
maladaptive perfectionism and self-concealment, (r = 0.471, p<0.01), although, adaptive
perfectionism and self-concealment were shown to be uncorrelated. This may suggest that
self-concealment is a factor present predominantly in maladaptive perfectionism and not
perfectionism per se. When the relationship between self-concealment and engagement
was examined, an inverse relationship was found (r = .0.346, p<0.01) suggesting as selfconcealment increases, there is a corresponding decrease in engagement in preventive
health behaviours, (hypothesis 2).
Addressing the relationship between perfectionism (adaptive and maladaptive) and
psychological distress, no relationship was observed for adaptive perfectionism, although a
significant positive correlation was observed for maladaptive perfectionism (r = 0.533,
p<0.01). Such findings support previous research linking the negative aspects of
perfectionism with greater psychological distress. As expected and in support of earlier
work, self-concealment and psychological distress were positively correlated (r = 0.486,
p<0.01). In consideration of the relationships between perfectionism, life-satisfaction and
wellbeing, maladaptive perfectionism was associated with lower levels of both variables (r
= -0.376, p<0.01 and r = -0.439, p<0.01 respectively). No relationship was observed
between adaptive perfectionism and either life-satisfaction or wellbeing. Similar to
maladaptive perfectionism, self-concealment was also associated with diminished levels of
both, life-satisfaction and wellbeing, r = -0.361, p<0.01 and r = -0.355, p<0.01
respectively, (hypothesis 3).
77
Table 3.2
Correlation matrix for all major variables
Variables
1. Adaptive Perf.
2. Maladaptive Perf.
3. Self-Concealment
4. Engagement
5. Psychological Distress
6. Wellbeing
7. Life-Satisfaction
1
.347**
-.011
.254**
-.012
.081
.112*
2
.471**
-.330**
.533**
-.439**
-.376**
3
-.346**
.486**
-.355**
-.361**
4
-.396**
.524**
.380**
5
-.562**
-.404**
6
7
.563**
-
Note. Engagement = Engagement in Preventive Health Behaviours
*p < .05. **p <.01
78
Mediation Analyses
Mediation (hypothesis 4) was tested according to the method outlined by Baron and Kenny
(1984) and the significance of the indirect effect calculated using the Sobel Test (Sobel,
1982). Unstandardised regression coefficients were used in the calculations. The results of
the Sobel Test are presented diagrammatically to aid understanding, and the regression
coefficients presented in Table 3 and 4.
Figure 3.2
The Mediating Role of Self-Concealment in the Relationship Between
maladaptive Perfectionism and Engagement in Preventive Health
Behaviours
SelfConcealment
(Sa) = .044
(Sb) = .052
a = .451
Maladaptive
Perfectionism
b = -.232
c
Engagement
in Preventive
Health
Behaviours
Z = -4.091
79
Table 3.3
Summary of the Regression Analysis for the Variables; Maladaptive
Perfectionism, Self-Concealment and Engagement in Preventive Health
Behaviours
Variable/s
Unstandardised (B)
Standardised (Beta)
Step 1
Mal P

X
Engagement
-.300†
-.330†
.451†
.471†
Y
Step 2
Mal P

X
Self-Concealment
M
Step 3
Mal P + Self-C  Engagement
X
M
Y
-.195† (Mal P)
-.215† (Mal P)
-.232† (Self-C)
-.244† (Self-C)
Note: Step 2 is identical for both mediation analyses and therefore will not appear on the next table.
Mal P = maladaptive perfectionism, Self-C = self-concealment, Engagement = engagement in preventive
health behaviours.
† p<.001
When considering self-concealment as a mediator in the relationship between maladaptive
perfectionism and engagement in preventive health behaviours, the result of the Sobel Test
was significant (z = -4.091). The regression coefficient (Step 1, B = -.300, p<.001; Step 3,
B = -.195, p<0.001), however has not been reduced adequately to suggest full mediation.
This result suggests that self-concealment partially mediates the relationship between
maladaptive perfectionism and engagement in preventive health behaviours.
80
Figure 3.3
The Mediating Role of Self-Concealment in the Relationship Between
maladaptive Perfectionism and Psychological Distress
SelfConcealment
(Sa) = .044
(Sb) = .054
a = .451
Maladaptive
Perfectionism
b = .341
Psychological
Distress
c
Z = 5.395
Table 3.4
Summary for the Regression Analysis for the Variables; Maladaptive
Perfectionism, Self-Concealment and Psychological Distress
Variable/s
Unstandardised (B)
Standardised (Beta)
Step 1
Mal P

.577†
Psych dist
X
.533†
Y
Step 3
Mal P + Self-C  Psych dist
X
M
Y
.423† (Mal P)
.390† (Mal P)
.341† (Self-C)
.302† (Self-C)
Note. Psych dist = psychological distress,
† p<.001
Similarly for the relationship between maladaptive perfectionism and psychological
distress although the result of the Sobel Test was again significant (z = 5.395), the
regression coefficient, was not reduced enough to indicate full mediation (Step 1, B = .557,
p<.001; Step 3, B =.423, p<,001), therefore self-concealment can only be considered a
partial mediator.
81
3.4 Discussion
In accordance with the proposed hypotheses, maladaptive perfectionism was found to be
related to lower levels of engagement in preventive health behaviours and adaptive
perfectionism related to higher levels of engagement. This finding was consistent with
Slade and Owens’ (1998) theory concerning the motivations driving perfectionistic
behaviour, specifically the suggestion that adaptive perfectionists may be more inclined to
“approach” challenging situations and maladaptive perfectionists more likely to “avoid” or
escape from difficult situations (see chapter 2, part 1). Research by Longbottom et al
(2010) has also identified adaptive perfectionism being associated with adaptive cognitions
and behaviours related to engagement in exercise. Furthermore research by Chang et al
(2008) has identified a positive association between the adaptive dimension of
perfectionism and increased uptake of health behaviours.
There may be many reasons for the lower levels of engagement identified for maladaptive
perfectionism. One possible avenue of reasoning for the lower levels of engagement on the
part of maladaptive perfectionists may be related to the self-presentational dimension of
perfectionism. Avoidance may seem to be the logical and preferred option when there is
the fear of exposing one’s imperfections to others. Certain health behaviours do often
involve the need to perform in front of others such as exercise classes or attending a gym,
and these activities may be particularly challenging for perfectionists as there is the risk
that their imperfections may be on public display. This could arguably interfere with their
core perception of themselves and specifically their need and ability to maintain a flawless
persona. Hewitt et al (2003) have identified that some perfectionists will go to great
lengths to avoid negative evaluation and will at all costs endeavour to keep their
imperfections hidden.
A further explanation for the lack of engagement may involve the use of self-handicapping
tendencies such as procrastination, over-committing, not putting effort in and avoiding
challenges (Kearns, Forbes & Gardiner, 2007). Self-handicapping behaviour can be
described as a type self-presentational strategy that has been associated with a reduced
intention to engage in preventive health behaviours (Sirois, 2004) (see chapter 3). Higher
levels of perfectionism have also been associated with a greater propensity to use selfhandicapping behaviours (Frost et al, 1990; Hobden & Pliner, 1995) and such behaviours
are thought to have an inherent appeal to perfectionists who may feel they have much to
82
lose in evaluative situations. Perfectionism and self-handicapping are thought to share
many common features including striving for extremely high standards, dissatisfaction if
such standards are not met and an excessive and often debilitating fear of failure. The role
of self-handicapping is explored in study 4 (chapter 6) as one of a number of possible
obstacles to engagement in exercise behaviours/physical activity.
In terms of the relationships between perfectionism (adaptive and maladaptive) and selfconcealment and self-concealment and engagement in preventive health behaviours,
maladaptive perfectionism was found to be associated with elevated levels of selfconcealment which was consistent with earlier work in the research literature (Frost,
Turcotte, Heimberg et al, 1995; Kawamura & Frost, 2004) suggesting that highly
perfectionistic individuals may self-conceal in an attempt to maintain a “flawless image”
and avoid negative evaluation. Additionally self-concealment was found to be associated
with lower engagement in preventive health behaviours supporting previous research
suggesting that the tendency to self-conceal has been associated with a reluctance to
engage in certain health related behaviours such as seeking professional help for personal
difficulties (Cepeda-Benito & Short, 1998; Kelly & Achter, 1995; Hewitt et al, 2003), less
of an inclination to pursue counselling (Cepeda-Benito & Short, 1998) and decreased
motivation to engage in exercise behaviours (Leary, 1992).
Both maladaptive perfectionism and self-concealment were found to be related to higher
levels of psychological distress and lower levels of both life-satisfaction and wellbeing.
This supports earlier research that has highlighted the maladaptiveness of both
perfectionism and self-concealment. This may also help explain the lower level of
engagement associated with maladaptive perfectionism as previous research has identified
that psychological distress may affect the likelihood of engaging in various health
promoting activities such as attending for health screenings (Lieferman & Pheley, 2006),
adhering to preventive health care guidelines (Thorpe, Kalinowski, Patterson et al, 2006)
and delaying routine health examinations (Witt, Kahn, Fortuna et al, 2009).
Supporting the positive stance set out in chapter 1 and previous research regarding
adaptive perfectionism (Kearns et al, 2008; Slade & Owens, 1998) it was hypothesised that
adaptive perfectionism would be associated with lower levels of psychological distress and
higher levels of life-satisfaction and wellbeing. The present study, however, did not find
83
support for this premise as no relationships were observed between adaptive perfectionism
and any of these variables apart from engagement in preventive health behaviours.
Self-concealment was identified to be a partial mediator in the relationships between
maladaptive perfectionism and engagement in preventive health behaviours and
maladaptive perfectionism and psychological distress (hypothesis 4). Previous research by
Kawamura and Frost (2004) identified self-concealment to fully mediate the relationship
between maladaptive perfectionism and psychological distress and as such discussed the
potential for this aspect of self-presentation to play a significant role in the amount of
psychological distress experienced by individuals with maladaptive perfectionism. Despite
not fully supporting the mediation hypotheses, this study does demonstrate that selfconcealment may be an important factor when considering the health implications of being
a maladaptive perfectionist, specifically that it may influence decisions concerning
whether or not to engage in preventive health behaviours. Elevated levels of both
maladaptive perfectionism and self-concealment may represent an increased vulnerability
towards psychological problems and be a toxic combination as far as health and wellbeing
are concerned.
To summarise, the present study suggests that maladaptive perfectionists may be putting
their long-term health and wellbeing at risk for a number of reasons.

As maladaptive perfectionism increases there seems to be a corresponding decline
in engagement in preventive health behaviours. Engaging in such behaviours is
considered an important way of reducing the risks of developing various illnesses
and chronic conditions such as heart disease, cancer and diabetes

Maladaptive perfectionism seems to be associated with high levels of selfconcealment which itself has been associated with unfavourable health outcomes as
well as a decreased desire to engage in preventive health behaviours.

Maladaptive perfectionism has consistently been associated with higher levels of
psychological distress (which has the potential to lead to various psychological and
physical difficulties) and lower levels of life satisfaction and wellbeing.

The combination of high levels of; maladaptive perfectionism and self-concealment
may be a harmful blend of characteristics and may increase susceptibility to
various health difficulties.
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In terms of the adaptive dimension of perfectionism, it is not possible to make any
assumptions about the potential adaptiveness of the construct based on the results of this
study. However, the results do point to a disparity between the two dimensions of
perfectionism in relation to a number of areas and specifically decision to engage in
preventive health behaviours. Clearly more research is required to attempt to discover the
precise mechanisms that may be involved in this relationship and that may be instrumental
in encouraging higher levels of engagement as well as discouraging engagement.
There are several limitations to the present study. A reliance on self-report data and a
cross-sectional sample restricted to University students makes generalisations problematic.
A positive view of this could be that although the sample was narrow in focus, these
individuals do represent the next generation of workers and as such their views may be
considered particularly relevant when thinking about preventive measures and protecting
the psychological and physical wellbeing of workers in an occupational setting. Another
limitation reflects a conceptual difficulty. The present study utilises the conceptualisation
of perfectionism supported by Frost et al (1990) and defends the use of a
maladaptive/adaptive split to define perfectionism. What has to be remembered is that
extreme forms of perfectionism may be characterised by elevated levels of both adaptive
and maladaptive traits (Slade and Owens, 1998) and the coexistence of both positive and
negative traits may, in itself, have particular health implications. It would be interesting to
utilise a different conceptualisation for perfectionism, perhaps one that recognises the
within-person combination of the adaptive and maladaptive traits (Gaudreau & Thompson,
2010; Stoeber & Otto, 2006). Additionally more research is needed looking specifically at
other variables that have been shown to have a particularly robust association with
perfectionism and that have also been associated with low levels of engagement in
preventive health behaviours such as perceived stress.
3.5 Conclusion.
The present study has aimed to extend previous research in the field of perfectionism and
health by highlighting a need to address whether or not maladaptive perfectionists
represent a “high risk” group in terms of health and wellbeing. The primary means of
gauging this was based on addressing the association between perfectionism (adaptive and
maladaptive) and engagement in preventive health behaviours as well as considering the
85
role of self-concealment in this relationship. Additionally the intention was to identify any
apparent advantages (in terms of health and wellbeing) associated with the adaptive
dimension of perfectionism. The present study highlighted a number of factors that may
suggest that maladaptive perfectionists represent a “high risk” group in terms of potential
health outcomes and their psychological wellbeing as well as highlighting the important
role of self-concealment in the relationship between perfectionism and engagement in
preventive health behaviours. Limited evidence was found to suggest any apparent health
benefits of being an adaptive perfectionist. To continue to explore the relationship between
perfectionism and engagement, the next chapter addresses the relationship between
perfectionism and perceived stress in relation to engagement in preventive health
behaviours.
.
86
Chapter 4
Study 2
The Relationship between Perfectionism and Engagement in Preventive Health
Behaviours: The Role of Perceived Stress
The previous chapter explored the mediating role of self-concealment in the relationship
between perfectionism and engagement in preventive health behaviours. Findings
suggested that the desire to conceal sensitive and personal information from others in an
attempt to maintain a perfect and flawless image may influence perfectionists’ desire to
engage in preventive health behaviours as well increase their levels of psychological
distress. The previous study supported the possibility that the combination of high
maladaptive perfectionism and high self-concealment may be a dangerous combination
and have implications for the health and wellbeing of highly perfectionistic individuals.
The present study is considered to be an adjunct to the previous one in that it considers the
relationship between perfectionism (adaptive and maladaptive) and engagement in
preventive health behaviours as the primary focus, although for this study, the emphasis is
on the role of perceived stress. Again, supporting the main aims of the thesis, the present
study seeks to provide further support for the suggestion that maladaptive perfectionists
may present as a “high risk” client group in terms of their health and wellbeing, by
exploring whether the combination of type of perfectionism and level of perceived stress
may influence health outcomes. This study aimed to extend the conceptualisation of
perfectionism utilised in the previous study by focussing on the interactive effects of the
two dimensions of perfectionism (adaptive and maladaptive) rather than focussing on the
core facets of perfectionism individually.
4.1 Introduction
Research in the field of perfectionism and health has identified a well-established
relationship between perfectionism and stress with stress being associated with poorer
health outcomes, specifically, psychological problems such as depression and anxiety
(Blatt, 1995; Flett & Hewitt, 2002). Perfectionists are considered to have particular
difficulty dealing with stress from two sources; firstly from the experience of daily hassles
and secondly having to deal with the constant burden of trying to live up to their own high
87
standards (Flett & Hewitt, 2002). The relationship between perfectionism and stress has
been reviewed in chapter 2 (part 2).
The relationship between perfectionism and stress appears to be a complicated one with
perfectionism being implicated in the generation, anticipation, perpetuation and
enhancement of stress (Flett & Hewitt, 2002). It would appear that perfectionists may be
responsible for generating more stress for themselves and this, according to Hewitt and
Flett (2002) may be a product of their unrealistic approach to life. Experiencing little
satisfaction from their efforts, possessing an inflexible attitude in relation to adjusting their
standards and expectations (Ferrari & Mautz, 1997) and over-estimating the threats
associated with everyday situations (Dunkley et al, 2003) can all lead to the generation of
greater amounts of stress than for non-perfectionists. In terms of perpetuating a stress
response, it would appear that perfectionists have a propensity to draw on maladaptive
tendencies that keep a stressful experience going for longer (Hewitt and Flett, 2002). Once
a stressful event has occurred, perfectionists then tend to hold these experiences in their
memory and ruminate about the consequences. Unfortunately this can act as a constant
reminder of the discrepancy between their “actual” and “ideal” self and have the effect of
increasing levels of psychological distress (Strauman, 1989). Furthermore it may set up a
failure orientation whereby the perfectionist ruminates and experiences anxiety about
having similar stressful episodes in the future (Flett & Hewitt, 2002).
When addressing the possible differences between adaptive and maladaptive perfectionists
and their corresponding responses to stressful experiences, it would appear that
maladaptive perfectionists may be at greater risk of developing problems (Flett & Hewitt,
2002). A considerable amount of research has focussed on the particular coping strategy
utilised by adaptive and maladaptive perfectionists in response to stressful experiences.
Maladaptive perfectionists have a tendency to react to stressful experiences in a more
helpless manner and rely on dysfunctional coping styles predominantly concerned with
avoidance that are likely to have the effect of exacerbating an already difficult situation
(Flett, Hewitt, Blankstein et al, 1996). Adaptive perfectionists, on the other hand seem to
engage more readily in problem focussed coping strategies (Dunkley et al, 2000). Some
authors have suggested that adaptive perfectionists may possess a type of resiliency factor
when dealing with stress (Enns et al, 2005) which may act as a type of psychological
buffer to ameliorate the more serious consequences of being highly perfectionistic. Others
have proposed that adaptive perfectionists may be just as vulnerable as maladaptive
88
perfectionists and at risk of developing psychological problems in the long-term (Hewitt &
Flett, 1993).
Adaptive perfectionists may be most at risk when they believe there to be some block to
their achievement of personal goals or when they doubt that a positive outcome is possible
(Flett & Hewitt, 2006). The diathesis-stress model of perfectionism and depression (Hewitt
& Flett, 1993) has proposed that the adaptive qualities of perfectionism may be beneficial
up to a point, and particularly when daily stress levels are at a minimum, however, if stress
levels increase for a particular reason, individuals may be at risk of developing symptoms
of depression or any pre-existing psychopathology may be activated (Hewitt & Flett, 1993;
Flett et al, 1995). One of the problems appears to be that even minor hassles can lead to the
activation of much deeper beliefs relating to the individuals perception of their own flaws
and imperfections (Hewitt & Flett, 2003). The situation may be exacerbated because
perfectionists seem to find it harder than non-perfectionists to admit to having personal
problems, which seems to affect their ability to ask for or seek help at times of high stress
(Hewitt & Flett, 2002). The reluctance according to these authors may be because
perfectionists perceive the help seeking as an admission of failure and a sign of weakness.
The intention of this study was to explore perfectionists’ engagement in preventive health
behaviours as well as attempting to ascertain the role of perceived stress in the relationship
between perfectionism and engagement. Previous research exploring the relationship
between stress and health behaviours has identified there to be a well-established
relationship between perceived stress and engagement in health risk behaviours such as
smoking, eating high fat foods and consuming excessive amounts of alcohol (Parrott,
1995; Abbey et al, 1993; Macht & Simons, 2000) with the proposed rationale for engaging
in such behaviours being a means of offsetting the stress that one is faced with.
Research addressing the relationship between stress and preventive health behaviours has
not been so clear cut; some studies suggest levels of physical activity /exercise behaviour
increase when stress is perceived to be high (Spillman, 1990) and others proclaiming a
reduction in such activities in times of high stress (Adler & Matthews, 1994; Heslop et al,
2001; Stetson, Rahn, Dubbert et al,1997). According to Adler and Matthews (1994) the act
of engaging in certain health promoting behaviours at times of high stress may be too
overwhelming for the individual due to the additional behavioural demands that are
required to carry out such behaviours. This has been supported by research in an academic
89
setting that has addressed how students maintain preventive health behaviours in times of
increased academic pressure such as exams. Weidner et al (1996) found that certain
behaviours remained unchanged (at times of high stress) such as self-care and driving
safely, whereas, those that required additional resources and effort to keep them going (e.g.
exercising/physical activity and following a healthy diet) were diminished.
As previously stated, one of the main aims of the present thesis was to consider whether
maladaptive perfectionists may signify a “high risk” group in terms of their health and
wellbeing. The purpose of the present study was to focus on the role of perceived stress in
the relationship between adaptive/ maladaptive perfectionism and engagement in
preventive health behaviours and to try and establish whether there was an interaction
between type of perfectionism and level of perceived stress in terms of affecting
engagement in preventive health behaviours. Additionally by addressing a number of other
health related variables e.g. perception of general health, reporting of physical symptoms
and assessing levels of state and trait anxiety the intention was to gain a better
understanding of the health status of the different types of perfectionists. There are no
studies to date that have addressed this specific area of research and only a small number
of studies that have begun to address the relationship between perfectionism and any form
of preventive health behaviours (e.g. Longbottom et al, 2010; Williams & Cropley, 2014).
It was felt that addressing the area of perceived stress in relation to perfectionism was
important because it may be that level of perceived stress when combined with particular
type of perfectionism may have an interactive effect that may affect engagement. Perhaps
engaging in such behaviours may place additional demands on individuals who may
already be operating at a higher than average baseline level of perceived stress/anxiety and
this may be particularly relevant when considering maladaptive perfectionists.
As with the previous study and supporting the positive standpoint that has been adopted
for the purpose of the present thesis (with regards to adaptive perfectionism), the adaptive
dimension of perfectionism is considered to have the potential to provide some type of
benefits to the individual that may be beneficial in terms of health and wellbeing. For the
present study, it was hoped that the adaptive dimension of perfectionism would be
associated with greater engagement as this would support the findings of the previous
study as well as the support the ideas set out in chapter 1. To extend the findings of the
previous study and hopefully provide more information regarding the relative contribution
of both the adaptive and maladaptive dimensions of perfectionism, a more detailed
90
conceptualisation was proposed. Whilst still based on the original dimensions set out by
Frost et al (1990) this study proposed four groups of perfectionists (non-perfectionists,
adaptive perfectionists and two types of maladaptive perfectionists) based on the
conceptualisations of Stoeber and Otto’s (2006) Tripartite Model of Perfectionism and
Gaudreau and Thompson’s (2010) 2 x 2 Model of Dispositional Perfectionism. Both these
approaches have focussed on the interactive effects of the two dimensions of perfectionism
(adaptive and maladaptive) rather than consider the core facets as individual concepts. For
a detailed explanation of these two approaches please refer to chapter 2 (part 1).
For the present study four groups of perfectionists were proposed; non-perfectionists,
adaptive perfectionists and two types of maladaptive perfectionists. The groups were
distinguished by their relative levels of adaptive and maladaptive perfectionism traits; non
perfectionists were identified as having low levels of both adaptive and maladaptive traits,
adaptive perfectionists were characterised by high levels of adaptive traits and low levels
of maladaptive traits, maladaptive perfectionist group 1 were identified as having high
levels of both adaptive and maladaptive dimensions and maladaptive perfectionist group 2
considered to have high levels of maladaptive traits and low levels of adaptive traits. Based
on the ideas of Gaudreau and Thompson (2010), as discussed in chapter 2, the maladaptive
perfectionist 2 group were be predicted to have the most negative outcomes as this
subgroup lack the potentially protective qualities that high levels of adaptive perfectionism
may provide.
4.1.1 Hypotheses
1. Both types of maladaptive perfectionist are predicted to show lower levels of
engagement than adaptive perfectionists and non-perfectionists.Maladaptive
perfectionism group 2 are predicted to have the lowest level of engagement and
adaptive perfectionism, the highest level of engagement.
2. Perceived stress levels are predicted to be higher for both maladaptive groups
compared to both adaptive perfectionists and non-perfectionists. The maladaptive
perfectionist 2 group (high maladaptive traits/low adaptive traits) is predicted to
have the highest level of perceived stress. High perceived stress is also predicted to
be associated with less engagement in preventive health behaviours.
3. It is predicted that there will be interactions between type of perfectionism and
level of stress (high and low) in relation to engagement in preventive health
91
behaviours as well as a number of other health related variables (e.g. symptom
reporting, anxiety levels and perception of general health), although the precise
nature and strength of these interactions is not predicted.
4. It is predicted that adaptive perfectionism will be the most adaptive (out of the four
perfectionism groups) in terms of the other outcome variables; have lowest levels
of perceived stress, lowest levels of symptom reporting, lowest levels of anxiety
and the highest rating for general perception of health.
5. It is predicted that the maladaptive perfectionist group 2 will be the most
maladaptive (out of the four perfectionism groups) in terms of the other outcome
variables; highest levels of perceived stress, highest levels of symptom reporting,
highest levels of anxiety and lowest rating for perception of general health.
4.2 Methods
Participants and Procedure
Participants were students at the University of Surrey recruited through an email
advertisement circulated to all students. Participants were invited to participate in an online
health and wellbeing questionnaire which consisted of measures to assess perfectionism,
perceived stress, current engagement in preventive health behaviours, anxiety, perception
of general health and reporting of physical symptoms. Of the final sample (N=875), 593
(68%) were female and 282 (32%) were male. Of the sample 667 (76%) were
undergraduate students and 208 (24%) were postgraduate students.
4.2.1 Measures
Perfectionism
As in the previous study (chapter 3) the Frost Multidimensional perfectionism Scale
(FMPS, Frost et al., 1990) was utilised to assess the dimensions of adaptive and
maladaptive perfectionism. The subscales of “Concern over Mistakes” and “Doubts about
Actions” were summed to form the maladaptive measure and “Personal Standards” and
“Organisation” used to assess the dimension of positive perfectionism. This method has
been validated in previous research (Chang et al, 2004; Dunn et al, 2006; Frost et al, 1990;
Harris et al, 2008; Wei et al, 2004) and shown to have good internal reliability. Four new
92
groups of perfectionism were created from participants’ scores on the adaptive and
maladaptive subscales of the Frost Multidimensional Perfectionism Scale. A median split
was taken of the scores on both measures to form a high/low adaptive perfectionism score
and a high/low maladaptive perfectionism score. These two scores (adaptive and
maladaptive perfectionism) were then collapsed to provide four new categories of
perfectionism. These four groups were based on the conceptualisations of two models of
perfectionism; Stoeber and Otto’s (2006) Tripartite Model of Perfectionism and Gaudreau
and Thompson’s (2010) 2 x 2 Model of Dispositional Perfectionism.
Whilst there are similarities between the two models, there is one fundamental difference
which concerns the respective authors theorising and labelling of the most maladaptive
category of perfectionism. Stoeber and Otto (2006) propose the most maladaptive category
to be the group identified to have both high maladaptive traits and high adaptive trait
(maladaptive perfectionism group 1), whereas Gaudreau and Thompson (2010) have
identified the most maladaptive group to have high maladaptive traits but low adaptive
traits (maladaptive perfectionism group 2). The reasoning behind the latter is that
maladaptive perfectionists are believed to be at a disadvantage when they don’t have high
levels of adaptive traits to perhaps buffer and ameliorate the more serious consequences of
the maladaptive traits.
93
Table 4.1 The four perfectionism groups formulated for the study
MALADAPTIVE PERFECTIONISM
LOW
HIGH
HIGH
ADAPTIVE PERFECTIONISM
PERFECTIONISM GROUP 1
(according to Stoeber & Otto, 2006, this
group represent the most maladaptive)
MALADAPTIVE
LOW
ADAPTIVE PERFECTIONISM
MALADAPTIVE
NON-PERFECTIONISM
PERFECTIONISM GROUP 2
(according to Gaudreau & Thompson, this
group represent the most maladaptive)
For the purposes of the present study, two conceptualisations of maladaptive perfectionism
have been included: the first comprising of high levels of both adaptive and maladaptive
perfectionism (Maladaptive perfectionism group 1) which supports the work of Stoeber
and Otto (2006) and the second consisting of a low level of adaptive perfectionism and
high level of maladaptive perfectionism (Maladaptive perfectionism group 2) which
supports the work of Gaudreau and Thompson, (2010). Although both maladaptive
categories have been included, the present study supports Gaudreau and Thompson’s
(2010) conceptualisation of the most maladaptive category of perfectionism consisting of a
combination of high maladaptive traits and low adaptive traits.
Perceived Stress
To assess perceived stress, The Perceived Stress Scale (PSS) was used (Cohen, Kamarck
& Mermelstein, 1983). This is a widely used measure that aims to assess an individual’s
appraisal of stress in response to particular situations over the past month. The measure
consists of 10 items that ask respondents to rate on a five point Likert scale (ranging from
never to very often) how they have been feeling over the last month. Examples of
questions include “in the last month, how often have you felt that you were unable to
control the important things in your life?” and “In the last month, how often have you felt
that things were going your way?” Scoring involves reversing responses to the four
94
positively worded questions and then summing across all responses. A higher score
indicates a higher level of perceived stress. Cohen & Williamson (1988) have found the
scale to correlate with other stress measures, health behaviour measures and help seeking
behaviour. The scale is reported to have reasonable internal reliability, Coefficient alpha of
.78 and has been found to be related to other self-report measures aiming to assess the
appraisal of stress (Cohen and Williamson, 1988). The reliability and validity of the scale
has been confirmed for other student samples (Roberti, Harrington & Storch, 2006). The
scores on the perceived stress scale were used to form two new groups; a high stress group
and a low stress group. As with perfectionism, a median split was taken of these scores to
form two new groups; high and low stress groups.
Engagement in Preventive Health Behaviours
As utilised in study 1 (chapter 3) to measure Engagement in Preventive Health Behaviours,
an adaptation of the General Preventive Behaviours Checklist (Amir, 1987) was used.
Respondents were asked to rate the frequency with which they engage in a variety of
preventive health behaviours on a three point scale (0 = never do, 1 = sometimes do and 2
= always do). Areas that are dealt with include exercise, diet, avoidance of substances such
as cigarettes and alcohol, emotional well-being and social interaction. Examples of
questions include “I have avoided too much emotional distress”, “I have friends and
maintain a good social life” and “I have been doing regular aerobic exercise”. Responses
to the questions are summed to form a total score that represents desire to engage in
preventive health behaviours.
Physical Symptoms
To measure self-reporting of physical symptoms and sensations The Pennebaker Inventory
of Limbic Languidness (PILL, Pennebaker, 1982) was employed. This measure assesses
the occurrence of various physical symptoms and sensations (54 items). Answers are
scored on a five point Likert scale ranging from “have never or almost never experienced”
to experiencing “more than once every week”. A total score is achieved by summing all
responses across the measure and a higher score indicates more reporting of physical
symptoms and sensations. Cronbach alphas for the measure have been reported as ranging
from .88 to .91 (Pennebaker, 1982).
95
Perception of General Self Rated Health
Perception of general health was identified using a single item measure of general selfrated health that is included in the SF-36 (Ware, Kosinski & Keller, 1996), and asks
respondents “In general would you say your health is, “Excellent”, “Very Good”, “Good”,
“Fair” or “Poor”. The use of a single measure to assess self-rated health has been
supported in the research literature as being comparable to multi-item status measures and
deemed a valid way of assessing self-reported general health (DeSalvo, Fisher, Tran et al,
2006; DeSalvo, Fan, McDonnell, & Fihn, 2006).
Anxiety
Anxiety was assessed using both parts of the State-Trait Anxiety Inventory (STAI;
Spielberger, Gorsuch, Lushene et al, 1983). This is a widely used self-report assessment
measure for addressing both the more enduring qualities of “Trait Anxiety” as well an
individual’s current experience of anxiety (State Anxiety). The measure consists of two
twenty item scales and respondents are asked respond according to how they feel “right
now” e.g. “I feel calm”, “I am strained” and “I feel self-confident” and also how they
“generally feel” e.g. “I tire easily”, “I am cool, calm and collected” and “I lack selfconfidence”. A total score for each of the scales is calculated by first addressing the
reversed scored items and then summing to form two scores, one for “State Anxiety” and
“Trait Anxiety” respectively. Test-retest reliabilities have ranged from .65 to .75 over the
course of a two month interval and internal reliabilities of between .86 to .95 (Spielberger
et al, 1983).
4.2.2 Data Analysis
Data analysis included first obtaining descriptive statistics for the sample and the major
variables under study then correlational analyses were performed to look at the
associations between all the major variables. For the correlations, raw scores were utilised
for both perceived stress and adaptive/maladaptive perfectionism as these were on a
continuous scale as opposed to the groups (high/low stress; non
perfectionist/adaptive/maladaptive 1/maladaptive 2) that were created to carry out the
further analyses. To look for interactions and main effects for perfectionism group (nonperfectionism, adaptive perfectionist, maladaptive perfectionist 1, maladaptive
perfectionist 2) and stress group (high/low), two way ANOVA’s were carried out on the
96
following dependent variables; engagement in preventive health behaviours, symptom
reporting, anxiety, perception of general self-rated health and raw perceived stress scores
4.3 Results
Sample demographics
All descriptive statistics for the sample and all the variables are displayed in table 4.2 and
participant characteristics by perfectionism group are displayed in table 4.3.
97
Table 4.2
Sample Demographics, Means, Standard Deviations and reliabilities for all
variables
Age (years)
18 – 29
30 – 39
40 – 49
50 – 59
60 – 69
Gender
Male
Female
Level of Study
Undergraduate
Postgraduate
Perfectionist Type
Non Perfectionist (NP)
Adaptive Perfectionist (AP)
Maladaptive Perfectionist 1 (MP1)
Maladaptive Perfectionist 2 (MP2)
Stress Group
High
Low
Variables
Adaptive perfectionism
(PS and O)
Maladaptive perfectionism
(CM and DA)
Perceived stress
(PSS)
Engagement in preventive
Health behaviours
Symptom reporting
(PILL)
Anxiety
(STAI)
State
Trait
General Health
n
%
798
44
23
6
4
91.2
5
2.6
.7
.5
282
593
32.2
67.8
667
208
76.2
23.8
253
165
258
199
28.9
18.9
29.5
22.7
402
473
45.9
54.1
(SD)
(α)
45.9
8.0
0.86
36.8
9.6
0.91
19.2
7.3
0.77
50.2
7.6
0.84
105.8
26.3
0.91
40.4
44.0
3.4
11.0
10.0
0.9
(M)
0.88
N/A
98
Table 4.3
Participant Characteristics by Perfectionism Group
Non Perfectionist
(n = 253)
Adaptive
Perfectionist
(n = 165)
Maladaptive
Perfectionist 1
(n = 258)
Maladaptive
Perfectionist 2
(n= 199)
Engagement in
Preventive
Health
Behaviours
51.0 (7.3)a*
54.1 (6.6)
49.9 (7.6)a
46.4 (7.0)
Reporting of
Physical
Symptoms
97.9 (21.4)a
99.1 (20.5)a
111.8 (27.6)b
113.6 (30.3)b
State Anxiety
37.2 (9.3)a
35.6 (9.4)a
43.1 (11.5)b
44.9 (10.6)b
Trait Anxiety
40.0 (8.5)a
38.0 (7.7)a
48.0 (9.8)b
48.9 (9.0)b
Perception of
General Health
3.5 (0.8)a
3.7 (0.9)a
3.4 (0.9)a
3.3 (0.9)a
Perceived
Stress
17.2 (6.8)
14.9 (6.4)
21.5 (7.2)a
22.2 (6.1)a
*Means in the same row that do not share the same subscripts differ at the p<.05 level. Standard Deviations are shown in brackets
Correlational Analyses
All correlations are displayed in table 4.4. As predicted a significant negative association
was found between maladaptive perfectionism and engagement in preventive health
behaviours (r = -.284, p<0.01) suggesting that maladaptive perfectionism was related to
lower levels of engagement in preventive health behaviours. Maladaptive perfectionism
was also predicted to be positively associated to higher levels of perceived stress and
results show this to be the case (r = .373, p<0.01). A small but significant association was
found between adaptive perfectionism and engagement in preventive health behaviours (r
= .170, p<0.01) and a non-significant correlation between adaptive perfectionism and
perceived stress. Maladaptive perfectionism was found to be positively associated with
symptom reporting (r = .331, p<0.01), state and trait anxiety (r = .397, p>0.01 and r =
.582, p<0.01 respectively) and negatively associated with perception of general health (r =
-.169, p<0.01) suggesting that maladaptive perfectionism is associated with a higher level
99
of symptom reporting, higher levels of both state and trait anxiety and a poorer perception
of general health. Non-significant associations were found for adaptive perfectionism on
all these variables. Correlations between all the major variables are displayed in table 4.4
Table 4.4
Correlation Matrix for all Major Variables
Variables
1
1. Adaptive Perf
-
2
3
4
5
6
7
2. Maladaptive Perf
.376*
-
3. Perceived Stress
.001
.373*
4. Engagement
.170*
-.284*
-.417*
-
5. Symptom Reporting
.044
.331*
.317*
-.262*
-
6. State Anxiety
-.001
.397*
.500*
-.410*
.330*
-
7. Trait Anxiety
.016
.582*
.592*
-.493*
.458*
.658*
-
8. Perception Gen
Health
.097*
-.169*
-.272*
.337*
-.297*
-.332*
-.389*
8
-
-
Note. Engagement = Engagement in preventive health behaviours. *p < .01
Main effects and interactions
Engagement in preventive health behaviours
A two way ANOVA was conducted to examine the effect of perfectionism group and
perceived stress on engagement in preventive health behaviours. Although the interaction
effect was non-significant F(3,867) = 2.204, p = .086, significant main effects were found
for both perfectionism group and stress group; F(3, 867) = 19.25, p < .001 and F(1,867) =
107.9, p < .001 respectively. Looking at the means for the two stress groups; low (M =
53.65, SD = 6.9) and high (M = 47.3, SD = 6.9), these results suggest engagement in
preventive health behaviours to be significantly higher when stress was perceived to be
low. For perfectionism group, post hoc tests showed significant differences between all the
combinations of perfectionism groups (at the p < .001 level) with the exception of the nonperfectionism and maladaptive perfectionism 1 group. Specifically, significant differences
were found between the following groups; non perfectionist (M = 51, SD = 7.3), and
100
adaptive perfectionist (M = 54.1, SD =6.6), non-perfectionist (M = 51, SD = 7.3). and
maladaptive perfectionist 2 (M = 46.4, SD = 7), adaptive perfectionist (M = 54.1, SD =6.6)
and maladaptive perfectionist 2 (M = 46.4, SD = 7), adaptive perfectionist (M = 54.1, SD
=6.6) and maladaptive perfectionist 1 (M = 49.9, SD = 7.6) and maladaptive perfectionist 2
(M = 46.4, SD = 7) and maladaptive perfectionist 1 (M = 49.9, SD = 7.6).
Chart 4.1
Engagement in preventive health behaviours by perfectionism group and
stress group
58
56
54
Engagement
52
50
Low Stress
48
High Stress
46
44
42
40
Non Perfectionism
Adaptive
Perfectionism
Maladaptive
Perfectionim 1
Maladaptive
Perfectionism 2
Physical Symptoms
For reporting of physical symptoms, a non-significant interaction effect was found (F(3,
867) = 1.52, p =.207). Main effects for both perfectionism group and perceived stress
(high/low) were obtained (F(3, 867) = 10.89, p < .001 and F(1, 867) = 59.68, p < .001
respectively). For perfectionism group, post hoc tests showed significant differences
between the following groups (all at the p < .001 level); non perfectionist (M = 97.9, SD =
21.4) and maladaptive perfectionist 1 (M = 111.8, SD = 27.6), non-perfectionist (M = 97.9,
SD = 21.4) and maladaptive perfectionist 2 (M = 113.6, SD = 30.3), adaptive perfectionist
(M = 99.1, SD = 20.5) and maladaptive perfectionist 2 (M = 113.6, SD = 30.3) and
101
adaptive perfectionist (M = 99.1, SD = 20.5) and maladaptive perfectionist 1 (M = 111.8,
SD = 27.6). Significant differences were not found between non perfectionist and adaptive
perfectionist or maladaptive perfectionist 1 and maladaptive perfectionist 2. For stress
group (low/high), reporting of common physical symptoms was found to be higher when
perceived stress was perceived to be higher, (M = 96.4, SD = 19.1 and M = 113.5, SD = 29
respectively).
Chart 4.2 Reporting of physical symptoms by perfectionism group and stress group
125
120
Symptom Reporting
115
110
105
Low Stress
100
High Stress
95
90
85
80
Non Perfectionism
Adaptive
Perfectionism
Maladaptive
Perfectionism 1
Maladaptive
Perfectionism 2
General Health
For the perception of general health status, a significant main effect was found for stress
group F(1, 867) = 48.02, p < .001, however a non-significant main effect was found for
perfectionism group F(3, 867) = 2.199, p = .087 suggesting that perception of health
status is influenced by level of stress but not type of perfectionism and that that perception
of health status is better for the people who are in the low stress group (low stress, M =
3.68, SD = 0.8 and high stress, M = 3.21, SD = 0.8). A non-significant interaction effect
was obtained F(3, 867) = .850, p = .467.
Anxiety
For state anxiety, significant main effects were found for both perfectionism group and
stress group, F(3, 867) = 14.19, p < .001 and F(1, 867) = 195.15, p < .001 respectively,
102
however, a non-significant interaction effect was found, F(3, 867) = 1.85, p = .136. Post
hoc tests revealed significant differences in the following combinations of groups; non
perfectionist (M = 37.2, SD = 9.3) and maladaptive perfectionist 2 (M = 44.9, SD = 10.6),
non-perfectionist (M = 37.2, SD = 9.3) and maladaptive perfectionist 1 (M = 43.1, SD =
11.5), adaptive perfectionist (M = 35.6, SD = 9.4) and maladaptive perfectionist 2 (M =
44.9, SD = 10.6) and finally adaptive perfectionist (M = 35.6, SD = 9.4) and maladaptive
perfectionist 1 (M = 43.1, SD = 11.5). Significant differences were not obtained for the
combinations of non-perfectionist and adaptive perfectionist and maladaptive perfectionist
1 and maladaptive perfectionist 2.
Chart 4.3 State anxiety by perfectionism group and stress group
50
48
46
State Anxiety
44
42
40
Low Stress
38
High Stress
36
34
32
30
Non Perfectionism
Adaptive
Perfectionism
Maladaptive
Perfectionism 1
Maladaptive
Perfectionism 2
For trait anxiety, again a non-significant interaction effect was found F(3, 867) = 1.253, p
= .289 although, significant main affects were obtained for both stress group and
perfectionism group; F(1, 867) = 314.08, p < .001 and F(3, 867) = 41.73, p < .001
respectively. For stress group it was observed that higher levels of perceived stress were
associated with a higher mean score for trait anxiety (high stress, M = 49.48, SD = 8.83;
low stress, M = 37.6, SD = 7.1) and for perfectionism group significant differences were
identified between the following (at the p < .001 level); non perfectionist (M = 40, SD =
8.5) and maladaptive perfectionist 2 (M = 48.9, SD = 9), non-perfectionist (M = 40, SD =
8.5) and maladaptive perfectionist 1 (M = 48, SD = 9.8), adaptive perfectionist (M = 38,
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SD = 7.7) and maladaptive perfectionist 2 (M = 48.9, SD = 9) and finally adaptive
perfectionist (M = 38, SD = 7.7) and maladaptive perfectionist 1 (M = 48, SD = 9.8).
Chart 4.4 Trait anxiety by perfectionism group
55
Trait Anxiety
50
45
Low Stress
40
High Stress
35
30
Non Perfectionism
Adaptive
Perfectionism
Maladaptive
Perfectionism 1
Maladaptive
Perfectionism 2
4.4 Discussion
Supporting the first hypothesis, and the results of the previous study (study 1, chapter 3),
maladaptive perfectionists (both groups) were found to show lower levels of engagement
in preventive health behaviours (such as exercising regularly, eating sensibly and taking
care of their emotional wellbeing) than either adaptive perfectionists and nonperfectionists. Interestingly the perfectionism group that showed the least amount of
engagement was the maladaptive perfectionist group 2 who were identified as having high
levels of maladaptive perfectionism coupled with low levels of adaptive perfectionism.
Gaudreau and Thompson (2010) have suggested that this combination of perfectionism
traits results in these individuals being labelled the ‘most maladaptive’ type of
perfectionists. It is believed that such individuals may be at a disadvantage because they do
not possess high amounts of the positive and potentially protective traits that are believed
to be inherent in adaptive perfectionism (Gaudreau & Thompson, 2010). Adaptive
perfectionism was found to have the highest level of engagement in preventive health
behaviours. The fact that the adaptive perfectionist group demonstrated the highest level of
engagement over and above non-perfectionists suggest there may be something inherently
104
positive (at least from a preventive health perspective) in adaptive perfectionists that
makes them more inclined to engage in preventive health behaviours. This result supports
previous research by Slade and Owens, 1998, that has proposed adaptive perfectionists are
more likely to actively ‘approach’, rather than ‘avoid’ situations and also ties in with
previous research by Longbottom at al, (2010) addressing the differences between adaptive
and maladaptive perfectionists in terms of physical activity motivation. Adaptive
perfectionism was found to be associated with more positive motivational attributes
associated with engaging in physical activity such as organisation, perseverance and selfefficacy and maladaptive perfectionism was associated with reduced confidence in relation
to exercising, fear of failure and a general reluctance to engage in such activities.
In support of hypothesis 2, Perceived stress levels were found to be higher for both the
maladaptive perfectionist groups with the maladaptive perfectionist 2 group (high
maladaptive/low adaptive perfectionism traits) showing the highest level of perceived
stress. This result supports previous research that has identified a relationship between the
maladaptive dimension of perfectionism and perceived stress (Flett & Hewitt, 2002).
Additionally, in the present study, high perceived stress was identified as being related to a
lower level of engagement in preventive health behaviours supporting previous research
(Stetson et al, 1997). Overall these results suggest that the ability to engage in preventive
health behaviours at times of high stress may be compromised (Adler & Matthews, 1994).
Contrary to the predictions for hypothesis 3, No significant interactions were observed
between perfectionism group and stress group across all dependent variables. This may
have been related to problems with how one or both of the independent variables
(perfectionism and perceived stress) were operationalised. Rather than dichotomising
perceived stress into two separate groups, it may have been advisable to have more
groupings. Although this would have added to the complexity of the research design, it
may have avoided some of the common problems associated with dichotomisation (see
MacCallum, Zhang, Preacher & Rucker, 2002). There is clearly a relationship between
perfectionism and stress (Hewitt & Flett, 2002; also see chapter 3, section 3.3) and perhaps
it would have been more prudent to perform regression analyses on the data and consider
the effect of perceived stress as a potential mediator/moderator in the relationship between
perfectionism and engagement in preventive health behaviours.
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When considering the main effect of perfectionism group across the dependent variables,
with the exception of the reporting of physical symptoms, adaptive perfectionism was
associated with the most positive outcomes (hypothesis 4) i.e. the highest level of
engagement in preventive health behaviours, the lowest levels of state and trait anxiety, the
most positive perception of general health and the lowest level of perceived stress (table
5.3), over and above non-perfectionists. These results support research identifying the
presence of a positive and adaptive form of perfectionism that may bring with it benefits to
health and wellbeing (Frost et al, 1993; Slade & Owens, 1998).
Aside from engagement in preventive health behaviours, the maladaptive perfectionist
group 2 was not identified to be more maladaptive (in terms of the results on the other
outcome variables) than the maladaptive perfectionist group 1. The results of the present
study, therefore, do not fully support the predictions of hypothesis 5 or the theories of
Gaudreau and Thompson (2010) and Stoeber and Otto (2006) in terms of identifying the
‘most maladaptive’ category of perfectionists, i.e. having high levels of maladaptive
perfectionism coupled with low levels of adaptive traits was not found to be any more
maladaptive than possessing high levels of both adaptive and maladaptive traits in relation
to the other health related variables. In terms of levels of state and trait anxiety, reporting
of physical symptoms and perception of general health, no evidence was found to suggest
that either combination of traits (high maladaptive/low adaptive and high maladaptive/high
adaptive) were more detrimental in terms of the effects on health and wellbeing.
Putting the additional issue of whether there may be a more maladaptive type of
perfectionism to one side, there is still the very real issue of whether maladaptive
perfectionists may represent a high risk group in terms of health and wellbeing. Both
groups of maladaptive perfectionists were related to elevated levels of state and trait
anxiety as well as perceived stress suggesting that both maladaptive groups may be
functioning with an already elevated baseline level of anxiety/stress which as a
consequence may make them more vulnerable to stressful experiences, specifically in
terms of leading to further psychological difficulties. This supports previous research by
Flett and Hewitt (2002) who have suggested that for certain perfectionists’ increases in
stress levels can lead to an activation of pre-existing psychopathology and a greater risk of
developing depression. As discussed in chapter 2 (part 2), there is a well-established
relationship between perfectionism and a number of anxiety disorders including OCD,
social anxiety (Antony et al, 1998) and Generalised Anxiety Disorder (Handley, Egan,
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Kane & Rees, 2014). Research has also found evidence to suggest that individuals with
anxiety disorders have particularly low levels of the positive or achievement striving
dimension of perfectionism (Bardone-Cone et al, 2007), which raises the question of
whether such individuals may be particularly vulnerable from a health and wellbeing point
because they lack the potential psychological buffer that may be present with higher levels
of the adaptive perfectionism traits. Maladaptive perfectionists (both groups) were also
identified as noticing and reporting more physical symptoms than either non-perfectionists
or adaptive perfectionists. Attending and reporting a high level of bodily symptoms has
been associated with a greater amount of unhappiness, nervousness and distress
(CounsellingResource.com).
Methodologically, using a cross-sectional design has limitations as it only provides a
snapshot at one time point and therefore it is difficult to make generalisations about the
population under investigation. Additionally, as has been mentioned earlier, there may
have been issues with the methods utilised to achieve some of the groupings for the
predictor variables (perfectionism and perceived stress). Despite the limitations, the
present study has endeavoured to further research in this area by exploring the two
variables of perceived stress and type of perfectionism in relation to engagement in
preventive health behaviours. Future studies may benefit from exploring factors that
intervene in the relationship between maladaptive perfectionism and stress as well as stress
and engagement in preventive health behaviours. By utilising an alternative
conceptualisation (to that used in study 1, chapter 3) it has been possible to gain more
specific information regarding the potential role of adaptive perfectionism in the
relationship between perfectionism and engagement in preventive health behaviours. The
present study supports the possibility of there being some positive benefits attached to
being an adaptive perfectionist. It also supports the prospect of identifying a particularly
vulnerable group of perfectionists (maladaptive perfectionism group 2) who possess high
levels of maladaptive perfectionism and low levels of the adaptive perfectionism traits and
who may be at risk of developing health problems in the future. Studies addressing a range
of obstacles/barriers to engagement would be useful in trying to pinpoint other variables
aside from self-concealment and perceived stress that may influence the relationship
between perfectionism and engagement in preventive health behaviours. To gain more
detail about the decisions adaptive and maladaptive perfectionists make in relation to
looking after their health and wellbeing, qualitative studies may prove to be beneficial.
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4.5 Conclusion
The present study attempted to address how perfectionism and stress may be related to
engagement in preventive health behaviours and a number of other health related variables.
Although no interactions were found between type of perfectionism and level of perceived
stress in relation to engagement, both variables were identified to be key factors that need
to be considered in the decision making process of perfectionists, specifically with regards
to the steps perfectionists take to look after their own health and wellbeing. The study also
provided some useful insights concerning the potential adaptiveness of the perfectionism
construct and how utilising a different conceptualisation (based on the interactive power of
the two dimensions of perfectionism) may have highlighted some potential benefits that
may be associated with the adaptive dimension of perfectionism. These findings support a
number of the main aims of the present thesis; that maladaptive perfectionists do seem to
engage less in preventive health behaviours, that there may be a distinction between the
two dimensions of perfectionism (adaptive and maladaptive) specifically in relation to the
adaptive dimension being associated with potential benefits to health and wellbeing. This
study also provides support for the premise that maladaptive perfectionism may be
associated with an elevated level of health risk, certainly in relation to engagement in
preventive health behaviours. To further investigate the area of perfectionism and
engagement in preventive health behaviours, the next chapter explores possible obstacles
to engagement in a sample of adaptive and maladaptive perfectionists, from a qualitative
perspective using Interpretative Phenomenological Analysis.
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Chapter 5
Study 3
A Qualitative Study Exploring Engagement in Preventive Health Behaviours and
Obstacles to Engagement in Adaptive and Maladaptive perfectionists: An Interpretative
Phenomenological Analysis
The previous chapter focussed on the associations between type of perfectionism,
perceived stress and engagement in preventive health behaviours. Although no interactions
were observed between subtype of perfectionism and level of perceived stress (in relation
to engagement and a number of other health related variables), type of perfectionism and
perceived stress were considered to represent important factors in the perfectionism/health
relationship and specifically in relation to engagement. Using a slightly different
conceptualisation (i.e. creating four perfectionism groups) it was possible to gain a more
thorough insight into the potential role of the two dimensions of perfectionism (adaptive
and maladaptive) in relation to engagement and a number of other health related variables.
The most maladaptive group (in terms of engagement) was found to be those individuals
who possessed high levels of maladaptive perfectionism and low levels of adaptive
perfectionism. It was suggested the adaptive dimension of perfectionism may serve to
protect or buffer against the maladaptive perfectionistic traits and that the absence of a
high level of adaptive perfectionism coupled with high levels of maladaptive perfectionism
may be a problematic combination and produce negative consequences in terms of health
outcomes
The next two studies in the thesis aim to address the area of engagement in preventive
health behaviours by exploring in more detail the possible factors that may influence the
desire to engage. The present study aims to explore the subject of engagement from a
qualitative perspective; specifically trying to gain a deeper understanding of the decisions
adaptive and maladaptive perfectionists make in relation to looking after their health and
wellbeing whilst trying to identify potential obstacles to engagement. The final study
(chapter 6) aims to address perceived barriers/obstacles to engagement from a quantitative
perspective whilst looking for potential differences between adaptive, maladaptive and
non-perfectionists.
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5.1 Introduction
There is clear research evidence to suggest that engaging in preventive health behaviours
protects both physical and psychological health (e.g. Biddle, 2004; Bouchard et al, 2007;
Fox et al, 2006; Netz et al, 2005). Research evidence suggests that perfectionists,
particularly those identified as possessing high maladaptive traits, may not be readily
engaging in preventive health behaviours such as regular exercise/physical activity
(Longbottom et al, 2010, 2012; Williams and Cropley, 2014).
By not engaging in preventive health behaviours (that address both physical and emotional
health needs), it could be argued that highly perfectionistic individuals may be putting
themselves at greater risk from experiencing, long-term health problems, particularly when
one considers the already well-established links between maladaptive perfectionism and
various psychological and physical health problems (for a detailed review please refer to
chapter 2, part 2). Added to this, study 1 identified a close relationship between
perfectionism and self-concealment, which in itself has been linked to; a greater incidence
of psychopathology (Kahn and Hessling, 2001; Cepeda-Benito and Short, 1998), less help
seeking behaviours (Cepeda-Benito and Short, 1998; Hewitt et al, 2003; Kawamura and
Frost, 2004) and a reduced motivation to engage in preventive health behaviours (Leary,
1992). Study 2 (chapter 4) supported previous research by identifying an association
between perfectionism and perceived stress (Flett and Hewitt, 2002) and also perceived
stress and a reduction in preventive health behaviours (Adler and Matthews, 1994; Heslop
et al, 2001). Considering there may be long-term health risks associated with not engaging
in preventive health behaviours, it seems logical to explore in more detail the possible
reasons that may prohibit individuals from engaging in these particular activities.
Perceived barriers to engagement have received considerable attention in the research
literature and been identified as being either internal (e.g. low self-efficacy, lack of
motivation or worries about performing exercise behaviour in public) or external (e.g. lack
of finances, lack of time and lack of support from family and friends). Other factors that
have been considered as possible obstacles to engagement and which may be particularly
relevant to perfectionists include self-presentational factors (e.g. Hausenblas et al, 2004),
self-handicapping (e.g. Martin and Brawley, 1999), exercise self-efficacy (e.g. Hofstetter,
Sallis and Hovell, 1990), physical activity motivation (Longbottom et al, 2010, perceived
110
stress (Adler and Matthews, 1994; Heslop et al, 2001) and psychological distress
Leiferman and Pheley (2004).
The primary aim of this chapter was to present a qualitative study to explore perfectionists’
beliefs (adaptive and maladaptive) in relation to preventive health behaviours and possible
reasons why they might choose to abstain from such activities. There are very few
qualitative studies that have focussed on the differential aspects of the perfectionism
construct (e.g. Slaney, Ashby and Trippi, 1995; Rice, Bair, Castro et al, 2003) and there
are no qualitative studies to date that have examined the adaptive and maladaptive aspects
of perfectionism in relation to engagement in preventive health behaviours. The current
study therefore addresses a gap in the existing research literature.
The main aim of the current study was to explore adaptive and maladaptive perfectionists’
beliefs related to engaging/not engaging in preventive health behaviours and to identify the
possible obstacles to engagement. To help capture these beliefs, participants were asked a
variety of questions concerning their beliefs and behaviours related to health. They were
also asked about factors that may influence their engagement and how they manage to
maintain a balance when there are other pressures and distractions that may conflict with
their ability to maintain their high standards. As well as providing an insight into the minds
of adaptive and maladaptive perfectionists in relation to preventive health behaviours it
was expected that such a qualitative exploration of the health behaviours of the different
types of perfectionist, may provide important additional information concerning the
possible conceptual differences between the two types of perfectionism, an area of
research that continues to be debated.
The study applied principles of Interpretative Phenomenological Analysis (IPA) to analyse
the transcripts obtained from semi-structured interviews (Smith, 1996; Smith, 2004; Smith
and Osborn, 2008). This method is an established qualitative approach that was originally
developed for exploring how individuals make sense of their lived experiences and is
considered to have particular relevance in the field of health psychology (Smith, Jarman &
Osborn, 1999). The theoretical underpinnings of the approach are drawn from three
distinct disciplines: phenomenology, symbolic interactionism and hermeneutics.
When thinking about a particular event, situation or object, the central idea of
phenomenology has been to recognise the unique and invaluable contribution that each
individual can make in providing their own personal thoughts and perceptions (see Giorgi,
111
2009 for a review). For IPA, the contribution of phenomenology can be seen in the
emphasis and importance that the approach places on individual lived experience, and the
need of the researcher to try and enter the individual world of the participant. IPA also
draws on the symbolic interactionist perspective (e.g. Denzin, 1995) which emphasises the
importance of gaining an understanding of the meanings that individuals assign to events,
situations and objects through their interactions and dialogue with their social
environment. This is achieved by the researcher entering into a process of interpretation to
fully understand the participant’s perspective. The contribution of hermeneutics
(Bernstein, 1983) to IPA helps explain this interpretive process which requires the
researcher to employ both an empathic hermeneutic (with the researcher empathising with
the participant) as well as a questioning hermeneutic (where the researcher is
simultaneously trying to make sense of the participant’s ability to make sense of the
particular phenomenon). The process of interpretation is also aided by the researcher
asking critical questions of the text whilst analysing the participant’s narrative.
Pivotal to the philosophy of the IPA approach is the notion that “…a two-stage
interpretation process, or a double hermeneutic, is involved. This means that the
participants are trying to make sense of their world..(whilst)… the researcher is trying to
make sense of the participants trying to make sense of their world” (Smith and Osborn,
2008). According to Smith (2011) the primary reason for analysing the detailed personal
accounts of participants is “to learn about the participant’s cognitive and affective reaction
to what is happening to them” (p. 10). The task of the researcher is a challenging one, as it
requires a need to engage deeply with, and be critical of, the text whilst attempting to
interpret a participant’s emotional state and perhaps identify what they may have been
trying to say but found it difficult to express in words.
5.2 Method
Participants
Ten participants (undergraduate and postgraduate students) were purposively selected from
an initial sample of 250 on the basis of their scores on a perfectionism screening
questionnaire (an adaptation of the Frost et al, 1990 Multidimensional Perfectionism
Questionnaire). An advert was placed on the University of Surrey intranet to the student
community specifically asking the question “Does being a perfectionist affect your health
and wellbeing?” Of the ten participants, five scored highly on the adaptive aspects of
112
perfectionism (adaptive perfectionists) and five scored highly on the maladaptive aspects
(maladaptive perfectionists). It has been suggested that it is beneficial to keep sample sizes
small when utilising IPA, partly so that it keeps research closely focussed on
understanding the perceptions of the particular group under study but also because of the
lengthy process of transcribing the interviews (Smith and Osborn, 2007).
Table 5.1 Interview participants
Name
Age
Sex
Type of perfectionist
Hannah
19
Female
Adaptive
Kate
20
Female
Adaptive
Mason
21
Male
Adaptive
Karl
19
Male
Adaptive
Finn
19
Male
Adaptive
Sara
20
Female
Maladaptive
Paul
19
Male
Maladaptive
Rachel
21
Female
Maladaptive
James
19
Male
Maladaptive
Ally
18
Female
Maladaptive
Procedure
Following the screening questionnaire, the participants were invited to attend an interview
on the University Campus. Prior to the start of the interview, participants were asked to
complete a brief questionnaire requesting demographic information, read through an
information sheet explaining briefly the nature of the research project and sign a consent
form. The interviewer explained that all information provided would remain confidential
and that it would not be possible for participants to be identified from the responses given
and the subsequent write up of the study.
The interviews were semi-structured (see appendix for interview schedule) and lasted
between thirty and forty five minutes. Using semi-structured interviews is often
recommended when performing IPA as according to Smith and Osborn (2008) “this form
113
of interviewing allows the researcher and participant to engage in a dialogue whereby
initial questions are modified in the light of the participant’s responses and the investigator
is able to probe interesting and important areas which arise”. This type of interview allows
the researcher the flexibility of being able to deviate from the interview schedule and
explore novel areas if thought to be interesting or necessary.
The semi-structures interviews consisted of a series of questions designed to tap into
perfectionists’ beliefs relating to their current engagement in preventive health behaviours
and the factors that might present as obstacles/barriers to their engagement. Examples of
the questions in the interview schedule included: “What factors influence your engagement
in preventive health behaviours?”, “How do you look after yourself when you have other
pressures?” and “describe what you do when you encounter obstacles that may affect how
you look after your health and wellbeing?” Additionally to gain an understanding of the
value perfectionists place on their own health and wellbeing, participants were also asked
questions that addressed whether they consider themselves to be healthy, how important
they feel it is to look after both physical and emotional health, whether they have clearly
defined health goals, current preventive health behaviours, past behaviours and likelihood
that they would seek medical attention if they had a physical/emotional problem.
Each interview was digitally recorded and transcribed verbatim. Interviewees were
provided with a payment of £10 for their time as well as refreshments during the interview
if required.
5.2.1 Data Analysis
The full verbatim transcripts were subjected to IPA (Smith, 1996; Smith, 2004; Smith and
Osborn, 2008). It is generally recognised that there is no definitive way of performing IPA,
although commonly, the first transcript is studied in detail and the emerging themes
documented in the margins. The emerging themes are then recorded and as the process
continues, attempts are made to see if there are any connections between the developing
themes. As the process continues some of the themes naturally cluster together and present
themselves as stand-alone superordinate themes. Generally the aim of the process is to
identify clusters of themes and to pull them together to represent other superordinate
themes (alongside the stand alone ones). According to Smith and Osborn (2008) it is
recommended that as the themes begin to emerge, the researcher needs to engage in a
continual process of checking back with the transcript to see if the connections accurately
114
reflect the actual words of the interviewee. For the present study, as well as detailing the
emerging themes, specific extracts were also written down at this stage to provide
examples of the particular themes (verbatim sections from the transcript). The themes that
emerged from the first transcript were then used to inform subsequent transcripts. Smith
and Osborn (2009) have noted that this a valid means of continuing with the analysis.
Once all the transcripts were analysed, all superordinate themes for the group of
perfectionists were documented in table 5.2.
5.3 Results
The results were organised according to the following superordinate themes (See table
5.2). Within each of the superordinate themes were a number of subthemes which will be
discussed and references made to the relevant sections of the transcripts to help illustrate
the chosen themes.
Table 5.2 The three superordinate themes
SUPERORDINATE
SUBTHEMES
THEMES
1
Taking personal
a)Physical and emotional aspects of health
responsibility for health and
b)Ability to function
wellbeing
c)Ability to deal with transition to university
d)Engaging in preventive health behaviours
2
3
Lack of awareness of
a)Actions are never “good enough”
limitations
b)Significant event to re-establish awareness
Control over health and
a)Having clearly defined health goals
wellbeing
b)Not wanting to seek help
c)Flexibility to adjust one’s standards
i)Ability to adjust standards
ii)Inability to adjust standards
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5.3.1 Taking personal responsibility for health and wellbeing
The first superordinate theme to emerge has been identified as “taking personal
responsibility for health and wellbeing”. A number of subthemes were considered to
represent and embody this major theme; being able to identify the importance of both the
physical and emotional aspects of health, ability to function, dealing with the transition to
University and engaging in preventive health behaviours.
(a) Physical and emotional aspects of health
Participants were asked the question “What does the term being healthy mean to you”? It
was evident from their responses that all participants were able to acknowledge the
importance of both the physical and emotional aspects of health, suggesting that they were
aware of the mind-body link; a selection of the responses are included below;
‘You don’t need to worry about your health and you’re mentally and physically fit’.
(Hannah; A)4
‘…I guess overall it means being both in good physical and mental health…mentally
keeping your brain healthy….so you don’t start causing yourself problems, you know for
your own brain and…physically’. (Mason; A)
‘…..two things, being physically healthy and mentally health….physically healthy is not
having any ailments and kind of like fully functional, I guess is the word I think right now,
and mental health is similar things, you know….having no mental illness and you can
operate within society, like an average amount’.(Karl; A)
‘What comes to mind first would be like the physical readiness or how well you are doing
in terms of your body and…..erm…would be the mental psychological afterwards’.(Finn;
A)
‘…I think it can have lots of different aspects to it, I think it can be like physically
healthy…, like having a healthy body and a good complexion and having clean looking
4
For ease of understanding, an ‘A’ or an ‘M’ appears after each name to denote adaptive or maladaptive perfectionist
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hair and there is also good mental health as well…like.. being happy, being content with
who you are..being able to integrate well with other people, being able to cope with
difficult situations…and things like that’. (Ally; M)
‘..being healthy physically and mentally…physically no illness and no pain in your body
and mentally it means no stress, no depression, that’s about it’.(Sara; M)
‘I would say it kind of goes with being happy, like I guess when I’m feeling healthy and
good about myself then I kind of feel happier and generally physically better, if that makes
sense….’ (Paul; M)
It is interesting that some of the participants acknowledged what they considered to be
necessary for good health/wellbeing, for example, Ally (M) mentioned having a healthy
body, being happy and content and able to cope with difficult situations. Others referred to
an absence of something as a means to define what being healthy means to them. This was
demonstrated by Sara (M) and Karl’s (A) responses suggesting that to be healthy one
needs to be free from illness, ailments, pain, stress and depression.
When asked more specifically about the relative importance they placed on each of these
aspects of health (both physical and emotional) a number of the participants felt that
physical problems were less serious and easier to treat than emotional ones. Emotional
problems were considered to be more of a problem because they were believed to be
harder to assess, less visible than physical problems and have the potential to quietly
simmer away relatively undetected. Interestingly only two out of the ten participants
(Hannah, A and Kate, A) mentioned emotional health before physical health, which may
give insight into participants’ beliefs about which they considered to be more important to
them personally.
‘I think your physical health is quite easy to see and you can look at somebody and see
how fit they are, but emotional health is very difficult for other people to see and very
difficult for you to assess yourself..so you need to look at it in more detail I think…
because it is more important. (Mason; A)
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‘….it sounds like physical health is less serious in a way and it’s easier to do something
about’. (Hannah; A)
‘I think emotional health probably has slightly more importance for me partially for what I
want to do in my life. Being physically ill is less of a problem, it’s less inhibitory to what I
want to do than if I was stressed all the time. I’m in my second year and at the end of my
first year I got quite ill and I didn’t realise at the time but it was because I was stressed
because of the exams and so on….so since then particularly, I’ve been a lot more
conscious of having to look after my emotional side and just keep an eye on my stress
levels and realise that it’s not always that I’ll feel stressed, quite often it’ll come out
physically in some other way. So I’m a lot more aware of that now and I feel it’s a lot
more important for me to be consciously aware of it and look after that side of things’.
(Kate; A)
The above section taken from Kate’s transcript provides an insight into the importance that
she places on both her emotional and physical health status. Kate was able to reflect that
becoming ill was a turning point for her and as a result of her illness episode, she was able
to take personal responsibility for her emotional health and adjust her priorities to attend to
both aspects of health.
(b) Ability to function
The awareness of health being linked to an “ability to function” was considered to
represent another aspect of taking personal responsibility for health and wellbeing.
Interestingly all of the adaptive perfectionists mentioned this aspect of health at some point
during their interviews. The importance of being able to function was emphasised by
Kate;
‘..functioning is great. Functioning is sort of what most people are aiming for quite often I
think. By functioning I mean achieving what you can achieve, not just floating about at a
level’. (Kate; A)
The above excerpt from Kate suggests that the ability to function is a conscious motive on
the part of the individual to take responsibility for their own health and wellbeing. Being
able to function was considered to be important because it was viewed as “enabling”.
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Specifically, enabling them have the resources to cope with situations and tasks, being able
to function in society and being able to pursue what they want to do in the future. This was
demonstrated from a section of the interview transcript from Finn.
‘Well in the first place I need to stay healthy if I want to perform the things I want to do…
I need to have a clear mind and good body to…like worry too much about things in
life…..being healthy is like allowing you to continue with what you are doing and to
achieve what you want to do in the future’. (Finn; A)
Finn describes the need to stay healthy so that he will have the resources to be able to
achieve what he wants to do in the future. It was noteworthy that none of the maladaptive
perfectionists mentioned “ability to function” in their explanations of what being healthy
meant to them.
(c) Ability to deal with the transition to university
From the transcripts it is clear that starting university was a transition that had a marked
effect on potentially reshaping some of the participant’s beliefs and behaviours relating to
health, specifically in relation to a shift in awareness of having to take personal
responsibility for their own health and wellbeing.
Ally (M) talks of her feelings of isolation from her Mum when she left home to begin her
studies, and the realisation that she would have to take responsibility for her own personal
goals and keeping a sense of balance between her studies and maintaining a healthy
lifestyle.
‘When I came to university I realised that I had been completely displaced from my
comfort zone, where…when I would panic about things before, I always had my mum to go
to,….like she was the one who would say to me, okay let’s sit down and this is what we
have to do… this is how we will do it. Then I came to university and I
thought….one, my mum isn’t here and two, I have got to move on from that anyway
because I am an adult now and….then I realised that I have to take those goals upon
myself….when it comes to work, I set myself goals and when it comes to diet I set those
goals too’. (Ally; M)
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When Kate (A) talks about becoming ill during her first year of university she describes
how this was the first time that she had to knowingly take personal responsibility for her
own health and wellbeing..
‘I never really thought about consciously stopping myself get ill and that kind of thing
because it’d never been an issue before. I had been living with my partner so he had been
looking after me in that respect and before that I was living with my parents….. so they
were looking after me and last year was the first time I was really on my own. So it was the
first time that I had to consciously take responsibility for my own health’. (Kate; A)
For Ally (M), the transition to university appears to have empowered her to make
decisions about her own health and wellbeing, despite her initial struggle with feelings of
isolation.
‘Being away at university, you are kind of more on your own….you are a bit more isolated
so learn to deal with things more by yourself, so I am quite good at dealing with things in
my own head at the moment’. (Ally; M)
These feelings of being empowered and taking control of health have been echoed by Paul
(M) who identified that he relied on both school and his parents to keep him healthy before
coming to university. He insisted that being away from home had increased his awareness
of his own personal responsibility.
‘When I was at school I was involved in loads of sports teams and obviously my parents
fed me. I mean they’ve always been quite like….you must have fruit…..you must drink
water and….like when it’s them feeding you…..and I was doing all the sport and things, it
never really crossed my mind and….like now I’m kind of moving out…when it’s my
responsibility, I think it’s made me more aware, it’s made me think about what I eat and
making…sure I buy the right things and making sure I go out and exercise’. (Paul; M)
Part of the realisation of taking personal responsibility appeared to involve the need to
balance the healthy and unhealthy aspects of university life. A number of participants
identified there to be certain expectations that were an integral in the university
environment that made it difficult to maintain a healthy lifestyle such as frequent
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socialising, drinking often to excess and eating a poor diet. James identified these factors
to have an impact on his ability to engage in preventive health behaviours.
‘To be honest it’s quite difficult sometimes cos things happen like my friend’s birthday last
Wednesday…I could’ve gone to the gym…but… instead I went to a Thai restaurant and we
ended up eating a lot of food… I do have lots of distractions, so like my friends, you know,
I live with my friends from the uni and they don’t really do much exercise…..we’ve got a
playstation and we’ll all play on that together. So we’re playing at like 7 o clock for half
an hour and it ends up being like nearly two hours and then it’s too late to do
anything…..just sit there, get a bit depressed, eating chocolate, you know, watching TV
and then you’re like, shall I do some work and you’re like no’.(James; A)
Kate (A) and Sara (M) also felt that being at University challenged their ability to look
after themselves and maintain a healthy lifestyle. Although not impossible, Kate identified
that at University she had to make a conscious effort to engage in healthy behaviours
whereas at home it had seemed a much more intuitive process.
‘Since I moved to Guildford and spent more time in the city I have to be more conscious to
do more exercise….because, I could just get on a bus, whereas at home that’s not an
option and you have to walk. So I have been more conscious of making myself do that
rather than just allowing myself to be lazy’. (Kate; A)
Sara (M) felt that the sedentary lifestyle, i.e. spending considerable time sitting either in
lectures, in her student office or at home studying meant that she felt much less healthy
than before she started University. She also identified that it had taken her a while to
accept that it was her responsibility to make the effort to engage in healthy behaviours.
Paul identified having problems with continuing with healthy behaviours when he started
university and acknowledged that he was engaging in more health risk behaviours such as
drinking and smoking. It is interesting from this section of Paul’s transcript that he
recognises that he wouldn’t want to continue with these behaviours outside of the
university environment.
‘I still drink a couple of times a week, which I think is more of the student lifestyle thing. I
don’t think it’s something,….I hope it’s not something that’s going to carry on once I
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finish Uni. It’s not really acceptable behaviour outside the university environment’. (Paul;
M)
(d) Engaging in preventive health behaviours
Perfectionists were asked about their current engagement in preventive health behaviours,
specifically the steps they take to look after their physical and emotional health. All of the
perfectionists (adaptive and maladaptive) identified engaging in at least some health
enhancing behaviours such as going to the gym, running, swimming, playing various
sports, eating healthily/limiting intake of junk food, limiting alcohol intake, limiting over
the counter medications and trying to ensure that they get enough sleep. Some of the
interviewees mentioned that they would like to participate in more activities specifically to
address their physical fitness but that work commitments prohibited such engagement.
When asked about what they did currently to look after their emotional health, three out of
the five adaptive perfectionists mentioned strategies that they employed such as reading
and praying (Kate), taking regular breaks from work (Mason) and planning various
aspects of work and home life to avoid uncertainty (Karl). Similarly three out of the five
maladaptive perfectionists stated that they too had various strategies to help with
emotional health and wellbeing e.g. discussing difficulties with friends/family (Ally and
Paul), trying to avoid conflicts with other people and avoiding an unhealthy lifestyle
(Sara). Feeling happy and contented about life was also mentioned as a positive strategy to
looking after emotional health (Paul and Karl)
In the following extract, Mason describes his experiences of studying in both the United
States and the UK and the different demands that he faced. In describing his strategy of
taking regular breaks from his work, this illustrates how he has now taken personal
responsibility for looking after his emotional health.
‘I say that occasionally, I am stressed but I don’t take it to extremes. When I was in the
United States it was stressful and I always had 100 hours of work to do and it was very
stressful over there, but I’ve decided coming back to the UK, that I am going to take it a bit
more easy, there’s only a certain amount of work that you can do, if you push yourself too
far then results start to become detrimental. So it’s good to sometimes take a break and I
do this regularly with my work……if you can’t think of anything original, you’ve got to go
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away and take a break and do something else, otherwise it will become detrimental to your
mental health’. (Mason; A)
Four of the perfectionists (Hannah (A), James (M), Finn (A) and Rachel (M) stated that
they felt they were (currently) not doing anything to look after their emotional health. The
following excerpts from the transcripts of James (M) and Rachel (M) demonstrate an
awareness of the importance of looking after the psychological/emotional aspects of
health, although this is not accompanied by any engagement in behaviours that could
address their emotional needs.
‘I’m really not sure I do anything,…. I just,…. I think I’m more like trying to hide the stuff
and not get as stressed….but then I get to the deadline and then when I know that I am too
close to a deadline or something I get really stressed about, and then I start panicking a
lot and not much happens’. (James; M)
‘I think it’s probably being neglected so far as… because I spend so much time trying to
achieve stuff I don’t think as much about the emotional side. (Rachel; M)
There seemed to be a discrepancy for some perfectionists between acknowledging the
importance of emotional health and taking action to protect themselves when work
commitments increased or when participants noticed their stress levels rising. When asked,
all participants (both adaptive and maladaptive perfectionists) were able to acknowledge
the relevance and value of addressing emotional health, they were able to identify the mind
body link and they also acknowledged the importance of engaging in preventive health
behaviours to address emotional needs. However, they didn’t seem to be engaging in any
behaviour that would support or protect their emotional wellbeing.
‘….I don’t do anything….that’s impossible (laughs), too many things to compromise on…I
think right now the stress in my life is one of the highest it’s ever been…it is important
because after all it… can affect your physical health as well. You’ve got all the stress, like
back problems and stuff….a lot of things going on at work, that it’s very difficult to look
after that side of things’. (Hannah; A)
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Within Hannah’s account there seemed to be the most discrepancy between her
beliefs/intentions and her actual behaviours. Hannah was decisive in her view that
emotional health was important because of how it influences physical health. She also
mentioned her high levels of stress however it sounds like work commitments prohibit her
ability to look after this aspect of her life. When Hannah laughs after saying that she
doesn’t do anything, it suggests that she is aware of the discrepancy. Throughout the
interview she continued to acknowledge the importance of exercising self-care whilst
almost simultaneously trying to justify her lack of engagement in such behaviours.
‘It is important to look after yourself (laughs)… I don’t think I take care at all (laughs), I
don’t sleep, then I just …I’m getting stressed and being annoyed with my parents.. I try
and deal with it until the task is over and then have, maybe a day off and not have to
study…then it’s a perfect day, but that doesn’t happen much. If I have things to do then no
time to look after myself’. (Hannah; A)
5.3.2 Lack of awareness of limitations
There seemed to be a lack of awareness or ability on the part of both adaptive and
maladaptive perfectionists in being able to judge when they had pushed themselves too far
and/or when they had reached their limits in a given situation. This lack of awareness of
limitations was found to be demonstrated in two main ways; beliefs suggesting that actions
are never good enough and the occurrence of a significant event that has had the effect of
re-establishing awareness.
(a) Actions are never good enough
A well-established trait of perfectionism appears to be the inability to appreciate one’s
personal strivings and evaluate them as being “good enough”. This trait seems to be more
pronounced for maladaptive perfectionists. From the interviews it was apparent that a
number of the adaptive perfectionists as well as maladaptive perfectionists appeared to
doubt the quality of their actions specifically related to their engagement in preventive
health behaviours. Hannah (A) does demonstrates a number of examples of her doubting
the quality of her actions. Throughout her interview she made frequent references to the
preventive health behaviours that she engaged in, such as volley ball, swimming, going to
the gym and table tennis, however, she seemed to play down the significance of these
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activities as not being good enough. Hannah suggested that if she wasn’t so busy with her
studies, she could and should do more. When Kate (A) was describing whether or not she
considered herself to be healthy, she focussed on the one negative (that she found it
difficult to stick to a healthy diet at all times) whilst almost negating all of the health
enhancing behaviours that she does engage in, such as walking regularly, being aware of
trying to keep stress levels under control and utilising social support networks.
James also mentioned his attempts to be healthy as not being good enough in his eyes:
‘I eat quite a lot of fruit and vegetables during the week and I go to the gym maybe 3 or 4
times a week but I know I should be doing more but it’s quite hard with what I do in my
course as well…….at the gym we exercise all our muscles, we try and do a bit of cardio, a
bit of abs.. it’s a bit limited, I’d like to do more but it’s the time restraint as well’. (James;
M)
Despite demonstrating that he does take steps to look after his health and wellbeing, James
makes two references to wanting to and feeling like he should be doing more if he didn’t
have to deal with the time pressures.
Finn was the only one of the participants to mention that he experienced a sense of
satisfaction when he felt he had done a good job or had achieved what he set out to
achieve.
‘Sometimes after I achieve the work and the things I need to do, you feel good and well,
you create some value and well….you do something good but on the other hand you feel
that you have pushed yourself so hard just for this and those things are not compulsory,
you chose to do it but you are pushing yourself to achieve other things so…. But at the end
of the day if the job is over you feel proud’. (Finn; A)
Research looking at the possible differences between adaptive and maladaptive
perfectionism has suggested that adaptive perfectionists are more likely than maladaptive
perfectionists to experience a sense of satisfaction from their personal strivings
(Hamachek, 1978). Finn (A) described gaining some satisfaction from his actions,
although it is noteworthy that he does also refer to the personal sacrifice that accompanied
his achievements.
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(b) A significant event to re-establish awareness
A number of perfectionists were able to draw on their personal experiences to identify a
significant event that had acted to re-establish their awareness of their own personal
limitations with regards to their health and wellbeing.
During her interview Kate (A) described an incident where she became very ill at the end
of her first year of University. She saw this illness as the result of a build-up of stress
surrounding her end of year exams and at the time she described herself as having little
awareness of how poorly she was feeling. She described how she virtually stopped eating
and lost two stone in weight and as a result she was admitted to hospital and once
discharged, returned to her family home where her Mum looked after her and helped her to
establish normal eating patterns again. Kate mentioned that it was only after the event that
she realised that she had not been aware of how hard she was pushing herself with her
work and as a result, had little awareness of her stress levels until they started to affect her
physically (i.e. her appetite and weight). She described how she felt annoyed and frustrated
with herself that she had allowed it to reach the point where she had become so ill and had
not been able to see the warning signs.
‘It annoyed me that I had allowed it to get that far, it felt like it had been, that those health
issues had sort of been my fault by not being more sensible about the way I was eating and
so on…I had my mum to help me.. it’s a bit like being a child again, but it definitely
helped’. (Kate; A)
Kate (A) describes this incident as significant in helping to re-establish her awareness of
where her own personal limitations were. She also talked about how it opened her eyes to
how emotional health can have an impact on physical health and enabled her to put
strategies in place to protect herself when she found herself preparing for exams the
following year. Kate also described how, following her episode of illness, she now takes
steps to look after both her physical and emotional health e.g. making sure she gets enough
exercise, following a healthy diet, taking regular breaks from work, utilising the support
from family and friends and monitoring her emotional health to ensure that she doesn’t get
too stressed and that her physical health doesn’t suffer as a consequence.
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‘…..it’s getting towards that time of year again now of sort of the anniversary of when I
started to get ill… I am being, I am taking note of how I am feeling and really taking time
to make sure that I am emotionally ok…umm, and then physically ok as well….sort of
follows that’. (Kate; A)
Mason (A) discussed his experiences of living and studying in the United States before
coming to the UK to study. He explained how he found the workload much heavier in the
US, compared to over here.
‘the UK system is… you do less work during the term (compared to the US) so I think
overall, I think it’s less stressful. And then you have exams at the end which you have to
prepare for… there’s more stress at the end..but when you live in the US their whole
system there is based on erm… continuous work, you know 100 hour weeks.. and over
there they basically say… you have to sacrifice your health for work, because if you don’t
sacrifice, you fail’. (Mason; A)
In further accounts of his time studying in the US, it would seem that the unrealistic
expectations that were imposed upon him (in terms of academic work), made it difficult
for him to accurately judge where his personal limitations were. This was further
exacerbated by his experiences of trying to look after his physical health whilst studying
overseas. He described a close friend who pushed himself to extremes in his quest to have
the perfect body. It seems like Mason has been able to reflect on his experiences to provide
him with the ability to judge where his own personal limitations were, for example he does
push himself when he goes to the gym but if he doesn’t meet the targets that he has set
himself, he doesn’t get angry (like he may have done previously), instead he plans to try a
little harder next time. Additionally he monitors his stress levels so that he doesn’t push
himself beyond his limitations with regards to academic work.
‘I’ve decided that over here, coming back to the UK, that I am going to take it a bit more
easy. There’s only a certain amount of work that you can do, if you push yourself too far
then results start to become detrimental. So it’s good to take a break and I do this
regularly with my work…if you can’t think of anything original, you’ve just got to go away
and take a break and do something else. Otherwise it will become detrimental to your
mental health’ (Mason; A)
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This extract from Mason’s interview shows how he was able to identify that if he
continued to push himself with his academic work and neglect his health and wellbeing
(e.g. by not taking regular breaks form his work) then his work and/or health would suffer
as a consequence.
Ally (M) discussed her experience of having a female friend at college who suffered from
depression. She described how her friend kept her feelings and anxieties to herself and
didn’t let on to anyone about her problems. Ally also talked about how her friend
continued to push herself relentlessly with her studies despite suffering from emotional
problems. Ultimately her friend reached the point where she was unable to continue at
college and had to leave and try and study for her A Levels at home. Eventually she ran
away from home and didn’t go to University. In reflecting on this experience, Ally was
able to identify the importance of looking after emotional as well as physical health.
Thinking about specific health behaviours that would be beneficial for emotional
wellbeing, Ally was also able to see how helpful it would have been had her friend been
able to utilise her social support network of friends and family which would have enabled
others to offer help. She describes how this experience enabled her to realise where her
own personal limitations were as well as the importance of being able to share difficult
feelings with friends and family as a means of looking after her emotional health and
wellbeing.
‘I feel that I kind of,….I take time when I’m suffering from problems with university work
or like a personal problem and I know, I have kind of identified in my head who I can talk
to and I know that I have like one friend who will always be there for me and….I always
know that my mum is like always on the end of the phone for me to talk to’. (Ally; M)
From the interviews it became apparent that how individuals’ dealt with the pressure of
work/exams whilst at school represented a significant point which helped raise their
awareness of their own personal limitations (in terms of how hard they could push
themselves). For some, it was evident that this awareness only became activated when they
started university and encountered their first year exams.
Hannah (A) discussed how her experiences at school during her GCSE’s made her realise
that she would have to adopt a different strategy to most other people in order to achieve
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her goals. She described how her desire to do everything perfectly meant that she was
aware she would have to work for longer on certain tasks to meet her own high standards.
When discussing how she dealt with exams at university, Hannah described how this
awareness whilst at school helped her to develop a strategy whereby she would allocate
more time to tasks such as revising and preparing for exams.
Ally (M) described some of the problems that she had encountered when she was studying
for her GCSE’s
‘I have always, since GCSE’s.. I have always had this problem of when it gets to exam
period I always get really panicky, thinking I am going to completely fail and then
somehow that manages to make me do well but I think last year I had quite a tough time, I
didn’t really adjust to university that well straight away. When I kind of saw exams
approaching and I thought I need to take a new look at this, I need to really think about it
so…kind of prevented that from happening… what had always happened before, because
before it was always panic, panic, panic… cry…. I am going to fail…and then last year I
thought, actually I can see this happening again, it always happens, why would it be
different this year?... so I thought..like… I need to get myself calm, I need to tell myself
before.. I can do it and just prepare myself and I know that this year… I have liked looked
at my second year in a different way… like trying to prevent all that stress’. (Ally; M)
In this extract, Ally (M) reflected on the difficulties she faced in the first year of
University, specifically when she was approaching her end of year exams. It seemed that at
this point she was able to reflect on her experiences that she faced when she had studied
for her GCSE’s and make some changes so as not to repeat the same again.
Ally (M) described that despite getting panicky around exam time at school, she normally
ended up doing well, therefore, it may be the case that she didn’t question her (potentially
dysfunctional) strategy as it had always appeared to serve her well. Ultimately it would
seem, Ally was able to draw on her school experiences to create a shift in her outlook and
her awareness of how else she might tackle the stress surrounding exams. The approaching
first year exams appeared to act as a trigger for her to readjust her thinking about her own
personal limitations surrounding exams.
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Sara (M) recalls when she was younger she would push herself with her academic work at
the possible detriment of her health.
‘…..when I was younger, would do my work until midnight, maybe until three or four in
the morning and it is very exhausting. I really like to push and work to the last minute and
it is very exhausting.. but nowadays I pay more attention to my health and don’t do it
anymore…maybe the latest time I go to bed is twelve’. (Sara; M)
During the interview she was able to reflect how a recent episode of illness enabled her to
become aware of how much she was pushing herself. Although her behaviours at the time
(when she was at school) did not provide her with the necessary impetus to change the way
she dealt with the pressure of work and exams, she was able to draw on those experiences
now she was at university to gain a new perspective on creating a balance between
working hard but also looking after her health.
Paul remembered very clearly his experiences of becoming stressed at the time of his
GCSE’s.
‘I didn’t used to be very good at it. I used to get… I think I put a lot of pressure on myself
and then when things didn’t go as I’d hoped I used to get really worried. Like with my
GCSE’s when I did them, I remember when the results came out, I ended up doing really
well but I’d convinced myself I’d done awfully and had like…. For a while… I did get
stressed, I’d get like chest pains and then I had to go to hospital for it. But they didn’t
know what it was… but I think it was stress related and then since then, like I know when
I.. you know.. that rising feeling of panic when you worry about something, I’ve kind of
learnt to control it a bit now because I just sit down, stop thinking about it, take deep
breaths and it’s not really been a problem since.. I think after having problems with it…
I’d know how to deal with it now’. (Paul; M)
From this extract it suggests that his experiences of having to deal with the physical
consequences of stress enabled him, (with the reassurance from the hospital that there
wasn’t a physical reason for his pains) to develop a strategy to deal with the stress
surrounding exams. This awareness appears to have enabled him to develop a more
functional strategy to deal with his reaction to stress in the future.
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5.3.3 Control over health and wellbeing
Three subthemes were identified under the heading of control over health and wellbeing;
health goals, not wanting to seek help and inflexibility to adjust standards.
(a) health goals
Most definitions of perfectionism place an emphasis on organisation and planning as key
characteristics (e.g. Frost et al, 1990). In terms of health goals, research has identified that
when individuals have a clear idea about their health goals e.g. what they are going to do
and when they are going to do it, then there is a greater chance that individuals will be able
to direct their own lives to achieve these goals (Kraus, 2003). When asked whether they
had clearly defined health goals, only James and Ally could specify any specific strategies
that they had implemented.
With regards to general planning, Karl (A) described how he likes to plan out virtually
every aspect of his life:
‘….I think the more you plan what you are going to do with your life, from what you are
going to do in your day to day life, like waking up in the morning to making sure you get
things that you want to get done in a week, to what you want to do with your life in the next
three years. If you can do that they you are going to be in a better frame of mind…sort of
thing…you’re going to be in better mental health’. (Karl; A)
Karl’s descriptions show the importance he places on plans and organisation and how he
feels these have a positive impact on his emotional wellbeing, specifically, he suggests that
planning puts him in a good place emotionally and gives him a sense of happiness and
contentment in his life. Despite having most areas of his life mapped out, he states that he
doesn’t have specific goals in terms of looking after his health.
‘I wouldn’t say goals as much as I’m in a place right now and I want to get to a different
place… but I do have goals in the sense of a kind of routine that I want to keep going…
and obviously I’ll improve as I go along, which will hopefully in turn improve my health’.
(Karl; A)
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Despite all the perfectionists expressing that they felt it was important to have clearly
defined health goals, only two felt they had addressed this area of their lives. James (M)
explained that he makes weekly plans of what he wants to achieve (e.g. healthy eating and
going to the gym) which he believes keeps him on track. Ally (M) felt her health goals
were clearly defined and necessary for her to be able to work towards achieving them.
‘I think if I didn’t have them (health goals).. I think I am the sort of person who needs to
have goals otherwise I would let myself slip and I wouldn’t achieve what I wanted so…. I
think if I didn’t think about things, then I wouldn’t achieve them. I think that is the best
way for me to work’.(Ally; M)
It would seem that Ally (M) had some doubt surrounding her ability to maintain a healthy
lifestyle in the absence of having clearly defined health goals. She suggested that these act
as a useful frame of reference for her to organise her behaviour.
The majority of the perfectionists (adaptive and maladaptive) seemed to have a more
vague idea of what they might like to do to look after their health and wellbeing rather than
specific objectives or plans. Sara felt such goals to be more important for people who don’t
have a clear idea of how to look after themselves and described that she has a more general
approach that didn’t involve writing down or listing what she wanted to achieve. Finn (A)
also subscribed to a more general view:
‘I have never really set up goals or like what I want to achieve in terms of health.. but just
have a more generic or cloudy objective of staying healthy… I think if you are generally
more healthy then it would be more generic to just keep as you are…but…if people are in
a more….undergoing a more negative situation I think it is good for them to set a goal for
them, knowing how to improve or have the objective to improve the situation’. (Finn; A)
From this extract there is the suggestion that Finn (A), although realising the importance of
such health goals, felt these are more relevant for other people who perhaps weren’t as
healthy as him and who perhaps who were in a more negative emotional state. Such a
premise was also supported by Paul (M) who advocated a more general approach to taking
care of himself and identified that such goals would have more relevance if he had a
particular health concern. He did admit to attempting to set goals but confessed that other
factors often get in the way:
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‘I’d say I always attempt to set myself goals, like I’ve put on a bit of weight since coming
to uni and I’m always like.. oh I’m going to lose it but then it kind of gets lost in the
wayside amongst everything else.. like..and never quite happens. But I think if things, if
things ever became a problem, I think I would sort it out, but at the
moment because I am generally quite healthy and stuff, I’m just kind of quite happy going
along as I am because nothing’s wrong yet, if that makes sense..’ (Paul; M)
It would seem that Paul (M) would like to have clearly defined health goals, however,
when he has tried to implement them, he felt that various obstacles tend to get in the way
and then he lost his focus.
Mason (A) explains that he was intentionally vague about his health goals. He further
elaborated that this was necessary because he felt that planning in this area of his life
would have provided him with yet another thing to think about that it would potentially tip
the balance in terms of him maintaining a stable emotional state.
‘I plan so many other things in the days throughout my life, there are so many aspects of
my life I plan, that if I planned all the other things, it would be a very stressful lifestyle’.
(Mason; A)
Hannah (A) was the only participant who identified herself as having no health goals at all
(general or specific). Similar to Mason (A) she explained that having to deal with that area
of her life would put too much strain on her and force her to make compromises in other
areas e.g. academic work which she described as an area that she is not prepared to
compromise on:
‘I was trying to have but…. It’s impossible really now cos I don’t have any time to do
anything extra… I Would like to do it and I made a schedule and I always have to change
something because of the work .. if I get the place next year (she is applying to graduate
medical school) then I can rest for a bit and I can Think about this stuff, but before that it
is not really possible’. (Hannah; A)
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Although Hannah (A) described herself as trying to have goals related to health, she felt
that her heavy workload prohibited her from being able to address this area of her life.
(b) Not wanting to seek help
When asked how likely it would be that they would seek help for both physical and
emotional difficulties, there seemed to be a general reluctance from all participants, both
adaptive and maladaptive perfectionists. Reasons given for not wanting to seek
professional help or delaying seeking help for physical problems included: heavy workload
so no time (Hannah, A), feeling personally responsible for wanting to sorting out own
problems (Kate, A, Karl, A, Paul, M), a belief that family and friends could give better
advice (Kate, A; Mason, A), inconvenience (Karl, A), the internet being more convenient
and quicker to use (Kate, A; Mason, A; Karl, A; Paul, M; Ally, M; Finn, A; Rachel, M),
difficulty building up trust in a new doctor (Kate, A) and previous bad experiences with
health care providers (Karl, A).
Most of the interviewees stated that their decisions to seek help for physical health worries
would be influenced by: the severity of the problems, how scared they felt by not going
and also whether it was a one off problem or a recurring problem. Ally, M, Finn, A,
Rachel, M and Sara (M) explained that they would go quite readily because they could see
how putting things off may make the situation worse but Hannah and Paul admitted that
they would only go if their problem interfered with their ability to function. For physical
problems, most participants suggested that they would use the internet to check out
symptoms and general queries that they had in preference to going to see a doctor or other
health professional.
For emotional problems none of the perfectionists suggested they would readily seek help.
Although acknowledging the importance of this type of support many of the participants
felt that they would prefer to deal with such difficulties on their own. Some of the
participants suggested that they might enlist the help of their social support network (Kate,
A, Finn, A, and James, M). Others felt that such matters should be kept private (Paul, M,
Mason, A, Karl, A and Sara, M). The majority of participants mentioned the internet as a
potential source of support for emotional problems but didn’t admit to using such
resources regularly.
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‘With the emotion thing, although I want to talk it through with other people, I prefer to
keep things private, if I can. I’m not one of those people that would talk about things with
anyone, I mean I’d sit down with my Mum and have a chat or with a close friend if
something was a problem, but like..I don’t like to umm…. It’s going to sound really awful,
but I feel like if I display even extreme emotion, it make me feel kind of……..feel weak and
I know that’s a really awful thing to say but I don’t like it’. (Paul; M)
This extract from Paul’s transcript shows how his fears about being perceived as weak
may stop him from seeking help for emotional problems.
Finn (A) and Karl (A) expressed confidence about being able to deal with emotional
difficulties on their own. However, others seemed to feel unsure of their ability to
accurately judge when emotional problems may need attention (Kate and Ally). Kate,
possibly due to her past difficulties dealing with stress, seemed to recognise that
personally, individuals’ are not always the best judge of whether they are functioning or
not. Ally felt that it was much harder to admit having emotional problems and that
individuals may need help and encouragement from others to motivate them to go and seek
help.
‘I have actually been like a couple of times to seek help but I didn’t go immediately. That is
a different thing to me, I think that is something that is harder to admit to and I think
sometimes you need somebody else to encourage you or it is quite hard to say….look at
yourself and say, oh I have got this problem, I have got that problem and actually do
something about it, I think sometimes you do see it and sometimes you need somebody else
to see it, somebody who cares about you to kind of like…make you, like encourage you that
you are doing the right thing, that you are not going crazy, that there is something wrong
actually wrong …it is quite hard to motivate yourself to do something like that’. (Ally; M)
This extract from Ally’s transcript suggests that individuals don’t always recognise
emotional problems and emphasised that it is important to have a social support network in
place that can help you with decisions regarding when to seek professional advice.
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(c) Flexibility to adjust standards
There are inevitably going to be times when it is necessary to adjust one’s standards and
expectations for example when academic pressures increase at exam times and other
activities have to take a back seat or perhaps when one is ill and one’s academic goals have
to be readjusted. From the interviews it was evident that there was a split between those
individuals who possessed the flexibility to adjust their personal standards and those who
struggled. The distinction did not seem to be based on type of perfectionism i.e. both
adaptive and maladaptive perfectionists were seen to exhibit both flexible and inflexible
attitudes towards changing goals and standards.
Not surprisingly, for most of the participants this balance seemed to be weighted in favour
of being driven to fulfil their academic goals first and foremost and having to give a lower
priority to engaging in preventive health behaviours. Through discussions with the
interviewees it became apparent that the crucial determining factor, in how successful
attempts were to balance the two domains, was not primarily concerned with having the
flexibility to be able to adjust one’s standards but rather having the knowledge and
confidence that once the situation had returned to normal (i.e. the particular threat or
pressure had subsided) a sense of balance would be resumed.
The responses of the participants have been distinguished by those individuals who had the
flexibility to adjust standards and those who didn’t
(i)
Ability to adjust standards
Kate’s (A) experience of becoming ill at the end of her first year seems to have enabled her
to develop the flexibility to deal with situations where she felt there was conflict between
work and health (e.g. when assignments are due or around exam time). Before her illness
she identified the importance of looking after both physical and emotional health,
however, it wasn’t until after this episode that she was able to see how important it was to
have strategies in place to safeguard her health and wellbeing:
‘….my health didn’t take priority at all. I think I’d always taken it for granted that I would
be ok, sort of regardless of how much I was eating or how much work I was doing or how
tired I was making myself. I don’t get ill that much so I never really thought about
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consciously stopping myself get ill…. and that kind of thing.. because it had never been an
issue before’. (Kate; A)
Kate (A) explains that when she experienced conflict (between work and health) she took
time to acknowledge that she needed to take steps to safeguard her health such as taking
regular breaks from her work, rewarding herself with time off when she has worked hard
e.g. going out and getting some fresh air, enlisting the help of her friends to remind her to
eat and stocking up on healthy foods during busy times.
Whilst she had tried to create a balance between these two aspects of her life (university
and health) she explained that she was now better equipped to spot the signs when she was
pushing herself too hard and when this happened she had to adjust her standards and put
her health ahead of her academic work.
‘Where you’ve got that conflict of I need to do both things but one of them has to take
priority. I tend to try and balance them rather than give one priority over the other. I try to
keep balance, which isn’t always the best thing because sometimes my health has to come
first…. But as much as possible I try to keep on top of things and particularly work wise,
working steadily is really important to me, just to keep my stress levels down that really
helps, it also means that if I do start feeling ill, I can take the time and make myself better
because I know that quite often just having time off completely will get me better faster
rather than just trying to work through it and the work will suffer anyway’. (Kate; A)
As well as acknowledging the health benefits of adopting these strategies, Kate was able to
recognise how taking regular breaks was more beneficial to her academic work in the long
term.
Finn (A) acknowledged that when he experienced conflict, his emotional and physical
health had to take a back seat, however, he felt that lowering his engagement in preventive
health behaviours, at such times, was justifiable and fell within an acceptable margin.
When he experienced increased pressure at University he dealt with it by taking regular
breaks from work, actively seeking some entertainment after a long day’s studying, and
rewarding himself after he achieved his academic goals. He felt that by allowing himself to
temporarily reduce his engagement in preventive health behaviours, this provided him with
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the extra time that he needed to complete his academic work, as well as enabling him to
resume such activities when the work pressure has subsided.
Taking regular breaks was also mentioned by Sara (M) to be her main strategy that she
adopted to deal with situations where she experiences increasing pressure to perform well
with her academic work.
‘I try to escape for a little while and then come back to it and feel like it is not the whole
world, it is just work… or something like that…I say it to myself that it is just work.
Sometimes I feel that it is just an escape but not that
effective or it didn’t solve the problem but sometimes it works, it works because after
maybe one night to have a good sleep and in the morning you think…ok.. I can solve it, it
is just going to take time’. (Sara; M)
In this extract she acknowledged that having the flexibility to step away from work and get
a good night’s sleep is a better way of dealing with a difficult situation rather than letting
work take over her entire life. By “escaping” she was able to gain the perspective she
needed to create a balance between doing well academically but not putting excessive
pressure on her health.
James (M) was very clear about the need to have a clear mind and a healthy body to
accomplish his academic goals. He viewed his engagement in preventive health behaviours
such as eating healthily and regularly going to the gym as instrumental in helping him
achieve these goals as well as helping him to deal with obstacles that may lead to conflict
(in terms of trying to meet his academic goals whilst also maintaining his emotional and
physical health). He expressed that he endeavoured to continue to go to the gym and eat
healthily even when he had deadlines because he felt this to be beneficial to him physically
and emotionally. Despite his commitment to maintaining a sense of balance between the
two domains he was able to rationalise that occasionally he had to reduce his gym
attendance to deal with the increasing pressures of work. Identifying this as a temporary
measure enabled him to have the confidence and knowledge that he would be able to
resume normal activities and return to a more balanced lifestyle when the academic
pressures had subsided.
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When dealing with the increasing pressures of work, Mason (A) felt occasionally it was
necessary to push himself and that in such situations he would be prepared to adjust his
standards (health) and briefly reduce his gym attendance.
‘If I’m on the thread of something, I just have to keep going and I think the health has to
sacrifice for that period…erm… when I’m working. Not to a crazy extent where I have to
start taking caffeine tablets and things like that, but just to the extent that if there is work
to be done, I’ve got to skip going to the gym… I do know that I need at least five hours
sleep at night and if it starts to get worse that then I have to cut down on the work’.
(Mason; A)
From this extract Mason suggests that putting off preventive health behaviours was just a
temporary measure until the pressure of work subsided. Similar to James, Mason
expressed confidence at being able to return to his normal activities (looking after his
health) after the deadline or exam had passed.
Karl (A) and Paul (M) also both admitted to putting off preventive health behaviours as a
way of dealing with the conflicting pressures of having a deadline or exam whilst still
wanting to maintain a healthy lifestyle.
‘I guess I do let things drop, like obviously uni for example, if the work load really does
pile on…I’ll kind of drop other things that I know make my life better, like cycling all the
time, making sure that I’ve got my packed lunches so that I’m not spending lots of money
and I’m eating properly… and all these sorts of things do kind of fall through the cracks a
bit I guess. But it doesn’t affect… like… the things it makes me stop doing aren’t kind of
going to have an instant effect sort of thing…it’s more, it’s obviously, I want to be doing
them long term but I guess I pick them back up again when load eases off.’
Here, Karl (A) identified that he had to put certain things on hold to be able to meet the
pressures of university life but was able to tolerate this in the short-term because he felt it
would be time limited and not have a lasting impact on his health. In the long-term he was
able to see that he would be able to resume his normal activities.
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Karl (A) also seemed to be accepting of the need to prioritise and temporarily suspend his
engagement in preventive health behaviours because he felt that his actions were largely
down to personal choice.
‘……those obstacles… are generally, all the obstacles that I’ve kind of put in place
anyway, like I chose to do a degree and I’m doing a degree for a reason and I want to be
doing it… so I wouldn’t really call it an obstacle so much as more… something that I’m
doing at a particular time. Obviously I do have to drop other things, but it doesn’t really
affect me emotionally because it’s still like valid and relevant to what I
want to be doing’. (Karl; A)
From this extract, it would appear that when academic demands increased and conflicted
with his desire to keep up with his normal healthy routine, Karl (A) was able to reflect on
the self-determined nature of the situation which allowed him to prioritise one domain over
the other (in his case work over health). Additionally, Paul was able to rationalise that
putting off engaging in preventive health behaviours was only temporary and that this was
acceptable because he was young, didn’t have any existing health problems and therefore
this decision would not endure any long term damage to his health and wellbeing.
(ii)
Inability to adjust standards
Hannah (A) displayed little flexibility in being able to adjust her standards and expressed
having no strategies in place to try and ensure a balance between work and looking after
her health and was clear in her intention to always put her academic work before her
health. Despite being able to identify that her health was suffering physically (lack of
sleep) and emotionally (acknowledging that her stress levels are the highest they have ever
been) she seemed unwilling to even consider adjusting her academic goals and standards.
As well as an inability to adjust her own standards, even temporarily, Hannah revealed that
she was engaging in behaviours that could be putting her health and wellbeing at further
risk such as functioning on little sleep and shutting herself away from all sources of social
support. The main worry for Hannah appears to be that she has continued to push herself
relentlessly in her quest to achieve her academic goals but is doing little to look after her
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health and wellbeing. Additionally she is also engaging in behaviours that may be putting
additional pressure on her physical and emotional health.
For Rachel (M), she was clearly trying to balance both work and health by continuing to
push herself with her academic studies whilst also trying her best to continue with
preventive health behaviours such as going to the gym and going for a run.
‘When it’s coming up to exams a lot of my friends.. like they stop going to the gym cos they
think they don’t have enough time but you always have to make time to do something
else… so I’ll always make sure I’m doing something else cos as long as you do the work
when you plan to do it, you’ve always got… you’re not doing it twenty four hours a day’.
(Rachel; M)
Rachel expressed in her interview that she would try at all costs to keep both areas going
and would always try to find a way to do both. The worry for Rachel is that although she is
trying to keep a sense of balance in her life and not let her academic work take priority
over her health, it may be that in her attempts to keep everything going and a reluctance to
adjust her standards in either area, she could actually be pushing herself too far. This is
suggested in the following extract:
‘….all my goals are set because I feel I have to achieve them, like I have to reach the best
that I can and if I don’t then it is a failure, there’s no in between. There’s really only one
or the other which is probably bad then you don’t reach it….’. (Rachel, M)
Although not making it clear which specific domain she is talking about, this extract
reveals how she experiences considerable dissatisfaction when she does not reach her
goals or achieve her expectations. If she places equal importance on both domains and
does not have the flexibility to adjust her standards depending on the situation (e.g. easing
off on going to the gym when she has a deadline or exams approaching) then there is the
chance that she is setting herself the unrealistic expectation of being able to do everything
at all times which could prove detrimental to her long term health.
Similarly to Rachel, Ally (M) did seem to employ some adaptive strategies to try and deal
with situations where she experienced conflict between work and health e.g. carefully
planning her time when there are deadlines and exams so leaving nothing to chance and
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rewarding herself when she has pushed herself with her academic work. The potential
problem, however, is that her rewards tend to be going to the gym and pushing herself
physically. Although it is clearly important to continue to look after her health when there
are additional pressures from work, there is the danger that she may be pushing herself too
far in both areas because of a lack of flexibility in being able to adjust her standards in
either domain.
Ally (M) does acknowledge that some of her strategies may be maladaptive. In this brief
extract she seemed to be questioning the value of one of her strategies.
‘….I think the way I prioritise by starting to worry about everything so far in advance so I
have a long time to work it out… I don’t know if that is probably a bad thing in a way
because I stress myself out so early…. It is probably unhealthy to be starting to worry that
early, I am not sure’. (Ally; M)
For both Ally (M) and Rachel (M), the long term consequences of pushing themselves in
both domains (health and work) coupled with a lack of flexibility and reluctance to lower
their standards in either of these areas, could prove detrimental to both work and health in
the long term.
5.4 Discussion
The aim of the present study was to explore perfectionists’ beliefs and behaviours related
to health and wellbeing as well as gain some insight into engagement in preventive health
behaviours and possible obstacles to engagement. The rationale being, that the qualitative
nature of the study would allow for a more detailed understanding of how perfectionists
manage to balance the demands of increasing academic pressures such as assignments and
exams, with the ability to take care of themselves and remain healthy. Ultimately the
intention was to try and gain more insight into some of the factors that may prohibit
engagement in preventive health behaviours and whether there were any noticeable
differences between adaptive and maladaptive perfectionists.
As has been identified in the earlier chapters, there may be long-term risks associated with
a lack of engagement in preventive health behaviours and maladaptive perfectionists
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compared to adaptive perfectionists appear to show less engagement in such behaviours
(Longbottom et al, 2012; Williams and Cropley, 2014). By implementing a qualitative
study it was expected that it would be possible to provide additional evidence to suggest
that maladaptive perfectionists particularly, may represent a high risk group based on their
level of engagement and the specific ways that they deal with obstacles/barriers to
engagement, such as increased academic pressure. Using IPA, three overriding themes
were identified; taking personal responsibility for health and wellbeing, lack of awareness
of limitations and control over health and wellbeing. Within these themes, however, a clear
pattern of differences between adaptive and maladaptive perfectionists was not observed.
Nonetheless some interesting findings did emerge from the interviews.
Taking personal responsibility for health was identified to be tied in with understanding
the importance of attending to both the physical and emotional aspects. The majority of the
participants (adaptive and maladaptive) were able to acknowledge the importance of
looking after both physical and emotional needs, although physical health was frequently
discussed before emotional health, which could perhaps give an insight into priorities.
Many of the adaptive perfectionists were able to identify that the value of health, for them,
was tied to an “ability to function”, i.e. that health was a precious commodity because it
enabled them to do what they had to or wanted to do in the present and also the future in
terms of goals and aspirations. Interestingly none of the maladaptive perfectionists made
any reference to linking the value of health to an “ability to function”. This may suggest
that for maladaptive perfectionists the primary emphasis was not concerned with
functioning, rather meeting the required standard or getting the job done. Unfortunately
focussing only on the end product (i.e. the set goal or expectation) may have negative
implications in terms of personal fulfilment and quality of life. Future work could address
this as a potential difference between adaptive and maladaptive types of perfectionism.
The transition to university stood out as a key factor for many of the perfectionists in terms
of reshaping their ideas about taking personal responsibility for their health and wellbeing.
For most, it was the first time they had to make the important decisions relating to how
they lived their lives and looked after themselves rather than relying on their parent/s to
take care of them. Moving away from home and embarking on a chosen course of study
seemed to engender new pressures (e.g. an increase in workload) that had to be negotiated
simultaneously with trying to adjust to the expectations and pressures of university life
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(e.g. socialising, drinking, staying up late etc.). The focus seemed to be on trying to create
a sense of balance between meeting the academic demands, socialising themselves into
university life as well as trying to look after their health and wellbeing. From a preventive
health point of view, it seemed that a number of the participants struggled with trying to
remain healthy because university life seemed to present the opportunity for engagement
in more health risk behaviours. The main challenge for participants seemed to be the
ability to juggle several domains simultaneously. Although the majority of the
perfectionists (both adaptive and maladaptive) identified this to be a difficult task and one
that they had struggled with at the beginning, a number of the adaptive perfectionists
identified these experiences to be empowering, allowing them to have more faith in their
decision making abilities. Starting university is known to be a stressful experience for new
students (Bewick, Koutsopoulou, Miles et al, 2010; Lunau, 2012) and dealing with this
transition is likely to be more challenging for students who possess high levels of the
maladaptive traits associated with perfectionism. Although not looking directly at
perfectionism, a recent study identified that an alarming number of students (50%)
expressed feeling hopeless and overwhelmed by anxiety when they started university
(Lunau, 2012) and a longitudinal study (Bewick et al, 2010) in the UK identified that
although anxiety and depression scores varied considerable throughout the course of
individuals’ time at university, they remained elevated from pre-admission levels
throughout their entire university career. Therefore it would seem essential, knowing the
specific vulnerabilities of perfectionists that future research focusses on how this group of
individuals can be supported through this major transition in their lives.
Having to make their own decisions about how to look after themselves whilst at
university did appear to have a positive effect on decisions to engage in preventive health
behaviours, with all participants (both adaptive and maladaptive perfectionists) able to
identify an encouraging range of behaviours that they felt they had participated or
continued to participate in whilst at university. The challenge for many, however, was
continuing to take personal responsibility for their health when the pressures of work
increased and/or stress levels rose.
Although demonstrating encouraging levels of engagement (for both adaptive and
maladaptive perfectionists) there was the tendency to play down time spent engaging in
preventive health behaviours as well as doubting the quality of such engagement. The
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harsh self-talk expressed by a number of the participants suggested that they felt they
could and should be doing more and indeed performing to a higher standard than was
currently being achieved. Their lack of awareness or acknowledgement of their current
level of engagement could mean that such individuals may be in danger of overdoing it at
the potential detriment to their health and wellbeing and perhaps jeopardising their
performance in other areas such as with their academic work. Although previous research
has suggested doubting the quality of one’s actions is considered one of the more
maladaptive perfectionism traits (Frost et al, 1990), the present study found this quality to
be present in both adaptive and maladaptive perfectionists.
A lack of awareness of physical and emotional limitations may mean that perfectionists
have difficulty registering when they have pushed themselves too far in a particular
domain (e.g. work or health behaviours). Not being able to recognise that they may need to
take a break or perhaps step away from a task, could result in individuals pushing their
bodies too hard or not recognising their stress levels mounting. Added to this, there is the
danger that maladaptive perfectionists have a tendency to play down their successes. It was
interesting to note in the present study that only one of the adaptive perfectionists
expressed a sense of satisfaction with regards to his personal achievements. Hamachek
(1978) maintained that experiencing satisfaction from one’s personal strivings was an
essential component of the positive or adaptive facet of perfectionism. Not being able to
recognise when a task has been completed well or when a good grade has been achieved
coupled with an inability to recognise when to stop pushing oneself may be a worrying
combination for health and wellbeing. Specifically it may prohibit attending to the physical
and psychological symptoms that alert us to the fact that we need to slow down and take a
break, such as excessive tiredness, body aches, pains and feelings of exhaustion and
burnout.
For some of the perfectionists, experiencing a significant life event was a catalyst for them
to reassess their own personal limitations in relation to addressing their health and
wellbeing. Their experiences enabled them to acknowledge that perhaps they were pushing
themselves too far and re-evaluate how to create a sense of balance. For the majority of the
participants (both adaptive and maladaptive perfectionists), taking exams, particularly
GCSE’s was identified as a pivotal point in their lives when they experienced a
considerable amount of stress and were able to see that continually pushing themselves to
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meet their own high standards, whilst neglecting their physical and/or psychological health
needs proved to be detrimental for the most part to their academic success as well as their
health and wellbeing. For the most part, the participants in the study found that their
experiences during their GCSE’s years were instrumental in helping lay the foundations
for how they would respond to future pressures such as taking their A Levels and
University exams. However, this was not evident for all participants and the analysis of the
transcripts highlighted that this may be a critical first point of reference when some of the
perfectionists felt vulnerable and unable to balance several domains simultaneously.
Denscombe (2000) believes that “GCSE’s constitute a new and distinct source of stress in
the already stressful lives of young people”. These findings highlight the need for more
research specifically addressing how perfectionists cope with GCSE’s, (or equivalent) to
identify whether these exams represent a critical point in the lives of perfectionists and
how such individuals manage the academic pressures coupled with their perfectionistic
tendencies.
All of the perfectionists identified the importance of planning and organisation when
discussing the areas of work and health. The primary reasons given for such planning
tended to be to avoid uncertainty and to remain in control of the ability to achieve selfimposed standards and expectations. An interesting observation was that despite being
organised in many life domains, including with their academic work and also stating the
importance of engaging in preventive health behaviours, the majority of participants did
not have a clear or organised plan as far as their health goals were concerned. Only two
participants (two maladaptive perfectionists) could specify any specific strategies that they
used in addressing their health needs, although a number of both adaptive and maladaptive
perfectionists reported that did have a vague idea of what they wanted to achieve e.g.
getting fit, going to the gym, controlling stress levels etc. It was also evident that some
participants experienced frustration because they were aware of the importance of looking
after themselves and would ideally have had specific plans in place for doing this, but
identified that other pressures often got in the way of their ability to achieve this e.g. lack
of time due to increased academic demands. It was also noted for some participants, that
having goals and expectations as far as health and wellbeing was concerned was perceived
as yet another stress and therefore there was justification for keeping this particular area of
their lives intentionally vague. It is interesting that the participants were able to demand
perfectionism in an academic domain but not in terms of health goals. Historically
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perfectionism has been conceptualised and measured from the viewpoint of it being a
global rather than a specific personality trait, although more recent empirical studies have
emphasised the usefulness of measuring perfectionism from a domain specific perspective
(Dunn, Gotwals & Dunn, 2005; McArdle, 2010; Stoeber and Stoeber, 2009). Clearly
resolving this issue has implications from a theoretical and conceptual viewpoint as it
would influence how perfectionism would be defined and from a treatment point of view
in terms of finding the most appropriate treatment strategies for the extreme forms of
maladaptive perfectionism.
From the interviews it was evident that there was a general reluctance to seek help for
either physical or psychological health difficulties. Although there was no obvious
distinction between adaptive and maladaptive perfectionists, some of the participants
suggested they would consider seeking medical help although it would depend on; the
severity of the problem, the fear of what might happen if they didn’t go and whether or not
the particular health concern compromised or interfered with their “ability to function”.
For emotional problems, all of the participants demonstrated a reluctance to seek help,
suggesting that they would prefer to deal with psychological difficulties themselves. There
also seemed to be some uncertainty from both the adaptive and maladaptive perfectionists,
over their own ability to judge when this type of emotional support might be necessary.
The combination of not being able to judge personally that you might need help and not
being able to ask for help does raise alarm bells for perfectionists who are often
unwaveringly driven to meet and often exceed their often self-determined high standards.
As has been discussed in previous chapters, the reluctance to seek help may represent the
deeper need of perfectionists to maintain a perfect and flawless public image and research
has identified that perfectionists may go to great lengths to hide their imperfections from
others (Hewitt et al, 2003). Another point of interest was the tendency for a many of the
participants to either use the internet to check out their symptoms or to seek support if or
suggest that they would use this type of support in the future. This seemed to be preferred
over face to face contact with a medical professional or a counsellor. It would be
interesting for future research to investigate the avenue of providing specific support for
perfectionists via the internet, as the private nature of this type of support would certainly
help alleviate worries associated with the self-presentational needs of perfectionists.
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In terms of possessing the flexibility to adjust standards in the light of unexpected
difficulties or obstacles, it was encouraging that a considerable number of participants
(both adaptive and maladaptive) demonstrated an ability to do this, for example when
academic pressures increased they were able to adjust their engagement in preventive
health behaviours to accommodate the extra time required to devote to their work and
studies. Some participants (again both adaptive and maladaptive) displayed a lack of
flexibility in being able to adjust their standards in either domain (work and health) and
continued to push themselves relentlessly in one or both areas. The concern is that this lack
of flexibility and the need to remain in control could potentially put pressure on work and
health behaviours as well as lead to a reduction in quality in one or both of these areas. The
overriding factor that seemed to determine the amount of flexibility (in being able to
adjust standards) was the level of confidence they could resume a sense of balance once
the immediate threat had passed i.e. when stress levels returned to normal or when the
academic pressure subsided. It was interesting to find that the majority of both adaptive
and maladaptive perfectionists were able to rationalise that at times of high stress,
standards and goals had to be temporarily readjusted so as to reduce the pressure on them.
A minority of the participants displayed little signs of being able to adjust their standards
in times of high stress or when academic demands were increased. For such individuals
there was the sense that they would continue to push themselves whatever the cost and the
idea of reducing their involvement in either the work domain or health domain (in terms of
their engagement in preventive health behaviours) seemingly unthinkable. Research has
investigated and found a strong association between perfectionism and workaholism
(Clark, Lelchook & Taylor, 2010; van Beek, Hu, Schaufeli et al, 2012) as well as the
maladaptive perfectionistic traits with burnout (Fairlie and Flett, 2003).
Focussing specifically on obstacles to engagement in preventive health behaviours, there
appear to be some factors that seem to be linked inherently to the experience of being at
university and others that seem to be tied more exclusively with perfectionism and
perfectionistic traits. Table 5.3 provides a summary of possible obstacles to engagement;
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Table 5.3
Possible Obstacles to engagement
Factors Inherent in the University
Factors Associated more Specifically
Environment
with Perfectionism
Lack of time due to increased amounts
Doubting the quality of one’s actions
of academic work
means that perfectionists may play
down their engagement in preventive
University life encourages bad health
health behaviours as not being good
habits (e.g. drinking, smoking, staying
enough or the frequency of engagement
out late etc.) which interfere with
not seen as enough
resources and motivation to engage in
preventive health behaviours
No clearly defined health goals. A lack
of clearly defined health goals may
Problems associated with balancing lots
mean less motivation to engage
of domains e.g. work, health, wanting to
have fun
Lack of flexibility to adjust standards
e.g. an exaggerated focus on academic
Having to take personal responsibility
goals and achievement may mean no
for health and wellbeing – often moving
time, resources or motivation to engage
away to go to university means the first
in preventive health behaviours
time that individuals have to make their
own decisions about how to look after
Perfectionists may be operating with a
their health
higher than average baseline levels of
stress which therefore makes it more
Increased stress due to new pressures
likely that they are going to react in a
and targets
more extreme way when the demands of
university life increase.
A Lack of confidence that a sense of
balance with be regained if standards
have to be adjusted temporarily e.g.
when exam time approaches there may
be the need to reduce time spent at the
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gym in favour of doing more work.
Some perfectionists find it difficult to let
go of their standards because they lack
the belief that a sense of balance with be
regained after the particular
threat/pressure has passed
There are some limitations to the present study. The small sample size involved, although
considered beneficial to support the practical implications of IPA (Smith and Osborn,
2008) does raise questions about the generalizability of the findings. The other potential
difficulty relates to the specificity of the sample; the sample was selected on the basis of
type of perfectionism. Smith et al, (2009) have highlighted a preference for a less specific
sample as the method then allows for the possibility of gaining a more thorough
understanding of a wider context, however, Willig (2001) has suggested that the scope for
autonomy and originality inherent in the approach makes it highly appropriate when
studying atypical groups. To improve validity, further studies could utilise other methods
to support the findings. Casey and Murphy (2009) have suggested the use of a variety of
methods (such as diaries as well as interviews) which could further improve the credibility
of the findings.
Another limitation may be the use of only perfectionists in a university environment.
Whilst this enabled a detailed exploration of young people in a university setting, it does
rule out any potential differences that could be associated with other demographic
variables such as age and work environment. A further limitation may be a lack of
objective measures to assess actual engagement in preventive health behaviours. The study
relied solely on self-reports of engagement and it would have been interesting to utilise
other measures that could perhaps be externally verified, such as recorded attendance at a
gym or exercise class. The final potential limitation with the study is the possibility of a
response bias in favour of adaptive perfectionists. Adaptive perfectionists were noticeably
more willing (than maladaptive perfectionists) to divulge more personal information and
were generally more ‘talkative’. It is therefore difficult to accurately compare between the
two types of perfectionists.
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5.5 Conclusion
The present study sought to explore adaptive and maladaptive perfectionists’ beliefs
related to health and wellbeing and to gain a more thorough understanding of the decisions
perfectionists make in relation to whether or not to engage in preventive health behaviours.
Additionally it was intended that any factors that might prohibit engagement may be
identified. Potential differences between adaptive and maladaptive perfectionists were also
of interest. For engagement, both adaptive and maladaptive perfectionists demonstrated
encouraging levels of involvement in preventive health activities and were able to identify
the benefits of engaging in terms of protecting their health and wellbeing. Less emphasis
was given to looking after emotional health than physical health despite all participants
emphasising the importance of attending to emotional health needs. Generally, it seemed
that there were more similarities than differences between the two types of perfectionists.
Rather than being influenced by type of perfectionism, engagement seemed to be affected
by a number of factors that were considered relevant in making the transition to University
e.g. lack of time due to increased work load, increased stress due to new pressures and
targets, the realisation that students had to take personal responsibility for their health and
wellbeing and problems associated with balancing a number of domains simultaneously
(studying, health and wanting to have fun). There were also a number of factors that were
considered to be more closely related to being highly perfectionistic such as ; doubting the
quality of ones’ actions so that engagement may be either played down or negated, not
having clearly defined health goals when other areas are highly organised, having higher
than average baseline levels of stress, how individuals dealt with balancing the demands of
work and health previously (e.g. when they did their GCSE’s) and lacking confidence that
a sense of balance would be regained if one had to temporarily readjust standards in the
face of an immediate threat.
The present study highlights the fact that there may be critical points in life that are more
difficult for perfectionists to deal with such as GCSE’s and starting university. How
successfully an individual deals with these major life transitions may set the tone for future
competencies as well as vulnerabilities. The next study addresses potential intervening
variables in the relationship between perfectionism and preventive health behaviours from
a quanitative perspective.
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Chapter 6
Study 4
Moderators and Mediators in the Relationship between Perfectionism and Engagement in
Preventive Health Behaviours
The previous chapter explored adaptive and maladaptive perfectionists’ engagement in
preventive health behaviours and potential obstacles to engagement from a qualitative
perspective using IPA. Potential obstacles to engagement included a number of factors that
seemed to be inherent in the university environment such as more time pressure due to
increased work commitments, being tempted by unhealthy behaviours and having to juggle
a number of domains simultaneously (e.g. work, social life and looking after one’s health),
and a number of other factors that seemed more specific to perfectionism e.g. lack of
flexibility to adjust standards in a particular domain, lack of awareness of their own
personal limitations and doubting the quality and frequency of their current engagement in
health behaviours. In summary the previous study did not identify any noticeable
differences between the dimensions of adaptive and maladaptive perfectionism although it
did highlight that perfectionists may be particularly vulnerable when dealing with
transitions, particularly the transition to university.
The final study of the thesis continues with the theme of addressing potential
barriers/obstacles to engagement in preventive health behaviours. To expand on the
previous studies in the thesis, this study will address two areas of engagement; firstly
engagement in general health behaviours (as has been addressed in the previous two
quantitative studies, Chapters 4 and 5) and secondly, engagement in physical
activity/exercise behaviours. Additionally a general population sample will be utilised
which may provide a different perspective from the student samples used in the previous
three studies.
6.1 Introduction
Research has provided clear evidence that regular amounts of exercise/physical activity are
beneficial to health, both psychologically and physically. Psychological benefits include;
reduced levels of depression and anxiety (Biddle & Asare, 2011; Carek, Laibstain &
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Carek, 2011), protecting against the negative effects of stress (Childs & DeWit, 2014) and
improvements to self-esteem and cognitive function (Biddle & Asare, 2011). Physical
benefits include; improvements to longevity and mortality, preventing chronic illnesses
(particularly in relation to cardiovascular disease) and improving treatment outcomes for a
number of acute and chronic conditions (e.g. Biddle et al, 2004; Bouchard et al, 2007; Fox
et al, 2006; Netz et al, 2005).
Despite clear evidence of the benefits of engaging in physical activity/exercise, it seems
that many people do not engage in the recommended amount. According to the World
Health Organisation and the current UK Department of Health (DH, 2004)
recommendations, adults are advised to participate in one hundred and fifty minutes of
moderate intensity aerobic activity during a typical week. The Health Survey for England,
2006 (Craig & Mindell, 2008) identified that only 28% of women and 40% of men are
meeting the criteria set out by the American College of Sports Medicine (ACSM)
suggesting that adults should exercise for at least 30 minutes on most days.
This lack of engagement has led researchers to look into the possible obstacles to
engagement in physical activity and exercise, i.e. why some individuals may decide to
abstain from engaging despite the clear benefits of participating in such activities. One
area of research that has aimed to shed some light on this matter has addressed the
presence of perceived barriers to engagement. This was a concept that was first introduced
by the Health Belief Model (Becker and Rosenstock, 1984). Within a cognitive
behaviourist framework the model postulated that an individual’s willingness to engage in
health promoting behaviours was the result of a process of weighing up the relative costs
(barriers) and benefits of engagement. Perceived barriers were identified to be either
external factors such as a lack of resources (e.g. financial, time) or lack of support from
family and friends or internal factors such as low self-efficacy, lack of motivation or
worries about performing exercise behaviour in public. Not surprisingly research has
suggested that engagement in preventive health behaviours is less likely to occur when the
perceived costs outweigh the perceived benefits (Strecher and Rosenstock, 1997).
Perceived barriers have been identified as one of the most powerful predictors of health
related behaviours (Janz and Becker, 1984; Strecher and Rosenstock, 1997).
In terms of research addressing the association between perfectionism and
exercise/physical activity, aside from a well-established body of research addressing the
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role of exercise dependence in perfectionism (e.g. Miller & Mesagno, 2014), only a small
amount of research has addressed whether perfectionists may be looking after their health
and wellbeing by engaging in preventive health behaviours (Longbottom et al, 2010; 2012;
Williams & Cropley, 2014) and findings suggest that maladaptive perfectionists may
represent a vulnerable group due to a lower level of engagement. Taking this into
consideration, the present study aims to explore some of the factors that may act as
barriers/obstacles to engagement. Chapter 2, part 2 (literature review of the area of
perfectionism and health) identified a number of areas that may help to further elucidate
the relationship between perfectionism and engagement in preventive health behaviours
and which may also be potential obstacles or barriers to engagement. Such areas include;
self-presentation, self-handicapping behaviours, physical activity motivation, perceived
stress and self-efficacy.
Self-presentation has been described as a method employed by individuals to try and
control other peoples’ impressions of them (Leary et al, 1994) and its relationship with
perfectionism has been discussed in the preceding chapters of the thesis. Research into
self-presentational processes in relation to exercise behaviour (see Hausenblas et al, 2004)
has identified self-presentation to be an important factor influencing decision to engage in
physical activity. The way that a person deals with self-presentational motives is likely to
leave them feeling either encouraged or discouraged about engaging in such behaviours.
Leary, (1992) contended that if an individual feels self-assured about their sporting or
athletic ability and fairly certain that they can self-present themselves in a favourable way,
then this will increase the likelihood of engaging, however, If an individual lacks
confidence about their ability to self-present themselves favourably (i.e. they fear they will
be perceived as someone who is not sporty or athletic) then this is likely to discourage and
deter them from engaging in exercise activities. Being able to self-present and portray the
image of an ‘exerciser’ has been associated with a number of favourable outcomes, such as
being viewed as stronger, healthier, more sociable and independent, (Lamarche,
Gammage, Sullivan & Gabriel, 2013).
A well-established relationship has been identified between perfectionism and selfpresentational tendencies, with maladaptive perfectionists identified as more likely (than
adaptive perfectionists) to use such strategies (Hewitt et al, 2003) and particularly in
exercise settings (Hausenblas et al, 2004). Self-presentation efficacy is a particular form of
self-presentation that relates to the level of confidence that an individual has concerning
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their ability to present the desired image to others (Maddux, Norton & Leary, 1988) and
has been shown to be a relevant and important concept in exercise settings (Gammage,
Hall & Ginis, 2004). Self-presentational efficacy may be particularly relevant and
challenging for perfectionists because of their inherent need to self-present themselves
favourably. In an exercise context there are likely to be many opportunities to publicly
display ones’ athletic or sporting ability and for perfectionists their inherent need for
positive approval from others and fear that they may self-present in a less than favourable
manner may prohibit engagement in such activities.
Choosing to avoid or withdrawal from situations has been recognised as a selfpresentational strategy known as self-handicapping (Jones & Berglas, 1978) which is a
term used to explain a situation where an individual puts forth an impairment prior to their
performance, which will, in the event of failure, protect their self-esteem and self-worth
(Snyder, 1990). Examples of self-handicapping behaviours include procrastination,
overcommitting, not taking the time to practice, not putting in the required amount of
effort (Bailis, 2001; Kimble, Kimble and Croy, 1998), and choosing difficult or impossible
goals (Greenberg, 1985). In essesnce what the individual is trying to do by engaging in
such behaviours, is to put some distance between them and the potential failure of a task
so if things don’t work out, they can rationalise this as being the result of something other
than their own ability or skill. Self-handicapping has been identified as a type of selfpresentational strategy often used by individuals in sport and exercise settings (e.g. Martin
and Brawley, 1999; 2002). Such situations are thought to evoke such behaviours because
they often require individuals to publicly self-present their physical abilities and possible
incompetencies to others (Chen, Chen, Lin et al, 2008; Ommundsen, 2001).
Perfectionism has been related to a greater desire to engage in self-handicapping
behaviours (Hobden and Pliner, 1995) and such behaviours may be utilised by
perfectionists because they may fear they have a lot to lose in evaluative situations (Hewitt
& Flett, 2002). The relationship between perfectionism and self-handicapping behaviours
has been investigated by Kearns et al (2007) who have identified that self-handicapping
may be a function of the negative and biased cognitions that are characteristic of some
perfectionists. Taking into consideration the close relationship between perfectionism and
self-handicapping it would be interesting to see if perfectionists use these behaviours as a
means of avoiding engaging in exercise behaviour
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Decisions to engage in preventive health behaviours may be influenced by motivational
factors such as cognitions and behaviours related to engagement. Research has consistently
found that the ability to maintain and persevere with exercise/physical activity has been
linked to self-determined motivational tendencies (Huberty et al, 2008; Wang and Biddle,
2001). To further explore the role of motivation in exercise, a four factor model of physical
activity motivation was developed by encompassing two positive oriented dimensions
(adaptive cognitions and adaptive behaviours) and two impeding dimensions (maladaptive
cognitions and maladaptive behaviours) which together influence motivation to engage in
physical activity. The model has been utilised to explore the relationships between
perfectionism and physical activity motivation with results suggesting that the two
dimensions of perfectionism (adaptive and maladaptive) map directly onto the adaptive
and maladaptive cognitions and behaviours that have been proposed to encompass physical
activity motivation (Martin, 2010). Such results lend support to there being two distinct
forms of perfectionism, and potentially a positive and healthy subtype. In terms of
motivational attributes, a recent study by Longbottom et al (2010) found that adaptive
perfectionism was associated with the positive motivational attributes of; perseverance,
organisation and self-efficacy and the maladaptive dimension of perfectionism related to
the negative aspects of motivation that are thought to encompass; a lack of confidence in
exercising, fear of making mistakes and a reluctance to engage. In terms of prohibiting
engagement, perhaps high levels of maladaptive cognitions and behaviours prohibit
decisions to engage.
Perceived stress has also been considered as an important variable that may affect
decisions to engage in exercise behaviour as it has been related independently to both
perfectionism and engagement. The relationship between perfectionism and stress has been
discussed in detail in chapter 3, and stress has been implicated as a key factor linking
perfectionism with a wide range of psychological problems (Hewitt and Flett, 2002).
Stress has been found to influence the ways in which an individual looks after their health
and high levels of stress have been associated with; reduced engagement in preventive
health behaviours (Adler and Matthews, 1994) and increased engagement in health risk
behaviours such as smoking and alcohol consumption (Kurspahić-Mujćić, HadžagićĆatibušić, Sivić & Hadžović, 2014). The relationship between stress and perfectionism is
complex (see chapter 2, part 2) and there may be many ways in which perceived stress
affects and is affected by perfectionism. One way may be to act as a possible obstacle to
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engagement. Previous research has identified that during times of high stress, there is the
likelihood that certain health behaviours may be reduced, particularly those requiring more
effort on the part of the individual (Weidner et al, 1996). Perhaps it is the case that for
certain perfectionists (particularly maladaptive) the joint pressure of having to meet high
standards whilst dealing with a higher than average baseline level of stress, may leave the
individual with few resources to take care of their health.
Self-efficacy is another factor that may act to influence or impede engagement in
preventive health behaviours such as exercise/physical activity. Self-efficacy can be
explained as cognitions that relate to an individual’s belief that they have the necessary
means to carry out a particular behaviour and keep it going despite potential setbacks. A
well-established association has been found between self-efficacy and participation and
perseverance in physical activity/exercise behaviour (Sallis et al, 1992; Sallis and Hovell,
1990; Sallis et al, 1989) with high self-efficacy being associated with increased effort at
mastering health promoting behaviours (Conn, 1998) and low self-efficacy associated with
the avoidance of difficult tasks (Bandura, 1993). Perfectionism and self-efficacy are
thought to share a close relationship and the adaptive dimension of perfectionism has being
associated with higher levels of self-efficacy and the maladaptive with lower levels
(LoCicero & Ashby, 2000). High levels of self-efficacy have been associated with a
‘performance-approach orientation’ indicating a greater desire to engage in certain
behaviours and low levels of self-efficacy with an ‘approach-avoidance perspective’,
reflecting the need to avoid engaging (Wolters et al, 1996). These constructs share
similarities with Slade and Owens’ (1998) approach-avoidance perspective for adaptive
and maladaptive perfectionists which concerns a greater desire on the part of adaptive
perfectionists to actively engage in tasks.
Although not addressing engagement in preventive health behaviours directly, the potential
differences between the adaptive and maladaptive dimensions of perfectionism in a sport
and exercise setting have been explored by a number of authors (e.g. Flett & Hewitt, 2005;
Stoeber, Stoll, Pescheck & Otto, 2008). According to Flett and Hewitt (2005), the more
adaptive perfectionistic attributes can contribute favourably to performance outcomes
provided that individuals have developed a pre-emptive stance on how to deal with
setbacks, when they arise. Having the flexibility to adjust standards seems to be a key
factor in maintaining adaptive functioning (Flett & Hewitt, 2002). Research by Stoeber et
al (2008) and Longbottom et al (2010) has supported the notion that within a sport and
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exercise setting, the cognitive and behavioural processes motivating the two dimensions of
perfectionism are fundamentally different. This has been reinforced by the model
developed by Slade and Owens (1998) proposing an approach/avoidance paradigm that
reflected the underlying cognitions and behaviours of adaptive and maladaptive
perfectionists respectively. Furthermore when addressing the specific area of physical
activity motivation, Longbottom et al (2010) found the dimensions of adaptive and
maladaptive perfectionism mapped directly onto the adaptive/maladaptive facets of
physical activity motivation (Martin et al, 2006) with the result being that adaptive
perfectionism was found to be associated with positive motivational tendencies such as
higher levels of self-efficacy and perseverance in an exercise setting and maladaptive
perfectionism being associated with negative motivational tendencies that reflected a fear
of making mistakes and a desire to avoid engagement.
The present study seeks to explore the role of a number of variables in the relationship
between perfectionism and engagement in both general preventive health behaviours and
the specific area of exercise/physical activity. Although the study takes an explorative
stance on the precise way that these intervening variables may be involved, it is suggested
that maladaptive perfectionism will be associated with more barriers/obstacles to
engagement and fewer benefits and adaptive perfectionism to be associated with more
benefits and fewer barriers/obstacles to engagement and that the relationship between
perfectionism and engagement will be either enhanced or diminished by their involvement.
The specific aims of the present study were to explore the potential obstacles/barriers and
benefits to engagement in both physical activity/exercise behaviours as well as general
preventive health behaviours for both adaptive and maladaptive perfectionists. By
identifying potential differences between the two perfectionism dimensions it is thought
that this will provide further support for the identification of two distinct subtypes of
perfectionism
6.1.1 Hypotheses
1.
Maladaptive perfectionism will be associated with lower levels of engagement in
physical activity/exercise behaviours and lower levels of engagement in general
preventive health behaviours.
2.
Adaptive perfectionism will be associated with higher levels of engagement in
physical activity/exercise and general preventive health behaviours.
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3.
Maladaptive perfectionism will be associated with more barriers5/obstacles to
engagement and less benefits to engagement, specifically;
a.
lower levels of:
i.
Self-presentational efficacy expectancy (how confident an
individual is to perform the desired behaviours and present the
desired image).
ii.
Adaptive cognitions related to exercise
iii
Adaptive behaviours related to exercise
iv
General exercise self-efficacy
v.
Specific perceived benefits to exercise (consisting of life
enhancement, social interaction, psychological outlook, physical
performance and preventive health)
vi.
b.
Positive affect
higher levels of:
i.
maladaptive cognitions related to exercise
ii.
Maladaptive behaviours related to exercise
iii.
Perceived stress
iv.
Specific perceived barriers to exercise (consisting of physical
exertion, time expenditure, exercise milieu and family
discouragement)
v.
4.
Negative affect
Adaptive perfectionism will be associated with greater benefits to engagement and
fewer perceived barriers/obstacles to engagement, specifically;
a.
higher levels of:
i.
Self-presentational efficacy expectancy
ii.
Adaptive cognitions related to exercise
iii.
Adaptive behaviours related to exercise
iv.
General exercise self-efficacy
v.
Specific perceived benefits to exercise (consisting of specific
benefits associated with life enhancement, social interaction,
psychological outlook, physical performance and preventive health)
5
The terms ‘barriers’ and ‘benefits’ are used to refer to a number of variables that may act to either encourage or discourage
engagement. the terms ‘specific perceived barriers’ and ‘specific perceived benefits’ are used to refer to the two dimensions of the
Exercise Benefits Barriers Scale.
159
vi.
b.
Positive affect
Lower levels of:
i.
Maladaptive cognitions related to exercise
ii.
Maladaptive behaviours related to exercise
iii.
Perceived stress
iv.
Specific perceived barriers to exercise (consisting of specific
barriers such as physical exertion, time expenditure, factors inherent
in the exercise environment and family discouragement
v.
5.
Negative affect
Moderation and mediation analyses will be performed to identify whether the
potential benefits/barriers to exercise act as moderators/mediators in the
relationship between perfectionism (adaptive and maladaptive) and engagement
(physical activity/exercise behaviour and engagement in general preventive health
behaviours). Variables tested for moderation/mediation will include; specific
perceived benefits to exercise, specific perceived barriers to exercise, selfpresentational efficacy expectancy, adaptive cognitions and adaptive behaviours
related to exercise, maladaptive cognitions and behaviours related to exercise,
perceived stress, exercise self-efficacy and positive/negative affect. Due to the
exploratory nature of this part of the analysis, no specific predictions have been
formulated about which variables will act as mediators/moderators.
6.2 Methods
Participants and Procedure
A general population sample was recruited through the Qualtrics survey software. The
only requirement was that participants were aged between 18 and 65 years of age. Of the
final sample (N=350), 174 (49.7) were males and 176 (51.3) were females. Their mean age
was 43 years (SD=13.5). Participants completed an online questionnaire that was designed
to find out about current physical activity/exercise behaviours, preventive health
behaviours and a number of variables that may act as obstacles/barriers to engagement
such as self-presentational efficacy, physical activity motivation, perceived barriers and
perceived stress.
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6.2.1 Measures
As utilised in the previous studies (study 1, chapter 4 and study 2, chapter 5) The Frost
Multidimensional Perfectionism Scale (F-MPS; Frost et al, 1990) was administered as a
measure of adaptive and maladaptive perfectionism. Similar to study 1, for adaptive
perfectionism the Personal Standards and Organisation subscales were amalgamated to
produce a total score for adaptive perfectionism and for maladaptive perfectionism the
subscales of Doubts about Actions and Concern over Mistakes were summed to form a
total maladaptive perfectionism score. As in the previous studies the parental
expectations/parental concerns subsections were excluded as they were not required to
formulate an adaptive and maladaptive score. The remaining 26 items (13 adaptive, 13
maladaptive) were scored on Likert scale, ranging from 1 (strongly disagree) to 5 (strongly
agree). Scores can range from 26 to 130 and a higher score indicates a higher level of
adaptive or maladaptive perfectionism. The use of the four subscales to produce separate
measures of adaptive and maladaptive perfectionism has been validated in previous
research (Chang et al, 2004; Dunn et al, 2006; Harris et al, 2008; Well et al, 2004) and
have been found to have good internal reliability with Coefficient alpha levels of .88 and
.87 respectively (Chang et al, 2004; Harris et al, 2008).
Exercise behaviour
To assess leisure time activity/exercise behaviour, the Godin Leisure-Time Physical
Activity Questionnaire (GLTEQ; Godin and Shephard, 1997) was utilised. This is a
relatively simple 3 item measure of all physical activity achieved during an individual’s
leisure time. Individuals were asked to consider how many times during the past 7 days
they had participated in vigorous, moderate and mild activity (of at least 15 minutes
duration). The leisure time physical activity score can be computed in two steps:
The weekly count of strenuous, moderate and mild activities are multiplied by the values
of 9, 5 and 3 respectively. These values are compatible with MET values of the activities
listed in the questionnaire (metabolic equivalent of task which represent the intensity of the
exercise/physical activity). A total weekly leisure activity score is calculated by adding the
three resulting values (9 x strenuous) + (5 x moderate) + (3 x mild).
Higher scores indicate participation in a greater amount of physical/activity and exercise in
one’s leisure time. Psychometric evaluations of the questionnaire have produced good testretest reliability and the questionnaire has been found to correlate well with other physical
161
activity measures (Godin and Shephard, 1987; Sallis, Buono, Roby et al, 1993; Jacobs,
Ainsworth, Hartman & Leon, 1993).
Preventive Health Behaviours
To retain a sense of consistency across studies, engagement in general preventive health
behaviours was assessed using an adaptation of the General Preventive Health Behaviours
Checklist (Amir, 1987). The original questionnaire was designed with the intention to
represent a comprehensive range of preventive health behaviours considered to be
appropriate to a British population. Respondents were asked about the frequency with
which they engage in a range of preventive health behaviours and items are scored on a
Likert scale with three possible responses (0 = never do, 1 = sometimes do and 2 = always
do). Questions address the following areas; physical activity, relaxation, safety practices,
personal health practices and risk avoidance. The measure consists of 27 items with a
possible range of scores from 0 to 54. Responses are summed to form a total engagement
score and higher scores indicate greater engagement in preventive health behaviours.
Internal reliability for the amended version of the scale utilised in studies 1 and 2 (chapters
4 and 5) achieved an acceptable result of Coefficient alpha .84.
Perceived benefits/barriers
Perceived barrier to engagement in physical activity/exercise were assessed using the
individual benefits and barriers subsections of the Exercise Benefits/Barriers scale (EBBS;
Sechrist, Walker & Pender, 1987). This scale assesses perceptions relating to the benefits
and barriers of participating in exercise/physical activity. When utilised as two
independent scales, perceived benefits consists of 29 items and the perceived barriers
subscale consists of 14 items. Within these two subsections, there are further subdivisions
(table 6.1).
162
Table 6.1
The scales and sub-scales of the Exercise Benefits/Barriers Questionnaire
Perceived Benefits to Exercise
Perceived Barriers to Exercise
Life enhancement (8 items)
Physical exertion (3 items)
Social interaction (4 items)
Time expenditure (3 items)
Psychological Outlook (6 items)
Exercise environment (6 items)
Physical performance (8 items)
Family discouragement (2 items)
Preventive health (3 items)
For all the subscales, responses are scored on a Likert scale ranging from 4 (strongly
agree) to 1 (strongly disagree). A total score can be derived to encompass both the benefits
and barriers scale or the two scales may be scored and utilised as independent entities.
Initial psychometric evaluation of the scale yielded favourable results with an internal
reliability of .95 for the 43 item scale as well as .94 and .87 for the separate Benefits and
Barriers scales respectively. Test-retest reliabilities were also found to be within an
acceptable range (Sechrist et al, 1987). More recent studies utilising the scale have
reported good internal consistency for both total and individual scores (Lovell, Ansari, &
Parker, 2010). For the purposes of the present study the two scales were used
independently.
Self-Presentational self-efficacy
Self-presentation in exercise/physical activity was assessed using the Self-Presentational
Efficacy Scale (SPES; Gammage et al, 2004) that assesses the concept of selfpresentational efficacy expectancy. This relates to how confident an individual is of being
able to perform the desired behaviours and present the desired image, e.g. of being
perceived as fit and healthy. This subscale consists of 5 items and participants are required
to indicate their level of confidence (from 0% to 100%) in a number of statements that
reflect what other people may think of them in an exercise setting such as “other people
will think that your body looks fit and toned” and “other people will think that you have
good stamina”. High scores on this scale represent higher levels of efficacy expectancy.
Internal reliability for this subscale have been found to be favourable (Cronbach’s alpha =
92, Gammage et al, 2004; Lamarche et al, 2013)
163
Physical activity motivation and self-handicapping behaviour
Physical activity motivation and self-handicapping were assessed using the Physical
Activity Motivation Scale-Revised (PAMS-R, Martin, 2010a; 2010b). This scale consists
of 20 questions addressing four underlying dimensions; adaptive cognitions, adaptive
behaviours; maladaptive cognitions and maladaptive behaviours. Adaptive cognition refers
to positive attitudes related to the confidence and value placed on engaging in physical
activity e.g. “I am able to benefit from regular physical activity in many parts of my life”
and “I feel very pleased with myself when I stick at regular physical activity”. Adaptive
behaviour considers behaviours that reflect the desire to persist with physical activity as
well as encompassing the planning and management aspects of behaviours e.g. “Before I
start my physical activity I get it clear what I am going to do” and “I try to have a rough
plan for my physical activity before I start it”. Maladaptive cognition refers to negative and
inhibiting cognitions that are related to fear of failure, uncertainty and anxiety in relation to
engaging in physical activity e.g. “I worry that I don’t do enough physical activity” and
“Often the main reason I’m physically active is because I don’t want others to think less of
me”. Finally maladaptive behaviours considers maladaptive behaviours related to
engagement such as self-handicapping, avoidance and withdrawal e.g. “I sometimes avoid
regular physical activity so I have an excuse if I don’t do well at sport/am not good at other
physical activities/ or don’t lose weight” and “I’ve pretty much given up doing any regular
physical activity”. Responses are rated on a 7 point Likert scale (1 = strongly disagree, 7 =
strongly agree). The scale is scored as four independent scales; adaptive cognitions,
adaptive behaviours, maladaptive cognitions and maladaptive behaviours). There is limited
evidence addressing the psychometric properties of this scale, although when evaluated as
four distinct components, acceptable internal reliabilities have been achieved for the four
dimensions of adaptive cognition, adaptive behaviour, maladaptive cognition and
maladaptive behaviour (Coefficient alpha levels of .91, .82, .79 and .80 respectively).
Exercise Self-Efficacy
Exercise self-efficacy was measured using the Exercise Self-Efficacy Scale (ESE;
Bandura, 1997). Bandura believed self-efficacy to be context specific and as such, the use
of a separate measure (instead of a general measure of self-efficacy) justified in an
exercise context. The scale consists of 18 items that address a number of situations that
make it difficult for an individual to stick to an exercise routine, e.g. “when I’m feeling
164
tired”, “when I have too much work to do at home”, “after experiencing family problems”
and “during a holiday”. Respondents are asked to rate their level of confidence (0% to
100%, with 0% indicating little confidence and 100% indicating complete confidence) in
being able to stick to an exercise routine whilst considering the different situations that
may pose a problem to their commitment to exercise. Responses are summed to form a
total score representing exercise self-efficacy with higher score indicating higher levels of
self-efficacy in exercise. High internal consistency has been reported for the scale
(Coefficient alpha of .95, Everett, Salamonson & Davidson, 2009) and the scale has been
validated by a number of authors (Shin, Jang & Pender, 2001; Everett et al, 2009) as a
valuable measure of exercise beliefs as well as an important factor to consider when
planning an exercise program (Shin, Hur, Pender et al, 2006).
Perceived Stress
The Perceived Stress Scale (PSS, Cohen et al, 1983) was used as a measure of perceived
stress. This 10 item scale assesses appraisals of stress in response to specific situations
over the past month. Examples of questions include; “in the last month, how often have
you felt that things were going your way?” and “in the last month, how often have you felt
that you were unable to control the important things in your life?”. After reverse scoring
the four positively worded questions, a total score is derived from summing all the
responses. Higher scores indicate higher levels of perceived stress. Psychometric
evaluations of the scale have yielded acceptable internal reliability (Coefficient alpha of
.78) and the scale has been found to correlate well with other self-report measures
designed to assess stress appraisals (Cohen & Williamson, 1988)
Emotions/Mood
Due to the well-established relationship between perfectionism and emotional and
difficulties (see chapter 2, part 2), it was thought necessary to include a measure to assess
affect. For this purpose the Positive and Negative Affect Schedule (PANAS, Watson et al,
1988b) was utilised. The scale consists of two 10 item scales purporting to address
Positive and Negative affect (PA and NA respectively). Individuals are asked to rate the
extent to which they have experienced each emotion within a particular time frame. The
scale is scored on a 5 point Likert scale (ranging from 1 = very slightly/not at all and 5 =
very much). Two separate scores are derived (one for positive affect and one for negative
affect). Initial assessment of reliability and validity provided favourable results (Watson et
165
al, 1988b) with good internal reliabilities (Coefficient alphas of .88 for PA and .87 for
NA), good test-retest reliability and good internal validity when compared to other
measures purporting to assess emotional distress and psychopathology e.g. the Beck
Depression Inventory (BDI, Beck, 1961) and the Hopkins Symptom Checklist (HSCL,
Derogatis, Lipman, Rickels et al, 1974).
6.2.2 Data Analysis
Descriptive statistics were first obtained for the sample as well as means, Standard
Deviations and reliabilities for all the major variables contained within the study.
Correlational analyses were then performed to establish the associations and directional
relationships between the major variables under study as well as to determine the strength
of the relationships between the predictor variables (adaptive and maladaptive
perfectionism) and the outcome variables (engagement in exercise/physical activity
behaviours and engagement in general preventive health behaviours) to establish if the
conditions were met to be able to perform moderation and mediation analysis. For both
moderation and mediation analysis, there is the assumption that there needs to be a linear
relationship between the predictor and outcome variable. Additionally for mediation
analysis there are also three other assumptions that need to be adhered to; the predictor
variable needs to significantly predict the mediator, the mediator needs to significantly
predict the outcome and finally there needs to be a weakening in the relationship between
the predictor and the outcome variable with the mediator included. The following variables
were tested as potential mediators and moderators; perceived benefits to exercise,
perceived barriers to exercise, self-presentational efficacy expectancy, self-presentational
outcome expectancy, self-presentational outcome value, adaptive cognitions and adaptive
behaviours related to exercise, maladaptive cognitions and behaviours related to exercise,
perceived stress, exercise self-efficacy and positive/negative affect. Although study 1
(chapter 4) tested for mediation using the steps set out by Baron and Kenny (1986), which
utilises a series of regression equations and the Sobel test as a means of testing the
significance of the indirect effect (Sobel, 1982), an alternative method was chosen for this
study, which involved the use bootstrapping to generate a confidence interval to
demonstrate the indirect effect. Moderation and mediation analysis were carried out on
SPSS (version 21) using Hayes’ (2012) PROCESS tool, a computational technique that
can compute both simple and complex moderation and mediation models.
166
6.3 Results
Analyses were separated into three sections; firstly the preliminary analysis that addresses
sample demographics, means (M), standard deviations (SD) and reliabilities (Cronbach’s
alpha) for all the major variables (table 6.2), secondly the correlations6 and thirdly the
mediation and moderation analysis.
Table 6.2 Sample demographics, means, standard deviations and reliabilities for all
variables.
n
%
Age
18-29
30-39
40-49
50-59
60+
74
72
80
70
54
21.1
20.6
22.9
20
15.4
Gender
Males
Females
174
176
49.7
50.3
Gym Member
Yes
No
179
171
51.1
48.9
Variables
Perfectionism
Adaptive Perfectionism
(PS and O)
Maladaptive Perfectionism
(CM and DA)
(M)
(SD)
(α)
51.1
11.4
0.91
39.1
12.1
0.93
Exercise/Physical activity
(GLTEQ)
56.8
22.2
Preventive Health Behs
33.3
8.4
0.87
Exercise Benefits/Barriers
(EBBS)
Specific perceived barriers
32.3
7.0
0.86
6
Due to the large numbers of correlations, only coefficients of .2 and above are reported in the text. All correlation coefficients are
displayed in table 6.3
167
to exercise
Specific perceived benefits
to exercise
57.8
14.2
0.96
Self-Presentational Efficacy
(SPES)
Self-Presentational EE
49.1
27.1
0.96
Physical Activity Motivation
(PAMS-R)
Adaptive cognitions
Adaptive behaviours
Maladaptive cognitions
Maladaptive behaviours
26.5
25.1
17.9
16.0
6.2
6.1
6.4
7.3
0.91
0.90
0.82
0.85
Perceived Stress
(PSS)
26.5
7.3
0.85
51.2
21.5
0.95
32.3
18.7
8.5
8.2
0.93
0.92
Exercise Self-Efficacy
(ESE)
Mood/Affect
(PANAS)
Positive Affect
Negative Affect
Correlational Analyses
Table 6.3 displays the correlations for all major variables in the present study. A positive
association was observed between adaptive perfectionism and engagement in general
preventive health behaviours, supporting hypothesis 2, (r = .259, p < .01), however
contrary to hypothesis 1, no association was identified between maladaptive perfectionism
and engagement in general preventive health behaviours. For engagement in physical
activity/exercise behaviours, only very weak correlations were observed for both adaptive
and maladaptive perfectionism.
In support of hypothesis 3, negative associations were identified between maladaptive
perfectionism and specific perceived benefits to exercise (r = -.272, p < .01). To further
explore this association the individual factors within the benefits subscale of the Exercise
168
Benefits Barriers Subscale (EBBS; Sechrist et al, 1985) were correlated with adaptive and
maladaptive perfectionism and further negative associations were identified for the
dimensions of; life enhancement (r = -.241, p < .01), social interaction (r = -.285, p < .01),
psychological outlook (r = -.212, p < .01) and preventive health (r = -.250, p < .01). Weak
or non-significant correlations were observed for the following variables; selfpresentational efficacy expectancy, adaptive cognitions, adaptive behaviours, exercise selfefficacy and positive affect. Further supporting hypothesis 3, the following positive
associations were observed for maladaptive perfectionism; maladaptive cognitions related
to exercise (r = .536, p < .01), maladaptive behaviours related to exercise (r = .319, p <
.01), perceived stress (r = .384, p < .01), negative affect (r = .453, p < .01) and specific
perceived barriers to exercise (r = .311, p < .01). To further explore the significant positive
association between maladaptive perfectionism and the specific barriers to exercise
dimension, the individual subscales of the EBBS were correlated with the dimensions of
perfectionism to give an indication of the factors that maladaptive and adaptive
perfectionists may have found the most prohibitive. This additional part of the analysis
yielded two additional significant positive associations for maladaptive perfectionists; time
expenditure (r = .341, p < .01) and factors inherent within the exercise environment (r =
.251, p < .01).
In support of hypothesis 4, significant positive associations were identified for adaptive
perfectionism and the following variables; adaptive cognitions related to exercise
(r = .380, p < .01), adaptive behaviours related to exercise (r = .365, p < .01), exercise selfefficacy (r = .230, p < .01), specific perceived benefits to exercise (r =.352, p < .01) and
positive affect (r = .489, p < .01). An interesting finding was that a significant positive
correlation was observed between adaptive perfectionism and maladaptive cognitions
related to exercise (r = . 223, p < .01), when a negative association was predicted. This
may indicate that adaptive perfectionists may also possess elevated levels of maladaptive
cognitions (as well as adaptive cognitions) related to exercise/physical activity behaviour.
Non-significant associations were identified between adaptive perfectionism and the
following variables; maladaptive behaviours related to exercise, perceived stress and
negative affect.
169
Table 6.3 Correlation Matrix for all Major Variables
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Adapt P
-
Mal P
.478**
-
Ex/PA
.139**
-.141**
-
Prev H
.259**
-.010
.286**
-
Barriers
-.113*
.311**
-.180**
-.303**
-
Benefits
-.352**
-.272**
-.373**
-.423**
.243**
-
SPres EE
.335**
.181**
.413**
.381**
-.225**
-.551**
-
PAM ac
.380**
.172**
.426**
.490**
-.419**
-.736**
.502**
-
PAM ab
.365**
.186**
.410**
.461**
-.373**
-.669**
.447**
.876**
-
PAM mc
.223**
.536**
-.005
-.044
.411**
-.187**
.102*
.082
.152**
-
PAM mb
-.026
.319**
-.188**
-.209**
.597**
.134**
-.101*
-.348**
-.298**
.634**
-
P Stress
-.018
.384**
-.052
-.427**
.431**
.118*
-.184**
-.231**
-.214**
.237**
.290**
-
ExSelf Eff
.230**
.138**
.335*
.383**
-.215**
-.428**
.545**
.418**
.406**
.034
-.138**
-.189**
-
Positive A
.479**
.074
.294**
.544**
-.305**
-.510**
.470**
.516**
.484**
.089*
-.106*
-.395**
.366**
-
Negative A
.032
.453**
.020
-.246**
.444**
.010
-.095
-.088
-.060
.277**
.323**
.654**
-.091*
-.154**
15
-
Adapt P = Adaptive Perfectionism, Mal P = Maladaptive Perfectionism, Ex/PA = weekly physical activity/exercise score, Prev H = preventive health behaviours, Barriers = perceived barriers to exercise, Benefit =
perceived benefits to exercise, SPres EE = self-presentational efficacy expectance, PAM ac = adaptive cognitions, PAM ab = adaptive behaviours, PAM mc = maladaptive cognitions, PAM mb = maladaptive
behaviours, P Stress = perceived stress, ExSelf Eff = exercise self-efficacy, Positive A = positive affect, Negative A = negative affect.
*p < .05. **p < .01
170
Moderation and mediation analysis (hypothesis 5)
Due to the fact that the correlations between maladaptive perfectionism and both general
engagement and engagement in physical activity/exercise behaviour were either very weak
or non-significant, maladaptive perfectionism was not utilised as a predictor variable in
either the moderation or mediation analysis. Additionally the association between adaptive
perfectionism and engagement in physical activity/exercise behaviour was categorised as a
weak correlation so was also excluded from the analysis. The following variables were
tested as potential moderators and/or mediators in the relationship between adaptive
perfectionism and engagement in general preventive health behaviours; specific perceived
benefits to exercise, specific perceived barriers to exercise, self-presentational efficacy
expectancy, adaptive cognitions and adaptive behaviours related to exercise, maladaptive
cognitions and behaviours related to exercise, perceived stress, exercise self-efficacy and
positive/negative affect. Only the significant moderators/mediators are reported in the text.
171
Moderation analysis
Table 6.4 Table showing predictors of engagement in preventive health behaviours
Constant
b
SE B
t
p
33.02
0.432
76.43
p < .001
0.030
7.08
p < .001
0.371
2.42
p < .05
0.005
0.002
2.44
p < .05
33.0
0.435
75.79
p < .001
0.066
-3.21
p < .005
0.039
4.94
p < .001
0.006
3.61
p < .001
0.440
75.12
p < .001
0.017
6.00
p < .001
0.039
2.75
p < .05
0.001
2.46
p < .05
(32.17, 33.87)
Specific perceived benefits
(centred)
Adaptive perfectionism
(centred)
Specific perceived benefits
0.21
(0.27, 0.15)
0.09
(0.02, 0.16)
x Adaptive perfectionism
Note. R² = .21.
Constant
(32.14, 33.86)
Maladaptive cognitions
related to exercise (centred)
Adaptive perfectionism
(centred)
Maladaptive cognitions x
Adaptive perfectionism
-0.21
(-0.34, -0.08)
0.19
(0.11, 0.27)
0.02
(0.01, 0.03)
Note. R² = .11.
Constant
33.0
(32.13, 33.86)
Self-presentational efficacy
expectancy (centred)
Adaptive perfectionism
(centred)
Self-presentational efficacy
expectancy x Adaptive
0.10
(0.07, 0.13)
0.11
(0.03, 0.18)
0.003
(0.001, 0.006)
perfectionism
Note. R² = .18.
172
To further explore and interpret the significant interaction effects, simple slopes analysis
was utilised. For specific perceived benefits, using the simple slopes technique, when
levels of perceived benefits were low, a non-significant relationship was identified
between adaptive perfectionism and engagement (b = 0.014, 95% CI [-0.088, 0,116], t =
0.27, p = .787) and at mean and high levels of this variable, the relationship became
significant (b = .090, 95% CI [0.017, 0.163], t = 2.42, p <.05 and b = 0.166, 95% CI
[0.078, 0.254], t = 3.71, p < .001 respectively), which was in the expected direction (i.e. as
perceived benefits increase, engagement increases). For maladaptive cognitions (negative
thoughts associated with exercise/physical activity) simple slopes analysis revealed that at
low values of this variable (b = 0.061, 95% CI [-0.050, 0.172], t = 1.09, p = .28), there
was a non-significant correlation between adaptive perfectionism and engagement in
preventive health behaviours, however, surprisingly at mean and higher levels of
maladaptive cognitions, the relationship between adaptive perfectionism and engagement
became highly significant (b = 0.190, 95% CI [0.115, 0.266], t = 4.94, p < .001 and b =
0.319, 95% CI [0.224, 0.414], t = 6.61, p < .001, respectively). This suggests that as
maladaptive cognitions feature more highly there may be a strengthening in the
relationship between adaptive perfectionism and engagement in preventive health
behaviours. For self-presentational efficacy expectancy (which relates to the level of
confidence in being able to self-present as being fit and healthy), at low levels of this
variable the relationship between adaptive perfectionism and engagement was nonsignificant (b = 0.021, 95% CI [-0.092, 0.134], t = 0.36, p = .72), however, at mean and
high levels of this variable a positive relationship between adaptive perfectionism and
engagement in preventive health behaviours was observed (b = 0.107, 95% CI [0.031,
0.184], t = 2.75, p < .005 and b = 0.194, 95% CI [0.101, 0.287], t = 4.10, p < .001
respectively). This was in the expected direction, with a higher level of confidence (in
being able to self-present) strengthening the relationship between adaptive perfectionism
and engagement.
Mediation analysis
A number of variables were identified as mediators in the relationship between adaptive
perfectionism and engagement in general preventive health behaviours7.
7
Only significant indirect effects have been reported in the text
173
i.
Specific perceived benefits to engagement (e.g. physical functioning,
enjoyment, relaxation, social interaction)
A significant indirect effect of adaptive perfectionism on engagement through perceived
benefits was identified, b = 0.098, BCa CI8 [0.064, 0.143]. which represented a medium
effect size, k² = .131, 95% BCa CI [0.088, 0.194]9. This result suggests that the perception
of benefits in an exercise setting has a significant effect of influencing the strength of
relationship between adaptive perfectionism and engagement.
ii.
Adaptive behaviours (related to exercise/physical activity)
Adaptive behaviours were also found to mediate the relationship between adaptive
perfectionism and engagement; a significant indirect effect was found when adaptive
behaviours were present in the model, b = 0.114, BCa CI [0.076, 0.162]. This was
identified as a medium effect size, k² = .152, 95% BCa CI [0.103, 0.208].
iii.
Exercise self-efficacy (the level of confidence at being able to stick to
exercise when there are other distractions)
Exercise self-efficacy was identified to be an important variable in altering the relationship
between adaptive perfectionism and engagement.
Figure 6.1
Model of adaptive perfectionism as a predictor of engagement in preventive
health behaviours mediated by exercise self-efficacy
b=0.435, p = <.001
Exercise selfefficacy
b = 0.134, p < .001
Engagement in
preventive health
behaviours
Adaptive
perfectionism
Direct effect, b = 0.133, p < .001
Indirect effect, b = 0.058, p < .001
8
The confidence interval for the indirect effect is a BCa bootstrapped CI based on 5000 samples
9
Preacher and Kelley (2011) have proposed using a standardised effect size to show the strength of the indirect effect. Effect sizes of
0.01, 0.09 and 0.25 have been considered to be small, medium and large effect sizes respectively
174
As can be seen from figure 6.1, there was a significant indirect effect of adaptive
perfectionism on engagement through exercise self-efficacy. This represented a small to
medium effect, k² = .80, 95% BCa CI [0.031, 0.091].
Self-presentational efficacy expectancy (the confidence in one’s ability to
iv.
self-present)
Figure 6.2
Model of adaptive perfectionism as a predictor of engagement in preventive
health behaviours, mediated by self-presentational efficacy expectancy
b = 0.797, p = <.001
Self-presentational
efficacy expectancy
Adaptive
perfectionism
b = 0.103, p <.001
Engagement in
preventive health
behaviours
Direct effect, b = 0.109, p < .05
Indirect effect, b = 0.082, p <.05
As shown in figure 6.2, there is a significant mediating effect of self-presentational selfefficacy in the relationship between adaptive perfectionism and engagement in preventive
health behaviours. This represented a medium effect size k² = .12, 95% BCa CI [0.070,
0.160].
6.4 Discussion
Contrary to previous research (Longbottom et al, 2010; 2012; Williams & Cropley, 2014),
maladaptive perfectionism was found to be unrelated to engagement in general preventive
health behaviours and only a weak negative association observed for engagement in
physical activity/exercise behaviours, (hypothesis 1). This was an unexpected result
considering the findings of the first two studies (chapters 4 and 5). A possible reason for
175
this may be due to the general population sample utilised for the present study. The three
previous studies utilised university students and it may be possible that the incidence of
maladaptive perfectionism in the general population is lower than in a university
population or at least diluted. Maladaptive perfectionism has been identified as a serious
problem for individuals entering into university life (Kearns et al, 2008) with incidence
rates as high as 25% (Radhu, Daskalakis & Arpin-Cribbie et al, 2012). Universities
represent a setting where there is likely to be a disproportionate amount of pressure to
perform to exceptionally high standards. Research by Kearns et al, (2008) has suggested
academic settings actively encourage perfectionism because students are constantly
subjected to assessments, assignments, and exams and to make matters worse, the results
of these are often put on public display. Another point of discussion may be the fact that
the transition to university is often marked by an increase in health risk behaviours such as
smoking, drinking, poor diet and decreased amounts of physical activity (Steptoe,
Feldman, Kunz et al, 2002) which may make it more of a challenge to engage in health
promoting behaviours. The findings of study 3 (chapter 6) explored some of the challenges
that perfectionists faced trying to remain healthy in a university environment when they
were faced with the task of having to juggle a number of domains simultaneously. Two
main areas emerged; firstly a number of factors that seemed to be more deeply ingrained
and representative of their perfectionism, such as doubting their current involvement in
preventive health activities (in terms of quality and quantity), not having the flexibility to
adjust their standards when other pressures increased (e.g. when an assignment was due or
exams were approaching) and lacking confidence that a sense of balance could be achieved
once the immediate threat had passed (i.e. that they could resume their normal level of
self-care once the deadline had been met). Secondly there were factors inherent in the
university environment that participants felt made it more difficult to look after themselves
adequately such as, dealing with increased academic pressures, having to take personal
responsibility for their own health and wellbeing (when parents had done this for them
previously) and wanting to make the most of the university experience which often
involved indulging in unhealthy pursuits (e.g. drinking, having a poor diet, partying). It is
possible that the demands of university life are particularly difficult for maladaptive
perfectionists to deal with and that looking after health and wellbeing may have a lower
priority.
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The finding that adaptive perfectionism was significantly associated with engagement in
general preventive health behaviours was in the expected direction (hypothesis 2) and
supported previous research identifying the adaptive dimension of perfectionism to be
associated with positive motivational tendencies that encourage persistence in engagement
(Longbottom et al, 2010). The findings also support the results of the first two studies
(chapters 4 and 5) and fits with the proactive desire to ‘approach’ situations that has been
described to be characteristic of adaptive perfectionists (Slade and Owens, 1998; Stoeber
& Otto, 2006). Interestingly, for this study a higher level of association was identified
between adaptive perfectionism and engagement in preventive health behaviours than for
the previous studies (chapters 4 and 5). Again this could be a product of the sample chosen
for this study and perhaps in the real world, outside of the high pressured demands of the
university environment, the high concentration of maladaptive perfectionism is watered
down and therefore the adaptive perfectionistic traits appear more prominent.
When addressing specific factors that may either discourage or encourage engagement in
preventive health behaviours (hypotheses 3 & 4) the majority of the results were in the
expected direction. Maladaptive perfectionism was found to be associated with higher
levels of perceived stress, supporting previous research (Flett & Hewitt, 2002; Flett et al,
2006) as well as the findings of study 2 (chapter 5). Maladaptive perfectionism was also
found to be related to elevated levels of maladaptive cognitions and behaviours related to
physical activity/exercise behaviour, which have been identified as having the potential to
inhibit engagement in physical activity (Longbottom et al, 2010). In an exercise and
physical activity context, maladaptive perfectionism has been found to be associated with
higher levels of uncertainty, anxiety and an exaggerated fear of failure (maladaptive
cognitions) as well as greater amounts of avoidance, self-handicapping and withdrawal
from physical activity (maladaptive behaviours, Longbottom, et al, 2010; 2012).
In terms of specific perceived barriers to engagement, for maladaptive perfectionists two
factors stood out as potential obstacles to engagement; factors inherent in the exercise
environment (such as cost, the inconvenience of exercise, what others might think when in
an exercise setting and distance to travel to an exercise location) as well as time. Thinking
about how maladaptive perfectionists may be trying to juggle multiple domains
simultaneously, it seems logical that lack of time would be perceived as a potential barrier
to engagement. Furthermore, one of the areas that maladaptive perfectionists struggle with
is doubting the quality of their actions/behaviours, which can result in having to redo tasks
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over and over (to try and achieve a result that they feel satisfied with) (Frost et al, 1990),
which in itself is likely to have implications regarding time management. In terms of
perceived benefits to exercise/physical activity, as expected, maladaptive perfectionism
was associated with a lower perception of specific perceived benefits to engagement (e.g.
life enhancement, social interaction, psychological outlook and preventive health).
Specific perceived benefits to engagement (as measured by the EBBS, Sechrist et al, 1987)
have been found to be important mediator of behavioural change in a physical activity
domain (Nahas, Goldfine & Collins, 2003) and according to the Health Belief Model
individuals who perceive there to be greater benefits and fewer barriers are likely to be
more actively involved in physical activity than individuals for whom perceived barriers
outweigh perceived benefits (Janz & Becker, 1984).
Adaptive perfectionism was associated with greater benefits to exercise and fewer barriers.
Specifically, higher levels of specific perceived benefits, positive affect, exercise selfefficacy and elevated levels of both adaptive cognitions and adaptive behaviours related to
exercise. Possessing a positive attitudes towards exercise (e.g. confidence in one’s ability
to maintain regular exercise patterns and belief that one can achieve the desired outcomes)
as well as exhibiting positive behaviours associated with exercise (e.g. setting goals and
achieving them and persisting with activities) have been found to be associated with
increased motivation to engage in physical activity (Longbottom et al, 2010). An
interesting and unexpected finding for adaptive perfectionism was a significant positive
association with maladaptive cognitions. As well as being associated with elevated levels
of adaptive cognitions, adaptive perfectionism was found to be related to cognitions that
are considered to impede motivations to engage in physical activity behaviour
(maladaptive cognitions; such as uncertainty, lack of control and fear of making mistakes).
This may suggest an underlying negative aspect to adaptive perfectionism. Research by
Stoeber et al (2008) maintains the contention that (in a competitive sport setting) there are
distinct cognitive processes that underpin the different dimensions of perfectionism but
maybe in an exercise/physical activity setting or considering engagement in general
preventive health behaviours, the cognitions of adaptive and maladaptive perfectionists are
more closely related, with adaptive perfectionists possessing high levels of both adaptive
and maladaptive cognitions. Perhaps it is the self-determined outlook of adaptive
perfectionists to achieve success (Slade & Owens, 1998) that allows them to override the
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more negative thought patterns to achieve a more positive outcome (i.e. greater
engagement).
Although the present study identified some similarities in the thought processes of
adaptive and maladaptive perfectionists in relation to engagement in preventive health
behaviours, there generally appears to be a greater level of disparity than similarity
between the two perfectionism dimensions. Adaptive perfectionism was associated with a
number of variables that have been associated with positive and functional health
outcomes e.g. higher levels of positive affect and exercise self-efficacy. Higher levels of
positive affect have been found to be associated with longevity and reduced pain
symptoms (Cohen & Pressman, 2006) and higher levels of exercise self-efficacy have been
related to an increased willingness to participate and persist with health promoting
behaviours (Laffrey, 2000; Sallis & Howell, 1990).
In terms of addressing factors that may alter the strength of the relationships between
perfectionism and engagement, three variables were found to moderate the relationship
between adaptive perfectionism and engagement in preventive health behaviours10 . These
were specific perceived benefits, self-presentational efficacy expectancy (the level of
confidence in being about to present self-confidently in an exercise setting) and
maladaptive cognitions. For both specific perceived benefits and self-presentational
efficacy expectancy as one might expect, as levels of both of these variables increased, the
relationship between adaptive perfectionism and engagement became stronger and more
significant. For maladaptive cognitions, the result was in the opposite to what might have
been expected; with the relationship between adaptive perfectionism becoming more
significant (in a positive direction) as levels of maladaptive cognitions increased. This
suggests that possessing high levels of maladaptive cognitions may create a stronger desire
to engage in preventive health behaviours. As has been mentioned earlier, adaptive
perfectionism may be characterised by high levels of both adaptive and maladaptive
cognitions in an exercise setting and it is possible that having high levels of adaptive traits
may have a protective or neutralising effect on the negative thoughts associated with
exercise. It could be argued that the moderating effect of maladaptive cognitions may be
related to the self-presentational aspect of perfectionism. In the present study, a significant
10
The relationship between adaptive perfectionism and engagement in exercise/physical activity behaviour showed only a very weak
correlation, therefore mediation/moderation analyses were only performed for the relationship between adaptive perfectionism and
engagement in general preventive health behaviours.
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positive relationship was found between adaptive perfectionism and self-presentational
efficacy expectancy (the belief that one can present the desired image, i.e. that of a
proficient exerciser) and perhaps it is the case that possessing strong beliefs about being
able to present oneself confidently and proficiently enables adaptive perfectionists to
dismiss some of the maladaptive thoughts they may that are associated with engagement.
Research has highlighted the fact that perfectionists (both adaptive and maladaptive) have
a powerful need to be admired and accepted and therefore will go to great lengths to selfpresent a positive image (Hewitt et al, 2003; Sorotzkin, 1985).
Four variables were identified to have a mediating influence on the relationship between
adaptive perfectionism and engagement in preventive health behaviours; specific perceived
benefits to exercise/physical activity, adaptive behaviours, exercise self-efficacy and selfpresentational efficacy expectancy. Specific perceived benefits have been discussed earlier
in this chapter and as well as specific perceived barriers have been found to be an
important determinant in decisions concerning whether or not to engage in exercise
behaviour (Health Belief Model; Janz & Becker, 1984; Nahas et al, 2003). Elevated levels
of self-efficacy have also been identified as playing a pivotal role in influencing a number
of other factors (e.g. motivations, and anticipation of possible future outcomes) that have
been found to increase the likelihood that a task will be performed (Bandura, 1997).
In terms of adaptive behaviours, it was interesting that only adaptive behaviours (and not
adaptive behaviours and cognitions) were found to mediate the relationship between
adaptive perfectionism and engagement in preventive health behaviours. Both adaptive
cognitions and behaviours were found to be significantly associated with adaptive
perfectionism and both variables significantly associated with engagement in preventive
health behaviours. Martin et al (2006) in their original conceptualisation of physical
activity motivation, described adaptive behaviours to be positive behaviours that increased
motivation to engage in physical activity such as planning, setting goals as well as
strategies to promote maintenance and persistence in exercise. Previous research has
emphasised the role of planning and goal setting as being a crucial stage to promote health
behaviour change (The Health Action Process Approach; Schwarzer, 1992; Sniehotta,
Scholz & Schwarzer, 2005). The planning stage, according to Sniehotta et al (2005)
enables the individual to formulate a mental representation of when, where and how health
behaviour will occur. Formulating this type of action plan that focuses more specifically
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on goal attainment has been identified as a powerful predictor of behaviour change
(Abraham, Sheeran, Norman et al, 1999). Perhaps for adaptive perfectionists, engaging in
adaptive behaviours such as planning and goal setting provides them with greater
motivation to engage and therefore this is a more powerful predictor of behavioural change
than adaptive cognitions.
Self-presentational efficacy expectancy was also identified as a mediator in the
relationship between adaptive perfectionism and engagement in preventive health
behaviours. This concept refers to the belief that one can present the desired image or carry
out the desired behaviour (Gammage et al, 2004). In an exercise setting this may refer to
one’s ability to be able to self-present as someone who is fit, healthy and coordinated.
According to Gammage et al (2004) self-presentational concerns have been found to affect
a multitude of different behaviours in an exercise setting including type of activity chosen,
effort expended as well as motivation to engage. Although it has been identified that selfpresentational needs have a positive impact on engagement in an exercise setting
(Gammage et al, 2004) little is known about the precise mechanisms involved. Although
the present study identified self-presentational efficacy expectancy to be higher for
adaptive perfectionism than maladaptive perfectionism and mediation analyses supported
this theory showing it to be a mediator in the relationship between adaptive perfectionism
and engagement, what has yet to be established is how functional and adaptive this quality
is for the individual and how effective it is in producing long-term engagement. Previous
research has suggested that self-presentation by its very nature can only be described as a
maladaptive trait (Hewitt et al, 2003) because ultimately it is promoting a false sense of
self that cannot be maintained in the long-term (Hewitt et al, 2003, Leary et al, 1994).
Additionally self-presentational traits have been associated with a reluctance to seek help
for personal difficulties (Cepida Benito & Short, 1998; Hewitt et al, 2003) and can impede
the development of authentic and trusting relationships (Derlaga et al, 1993). The health
implications of the self-presentational aspect of perfectionism have been discussed in more
detail in chapter 2, part 2.
A limitation to the present study involved only using a general population sample rather
than having a student population to compare with. As discussed earlier, there may be
fundamental differences between the pressures inherent in a university setting as compared
to ‘real life’ settings and universities may encourage a disproportionate amount of
maladaptive perfectionism. Future studies could compare different populations in terms of
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barriers/benefits to engagement in preventive health behaviours with the aim of identifying
potentially vulnerable groups that could then be targeted for specific health promotion
interventions. A second limitation relates to the wider issue of how to accurately
conceptualise adaptive and maladaptive perfectionism. To retain a sense of consistency the
same method of defining perfectionism (according to the Frost et al, 1990
conceptualisation) has been continued throughout the thesis but as discussed in chapter 2,
this represents only one way of operationalising perfectionism and other methods may
differ considerably in how they may dichotomise the adaptive and maladaptive
perfectionism traits. Future studies may benefit from using a variety of conceptualisations
and comparing the findings. A further limitation involves a reliance on the self-reporting
of participants. Previous research has identified that perfectionists, particularly
maladaptive perfectionists, frequently engage in self-presentational strategies to try and
project and protect a flawless persona (Hewitt et al, 2003), and will go to great lengths to
try and conceal information that could potentially jeopardise this image. There is the
possibility that the personal recollections of perfectionists may be biased towards
providing information that fits with their ideal perception of themselves. A final limitation
of the study concerns the large numbers of correlations performed. It has been suggested
that performing numerous simultaneous tests may increase the chances of obtaining a large
number of false positive results. A potential way of avoiding this is to perform bonferonni
corrections on the data, which involves the setting a more stringent p value. Unfortunately
the potential problem with this method is that although it can control against obtaining a
false positive result, it can also become very conservative and there is the potential that
some results may be missed. Although it may have been beneficial to have utilised this
test, it was decided that to allow for all potential associations to be observed, this test
would not be applied.
6.5 Conclusion
The main aims of the present study were to identify variables that may act as potential
barriers and benefits to engagement (in general preventive health behaviours and the
specific area of physical activity/exercise) for both adaptive and maladaptive perfectionists
and also variables that may intervene in the relationship between perfectionism and
engagement. Overall adaptive perfectionism was associated with more benefits than
barriers to engagement and maladaptive perfectionism was associated with more barriers
than benefits to engagement. The study supports the notion that there are two distinct
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forms of perfectionism (adaptive and maladaptive) with the adaptive dimension being
associated with factors that can be construed as being beneficial to health and wellbeing
(e.g. a greater perception of specific benefits to engagement, higher levels of adaptive
cognitions and behaviours related to physical activity/exercise and positive affect and the
maladaptive dimension being associated with factors that may be construed as being
detrimental to health (higher levels of perceived stress and higher levels of maladaptive
cognitions and behaviours related to exercise behaviour). A number of factors were
identified to act as moderators and mediators in the relationship between adaptive
perfectionism and engagement in general preventive health behaviours. Although no
moderating and mediating variables were able to be identified for maladaptive
perfectionism, the results of the study do support associations between maladaptive
perfectionism and variables that may be detrimental to health and wellbeing, which
supports one of the main aims of the thesis; to identify whether maladaptive perfectionists
represent a high risk group in terms of health and wellbeing
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Chapter 7
General Discussion and Conclusions
This thesis was set in the context of the perfectionism and health literature, which has been
dominated by studies that have addressed the relationship between maladaptive
perfectionism and various psychopathological and physical health concerns. To a lesser
extent, research in this field has also examined the possibility that there may be a health
enhancing and adaptive type of perfectionism that may potentially buffer or protect against
the deleterious consequences of the maladaptive dimension. The primary point of interest
was a preventive health perspective; to consider the potential health risks associated with
being highly perfectionistic and to find out if perfectionists actively look after their health
and wellbeing by engaging in preventive health behaviours. Previous research has not
addressed this area in detail and there are only a few studies that have considered the
relationship between perfectionism and engagement e.g. Longbottom et al (2010; 2012)
looked at the relationship between the dimensions of perfectionism and physical
activity/exercise behaviours and Williams and Cropley (2014) have addressed engagement
in general preventive health behaviours and the association with maladaptive
perfectionism. Both studies found that the maladaptive dimension of perfectionism was
associated with a lower level of engagement.
Engaging less frequently in preventive health behaviours has been proposed in the present
thesis to be a potential risk factor for perfectionists that may compromise their long term
health and wellbeing. Added to this risk, previous research in the perfectionism field has
highlighted that the self-presentational aspect of perfectionism (i.e. the need to present a
perfect and flawless persona at all times) makes it difficult for perfectionists to admit to or
seek help when they are having problems (Hewitt et al, 2003). The result of which may be
that the health risks of being highly perfectionistic have been seriously underestimated
(Flett et al, 2014). Stress also seem to be a particular problem for perfectionists and has
been implicated in the generation and maintenance of a variety of psychopathological
states associated with perfectionism (Flett & Hewitt, 2002).
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Specifically this thesis aimed to:
1. To explore engagement in preventive health behaviours (such as exercise, physical
activity, diet and looking after their emotional wellbeing) for both adaptive and
maladaptive perfectionists and try and establish if there were any differences
between the two perfectionism dimensions in terms of engagement.
2. To explore two key areas; self-presentation and perceived stress, that are
considered (according to previous research) to play an important role in the
relationship between perfectionism and health outcomes and on the basis of this
were predicted to influence the relationship between perfectionism and engagement
in preventive health behaviours
3. To explore the possible benefits and barriers to engagement, i.e. the factors that
might intervene in the relationship between perfectionism and engagement may
either encourage or discourage engagement in preventive health behaviours.
4. To generate support for the possibility that maladaptive perfectionists may
represent a high risk group in terms of health and wellbeing.
5. To support a distinction between the two dimensions of perfectionism: a
maladaptive type of perfectionism related to maladjustment and an adaptive type of
perfectionism associated with potential benefits to health and wellbeing.
Four studies were conducted to achieve these research aims. In study 1 (chapter 3), the role
of self-concealment (a self-presentational style associated with perfectionism) was
explored as a potential mediator in the relationship between adaptive/maladaptive
perfectionism and engagement in general preventive health behaviours. In study 2 (chapter
4), the role of perceived stress was explored along with type of perfectionism (nonperfectionists, adaptive perfectionists and two types of maladaptive perfectionists) to
identify whether both type of perfectionism and level of perceived stress interacted to
influence engagement. In study 3 (chapter 5), a qualitative study (using IPA) explored
adaptive and maladaptive perfectionists’ engagement in preventive health behaviours. The
main aims being; to explore the health behaviours of perfectionists, to try and establish the
factors that interfere with perfectionists’ ability to look after their health and wellbeing
(e.g. increased workload around exam time) and note any differences between adaptive
and maladaptive perfectionists. In study 4 (chapter 6), a number of potential moderators
and mediators (e.g. perceived benefits/barriers, self-efficacy, adaptive/maladaptive
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cognitions and behaviours, perceived stress and affect) were explored in the context of the
relationship between perfectionism and engagement. For this study, the specific area of
preventive health behaviours was explored (physical activity/exercise) as well as general
engagement (as in studies 1 and 2).
7.1
Summary of findings
Reviewing the literature concerning perfectionism and health it emerged that perfectionists
may be at a greater risk in terms of health and wellbeing because they don’t like to admit
to others that they are having problems or difficulties. The consequence of which,
according to Flett et al (2014) may be an underestimation of the extent to which
perfectionists may be struggling with psychological difficulties. Therefore, the first study
(chapter 3), explored the relationship between adaptive/maladaptive perfectionism, selfconcealment (the desire to actively withhold sensitive and personal information from
others), engagement in preventive health behaviours as well as life satisfaction and
wellbeing. Self-concealment was tested as a potential mediator in the relationship between
perfectionism and engagement in preventive health behaviours and supporting earlier
work, as a possible mediator in the relationship between perfectionism and psychological
distress (Kawamura & Frost, 2004). Using a cross-sectional design, within a sample of
university students (N = 370), maladaptive perfectionism (when compared to adaptive
perfectionism) was found to be associated with higher levels of self-concealment and
psychological distress and lower levels of engagement in preventive health behaviours,
supporting previous research (Longbottom et al, 2010; 2012; Williams & Cropley, 2014).
Maladaptive perfectionism was also associated with lower levels of life-satisfaction and
wellbeing (Park & Jeong, 2015). Adaptive perfectionism was found to be related to lower
levels of engagement but contrary to the expected findings, was found to be unrelated to
any of the other outcome variables. In terms of mediation analysis, self-concealment was
found to be a partial mediator between maladaptive perfectionism and engagement as well
as maladaptive perfectionism and psychological distress. Although adaptive perfectionism
was related to greater engagement in preventive health behaviours, no other observable
benefits were found for this perfectionism dimension. The results of the study provides
support for the premise that the combination of high levels of maladaptive perfectionism,
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high levels of self-concealment and elevated psychological distress may be detrimental for
the welfare of certain types of perfectionists.
The review of the available literature (chapter 2) also identified stress to be an important
variable in the relationship between perfectionism and health outcomes, therefore study 2
(chapter 4) addressed the relationships between adaptive/maladaptive perfectionism,
perceived stress, engagement in preventive health behaviours as well as a number of other
health related variables (symptom reporting, anxiety, and perception of general health). A
cross-sectional design using a larger sample of university students (N = 875) employed a
different conceptualisation of perfectionism by allocating participants to one of four
groups (non-perfectionists, adaptive perfectionists and two types of maladaptive
perfectionist) based on their coexisting levels of adaptive and maladaptive perfectionism
traits and supporting conceptualisations that have utilised the within-person combination
of both adaptive and maladaptive traits of perfectionism (Gaudreau & Thompson, 2010;
Stoeber & Otto, 2006). Although no interactions were found between perfectionist types
and level of perceived stress (high/low), results demonstrated across perfectionist groups
that maladaptive perfectionists possessing high levels of maladaptive traits coupled with
low levels of adaptive traits engaged the least amount in preventive health behaviours.
This raises the question of whether this subtype of maladaptive perfectionism (Gaudreau &
Thompson, 2010) may be more maladaptive than the subtype possessing high levels of
both maladaptive and adaptive perfectionism traits (Stoeber & Otto, 2006). Having high
levels of the adaptive perfectionism traits has been suggested to provide individuals with a
type of ‘psychological buffer’ (Altstötter-Gleich et al, 2012) that may protect or neutralise
some of the maladaptive traits. This was further supported by the finding that adaptive
perfectionists had the most positive outcomes across the majority of the outcome variables
(i.e. the highest level of engagement, the lowest levels of anxiety and perceived stress and,
the most positive perception of general health over and above non-perfectionists, therefore
supporting the potential adaptiveness of perfectionism.
Study 3 took a different approach by using IPA to explore perfectionists’ engagement in
preventive health behaviours. To explore potential factors that may intervene in this
relationship, semi-structured interviews were conducted (N = 10; 5 adaptive
perfectionists/5 maladaptive perfectionists). Adaptive and maladaptive perfectionists were
asked about what they do to look after their health and wellbeing, and how they manage to
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continue with these practices when there are barriers and obstacles that threaten to divert
their attention away (e.g. at exam times or trying to juggle a number of domains
simultaneously. Three superordinate themes were identified; taking personal responsibility
for health, a lack of awareness of limitations and finally, control over health and wellbeing.
Overall, possible obstacles to engagement were identified as falling into one of two
categories; factors inherent in the university environment (e.g. lack of time, university life
encouraging bad health habits, problems balancing a number of domains simultaneously,
having to take personal responsibility for health and increased stress) and factors that
seemed to be inherent to perfectionism (e.g. doubting the quality of one’s actions, not
having clearly defined health goals, a lack of flexibility to adjust standards and lack of
belief that a sense of balance would be regained after the temporary adjustment of
standards). No specific differences were observed between adaptive and maladaptive
perfectionists.
Continuing with the theme of potential obstacles and barriers to engagement, study 4,
considered a number of variables (e.g. perceived stress, adaptive and maladaptive
cognitions and behaviours, self-efficacy and specific benefits /barriers) as potential
moderators and mediators of the relationship between adaptive/maladaptive perfectionism
and two avenues of engagement; physical activity/exercise behaviour and general
preventive health behaviours. Using a general population sample (N = 350) results
identified adaptive perfectionism to be associated with a greater level of engagement in
general preventive health behaviours and only a weak association was observed for
physical activity/exercise behaviours. Maladaptive perfectionism was not found to be
related to engagement in general preventive health behaviours and only a weak association
was identified for the specific area of physical activity/exercise. Overall adaptive
perfectionism was associated with more benefits to engagement and fewer barriers and for
maladaptive perfectionists; more barriers and fewer benefits. A number of factors were
identified as potential moderators and mediators in the relationship between adaptive
perfectionism and engagement11. The maladaptive dimension was found to be associated
with a number of factors that may be detrimental from a health and wellbeing perspective.
11
As explained in chapter 6, because no relationship was identified between maladaptive perfectionism and either type of
engagement (general preventive health behaviours and physical activity/exercise behaviour), moderation and mediation analysis was
not performed on these variables.
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Findings suggest that the adaptive perfectionism dimension may be associated with a
number of variables that are beneficial to health and wellbeing
7.2
Contribution of research
The first aim of the thesis was to explore engagement in preventive health behaviours
(such as exercise, physical activity, diet and looking after emotional wellbeing) for both
adaptive and maladaptive perfectionists and try and establish if there were any differences
between the two dimensions of perfectionism.
Clear differences were observed between the dimensions of adaptive and maladaptive
perfectionism, with respect to engagement in general preventive health behaviours in
studies 1 and 2 (chapters 3 and 4). These studies reported findings consistent with previous
research, (i.e. lower engagement for maladaptive perfectionists and higher levels of
engagement for adaptive perfectionists). However, for studies 3 and 4, the picture was not
so clear. For study 4, in terms of engagement, both adaptive and maladaptive
perfectionism dimensions, were only weakly correlated with physical activity/exercise
behaviours (a positive correlation for adaptive perfectionism and a negative correlation for
maladaptive perfectionism). For engagement in general preventive health behaviours,
adaptive perfectionism was found to be positively associated with this outcome variable,
however, no relationship was observed for maladaptive perfectionism. For study 3, there
were no apparent differences between adaptive and maladaptive perfectionists with respect
to engagement in preventive health behaviours, with both types of perfectionists showing
an encouraging level of engagement.
A possible reason for the lack of an association between maladaptive perfectionism and
engagement in general preventive health behaviours in study 4 may have been related to
the particular samples selected for the studies; studies 1 and 2 used university students and
study 4 used a general population sample. Perhaps it is the case that in a high pressured,
highly evaluative environment such as a university, there is a greater concentration of
maladaptive perfectionists. This suggestion supports previous research that has explored
the incidence of maladaptive perfectionism in a university setting (Kearns et al, 2007;
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Kearns et al, 2008; Urdan & Midgley, 2001) although none of these studies addressed
whether perfectionism was related to engagement in preventive health activities.
To try and explain the lower levels of engagement for maladaptive perfectionists’ in
studies 1 and 2 (chapters 3 and 4), compared to study 4, there is evidence that health
behaviours may already be compromised in a university/college setting (Lowry, Galuska,
Fulton et al, 2000). Students often fall short of meeting current standards for recommended
amounts of physical activity (Steptoe et al, 2002) and there is also evidence that starting
university often leads to an increase in health risk behaviours such as smoking, lack of
physical activity, drinking and engaging in risky sexual behaviours (Steptoe et al, 2002).
Stress levels may also affect engagement (Adler & Matthews, 1994) and stress levels have
been found to be particularly high during the first year of university (Misra, McKean, West
et al, 2000).
These findings have been supported by the results of study 3 (chapter 5) where participants
identified a number of factors inherent in the university environment that they felt
interfered with their ability to engage in preventive health behaviours. These included lack
of time, high levels of stress, university life encouraging health risk behaviours (e.g.
drinking alcohol, poor diet, lack of exercise etc.), having to take personal responsibility for
health and wellbeing (often for the first time in their lives) and difficulties balancing the
demands of a number of different domains simultaneously (e.g. academic work, socialising
and taking care of themselves). To compound the problem, participants also identified
factors that were more specific to their perfectionistic traits and that they also felt might
compromise engagement such as; a lack of flexibility to adjust their standards when exam
pressures increased, doubts about the quality and quantity of their current engagement
(current activity levels were frequently played down or dismissed), higher baseline levels
of stress (as expressed by verbal self-reports) and a lack of confidence that a sense of
balance (between work and health behaviours) could be resumed once the deadline or
exam, had passed. These findings suggest that high levels of perfectionism, coupled with
the normal challenges of adaptive to university life may present as a particular challenge
for some individuals and have the potential to compromise engagement in preventive
health behaviours.
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Adaptive perfectionism was found to be associated with higher levels of engagement
across all three quantitative studies (chapter 3, 4 ad 6). These findings support previous
research identifying a proactive ’approach’ orientation associated with adaptive
perfectionism (Slade & Owens, 1998) and research that has considered that adaptive
perfectionists possess motivational tendencies (adaptive cognitions and behaviours; Martin
et al, 2006) that encourage them to engage and persist with preventive health behaviours
such as physical activity/exercise (Longbottom et al, 2010).
It must be noted, however, that simply engaging in preventive health behaviours and
demonstrating higher levels of engagement may not always be a positive and healthy
experience. Study 3 demonstrated that whilst perfectionists (both adaptive and
maladaptive) reported engagement in a range of preventive health behaviours (e.g.
frequent trips to the gym, engaging in different sporting activities on campus and eating
healthily) what also came across was a lack of awareness when they might be pushing
themselves too far, either physically and/or psychologically. A number of the
perfectionists interviewed, discussed the need to be performing at a very high level in more
than one life domain e.g. in both a work (academic) and exercise setting, which they
reported, often led to difficulties (in terms of balancing the various domains). This finding
supports previous research that has addressed domain-specificity in perfectionism and
identified that more extreme perfectionists often report being highly perfectionistic in more
than one life domain (Stoeber & Stoeber, 2009).
The second aim of the thesis was to explore two key areas, self-presentation and perceived
stress. Both are considered to play a pivotal role in the relationship between perfectionism
and health outcomes and on the basis of this are predicted to influence the relationship
between perfectionism and engagement in preventive health behaviours.
Self-presentational factors (the need to project ones perfectionism as well as conceal or
hide personal imperfections; Hewitt et al, 2003) appear to permeate numerous areas within
the perfectionism – health literature (chapter 2, part 2). The importance of considering selfpresentation has been exemplified by Flett et al (2014) who suggested that selfpresentational motives, (particularly the desire to conceal personal information) may mean
that the seriousness of the relationship between perfectionism and mental health issues
such as suicide has been, and continues to be, underestimated. Previous research has
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consistently associated self-concealment with maladaptive tendencies including higher
levels of psychological distress (Kawamura & Frost, 2004), more interpersonal conflicts
(Straits-Tröster et al, 1994), difficulties forming authentic and trusting relationships
(Derlaga et al, 1993), less utilisation of social support networks (Kawamura & Frost, 2004)
and reduced desire to seek help for personal problems (Cepida Benito & Short, 1998;
Hewitt et al, 2003),
Indirectly, the results of study 3 support an association between self-presentation and a
reduced desire to seek help. Both adaptive and maladaptive perfectionists expressed
considerable reluctance to consider seeking help for either psychological or physical health
problems, however, the majority of participants mentioned utilising online sources of
support either as a one-off or on an ad hoc basis when they felt they needed help or
support. It is interesting that perfectionists expressed a preference for utilising resources
where there was no need for face to face contact. Such services may be easier for
perfectionists to deal with because logically, there are fewer expectations and less pressure
to self-present in a particular way. Research studies, evaluating online counselling services
for maladaptive perfectionists have started to emerge (Arpin-Cribbie, Irvine & Ritvo,
2012; Radhu, Daskalakis, Arpin-Cribbie et al, 2012) with encouraging results. Perhaps the
best way to help perfectionists is to develop strategies that circumvent the inherent need to
self-present a perfect and flawless image. In doing so it may be possible to get past the
façade of perfection and treat the deeper issues.
The results of study 1 support the role of self-concealment (an aspect of self-presentation)
as an important intervening factor in the relationship between maladaptive perfectionism
and psychological distress (Kawamura & Frost, 2004) as well as adding to the current
literature by highlighting self-concealment to be an important factor in the relationship
between maladaptive perfectionism and engagement in preventive health behaviours. This
suggests that the tendency to conceal personal imperfections inhibits engagement, which
supports previous research by Leary, (1992) who identified high levels of self-concealment
to be related to decreased motivation to engage in physical activity and exercise behaviour.
The results of study 1 suggest that the combination of high levels of maladaptive
perfectionism and self-concealment may be a particularly toxic combination for health and
wellbeing (Williams & Cropley, 2014).
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Interestingly in study 4, (chapter 6) self-presentational motives were found to increase
rather than decrease engagement in preventive health behaviours for adaptive
perfectionists. In this study, adaptive perfectionism was found to be related to higher levels
of self-presentational efficacy expectancy (SPEE), which has been described as the
confidence someone has in being able to present themselves well in an exercise setting
(Gammage et al, 2004). Not only was adaptive perfectionism found to be related to this
concept, but SPEE was identified as both a moderator and mediator in the relationship
between adaptive perfectionism and engagement in general preventive health behaviours.
Further exploration of this relationship (simple slopes analysis) revealed that as levels of
SPEE increased, there was a corresponding increase in engagement. Although a higher
level of engagement does, on the surface seem to be a positive consequence of such
actions, one does have to question the apparent adaptiveness of such behaviours. Having
the confidence to present well in an exercise setting is not an accurate way of gauging if
someone is actually fit and healthy and it is questionable how functional and healthy this
type of behaviour might be in the long-term (Hewitt et al, 2003; Leary et al, 1994).
Exercise environments by their very nature often involve the need to present ones’
athletic/sporting ability in a very public way e.g. going to the gym or an exercise class.
According to Leary (1992) if someone feels confident in their ability to present themselves
well (in an exercise/sport setting), then they will be more willing to engage in such
activities. For perfectionists, where there is already a predisposition to want to present well
(Hewitt et al, 2003), exercise settings may present as a particular challenge. Perfectionists
may feel a heightened sense of awareness that they are being judged negatively and have
an exaggerated fear of failure in the presence of others.
A particular type of self-presentational strategy that has been found to be used frequently
in exercise settings is self-handicapping (Martin & Brawley, 1999; 2002), this is a strategy
where an individual puts forth an impediment prior to their performance of some task so
that if the outcome is less than favourable, they will have been able to put some distance
between themselves and the failure, which will help protect their self-esteem and selfworth (Snyder, 1990). Examples of such behaviours include procrastination,
overcommitting, not taking time to practice and not putting the required amount of effort
into something (Bailis, 2001; Kimble et al, 1998). Study 4 (chapter 6) supported an
association between the maladaptive dimension of perfectionism and self-handicapping
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with maladaptive perfectionism being associated with higher levels of ‘maladaptive
cognitions’ and ‘maladaptive behaviours’ related to physical activity/exercise (Martin et al,
2006; Martin, 2010a; 2010b). These are considered to reflect negative thoughts related to
exercise such a fear of failure, uncertainty and anxiety as well as behaviours related to selfhandicapping, avoidance and withdrawal.
The relationship between perfectionism and stress is well-researched area, with
perfectionism being implicated in the generation, anticipation and perpetuation of stress in
relation to psychopathology (Hewitt & Flett, 2002, chapter 2). Stress was addressed
directly in studies 2 and 4 (chapters 4 and 6) and indirectly in study 3 (chapter 5). In study
2, there was a notable absence of any significant interactions between type of
perfectionism and level of perceived stress12 in relation to engagement, which was
surprising considering maladaptive perfectionism was found to be related to high levels of
perceived stress in both studies 2 and 4, coupled with the fact that in the same two studies,
perceived stress was also associated with lower levels of engagement in preventive health
behaviours. These findings also supported previous research in this area (e.g. Adler &
Matthews, 1994). A lack of interaction could indicate that there are other intervening
variables that mediate the maladaptive perfectionism-stress relationship as well as the
stress-engagement relationship; clearly more research is required to establish the precise
nature of these associations.
For the associations between adaptive perfectionism and perceived stress, mixed results
were obtained. When perceived stress scores (measured on a continuous scale) were
correlated with adaptive perfectionism (as in studies 2 and 4), these two variables were
found to be unrelated, however, when four new perfectionism groups were formed and
mean scores for perceived stress compared across these groups, adaptive perfectionists
were identified as having significantly lower stress scores than all other groups and most
notably, non-perfectionists.
In the research literature inconsistent findings have been reported with regards to how
adaptive perfectionism is related to stress. Some authors have identified adaptive
perfectionists to be better placed (than maladaptive perfectionists) to deal with stress
12
For study 2, four groups of perfectionism were generated based on the interactive dimensions of both adaptive and maladaptive
traits; 1. Non-perfectionism (low levels of both adaptive and maladaptive traits), adaptive perfectionism (high adaptive/low
maladaptive), maladaptive perfectionist group 1 (low adaptive/high maladaptive) and maladaptive perfectionist group 2 (high levels of
both adaptive and maladaptive traits.
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because they tend to use more adaptive coping strategies in response to stressful
experiences (Dunkley et al, 2000). It has also been suggested that adaptive perfectionists
may possess a type of resiliency factor that protects them from the more serious
consequences of stress (Enns, Cox & Clara, 2005). On the other hand some research has
identified that adaptive perfectionists are just as vulnerable as maladaptive perfectionists in
terms of their reactions to stressful experiences (Hewitt & Flett, 1993) especially when
there may be some block to their achievement of personal goals or standards or when they
doubt that a positive outcome can be achieved (Blankstein, Flett, Hewitt & Eng, 1993).
Although the studies reported in the thesis were not able to further the knowledge base
regarding the precise way that perfectionism and stress are related, the findings (studies 2
and 4 and to a lesser extent, study 3) do support the well-established relationship between
perfectionism and stress and have potentially highlighted (due to the observed associations
between maladaptive perfectionism and perceived stress and perceived stress and
engagement) that preventive health behaviours may be a useful avenue for future research
concerning the perfectionism-stress relationship.
The third aim of the thesis was to explore the factors that might intervene in the
relationship between perfectionism (adaptive and maladaptive) and engagement, i.e.
factors that may encourage engagement (benefits) and others that might discourage
(barriers) engagement.
In terms of factors that potentially intervene in the relationship between perfectionism and
engagement, studies 1 and 4 (chapters 3 and 6) attempted to address this area directly;
study 1 looking at the mediating role of self-concealment and study 4 focussing on a range
of potential mediators and moderators between adaptive perfectionism and engagement in
general preventive health behaviours. Study 2, although not considering the mediating role
of perceived stress, did focus on the contribution of perceived stress in the perfectionism –
engagement relationship and Study 3 also explored intervening variables (as potential
barriers to engagement) from a qualitative perspective. It has generally been recognised
(in the perfectionism-health literature) that an essential and necessary avenue of research is
to address the potential mediators/moderators of the relationship between perfectionism
and health (e.g. Flett, Molnar, Nepon & Hewitt, 2012; Molnar et al, 2012).
195
For maladaptive perfectionism, as mentioned previously, study 1 was able to test for
mediation; identifying self-concealment to be a mediator in the relationships between
maladaptive perfectionism and both engagement in preventive health behaviours and
psychological distress. For study 4, despite not being able to address the intervening
variables directly, maladaptive perfectionism was found to be associated with a number of
factors that have identified as being involved in lowering engagement e.g. high levels of
perceived stress (Adler & Matthews, 1994), high levels of maladaptive cognitions and
behaviours (Longbottom et al, 2010) and low levels of perceived benefits vs high levels of
perceived barriers to exercise (Lovell et al, 2010; Strecher & Rosenstock, 1997). Study 1
also identified three factors that were associated with maladaptive perfectionism; higher
levels of psychological distress and lower levels of wellbeing and life satisfaction that have
also been linked to lower levels of engagement in health behaviours (KoivumaaHonkanen, Honkanen, Viinamaki et al, 2000 and Leiferman & Pheley, 2006,
respectively).
Study 4 examined a number of potential intervening variables in the relationship between
adaptive perfectionism and engagement in general preventive health behaviours. Higher
levels of specific perceived benefits were found to have both a moderating and mediating
effect and exercise self-efficacy was found to have a mediating effect on the
perfectionism-engagement relationship. Adaptive behaviours related to exercise (i.e.
behaviours that involve positive activities such as planning and goal setting) were also
identified to an important intervening variable. Clearly, planning and setting health goals
in advance seems to have a positive effect on engagement (Longbottom et al, 2010).
Related to this, an interesting finding from study 3 was that the majority of perfectionists
(both adaptive and maladaptive) admitted to having no clear ideas or goals about how they
were currently looking after their health or how they planned to look after their health in
the future. This seemed surprising since many of their personal accounts included multiple
references to planning and goals setting in other areas, specifically in a work/academic
domain. Historically, perfectionism has been identified as being highly associated with a
high degree or organisation and order (Frost et al, 1990).
Another interesting finding was that maladaptive cognitions were found to moderate the
relationship between adaptive perfectionism and engagement, in a positive direction, so as
levels of maladaptive cognitions increased, there was a corresponding increase in
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engagement. These findings contradict previous research that has suggested adaptive and
maladaptive perfectionists will be motivated by different cognitions and behaviours related
to exercise (Longbottom et al, 2010; Stoeber et al, 2008), It has been suggested that
adaptive perfectionists will be primarily motivated by adaptive cognitions and behaviours
and maladaptive perfectionists by maladaptive cognitions and behaviours. How then can
these findings be explained, i.e. how does a high level of maladaptive cognitions (which
includes behaviours that inhibit the engagement of exercise, such as self-handicapping,
avoidance and withdrawal), lead to greater engagement?
Perhaps it is an unrealistic and over simplistic proposition to assume that adaptive
perfectionists will only be motivated by adaptive cognitions and behaviours related to
exercise, rather than a combination of both adaptive and maladaptive motives. Existing
conceptualisations that have focussed on the interactive power of both perfectionism
dimensions do recognise that adaptive perfectionists possess qualities that are both
adaptive and maladaptive, albeit in varying degrees (i.e. adaptive perfectionists may
present as having high adaptive traits and low maladaptive traits), (Gaudreau &
Thompson, 2010; Stoeber & Otto, 2006). Perhaps it is the case that the accompanying high
levels of adaptive cognitions act as a type of psychological buffer and have the effect of
overriding the negative thoughts and behaviours (Altstötter-Gleich et al, 2012) which then
leads to greater engagement.
The fourth aim of the thesis was to generate support for the possibility that maladaptive
perfectionists may represent a high risk group in terms of health and wellbeing. The
existing literature in the perfectionism-health field has touched on a number of factors
(described in figure 7.1 also presented in the introduction of the thesis) that can be
considered potential health concerns for this particular client group.
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Figure 7.1 Possible reasons why maladaptive perfectionists may represent a high risk
group in terms of health and wellbeing
Difficult
client group
to treat
Reluctance
to seek help
Linked to
psychopathology
Increased risk of
suicide
Increased risk
mortality
Maladaptive
Perfectionists: A
“high risk” group?
Lower levels of
life satisfaction
and wellbeing
Linked to
physical health
problems
Stress
Conceal personal
difficulties
The present thesis sought to provide specific support for some of these factors as well as
explore another factor; engagement in preventive health behaviours. The intention was that
if maladaptive perfectionism was associated with lower levels of engagement across the
four studies, then it would be possible to suggest that lack of engagement may be a
potential risk factor associated with maladaptive perfectionism.
Taken as a whole, as discussed earlier, mixed results were obtained and therefore only
partial support has been obtained to suggest that lack of engagement may be a risk factor
specifically associated with maladaptive perfectionism. Despite the disparity in findings
related to engagement, there were a number of other factors that were identified, as a result
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of conducting the four studies, that do suggest an increased vulnerability associated with
maladaptive perfectionism;

The self-presentational aspect of perfectionism (i.e. self-concealment) was found to
inhibit engagement in preventive health behaviours for maladaptive perfectionists
(study 1).

Maladaptive perfectionists were identified to have the highest levels of perceived
stress and the highest levels of anxiety when compared to adaptive perfectionists
and non-perfectionists (studies 2 and 4).

Maladaptive perfectionists may be particularly vulnerable in a university setting
and university may represent a particularly risky environment for maladaptive
perfectionists due to high levels of perceived stress and low levels of engagement
in preventive health activities (studies 1, 2 and 3). Study 3 specifically identified
the transition to university to be a time of increased vulnerability for perfectionists
(both adaptive and maladaptive).

University environments may be particularly challenging for maladaptive
perfectionists because often results are publicly displayed which is likely to
activate the self-presentational dimension of perfectionism and create even more
pressure to achieve exceptionally high standards.

Maladaptive perfectionism was found to be related to low levels of exercise selfefficacy. High levels of this variable have been found to increase participation and
perseverance in certain preventive health behaviours (Hofstetter et al, 1990; Sallis
and Hovell, 1990; Sallis, Hovell, Hofstetter, Faucher, Elder et al, 1989), (study 4)

Maladaptive perfectionists (and adaptive perfectionists) were found to refrain from
making plans or setting goals related to preventive health activities, which was in
contrast to the organisation and order that was shown in relation to academic work
and which could suggest a lower priority placed on looking after health and
wellbeing, (study 3).

Maladaptive perfectionists were identified to express a reluctance to seek help for
either psychological or physical health problems (study 3)

Maladaptive perfectionists were identified to have higher levels of maladaptive
cognitions and behaviours related to exercise which suggests that they may
avoid/withdrawal from physical activity and use self-handicapping behaviours as a
reason for non-engagement.
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
Maladaptive (and adaptive perfectionists) were found to have a lack of awareness
of their own limitations, which could result in them pushing themselves too far
because of an inability to gauge when they are doing too much (study 3). A small
number of perfectionists (both adaptive and maladaptive) admitted to not looking
after their health at all, they stated that they were pushing themselves in multiple
life domains, knowing that they were doing too much but justifying this to be an
acceptable strategy and ‘hoping’ that their health would not suffer as a
consequence, (study 3).
The final aim of the thesis was to generate support for the distinction between the two
dimensions of perfectionism; a maladaptive type that is related to maladjustment and an
adaptive type that has been associated with providing potential benefits to health and
wellbeing. Previous research clearly supports the existence of two types of perfectionism
and, as stated previously, the majority of research has been focussed on the maladaptive
dimension of perfectionism and associations with maladjustment have been observed.
Where research is less clear concerns how healthy and functional the adaptive dimension
of perfectionism is (if at all) and this is an area that continues to be debated. Chapter 2
provides an overview of the research in this area.
Collectively the results of the three quantitative studies (chapters 3, 4 and 6) provide
support for there being two clear subtypes of perfectionism; a maladaptive subtype
associated with negative outcomes such as higher levels of; psychological distress,
perceived stress, anxiety, negative affect, symptom reporting and maladaptive cognitions
and behaviours related to exercise and lower levels of; life-satisfaction and wellbeing and
an adaptive subtype associated with positive outcomes such as higher levels of;
engagement in preventive health behaviours, adaptive cognitions and behaviours related to
exercise, exercise self-efficacy, positive affect, perceived benefits associated with
exercise/physical activity and a lower perception of perceived barriers to exercise/physical
activity.
By using a different conceptualisation for defining adaptive and maladaptive
perfectionism, study 2 provided some interesting findings that supported a functional and
adaptive subtype of perfectionism. By focussing on the within-person combinations of the
adaptive and maladaptive dimensions and in accordance with the theoretical models
200
proposed by Stoeber and Otto (2006) and Gaudreau and Thompson (2010)13, four subtypes
of perfectionism were developed; non-perfectionism (low levels of both adaptive and
maladaptive traits), adaptive perfectionism (high adaptive/low maladaptive), maladaptive
perfectionism group 1 (high levels of both adaptive and maladaptive traits) and
maladaptive perfectionism group 2 (high maladaptive/low adaptive traits). The most
striking finding was that when the four groups were compared, adaptive perfectionists
were identified as achieving the most positive outcomes (highest level of engagement,
lowest level of anxiety, lowest level of perceived stress and better overall perception of
general self-rated health) out of all the groups and most notably, over and above nonperfectionists. This finding supports research that has suggested the adaptive dimension of
perfectionism may provide a type of ‘psychological buffer’ (Alstötter-Gleich et al, 2012)
that can protect and ameliorate the maladaptive traits. Perhaps it is the case is that the
adaptive perfectionism traits may have the potential to cancel out the maladaptive traits
and therefore bring the individual back to a state of equilibrium. Interestingly, though, the
findings from study 2 suggest there may be something over and above this, a potentially
positive quality that actually enhances the experience for adaptive perfectionists. This
suggestion can be likened to research that has considered the potentially “enabling”
function of conscientiousness (Weiss & Costa, 2005). Previous research has suggested
there to be a degree of overlap between the adaptive dimension of perfectionism and
conscientiousness (Flett & Hewitt, 2006; Stober, Otto, Dalbert, 2009) and the protective
and health enhancing qualities of conscientiousness have received considerable support in
the research literature (e.g. Friedman, Tucker, Tomlinson-Keasey et al, 1993; Kern &
Friedman, 2008; Roberts, Kuncel, Shiner et al, 2007).
Not all the results support the potentially protective aspect of the adaptive dimension of
perfectionism. In study 2, the maladaptive perfectionist group 1 who possessed high levels
of both adaptive and maladaptive traits were found to be just as ‘unhealthy’14 as the
maladaptive perfectionist group 2 who possessed high levels of the maladaptive traits and
low levels of the adaptive traits. If high levels of adaptive traits were considered to buffer
and protect, then one might expect the maladaptive perfectionist group 1 to be better off
13
Stoeber and Otto (2006) proposed a tripartite model of perfectionism consisting of three subtypes; non-perfectionism (low levels of both adaptive and
maladaptive perfectionism), healthy perfectionism (high adaptive and low maladaptive traits) and unhealthy perfectionism (high levels of both
maladaptive and adaptive traits). The 2 x 2 model proposed by Gaudreau and Thompson consisted of four subtypes of perfectionism; non-perfectionism
(low levels of both adaptive and maladaptive perfectionism), pure personal standards perfectionism (high adaptive traits/low maladaptive traits), mixed
perfectionism (high levels of both adaptive and maladaptive traits) and pure evaluative concerns perfectionism (high maladaptive/low adaptive traits.
14 In terms of the outcome variables being studied
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(in terms of health and wellbeing) due to having high levels of the adaptive traits. Research
that has addressed the within person combinations of the adaptive and maladaptive traits in
relation to psychopathology and physical health concerns may provide a better indication
of how the underlying perfectionism constructs are ordered; for depression and CFS,
research has identified elevated levels of both the adaptive and maladaptive traits
(Bardone-Cone et al, 2007; Deary & Chalder, 2010) whereas for anxiety disorders, there
seems to be a common theme of high levels of the maladaptive traits and low levels of
adaptive traits (Bardone-Cone et al, 2007) suggesting that the psychological burden of
some disorders may be lessened by having high levels of the adaptive perfectionism traits.
Rather than identify potential differences between the two perfectionism dimensions,
Study 3 found that perfectionists demonstrated more similarities than differences. In
relation to their views concerning engagement in preventive health behaviours and factors
that were identified as potential obstacles to engagement, both adaptive and maladaptive
perfectionists displayed similarities in the following; level of engagement in preventive
health behaviours, tendency to doubt the quality of their actions in relation to engagement,
struggling with the transition to university, the challenge faced having to take personal
responsibility for health and wellbeing, lack of health goals and problems associated with
having to juggle multiple life domains simultaneously.
Overall the studies in the thesis do demonstrate some clear differences between the
maladaptive and adaptive dimensions of perfectionism. For adaptive perfectionists many
of these differences, do seem to be positively oriented and potentially beneficial from a
health and wellbeing perspective and for maladaptive perfectionists, the differences seem
to reflect a negatively oriented perspective that may increase the vulnerability of some
individuals.
7.3
Limitations of the research
One of the limitations of the thesis was the specific conceptualisation of perfectionism
chosen for the studies. The Frost Multidimensional Scale (Frost et al, 1990) was utilised to
determine levels of adaptive and maladaptive perfectionism, however this represents just
one of a number of formulations that could have been utilised to assess perfectionism, and
specifically, to assess the adaptive and maladaptive dimensions. The downside with this
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approach is that it only focusses on the self-directed intrapersonal aspects of perfectionism,
specifically the self-directed cognitions associated with perfectionism rather than, how
individuals may be affected by the interpersonal aspects of perfectionism (as in the Hewitt
& Flett, Multidimensional Perfectionism Scale (Hewitt & Flett, 1991a). Additionally,
many of the studies spoken of in the literature review have utilised the latter scale and
although there are similarities between the two scales (e.g. the socially prescribed
dimension has been considered to embody more of the maladaptive perfectionism traits
and the self-oriented dimension thought to embody both adaptive and maladaptive traits) it
is questionable how valid it is to compare research that has utilised different
conceptualisations that been developed from essentially different perspectives. For the
present thesis, the rationale for choosing the Frost MPS over the Hewitt and Flett scale was
that the former provided a more straightforward and decisive way of providing a measure
of both perfectionism dimensions, that has been validated for this exact purpose (Chang et
al, 2004; Dunn et al, 2006; Frost et al, 1990; Harris et al, 2008; Wei et al, 2004) and
importantly seemed to fit best with the main aims of the present thesis.
The subject of multiple conceptualisations represents and reflects a deeper issue in the
perfectionism field; i.e. the fact that at present there is still no agreed upon
definition/conceptualisation. The problem is further complicated by two factors; firstly,
there is no standard method of subdividing the perfectionism construct into its component
adaptive and maladaptive dimensions, and secondly, there is still a debate in the literature
centred on the disparity in findings related to a potentially healthy type of perfectionism.
Perhaps as Ben-Shahar (2009) has argued, it may be time to re-establish the concepts of
adaptive and maladaptive perfectionism altogether. In his book, “The pursuit of perfect”,
he explains that the terms ‘adaptive’ and ‘maladaptive’ perfectionist are so fundamentally
different that it is misleading to refer to them both, as types of perfectionism. Instead he
talks of ‘optimalists’ and ‘perfectionists’. The fundamental premise differentiating the two
categories seems to be the willingness/lack of willingness to accept the reality that
sometimes we fail and this is a normal and necessary part of the human condition.
According to Ben-Shahar the optimalist is willing to accept and deal with failure whereas
for the perfectionist, dealing with failure is inconceivable. As a result, optimalists will lead
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a more normal, healthy life and perfectionists will be constantly dragged down with the
burden that another failure could be just around the corner. It may be the case that,
particularly with the emergence of a number of more recent conceptualisations (that are
predominantly focussed on the clinical aspects of perfectionism), that it is becoming
increasingly difficult to accept the possibility of a positive and healthy form of
perfectionism.
Although beyond the scope of this thesis, future research could re-visit and re-examine the
literature addressing the associations between perfectionism and the big five personality
characteristics, particularly in relation to the potential overlap between adaptive
perfectionism and conscientiousness (e.g. Flett & Hewitt, 2006; Stober et al, 2009). The
similarities between conscientiousness and the adaptive perfectionism dimension have
been noted in chapter 2 (part 2) and some authors do maintain that what has been
described as an adaptive and functional form of perfectionism could perhaps be more
appropriately described as a form of conscientiousness (e.g. Flett & Hewitt, 2006). More
research is required within the personality domain to explore whether the adaptive
dimension of perfectionism can provide any additional improvements to health and
wellbeing over and above the benefits that have been associated with possessing high
levels of conscientiousness.
The second limitation relates to a methodological concern primarily with study 2. For this
study, it was decided, that to test for potential interactions between the two dimensions of
perfectionism and perceived stress, it may be helpful to provide four distinct categories of
perfectionism based on the within-person combinations of the adaptive and maladaptive
traits. As explained more thoroughly in chapter 4, to achieve this, scores on the adaptive
and maladaptive dimensions of the Frost MPS (1990) were dichotomised into high and
low categories, participants were then identified by their relative level of adaptive and
maladaptive perfectionism. Four new categories of perfectionist were created; nonperfectionists (low adaptive/low maladaptive), adaptive perfectionists (high adaptive/low
maladaptive), maladaptive perfectionist group 1 (high maladaptive/high adaptive) and
maladaptive perfectionist group 2 (high maladaptive/low adaptive). For perceived stress,
subjects were assigned to either a ‘high’ or ‘low’ perceived stress category.
Whilst this was conceptualised to be an acceptable method for study 4 as it would enable
comparisons to be made across the different groups, there were a number of
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methodological concerns that are associated with dichotomising continuous variables in
such a way. These include; splitting data at the median assumes that individuals either side
of this division are fundamentally different when in fact they may be very similar. As a
result there may be a considerable variability within the newly created groups with it being
possible that the differences within the newly formed group being greater than between the
two groups (Royston, Altman & Sauerbrei, 2006), which for the groupings in study 2,
could mean a misrepresentation of both the stress and the perfectionism categories.
Additionally dichotomising continuous variable reduces power because a lot of useful
information is lost. Some have suggested that this may be equivalent to throwing away up
to a third of all data (MacCallum et al, 2002). And finally, splitting the group may not
actually get you the result you want. Who is to say that cut off should be at the median
anyway? (MacCallum et al, 2002). Before the analysis an alternative was considered; to
divide the results into thirds and to discard the middle third, however, it was decided that
this method would have compromised the sample size in the respective groups.
Thirdly, Study 4 highlighted a potential problem with the population sample chosen for the
study. Using a general population sample appeared to have the outcome of ‘diluting’ the
effect that had been observed in studies 1 and 2. In the first two studies, there were
significant associations between maladaptive perfectionism and engagement in general
preventive health behaviours, however, in study 4, the association between maladaptive
perfectionism and engagement in general preventive health behaviours was non-significant
and for maladaptive perfectionism and engagement in physical activity/exercise the
association was very weak. As a consequence, it was impossible to carry out all of the
analyses (as there was little or no relationship between the predictor and outcome
variables). Although it was important to examine perfectionism in the general population it
would have been beneficial to have utilised a comparison population, ideally from a
university setting to explore potential differences between the two groups. Whilst being
identified as a limitation of the thesis, what this result did provide, was support for the fact
that university settings may be particularly challenging environments for maladaptive
perfectionists.
A fourth limitation of the thesis concerns the reliance on self-report measures to gather
data. All three quantitative studies (chapters 3, 4 and 6) requested that information be
gathered via questionnaire presented in an online format. A particular problem that can
205
stem from using self-report measures is ‘common method variance’. This refers to a
situation where, in using only one method to gather data e.g. a survey or questionnaire,
there is the chance that the potential source of the variance is more to do with the
measurement method utilised, rather than the constructs that are being investigated
(Podsakoff, MacKenzie, Lee & Podsakoff, 2003). In an attempt to control for common
method variance, when designing the format for each of the questionnaires, attempts were
made to alter the presentation of the questions by mixing them up as well as using different
scale types e.g. some questions required a click in a box and others involved sliding a scale
up and down to give a confidence rating. A potential method to improve this further might
include utilising other methods as well as self-reports such as objective measures of
exercise engagement/engagement in preventive health behaviours such as number of
recorded visits to the gym or providing food diaries for participants to record dietary
information.
Still related to the use of self-reports, another possible limitation involves the accuracy of
the information provided by the perfectionists. In using self-reports you are very much
relying on the honesty of your participants. A common theme that has been revisited
throughout the thesis concerns the self-presentational needs of perfectionists, specifically,
the need to present a perfect persona devoid of imperfections and flaws (Hewitt et al,
2003). Study 1 (chapter 3) discovered that the need to keep personal information concealed
was so great, that it influenced maladaptive perfectionists’ desire to engage in preventive
health behaviours. With this in mind, it is possible that such a deep-seated need to save
face and self-present well may even extend to situations where there is minimal risk of
exposure, such as questionnaires and surveys.
A final limitation relates to the construct validity of two of the measures utilised within the
thesis; the Frost Multidimensional Perfectionism Scale (Frost et al, 1990) and the health
behaviour questionnaire (an adaptation of the health behaviour questionnaire, Amir, 1987).
For the Frost MPS, although for the four studies, this scale was not been utilised in its
entirety (i.e. only four out of the six dimensions were included; CM, DA, O and PS), there
is the assumption that the four dimensions included provided an accurate and valid
representation of the underlying factors considered to represent the perfectionism
construct. Future work in this area could include the application of confirmatory factor
analysis to determine how well the questionnaire accurately reflects the underlying factors
206
that are hypothesised to be the core constructs of perfectionism. Additionally for the health
behaviour questionnaire, this measure includes a number of different concepts such as;
health risk behaviours, health promotion behaviours and items related to self-care. To
improve the construct validity of this measure for future studies, a psychometric
assessment of the scale is recommended to establish a clear factor structure within the
scale and to provide clear subscales for the different categories of health behaviours.
7.4
Future Research
A potential avenue for future research is to re-examine the relationship between
perfectionism and stress as well as how stress affects engagement in preventive health
behaviours. The methodological problems that have been identified above, specifically
concerning the groupings for the variables of perfectionism and perceived stress could be
overcome by using alternative methodology e.g. an alternative method to dichotomising
variables might be to use a regression model to identify potential intervening variables or
perhaps an alternative to linear regression could be to use a quantile regression model
which has the advantage over linear regression in that provides estimates of the
associations between the predictor and outcome variable at various points. This has been
found to be useful for exploring non-linear relationships, which may be particularly useful
for this research area where the precise nature of the perfectionism-stress relationship has
not been established. The associations identified (in this thesis) between the maladaptive
dimension of perfectionism and perceived stress as well as between perceived stress and
engagement do suggest that there may be a potential relationship to be found, further
research is therefore recommended.
Another possible avenue for future research is to conduct more longitudinal studies to
explore the health implications of being highly perfectionistic over time. Although
longitudinal studies of this nature have begun to emerge (e.g. Flaxman et al, 2012; Fry &
Debats, 2009; 2011), there is still a lack of research addressing the long-term consequences
of possessing high levels of either adaptive, maladaptive or both types of perfectionism.
Being able to follow perfectionists for an extended time would provide opportunities to
observe changes over time, specifically, in relation to how adaptive and maladaptive
perfectionists deal with difficulties and challenges in their lives. Such observations may
contribute to our understanding of the potentially different qualities associated with the
two perfectionism dimensions.
207
Study 4 highlighted the potential problems associated with using only one population of
participants. A suggestion for future work could be to use a number of comparison
populations to firstly identify the incidence of perfectionism. Interestingly, it was virtually
impossible to find any figures for the incidence of perfectionism (either general or
specifically adaptive/maladaptive) in the general population. A literature search of journal
articles in the perfectionism field could not reveal any specific statistics and a general
search of the internet seemed to indicate a figure of about 30%, although there were no
specific references to support this figure. Finding out about the incidence of perfectionism
is in the general population seems to be an essential element of any future research.
Still on the subject of sample populations, as discussed earlier, an interesting result that has
come out of the present thesis is the finding that engagement in preventive health
behaviours may be more compromised in a university setting, perhaps because there is a
higher incidence of maladaptive perfectionism in the first place (Kearns et al, 2007;
Kearns et al, 2008) and as study 3 demonstrated, both maladaptive and adaptive
perfectionists found it difficult to cope with the demands of university life. As such,
university environments may present as particularly high risk for vulnerable perfectionists
and an important area of research would be to look in more detail at the health and
wellbeing (psychological and physical health) of perfectionists in a university environment
to find out if they are engaging in an adequate amount of healthy activities to ensure that
they can remain healthy and achieve their academic potential. Study 3 identified that
perfectionists (adaptive and maladaptive) experienced frustration because lack of time and
other demands prevented them from being able to adequately plan their engagement in
preventive health behaviours, therefore interventions to help perfectionists with adequate
planning may assist them in being able to juggle more than one domain successfully. It is
important to remember that just as universities may represent a concentrated environment
where it is possible to observe potential problems (psychological and physical) they also
represents a very useful and focussed context in which to target and direct interventions.
7.5
Implications for Interventions
Although not a primary aim of this thesis, it is felt that it is important to consider possible
implications for interventions. As discussed in chapter 2 (part 2) from a treatment and
intervention perspective, perfectionists have been identified as a client group that may be
more challenging to treat than non-perfectionists (e.g. Blatt & Zuroff, 2002; Scott, 2001).
208
Examples of potential problems include; difficulties forming a good therapeutic
relationship, difficulties adhering to treatment guidelines and self-report of disappointing
treatment outcomes. These problems may be related to a reluctance or lack of confidence
on the part of the perfectionist in being able to discuss and disclose personal difficulties
with others or to seek help for personal problems which may reflect a much deeper
insecurity that such actions may be perceived as a personal failure or weakness (Habke,
1997; Nadler, 1983).
Specifically, perfectionism has been found to inhibit the successful treatment of eating
disorders (Sutander-Pinnock et al, 2003), anxiety disorders (Chik, Whittal, & O’Neil,
2008) and depression (Blatt et al, 1995). In the light of these findings, coupled with the
extensive body of research that has identified the maladaptive dimension of perfectionism
as a potential risk factor in the development of both psychological and physical health
problems there seems to be a particular need for future work specifically aimed at
identifying and developing successful interventions that are able to address the potentially
damaging consequences of extreme forms of perfectionism.
Recent research has supported the use of cognitive behavioural techniques in reducing the
symptoms of perfectionism. From a recent review of the literature, Lloyd and colleagues
have concluded that it may be possible to significantly reduce certain aspects of
perfectionism, across a range of disorders by utilising a cognitive behavioural approach
specifically involving short-term interventions (Lloyd, Schmidt, Khondoker & Tchanturia
(2014). This research supports the clinical model of perfectionism that advocates distorted
cognitive processes to be a defining feature in the development and maintenance of
perfectionism (Shafran et al, 2002) as well as the transdiagnostic nature of perfectionism
(Egan et al, 2011) as there is evidence to suggest that a reduction in symptoms across a
range of disorders is achievable by specifically targeting perfectionism.
In terms of identifying the specific dimensions of perfectionism that may need to be
addressed to achieve long-term change, there is the suggestion that both the maladaptive
and adaptive dimensions of perfectionism need to be addressed. This is based on previous
research that has identified the adaptive, achievement striving dimension of perfectionism
to have the potential to become maladaptive when it is combined with harsh selfevaluation in response to meeting high standards (see chapter 2, part 2).
209
This thesis has provided some insight into the nature of potential future interventions for
perfectionism. Study 3, indirectly provided some valuable information that may be useful
for health providers in planning treatment interventions specifically aimed at reducing the
symptoms of perfectionism. When asked directly about the likelihood that they would seek
help for psychological and/or physical health problems, participants stated that although
they didn’t feel comfortable doing this face to face, they would readily utilise online
services e.g. looking up symptoms on health websites or utilising online counselling
services as an alternative. Knowing the importance that perfectionists place on projecting
and maintaining a perfect and flawless persona (Hewitt et al, 2003) it may be the case that
developing therapeutic services that either bypass or reduce the need to self-present
publicly (e.g. in a traditional counselling setting) could provide a useful avenue for treating
perfectionists.
The thesis also identified that university environments may be particularly challenging
environments for maladaptive perfectionists; therefore a potential avenue for future
research could be to develop an online counselling resource for university students to
access via the university website. Such a service could be based on CBT principles and
include information to help perfectionists manage their time so that they are able to make
the most of their university experiences and are able to fulfil their academic potential
whilst also taking care of their physical and emotional health. It would also be an
interesting avenue for future research to compare an online counselling service (with no
face to face contact) with a face to face therapeutic modality, with specific attention to
self-presentational motives. By removing the pressures associated with self-presentation it
would be interesting to find out if a more successful outcome was possible.
210
7.6
Overall conclusions
Taken together, the results from this thesis suggest that there are differences between
adaptive and maladaptive perfectionists in terms of how much they engage in preventive
health behaviours. Across the studies, adaptive perfectionism was consistently associated
with increased engagement but the results for maladaptive perfectionism were more
dependent on the type of population being studied. Further differences were identified
between the two perfectionism dimensions with respect to a number of other health related
variables which supports the premise that there may be two distinct subtypes of
perfectionism. Studying potential intervening factors in the perfectionism, engagement
relationship revealed that maladaptive perfectionists perceive there to be greater barriers
(and fewer benefits) to engagement and conversely, for adaptive perfectionists, greater
benefits (and fewer barriers). Further work is warranted to explore the perfectionism,
engagement relationship in more detail and find out the precise ways that factors such as
self-presentation and perceived stress are involved. Additionally, looking at different
populations may establish whether maladaptive perfectionists in a university environment
represent a particularly vulnerable client group.
211
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Appendix A: Unpublished version of article submitted to the Journal of Health
Psychology
The Relationship between Perfectionism and Engagement in Preventive Health
Behaviours: The Mediating Role of Self Concealment
Charlotte J Williams and Mark Cropley
253
Abstract
If perfectionists avoid engaging in preventive health behaviours they may be putting their
long-term health and wellbeing at risk. Correlational analyses based on a sample of 370
university students identified maladaptive perfectionism to be associated with decreased
levels of; engagement in preventive health behaviours, life satisfaction and wellbeing and
increased levels of self-concealment and psychological distress. Adaptive perfectionism
was associated with higher levels of engagement in preventive health behaviours. Selfconcealment was identified as a partial mediator in the relationship between maladaptive
perfectionism and both engagement in preventive health behaviours and psychological
distress. Implications of the findings are discussed.
Keywords: Maladaptive and adaptive perfectionism, preventive health behaviours,
self-concealment.
Introduction
Over the last two decades there has been a striking increase in research concerned with
perfectionism. This growth in interest has been beneficial in enhancing our understanding
of this personality construct, however, there still remains a lack of consensus regarding
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how perfectionism has been conceptualised and defined. In the 1990s two research groups
independently suggested that perfectionism should be understood as a multidimensional
construct, possessing both positive and negative elements (Frost et al. 1990; Hewitt and
Flett, 1991). Since then many authors have investigated and supported a two factor model
of perfectionism encompassing positive/adaptive/healthy elements as well as
negative/maladaptive/unhealthy ones (e.g. Adkins and Parker, 1996; Blankstein and
Dunkley, 2002; Enns and Cox, 1999; Frost et al., 1993; Hill et al., 1997; Rheaume et al.,
2000; Terry-Short et al., 1995; Rice et al., 1998; Slade, 1982; Slade and Owens, 1998;
Slaney et al., 2002; Stumpf and Parker, 2000).
Adaptive perfectionism is believed to be driven by a desire for success (Hamachek, 1978)
and has been characterised by a high level of organisation, high personal standards,
conscientiousness and a desire to achieve personal goals (Slade and Owens, 1998). When
compared to maladaptive perfectionism, research suggests adaptive perfectionists;
ruminate less, are less susceptibility to negative affectivity and engage in fewer self-critical
evaluations in appraisal situations (Beiling et al., 2004; Enns et al., 2001; Rheaume et al.,
2000). Hamachek (1978) suggested that although adaptive perfectionists set themselves
extraordinarily high standards they do possess the flexibility to allow for occasional
mistakes and ultimately derive a real sense of satisfaction from their efforts.
Maladaptive perfectionism is believed to be driven by an intense fear of failure
(Hamachek, 1978) and has been associated with negative psychological functioning (Blatt,
1995; Chang,
2003; Flett and Hewitt, 2002; Shafran and Mansell, 2001). The negative aspects of
perfectionism have been related to a wide variety of psychological and physical disorders
including; anxiety (Antony et al., 1998; Flett et al., 1989), substance abuse (Pacht, 1984),
chronic pain (Liebman, 1978), coronary heart disease (Pacht, 1984), depression (Blatt,
1995; Chang, 2000; Enns and Cox, 1999; Frost et al., 1990; Frost et al., 1993; Hewitt and
Flett, 1991; Kawamura et al., 2001; Pacht, 1984), eating disorders (Fairburn et al., 1999;
Pacht, 1984), Obsessive Compulsive Disorder (Antony et al., 1998; Pacht, 1984), Chronic
Fatigue Syndrome (Deary and Chalder, 2010), increased fatigue following a period of
stress (Dittner et al., 2010) and suicide (Burns, 1980; Hewitt et al., 1992).
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Additionally maladaptive perfectionism has been linked with self-concealment (Frost et
al., 1995; Frost et al., 1997), which can be defined as the active concealment of negative
information relating to the self (Larson and Chastain, 1990). The need to conceal mistakes
and imperfections seems to be an important aspect of the perfectionism construct and has
the potential to exacerbate and perpetuate stress (Hewitt and Flett, 2002). Some authors
believe this is tied in with the desire to both present and protect a ‘flawless image’ (Frost et
al., 1995, 1997). It is thought that self-concealment may be particularly detrimental to
health because of the additional effort required in actively withholding sensitive and
potentially embarrassing information from others (Kahn and Hessling, 2001), as well as
the fact that it prevents the development of more adaptive coping strategies such as
utilising social support (Kawamura and Frost, 2004).
Longitudinal research by Fry and Debats (2009), identified perfectionism (as well as
neuroticism) to be associated with increased risk of death in later life. These authors
identified conscientiousness (often identified as one of the more adaptive elements of the
perfectionism construct) to be “enabling”, having a protective function in terms of health
and perfectionism and neuroticism to be more “disabling”, having a more detrimental
effect on health. Further research by these authors has put forward the suggestion that high
levels of self-oriented perfectionism (considered to represent the adaptive perfectionism
traits) to be health promoting and linked to a reduced risk of mortality (Fry and Debats,
2011).
Despite the wealth of research linking the negative aspects of perfectionism with various
psychological and physical difficulties and the association between perfectionism and selfconcealment, there has been little research to establish how well perfectionists look after
their health and wellbeing. One way to address this might be to ascertain how frequently
perfectionists engage in preventive health behaviours. Such behaviours have been defined
as “any activity undertaken by a person believing himself to be healthy for the purpose of
preventing disease or detecting it an asymptomatic stage” (Kasl and Cobb, 1966).
Investigating such behaviours may be useful as it could provide important information
regarding how maladaptive and adaptive perfectionists look after their health and
wellbeing. Research, has identified lower levels of socially prescribed perfectionism
(considered to reflect the more negative attributes of the perfectionism construct) and
higher levels of organisation (a positive attribute of perfectionism) to be associated with
increased health behaviours (Chang et al., 2008).
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The present study seeks to explore the relationship between perfectionism (adaptive and
maladaptive) and engagement in preventive health behaviours. It is hypothesised that
higher levels of maladaptive perfectionism will be associated with lower engagement and
conversely higher levels of adaptive perfectionism will be related to greater engagement in
preventive health behaviours (hypothesis 1).
Previous research has identified self-concealment as a mediator in the relationship between
maladaptive perfectionism and psychological distress (Kawamura and Frost, 2004). The
present study seeks to provide evidence for the relationship between perfectionism
(adaptive and maladaptive) and self-concealment, as well as, self-concealment and
engagement in preventive health behaviours (hypothesis 2). Additionally the purpose of
this study is to expand on previous research by identifying the mediating role of selfconcealment in both the relationship between maladaptive perfectionism and psychological
distress as well as maladaptive perfectionism and engagement in preventive health
behaviours (hypothesis 3).
Finally, the variables of psychological distress, life satisfaction and wellbeing will be
considered. It is predicted that maladaptive perfectionism and self-concealment will be
associated with elevated levels of psychological distress and reduced levels of both life
satisfaction and wellbeing. Adaptive perfectionism is hypothesised to be associated with
lower psychological distress and increased life satisfaction and wellbeing, (hypothesis 4).
Method
Participants and Procedure
Participants were students at the University of Surrey, recruited through an email
advertisement circulated to all students. Of the final sample (N=370), 287 (77%) were
women and 83 were men (23%). Their mean age was 26.72 years (SD = 9.4). Of the
sample, 44% were undergraduate students (n = 164) and 51% were postgraduate students
(n = 188), the remaining 5% (n = 18) did not specify level of study. Participants
completed an online questionnaire.
Measures
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Perfectionism
To assess adaptive and maladaptive perfectionism, four of the subscales of the Frost
Multidimensional Perfectionism Scale (FMPS, Frost et al., 1990) were used. For adaptive
perfectionism, the subscales of Personal Standards (7 items) and Organisation (6 items)
were summed to form a total adaptive perfectionism score (ADAPT-PERF). The use of
these two subscales to represent a measure of adaptive perfectionism has been supported
by previous research, showing good internal reliability, Cronbach’s alpha, 0.88 (Chang et
al., 2004; Harris et al., 2008). For maladaptive perfectionism, the Concern over Mistakes
(CM) and Doubts about Actions (DA) subscales have been utilised and summed to form a
total maladaptive perfectionism score (MAL-PERF). The use of these two subscales to
represent a measure of maladaptive perfectionism has been extensively supported in the
research literature (Dunn et al., 2006; Frost et al., 1990; Harris et al., 2008; Wei et al.,
2004). Cronbach’s alpha for the two subscales combines has been found to be 0.87 (Harris
et al., 2008).
Self-Concealment
The Self-Concealment Scale (SCS; Larson and Chastain, 1990) was used to assess selfconcealment. The scale consists of ten items addressing an individual’s desire to conceal
negative personal information. Participants are asked to rate their agreement with a
statement on a five point Likert scale ranging from strongly disagree (1) to strongly agree
(5). A total score is then derived, with high scores denoting a greater tendency to selfconceal. The scale has been shown to be reliable, with favourable test-retest and interim
reliability. Internal consistency has been reported to be good, α = 0.83 (Larson and
Chastain, 1990). The scale is generally considered to be a valid means of assessing the
tendency to conceal personal information.
Engagement in Preventive Health Behaviours
This questionnaire was designed for the present study and is an adaptation of the General
Preventive Behaviours Checklist (Amir, 1987). It requires respondents to rate on a three
point scale the frequency with which they carry out a range of preventive health
258
behaviours. Areas addressed include diet, exercise, avoidance or harmful substances such
as cigarettes and alcohol, social interaction, work, and emotional well-being. Examples of
questions include; “I eat a balanced diet”, “I do regular aerobic or strenuous exercise”, “I
avoid overworking” and “I avoid too much emotional distress”. Responses were summed
to form a total engagement score with higher scores indicating a greater amount of
engagement in preventive health behaviours.
Psychological Distress
The Hopkins Symptom Checklist-21 can be described as a general measure of
psychological distress and was utilised to assess general psychological and symptom
distress (HSCL-21; Green et al., 1988). This measure gauges the respondent’s current
experience of somatic, performance and general distress. The scale consists of 21 items
scored on a four point Likert scale ranging from 1 (strongly disagree) to 4 (strongly
agree). A high score overall, denotes a higher degree of psychological distress. The scale
has good internal reliability (α = 0.90; Green et al., 1988) and has adequate test-retest
reliability, construct and concurrent validity (Deane et al., 1992). The use of this scale as a
valid and reliable method of assessing psychological distress has been supported in the
research literature (Harari et al., 2005; Komiya et al., 2000).
Life satisfaction
To assess life satisfaction, the Satisfaction With Life Scale (SWLS; Diener et al., 1985)
was used. This consists of five items rated on a seven point Likert scale ranging from 1
(strongly disagree) to 7 (strongly agree). Higher scores denote greater life satisfaction. An
encouraging level of reliability and internal consistency has been found, Cronbach’s alpha,
0.87 (Diener, 1985). In terms of validity, the scale correlates moderately well with other
subjective well-being scales (Pavot et al., 1991).
Well-being
To provide a measure of general well-being the WHO-5 Well-Being index (Bech et al.,
1996) was employed. It covers the following areas; positive mood, vitality and general
interest. Each of the five items is rated on a six point Likert scale from 0 (not present) to 5
259
(constantly present). A total score is derived from summing the five items.. Findings
suggest good reliability and validity, Cronbach’s alpha = 0.82, (De Wit et al., 2007).
The research design for the present study was primarily correlational. Mediation analyses
were also carried out to determine the importance of self-concealment in the relationship
between maladaptive perfectionism and engagement in preventive health behaviours and
maladaptive perfectionism and psychological distress.
Results
Analyses are separated into three sections. The first section comprises the preliminary
analysis consisting of sample demographics, means (M), standard deviations (SDs) and
reliabilities (Cronbach’s alpha α) for all the major variables (Table 1). Secondly the results
of the correlational analyses are presented in Table 2. The results from the mediation
analyses are displayed diagrammatically and regression coefficients presented in Table 3.
INSERT TABLE 1 ABOUT HERE
Correlational Analyses
As predicted a significant negative association was found between maladaptive
perfectionism and engagement in preventive health behaviours (r = -0.330, p<0.01)
suggesting that those participants scoring highly on the negative aspects of perfectionism
engaged less in behaviours that could potentially benefit their health. A small yet
significant correlation was found for adaptive perfectionism and engagement in preventive
health behaviours (r = 0.254, p<0.01) suggesting those participants scoring highly on the
more adaptive elements of perfectionism may be more inclined to take preventive steps as
far as health behaviours are concerned (hypothesis 1).
INSERT TABLE 2 ABOUT HERE
For perfectionism and self-concealment, a positive association was observed between
maladaptive perfectionism and self-concealment, (r = 0.471, p<0.01), although, adaptive
perfectionism and self-concealment were shown to be uncorrelated. This may suggest that
260
self-concealment is a factor present predominantly in maladaptive perfectionism and not
perfectionism per se. When the relationship between self-concealment and engagement
was examined, an inverse relationship was found (r = .0.346, p<0.01) suggesting as selfconcealment increases, there is a corresponding decrease in engagement in preventive
health behaviours, (hypothesis 2).
Addressing the relationship between perfectionism (adaptive and maladaptive) and
psychological distress, no relationship was observed for adaptive perfectionism, although a
significant positive correlation was observed for maladaptive perfectionism (r = 0.533,
p<0.01). Such findings support previous research linking the negative aspects of
perfectionism with greater psychological distress. As expected and in support of earlier
work, self-concealment and psychological distress were positively correlated (r = 0.486,
p<0.01). In consideration of the relationships between perfectionism, life-satisfaction and
well-being, maladaptive perfectionism was associated with lower levels of both variables
(r = -0.376, p<0.01 and r = -0.439, p<0.01 respectively). No relationship was observed
between adaptive perfectionism and either life-satisfaction or well-being. Similar to
maladaptive perfectionism, self-concealment was also associated with diminished levels of
both life-satisfaction and well-being, r = -0.361, p<0.01 and r = -0.355, p<0.01
respectively, (hypothesis 4).
Mediation Analyses
Mediation (hypothesis 3) was tested according to the method outlined by Baron and Kenny
(1984) and the significance of the indirect effect calculated using the Sobel Test (Sobel,
1982). Unstandardised regression coefficients were used in the calculations. The results of
the Sobel Test are presented diagrammatically to aid understanding, and the regression
coefficients presented in Table 3 and 4.
INSERT FIG. 1 ABOUT HERE
INSERT TABLE 3 ABOUT HERE
When considering self-concealment as a mediator in the relationship between maladaptive
perfectionism and engagement in preventive health behaviours, the result of the Sobel Test
was significant (z = -4.091). The regression coefficient (Step 1, B = -.300, p<.001; Step 3,
B = -.195, p<0.001), however has not been reduced adequately to suggest full mediation.
261
This result suggests that self-concealment partially mediates the relationship between
maladaptive perfectionism and engagement in preventive health behaviours.
INSERT FIG. 2 ABOUT HERE
INSERT TABLE 4 ABOUT HERE
Similarly for the relationship between maladaptive perfectionism and psychological
distress although the result of the Sobel Test was again significant (z = 5.395), the
regression coefficient, was not reduced enough to indicate full mediation (Step 1, B = .557,
p<.001; Step 3, B =.423, p<,001), therefore self-concealment can only be considered a
partial mediator.
Discussion
Adaptive perfectionism was associated with higher levels of engagement, supporting
research by Chang et al (2008) identifying elevated levels of organisation to be associated
with increased health behaviours. Additionally this may suggest a positive benefit to being
adaptive perfectionist. Maladaptive perfectionism was associated with lower levels of
engagement in preventive health behaviours. One explanation, for the lack of engagement
on the part of maladaptive perfectionists might be that they avoid such activities because it
could potentially present a situation where one’s “imperfections” could be highlighted and
therefore create the potential of negative evaluation from others. It seems that
perfectionists will, at all costs, endeavour to keep such “imperfections” hidden, (Hewitt et
al., 2003). A further explanation for a lack of engagement may involve “selfhandicapping” behaviours. These include behaviours such as avoidance, procrastination,
over-committing (Kearns et al., 2007), lack of effort (Kimble et al., 1998), choosing
difficult goals (Greenberg, 1985) and a range of emotional and physical symptoms (Smith
et al., 1983). Perfectionism and self-handicapping are thought to share many common
features including striving for extremely high standards, dissatisfaction if such standards
are not met and an excessive and often debilitating fear of failure. Such behaviours are
thought to have an inherent appeal to perfectionists who are likely to feel most vulnerable
in evaluative situations. It is possible that maladaptive perfectionists may use various selfhandicapping behaviours as justification not to engage in preventive health behaviours. It
262
would be useful for future research to investigate the association between perfectionism
and self-handicapping in relation to health related behaviours.
Both maladaptive perfectionism and self-concealment were found to be related to higher
levels of psychological distress and lower levels of both life-satisfaction and well-being.
Research in the area of preventive health suggests that psychological distress may affect
the likelihood of engaging in various health promoting activities such as attending for
health screenings (Lieferman and Pheley, 2006), adhering to preventive health care
guidelines (Thorpe et al., 2006) and delaying routine health examinations (Witt et al.,
2009).
It was hypothesised that adaptive perfectionism would be associated with lower levels of
psychological distress and higher levels of life-satisfaction and wellbeing. This would
support research suggesting there to be positive benefits attached to being an adaptive
perfectionist (Kearns et al., 2008, Slade and Owens 1998). The present study did not
identify any relationships between these variables. Further, adaptive perfectionism was
also found to be unrelated to self-concealment. These results suggest no apparent benefits
to being an adaptive perfectionist, i.e. no associated increase in life satisfaction and wellbeing or noticeable decrease in psychological distress. It would be interesting for future
studies to investigate whether a lack of a desire to self-conceal may provide adaptive
perfectionists with a type of ‘psychological buffer’ that could potentially protect them
from the more harmful maladaptive traits.
Consistent with earlier work, maladaptive perfectionism was found to be associated with
elevated levels of self-concealment. Additionally, self-concealment was found to be
associated with lower engagement in preventive health behaviours. Previous research has
identified that highly perfectionistic individuals may self-conceal in an attempt to maintain
a ‘flawless image’ and avoid negative evaluation (Frost et al, 1995, 1997; Kawamura &
Frost, 2004). Further, a tendency to conceal has also been associated with a reluctance to
seek professional help for personal difficulties (Cepeda-Benito and Short, 1998; Kelly and
Achter, 1995).
When considering the mediating influence of self-concealment in the relationships
between maladaptive perfectionism and engagement in preventive health behaviours and
maladaptive perfectionism and psychological distress, self-concealment was identified as a
partial mediator. Despite not fully supporting the mediation hypotheses, this study does
263
demonstrate that self-concealment may be an important variable when considering the
health implications and consequences of being a maladaptive perfectionist. Elevated levels
of both maladaptive perfectionism and self-concealment may represent an increased
vulnerability towards both psychological and physical problems and be a toxic
combination as far as health and wellbeing are concerned. The relationship between
perfectionism and self-concealment and the impact of both these factors on health and
wellbeing requires further investigation.
In summary the present study suggests that maladaptive perfectionists may be putting their
immediate and long-term health and wellbeing at risk. Specifically; (i) As maladaptive
perfectionism increases there seems to be a corresponding decline in engagement in
preventive health behaviours. Engaging in such behaviours is considered to be an
important way of reducing the risks of developing various illnesses and chronic conditions
such as heart disease, cancer and diabetes, (ii) maladaptive perfectionism seems to be
linked to high levels of self-concealment which itself has been associated with various
unfavourable health outcomes, (iii) Maladaptive perfectionism has consistently been
linked with higher levels of psychological distress, which has the potential to lead to
various psychological and physical difficulties and finally (iv) maladaptive perfectionism
has been related to lower levels of life-satisfaction and well-being.
There is still relatively little research that has addressed the long-term psychological and
physical consequences of being a maladaptive perfectionist. Recent research studies have
begun to identify the potentially damaging effects of being highly perfectionistic (Fry and
Debats, 2009, 2011). Longitudinal studies that aim to investigate the long-term impact of
both the adaptive and maladaptive aspects perfectionism in relation to health and
wellbeing would be beneficial. Such findings may provide valuable information in the
field of health psychology in terms of treating and managing the psychological and
physical needs of extreme perfectionists.
There are several limitations with the present study. A reliance on self-report data and a
cross sectional sample restricted to University students makes generalisations problematic.
Future studies may benefit from comparing the health practices of maladaptive, adaptive
and non- perfectionists over an extended time period. Another limitation reflects a
conceptual difficulty. The present study utilises the conceptualisation supported by Frost et
al (1990) and defends the use of a maladaptive/adaptive split to define perfectionism. What
264
has to be remembered is that extreme forms of perfectionism may be characterised by
elevated levels of both adaptive and maladaptive traits (Slade and Owens, 1998) and that
the coexistence of both positive and negative traits may, in itself, have particular health
implications. Another limitation is the method used to assess engagement in preventive
health behaviours. The measure utilised provided an aggregate score derived from a
number of distinct health behaviours and a more valid means of assessment may be to look
at these behaviours separately. Additionally, this measure was limited to addressing more
traditional ways of looking after one’s health and wellbeing, and may have overlooked
alternative methods e.g. mindfulness, meditation, yoga, kinesiology and homeopathy.
Conclusion
The present study has aimed to extend previous research in the field of perfectionism and
health by highlighting a need to address whether maladaptive perfectionists, do indeed
represent a high risk group in terms of their health and wellbeing and whether the
associated tendency to self-conceal adds to this vulnerability. Additionally the intention
was to identify any apparent advantages (in terms of health and wellbeing) to being an
adaptive perfectionist. Previous research has focussed on identifying the negative side of
perfectionism, however, little has been done to examine what perfectionists actually do to
look after their health and wellbeing. Longitudinal studies designed to gain insight into
potential strategies that may be utilised by perfectionists to engage/not engage in
preventive health practices would be beneficial as well as qualitative studies looking in
more detail at the development of health beliefs and possible barriers to engaging/not
engaging. It may also be useful to look the relationship between perfectionism and stress in
relation to engagement in preventive health behaviours. Such information would enable
health professionals to gain a more comprehensive understanding of the way highly
perfectionistic individuals view and make decisions about how to manage their own health
and wellbeing.
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Terry-Short LA, Owens RG, Slade PD and Dewey ME (1995) Positive and negative
perfectionism. Personality and Individual Differences 18(5): 663-668.
Thorpe JM, Kalinowski CT, Patterson ME and Sleath BL (2006) Psychological distress as
a barrier to preventive care in community-dwelling elderly in the United States. Medical
Care 44(2): 187-191.
Wei M, Mallinckrodt B, Russell DW and Abraham WT (2004) Maladaptive perfectionism
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Counseling Psychology 51(2): 201-212.
Witt WP, Kahn R, Fortuna L, Winickoff J, Kuhlthau K, Pirraglia PA and Ferris T (2009)
Psychological distress as a barrier to preventive healthcare among U.S women. Journal of
Primary Prevention 30(5): 531-547.
272
TABLES
Table 1
Sample Demographics, Means, Standard Deviations and Reliabilities for all Major
Variables
n
Age
18-29
30-39
40-49
50-59
60+
Marital Status
Single
Living with partner
Married
Separated
Divorced
Level of Study
Undergraduate
Postgraduate
Not specified
Variables
ADAPT-PERF
(PS and O)
MAL-PERF
(CM and DA)
Self-Concealment
(SCS)
Engagement in
Preventive Health
Behaviour
Psychological Distress
(HSCL-21)
Well-being
(WHO-5)
Life-Satisfaction
(SWLS)
(%)
267
56
33
11
3
(72.2)
(15.1)
(8.9)
(3)
(0.8)
269
31
66
8
5
(70.3)
(8.4)
(17.8)
(2.2)
(1.4)
164
188
18
(44)
(51)
(5)
(M)
(SD)
(α)
45.42
8.41
0.88
34.90
9.12
0.89
27.96
8.74
0.89
31.9
8.30
0.84
37.55
9.88
0.90
12.55
6.96
0.87
22.14
6.96
0.88
273
Table 2
Correlation Matrix for all Major Variables
Variables
1. ADAPT-PERF
2. MAL-PERF
3. Self-Concealment
4. Engagement
5. Psychological Distress
6. Well-being
7. Life-Satisfaction
1
.347**
-.011
.254**
-.012
.081
.112*
2
.471**
-.330**
.533**
-.439**
-.376**
3
-.346**
.486**
-.355**
-.361**
4
-.396**
.524**
.380**
5
-.562**
-.404**
6
7
.563**
-
Note. Engagement = Engagement in Preventive Health Behaviours
*p < .05. **p <.01
274
Table 3.
Summary of the Regression Analysis for the Variables; Maladaptive Perfectionism, SelfConcealment and Engagement in Preventive Health Behaviours
Variable/s
Unstandardised (B)
Standardised (Beta)
Step 1
Mal P

X
Engagement
-.300†
-.330†
.451†
.471†
Y
Step 2
Mal P

X
Self-Concealment
M
Step 3
Mal P + Self-C  Engagement
X
M
Y
-.195† (Mal P)
-.215† (Mal P)
-.232† (Self-C)
-.244† (Self-C)
Note: Step 2 is identical for both mediation analyses and therefore will not appear on the next table.
Mal P = maladaptive perfectionism, Self-C = self-concealment, Engagement = engagement in preventive
health behaviours.
† p<.001
Table 4.
Summary for the Regression Analysis for the Variables; Maladaptive Perfectionism, SelfConcealment and Psychological Distress
Variable/s
Unstandardised (B)
Standardised (Beta)
Step 1
Mal P

X
Psych dist
.577†
.533†
Y
Step 3
Mal P + Self-C  Psych dist
X
M
Y
.423† (Mal P)
.390† (Mal P)
.341† (Self-C)
.302† (Self-C)
Note. Psych dist = psychological distress,
† p<.001
275
FIGURES
Figure 1. The Mediating Role of Self-Concealment in the Relationship Between
maladaptive Perfectionism and Engagement in Preventive Health Behaviours
SelfConcealment
(Sa) = .044
(Sb) = .052
a = .451
Maladaptive
Perfectionism
b = -.232
c
Engagement
in Preventive
Health
Behaviours
Z = -4.091
Figure 2.
The Mediating Role of Self-Concealment in the Relationship Between maladaptive
Perfectionism and Psychological Distress
SelfConcealment
(Sa) = .044
(Sb) = .054
a = .451
Maladaptive
Perfectionism
b = .341
c
Psychological
Distress
Z = 5.395
276
Appendix B: Interview Schedule for study 3
Study 3: Interview Schedule
1.
2.
3.
4.
5.
6.
7.
What does the term “being healthy” mean to you?
Do you consider yourself to be healthy?
What do you do specifically to look after your physical health?
How important do you think it is to look after your physical health?
What do you to look after your emotional health?
How important do you think it is to look after your emotional wellbeing?
Do you think that looking after your physical and emotional wellbeing are of
equal importance?
8. Do you have clearly defined health goals (ideas about how to look after your
health)?
9. What have you done in the past to look after your health and wellbeing?
10. What preventive health behaviours do you engage in (e.g. behaviours that are
designed to keep you healthy such as exercising, eating healthily and keeping
stress levels under control)?
11. What factors influence your engagement in such behaviours?
12. How do you look after yourself (physically and emotionally) when you have
other pressures building up (e.g. exams, assignments etc.)?
13. How do you prioritise when other things interfere with trying to look after
your health and wellbeing?
14. What do you do when you encounter obstacles that may affect how you look
after your health and wellbeing?
15. Do you ever worry about your health?
16. What sorts of things do you worry about?
17. If you were worried about something physical e.g. and ache or pain, how likely
would it be that you would go and see a health professional?
18. If you were finding it difficult to cope emotionally, how likely would it be that
you would seek professional help?
277
Appendix C: The Frost Multidimensional Perfectionism Scale
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
My parents set very high standards for me. PE
Organization is very important to me. O
As a child, I was punished for doing things less than perfect. PC
If I do not set the highest standards for myself, I am likely to end up a
second-rate person. PS
My parents never tried to understand my mistakes. PC
It is important to me that I am thoroughly competent in everything I do. PS
I am a neat person. O
I try to be an organised person. O
If I fail at work/school, I am a failure as a person, CM
I should be upset if I make a mistake. CM
My parents wanted me to be the best at everything. PE
I set higher goals than most people. PS
If someone does a task at work/school better than I, then I feel like I failed the whole
task. CM
If I fail partly, it is as bad as being a complete failure. CM
Only outstanding performance is good enough in my family. PE
I am very good at focussing my efforts on attaining a goal. PS
Even when I do something very carefully, I often feel that it is not quite right. DA
I hate being less than the best at things. CM
I have extremely high goals. PS
My parents have expected excellence from me. PE
People will probably think less of me if I made a mistake. CM
I never felt like I could meet my parents’ expectations. PC
If I do not do as well as other people, it means I am an inferior human being. CM
Other people seem to accept lower standards than I do. PS
If I do not do well all the time, people will not respect me. CM
My parents have always had higher expectations for my future than I have. PE
I try to be a neat person. O
I usually have doubts about the simple everyday things I do. DA
Neatness is very important to me. O
I expect higher performance in my daily tasks than most people. PS
I am an organised person. O
I tend to get behind on my work because I repeat things over and over. DA
It takes me a long time to do something right. DA
The fewer mistakes I make, the more people will like me. CM
I never felt like I could meet my parents standards. PC
(Subscales - PS = Personal Standards, O = Organisation, DA = Doubts about Actions, CM = Concern over
Mistakes, PE = Parental Expectations, PC = Parental Criticisms)
278
Appendix D: Self-Concealment Scale
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
I have an important secret that I haven’t shared with anyone
if I shared all my secrets with my friends, they’d like me less
there are lots of things about me that I keep to myself
some of my secrets have really tormented me
when something bad happens to me, I tend to keep it to myself
I’m often afraid I’ll reveal something I don’t want to
telling a secret often backfires and I wish I hadn’t told it
I have a secret that is so private I would lie if anybody
asked me about it
my secrets are too embarrassing to share with others
I have negative thoughts about myself that I never share with anyone
total score =
In the initial development research for the Self-Concealment Scale, the average score for a group of 306 adults (average
age 42, 82% with US college education) was 26, with about 70% scoring between 19 and 33 (Larson and Chastain 1990).
A high tendency to conceal was associated with increased physical and psychological illness, even after allowing for the
presence or absence of past trauma.
Larson, D. G. and R. L. Chastain (1990). "Self-Concealment: Conceptualization. Measurement, and Health Implications."
Journal of Social and Clinical Psychology 9(4): 439-455.
279
5=strongly agree
4=moderately agree
3=don’t disagree or agree
2=moderately disagree
This scale measures self-concealment, defined here as a tendency to conceal
from others personal information that one perceives as distressing or negative.
Please tick the box, to the right of each of the following 10 statements, that
best describes how much you personally agree or disagree with the statement.
1=strongly disagree
self-concealment scale (scs)
Appendix E: Preventive Health Behaviours Questionnaire
Preventive Health Behaviours Questionnaire
(adapted from the General Preventive Health Behaviours Checkllist; Amir, 1987)
Never
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Sometimes
Always
I avoid food with additives
I take vitamins and supplements
I eat bran and other high fibre foods
I do regular aerobic or strenuous
exercise
I get enough sleep
I try to drink plenty of water
I eat a balanced diet
I avoid smoking
I avoid salty and processed foods
I avoid too much alcohol
I avoid too much emotional stress
I have friends and maintain a good
social life
I avoid feelings like anger, anxiety
and depression
I try to think positively
I stay mentally alert and active
I get enough relaxation
I avoid overworking
I regularly eat breakfast
I maintain contact with friends and
family
I try and spend some time outdoors
every day
I avoid over the counter medication
I keep my weight under control
I get regular dental check ups
I limit certain foods e.g. those high in
fat and sugar
I control my cholesterol levels
I avoid snacking between meals
I fix broken things around the home
280
Appendix F: The Hopkins Symptom Checklist - 21
HOPKINS SYMPTOM CHECKLIST – 21
(Green, Walkey & McCormick, 1988
How have you felt during the past seven days including today? Use the following scale to
describe how distressing you have found these things over this time.
NOT AT ALL = 1
A LITTLE = 2
QUITE A BIT = 3
EXTREMELY = 4
1. Difficulty in speaking when you are excited
2. Trouble remembering things
3. Worried about sloppiness or carelessness
4. Blaming yourself for things
5. Pains in the lower part of your back
6. Feeling lonely
7. Feeling blue
8. Your feelings being easily hurt
9. Feeling others do not understand you or are unsympathetic
10. Feeling that people are unfriendly or dislike you
11. Having to do things very slowly in order to be sure you are doing them
right
12. Feeling inferior to others
13. Soreness of your muscles
14. Having to check and double-check what you do
15. Hot or cold spells
16. Your mind going blank
17. Numbness or tingling in parts of your body
18. A lump in your throat
19. Trouble concentrating
20. Weakness in parts of your body
21. Heavy feelings in your arms and legs
281
Appendix G: Satisfaction with Life Scale
Satisfaction with Life Scale
(SWLS; Diener, Emmons, Larson & Griffin, 1985)
Below are five statements with which you may agree or disagree. Using the
1 – 7 point scale below, please indicate your agreement with each item by
placing the appropriate number on the line preceding that item. Please be
open and honest in your responding.
The 7- point scale is:
1 = strongly disagree
2 = disagree
3 = slightly disagree
4 = neither agree or disagree
5 = slightly agree
6 = agree
7 = strongly agree
____1. In most ways my life is close to ideal
____2. The conditions of my life are excellent
____3. I am satisfied with my life
____4. So far I have got the important things I want in life
____5. If I could have my life over I would change almost
nothing
282
Appendix H: Perceived Stress Scale
Perceived Stress Scale
(PSS; Cohen, S., Kamarck, T., and Mermelstein, R.1983).
The questions in this scale ask you about your feelings and thoughts during the last
month. In each case, you will be asked to indicate by circling how often you felt or
thought a certain way.
_____________________________________
0 = Never 1 = Almost Never 2 = Sometimes 3 = Fairly Often 4 = Very Often
1.
In the last month, how often have you been upset
because of something that happened unexpectedly?.................................. 0 1 2 3 4
2.
In the last month, how often have you felt that you were unable
to control the important things in your life? .................................................. 0 1 2 3 4
3.
In the last month, how often have you felt nervous and “stressed”? ............ 0 1 2 3 4
4.
In the last month, how often have you felt confident about your ability
to handle your personal problems? ............................................................. 0 1 2 3 4
5.
In the last month, how often have you felt that things
were going your way?.................................................................................. 0 1 2 3 4
6.
In the last month, how often have you found that you could not cope
with all the things that you had to do? ......................................................... 0 1 2 3 4
7.
In the last month, how often have you been able
to control irritations in your life?................................................................... 0 1 2 3 4
8.
In the last month, how often have you felt that you were on top of things?.. 0 1 2 3 4
9.
In the last month, how often have you been angered
because of things that were outside of your control?................................... 0 1 2 3 4
10.
In the last month, how often have you felt difficulties
were piling up so high that you could not overcome them? ......................... 0 1 2 3 4
283
Appendix I: The Pennebaker Inventory of Limbic Languidness
The Pennebaker Inventory of Limbic Languidness
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
More than
once every
week
Every week or
so
Every month
or so
Less than 3 or
4 times per
year
Have never or
almost never
experienced
(PILL; Pennebaker, 1982)
Eyes water
Itchy eyes or skin
Ringing in ears
Temporary deafness or hard of
hearing
Lump in throat
Choking sensations
Sneezing spells
Runny nose
Congested nose
Bleeding nose
Asthmas or wheezing
Coughing
Out of breath
Swollen ankles
Chest pains
Racing heart
Cold hands or feet even in hot
weather
Leg cramps
Insomnia or difficulty sleeping
Toothaches
Upset stomachs
Indigestion
Heartburn or gas
Abdominal pain
Diarrhoea
Constipation
Haemorrhoids
Swollen joints
Stiff or sore muscles
Back pains
Sensitive or tender skin
Face flushes
284
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
More than
once every
week
Every week or
so
Every month
or so
Less than 3 or
4 times per
year
Have never or
almost never
experienced
…PILL continued
Tightness in chest
Skin breaks out in a rash
Acne or pimples on face
Acne/pimples other than face
Boils
Sweat even in cold weather
Strong reactions to insect bites
Headaches
Feeling pressure in head
Hot flashes
Chills
Dizziness
Feel faint
Numbness or tingling in any part of
body
Twitching of eyelid
Twitching other than eyelid
Hands tremble or shake
Stiff joints
Sore muscles
Sore throat
Sunburn
Nausea
285
Appendix J: The State-Trait Anxiety Inventory (form Y)
The State-Trait Anxiety Inventory Form Y
(STAI-Y; Spielberger, 1983)
A number of statements which people have used to describe themselves
are given below. Read each statement and then write the number in the blank at the end of
the statement that indicates how you feel right now, that is, at this moment. There are no
right or wrong answers. Do not spend too much time on any one statement but give the
answer which seems to describe your present feelings best.
1 = not at all
2 = somewhat
3 = moderately so
4 = very much so
1. I feel calm ____
2. I feel secure ____
3. I am tense ____
4. I feel strained ____
5. I feel at ease ____
6. I feel upset ____
7. I am presently worrying over possible misfortunes _____
8. I feel satisfied ____
9. I feel frightened ____
10. I feel comfortable ____
11. I feel self-confident ____
12. I feel nervous ____
13. I am jittery ____
14. I feel indecisive ____
15. I am relaxed ____
16. I feel content ____
17. I am worried ____
18. I feel confused ____
19. I feel steady ____
20. I feel pleasant _____
286
Please read each statement and then write the number in the blank at the end of
the statement that indicates how you generally feel. There are no right or wrong answers.
Do not spend too much time on any one statement but give the answer which seems to
describe how you generally feel.
1 = not at all
2 = somewhat
3 = moderately so
4 = very much so
21. I feel pleasant ____
22. I feel nervous and restless ____
23. I feel satisfied with myself ____
24. I wish I could be as happy as others seem to be ____
25. I feel like a failure ____
26. I feel rested ____
27. I am “calm, cool, and collected” ____
28. I feel that difficulties are piling up so that I cannot overcome them ____
29. I worry too much over something that really doesn’t matter ____
30. I am happy ____
31. I have disturbing thoughts ____
32. I lack self-confidence ____
33. I feel secure ____
34. I make decisions easily ____
35. I feel inadequate _____
36. I am content ____
37. Some unimportant thought runs through my mind and bothers me ____
38. I take disappointments so keenly that I can’t put them out of my mind ____
39. I am a steady person ____
40. I get in a state of tension or turmoil as I think over my recent concerns and interests ____
287
Appendix K: The Godin Leisure-Time Exercise Questionnaire
Godin Leisure-Time Exercise Questionnaire
(GLTEQ; Godin and Shepherd, 1997)
During a typical 7-Day period (a week), how many times on the
average do you do the following kinds of exercise for more than 15
minutes during your free time (write on each line the appropriate
number).
1.
a) STRENUOUS EXERCISE
(HEART BEATS RAPIDLY) __________
(e.g., running, jogging, hockey, football, soccer, squash, basketball, cross country
skiing, judo, roller skating, vigorous swimming, vigorous long distance bicycling)
b) MODERATE EXERCISE
(NOT EXHAUSTING) __________
(e.g., fast walking, baseball, tennis, easy bicycling, volleyball, badminton, easy
swimming, alpine skiing, popular and folk dancing)
c) MILD EXERCISE
(MINIMAL EFFORT) __________
(e.g., yoga, archery, fishing from river bank, bowling,
horseshoes, golf, snow-mobiling, easy walking)
288
Appendix L: The Exercise Benefits/Barriers Scale
EXERCISE BENEFITS/BARRIERS SCALE
(Sechrist, Walker & Pender, 1985)
Below are statements that relate to ideas about exercise. Please indicate the degree to
which you agree or disagree with the statements by circling SA for strongly agree, A for
agree, D for disagree, or SD
1. I enjoy exercise.
2. Exercise decreases feelings of stress and tension for me.
3. Exercise improves my mental health.
4. Exercising takes too much of my time.
5. I will prevent heart attacks by exercising.
6. Exercise tires me.
7. Exercise increases my muscle strength.
8. Exercise gives me a sense of personal accomplishment.
9. Places for me to exercise are too far away.
10. Exercising makes me feel relaxed.
11. Exercising lets me have contact with friends and persons I enjoy.
12. I am too embarrassed to exercise.
13. Exercising will keep me from having high blood pressure.
14. It costs too much to exercise.
15. Exercising increases my level of physical fitness.
16. Exercise facilities do not have convenient schedules for me.
17. My muscle tone is improved with exercise.
18. Exercising improves functioning of my cardiovascular system.
19. I am fatigued by exercise.
20. I have improved feelings of wellbeing from exercise.
21. My spouse (or significant other) does not encourage exercising.
22. Exercise increases my stamina.
23. Exercise improves my flexibility.
24. Exercise takes too much time from family relationships.
25. My disposition is improved with exercise.
26. Exercising helps me sleep better at night.
27. I will live longer if I exercise.
28. I think people in exercise clothes look funny.
29. Exercise helps me decrease fatigue.
30. Exercising is a good way for me to meet new people.
31. My physical endurance is improved by exercising.
32. Exercising improves my self-concept.
33. My family members do not encourage me to exercise.
34. Exercising increases my mental alertness.
35. Exercise allows me to carry out normal activities without
Becoming tired
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
289
36. Exercise improves the quality of my work.
37. Exercise takes too much time from my family responsibilities.
38. Exercise is good entertainment for me.
39. Exercising increases my acceptance by others.
40. Exercise is hard work for me.
41. Exercise improves overall body functioning for me.
42. There are too few places for me to exercise.
43. Exercise improves the way my body looks.
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
SA A D SD
290
Appendix M: The WHO-5 Well-being Index
WHO (Five) Well-Being Index
Please indicate for each of the five statements which is closest to how you have been feeling over the last two
weeks.
Notice that higher numbers mean better well-being.
3
4
5
4
3
2
1
0
5
4
3
2
1
0
I have felt active and
vigorous
I woke up feeling fresh and
rested
My daily life has been filled
with things that interest
me
5
4
3
2
1
0
5
4
3
2
1
0
5
4
3
2
1
0
At no time
5
Most of
the time
I have felt cheerful and in
good spirits
I have felt calm and relaxed
All of the
time
Some of
the time
2
Less than
half of the
time
1
More than
half of the
time
Over the last two weeks
291
Appendix N: Self-Presentational Efficacy Scale
Self-Presentational Efficacy Scale
(SPES, Gammage, Hall & Ginis, 2004)
(self-presentational efficacy expectancy subscale)
Think about the last time that you performed exercise/physical activity in public (e.g. gym,
exercise class). Using any values from this scale (0% to 100%), please indicate how
confident you are for each of the following:
How confident are you that…..
Other people will think that you have good physical coordination? _______
Other people will think that your body looks fit and toned?_______
Other people will think that you have good stamina?_______
Other people will think that you are someone who works out regularly?_______
Other people will think that you are in good shape?_______
292
Appendix O: Physical Activity Motivation Scale - Revised
Physical Activity Motivation Scale – Revised
1
2
3
4
5
6
7
8
9
10
11
I’m able to benefit from
regular physical activity in
many parts of my life
I feel very pleased with
myself when I do physical
activity on a regular basis
If I try, I believe I can do
physical activity regularly
Before I start my physical
activity, I get a clear idea
what I’m going to do
When I’m physically active,
it’s usually in places where I
can do it best
As I get older I’m doing less
and less regular physical
activity
Regular physical activity is
important to me
I feel very pleased with
myself when I stick at
regular physical activity
Before I start my physical
activity, I get it clear how
long I’m going to do it for
Often the main reason I’m
physically active is because
I don’t want people to think
I’m unhealthy
I sometimes avoid physical
activity so I have an excuse
if I don’t do well at sport,
am not good at other
physical activities or don’t
lose weight
Agree
strongly
Agree
Neither
agree or
disagree
Agree
somewhat
Disagree
somewhat
Disagree
Disagree
strongly
(Martin, 2010a; 2010b)
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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12
13
14
15
16
17
18
19
20
I try to have a rough plan for
my physical activity before I
start it
Often the main reason I’m
physically active is because
I don’t want people to think
I’m unfit
I sometimes do things other
than physical activity so I
have an excuse if I don’t do
well at sport or don’t lose
weight
I keep working at being
physically active until it
becomes a regular part of
my life
I worry that I don’t do
enough regular physical
activity
Often the main reason I’m
physically active is because
I don’t want others to think
less of me
I’m unsure how regular
physical activity can fit into
my life
I sometimes put off doing
physical activity so I have an
excuse if I don’t do well at
sport or don’t lose weight
I’ve pretty much given up
doing any regular physical
activity
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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Appendix P: Exercise Self-Efficacy Scale
Self-Efficacy to Regulate Exercise Scale
(Bandura, 1997)
A number of situations are described below that can make it hard to stick to
an exercise routing. Please rate in each of the blanks in the column how
certain you are that you can get yourself to perform your exercise routine
regularly (three or more times a week).
Rate your degree of confidence by recording a number between 0% - 100%
with 0% being “cannot do at all” and 100% being “highly certain can do”.
(Confidence 0-100%)
When I am feeling tired
_______
When I am feeling under pressure from work
_______
After recovering from an injury
_______
During bad weather
_______
During or after experiencing personal problems
_______
When I am feeling depressed
_______
When I am feeling anxious
_______
After recovering from an illness
_______
When I feel physical discomfort
_______
After a holiday
_______
When I have too much work to do at home
_______
When visitors are present
_______
When there are other interesting things to do
_______
If I don’t reach my exercise goals
_______
Without the support from my family/friends
_______
During a holiday
_______
When I have other commitments
_______
After experiencing family problems
_______
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Appendix Q: The Positive and Negative Affect Schedule
The Positive and Negative Affect Schedule
(PANAS; Watson et al, 1988)
This scale consists of a number of words that describe different feelings and
emotions. Read each item and then list the number from the scale below
next to each word. Indicate to what extent you feel this way right now
1
2
3
4
5
Very slightly
A little
Moderately
Quite a bit
Extremely
or not at all
__________ 1. Interested
__________ 11. Irritable
__________ 2. Distressed
__________ 12. Alert
__________ 3. Excited
__________ 13. Ashamed
__________ 4. Upset
__________ 14. Inspired
__________ 5. Strong
__________ 15. Nervous
__________ 6. Guilty
__________ 16. Determined
__________ 7. Scared
__________ 17. Attentive
__________ 8. Hostile
__________ 18. Jittery
__________ 9. Enthusiastic
__________ 19. Active
__________ 10. Proud
__________ 20. Afraid
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