Youth perfectionism: Too much of a good thing

July 26, 2017|Psychiatry

EXPERT ANALYSIS FROM THE ANXIETY AND DEPRESSION CONFERENCE 2017

SAN FRANCISCO – Maladaptive perfectionism contributes to and is a risk factor for many common psychiatric disorders in children and adolescents, panelists said at the annual conference of the Anxiety and Depression Association of America.

“Perfectionism isn’t a disorder, it’s a personality style. Some of the kids who come in don’t meet criteria for any psychiatric disorder, they just have this personality style that really warrants treatment, because it is getting in the way of their living happy and productive lives. But I would say most of the time we see overlap with DSM Axis I disorders,” said Deborah Ledley, PhD, a clinical psychologist at the Children’s and Adult Center for OCD and Anxiety in Plymouth Meeting, Pa.

At this specialty clinic, most who are perfectionists also meet diagnostic criteria for generalized anxiety disorder. Perfectionism and obsessive-compulsive disorder (OCD) is another common combination.

“Basically, when people present with multiple disorders and underlying perfectionism, it might actually be more effective to target the perfectionism, rather than treating each disorder sequentially,” according to Dr. Ledley. “Do we really need to treat social anxiety and panic disorder, and a subclinical eating disorder, or can we say, ‘This person is a perfectionist – let us treat that and see if we can remit all those disorders.’”

That strategy often has proved successful for Dr. Ledley and her fellow panelist Lynne Siqueland, PhD, who also practices at the center. Both specialize in cognitive-behavioral therapy (CBT). They were quick to note that there are essentially no published studies on CBT for pediatric perfectionism. Nonetheless, they have found CBT to be quite effective in clinical practice, with the caveat that the standard, full-speed-ahead, 12-sessions-and-we’re done manualized approach to CBT as often applied to anxiety disorders, depression, and other CBT-amenable disorders will not work for perfectionistic youths.

“Perfectionists are often quite guarded and wary of treatment. We have found that jumping to therapy immediately can be a mistake,” Dr. Siqueland said. “We’ve learned the hard way that the most important part of treatment is you have to woo these people – carefully, slowly, addressing things that matter to them – because they don’t want to change, especially if perfectionism is working for them. The process of assessment must go beyond labeling or assigning a diagnosis. We need to get to know these kids and earn their trust. So we start with long conversations about life and values, and what’s working and not working for them.”

Dr. Ledley agreed. “We are not rushing with these patients,” she said. “This is so different from the way we are with an OCD patient, for example. When I have an OCD patient, I have the initial session with the parents, then an assessment session with the kid, then in the next session, I do some psychoeducation, and in the session after that, I’m doing exposures, because I work fast. Working with perfectionist kids is different: I have to earn their trust. I tell them a lot of stories about patients I’ve worked with who are just like them.”

How to spot maladaptive perfectionism

When the therapists meet with the parents for the first time – generally without the kids present – what they hear over and over again is, “My child is wound like a spring.” These are generally children who excel at everything: school, sports, music lessons, and other activities. And they are stressed out.

“These are the kids who are working on their Beethoven at age 8, trying to master the Moonlight Sonata. But the parents say the child is too hard on himself, freaking out over a grade less than 100% on a small quiz,” Dr. Ledley observed.

Sometimes, though, perfectionism backfires even in grade school, and the parents’ concern is not that their child is super accomplished yet not enjoying it, but rather that their kid has great potential and never gets anything done because of procrastination or an inability to hand in work that is less than perfect.

Dr. Ledley said when she first meets a perfectionist child, she typically sees a kid who looks perfect, has impeccable manners, and is mature beyond their years.

“They’re invested in coming across as successful in every way. They definitely do not let their guard down when you first meet them. But with these kids who look so perfect, we feel that there’s this fragility and fear, and delicacy lurking just below the surface. It’s almost like they’re afraid they’re going to break because they’re so held together,” according to the psychologist.

Once trust has been established and the youth has drawn up a requested list of the pros and cons of their perfectionism, Dr. Siqueland said, she hears a familiar refrain: “No freedom, no fun, no choice, no time for friends, tired all the time, and no sleep. That’s the usual list of the kids.”

The notion that hard-driving parents typically are at fault for pushing their child into perfectionism is a misconception.

“In our practice, I would say it’s self-induced perfectionism in 75% of cases,” according to Dr. Siqueland.