Journal of Obsessive-Compulsive and Related Disorders 12 (2017) 102–108

Contents lists available at ScienceDirect

Journal of Obsessive–Compulsive and Related Disorders

journal homepage: www.elsevier.com/locate/jocrd

Review

Perfectionism in obsessive-compulsive disorder and related disorders: What MARK

should treating clinicians know?
⁎
Anthony Pintoa,b,c, , Navin Dargania, Michael G. Wheatond, Cynthia Cervonib, Clare S. Reese,
Sarah J. Egane
a
Department of Psychiatry, Hofstra Northwell School of Medicine, Hempstead, NY, USA
b
Division of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
c
Department of Psychiatry, Columbia University, New York, NY, USA
d
Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA
e
School of Psychology and Speech Pathology, Faculty of Health Sciences, Curtin University, Perth, Australia

A R T I C L E I N F O A BS T RAC T

Keywords: Perfectionism is known to be highly prevalent in obsessive-compulsive disorder (OCD). This review seeks to
Perfectionism explore perfectionism in OCD and related disorders, particularly in relation to treatment, in order to inform
Obsessive compulsive disorder treating clinicians. We also evaluate the potential role of perfectionism in the maintenance of OCD. Evidence
Treatment supports perfectionism as a transdiagnostic process central to the psychopathology of OCD and other mental
OCD
illnesses. Treatment outcomes in EX/RP for OCD are diminished in the presence of perfectionism, which is
thought to be due to inherent treatment interfering features of perfectionism. Successful OCD treatment has
been shown to decrease perfectionistic thinking, though data are mixed on whether reducing perfectionism
mediates subsequent reductions in OCD symptoms. Short-term cognitive behavioral protocols for perfectionism
are reviewed here and recommendations are made for the treatment of perfectionism in the context of OCD and
related disorders.

1. Introduction
Obsessive compulsive disorder (OCD) is characterized by recurrent,
intrusive, and distressing thoughts, images, or impulses (obsessions)
and repetitive mental or behavioral acts that the individual feels driven
to perform (compulsions) to prevent or reduce distress (APA, 2013).
OCD produces substantial impairment in social, family, and work
functioning (Koran, Leventhal, Fireman, & Jacobson, 2000).
Obsessions and compulsions are diverse and can be expressed with
great variability both within and across patients over time (Eisen et al.,
1998). Patients with OCD also differ in their course of illness, point of
onset, and comorbid clinical conditions. This heterogeneity in the OCD
clinical phenotype complicates research, possibly obscuring findings
and reducing power in studies of pathophysiology, course, and treat-
ment outcome. Dissecting the heterogeneous phenotype into less
complex, more homogeneous components could lead to the identifica-
tion of discrete mechanisms and the development of tailored treatment
strategies.
Categorical and dimensional symptom approaches have been
applied in research aimed at refining the phenotype of OCD (Miguel
et al., 2005). The use of symptom categories has been disputed, as most
patients with OCD are not monosymptomatic and typically present
with overlapping symptom clusters (Rufer, Frike, Moritz, Kloss, &
Hand, 2006). OCD symptom dimensions are also debated, due in part
to differences in clinical ascertainment, scoring, and statistical methods
across studies which have sometimes resulted in varying structures
(Bloch, Landeros-Weisenberger, Rosario, Pittenger, & Leckman,
2008).
While symptom subtyping remains unclear, there has been interest
in understanding the role of personality functioning in the psycho-
pathology of OCD, including comorbid personality disorders. Although
results are equivocal from studies that predate the DSM-IV (e.g., Baer
et al., 1990), most recent studies have suggested a strong link between
OCD and obsessive-compulsive personality disorder (OCPD). Studies
using DSM-IV criteria have consistently found elevated rates of OCPD
in OCD, with estimates ranging from 23% to 34% (Albert, Maina,
Forner, & Bogetto, 2004; Garyfallos et al., 2010; Lochner et al., 2011;
Pinto, Liebowitz, Foa, & Simpson, 2011; Samuels et al., 2000; Tenney,
Schotte, Denys, van Megen, & Westenberg, 2003) in comparison to
rates of OCPD in community samples. OCPD involves a chronic

⁎
Correspondence to: Anthony Pinto, Ph.D., OCD Center, Northwell Health-Zucker Hillside Hospital, Ambulatory Care Pavilion, 75-59 263rd Street, Glen Oaks, NY 11004, United
States.
E-mail address: apinto1@northwell.edu (A. Pinto).

http://dx.doi.org/10.1016/j.jocrd.2017.01.001
Received 3 May 2016; Received in revised form 22 December 2016; Accepted 6 January 2017
Available online 06 January 2017
2211-3649/ © 2017 Elsevier Inc. All rights reserved.
A. Pinto et al.
maladaptive pattern of excessive perfectionism, preoccupation with
orderliness and detail, and need for control over one's environment
that leads to significant distress or impairment, particularly in areas of
interpersonal functioning. Individuals with this disorder are often
characterized as rigid and overly controlling; they find relaxing difficult,
feel obligated to plan out their activities to the minute, and find
unstructured time unbearable (Pinto, Eisen, Mancebo, & Rasmussen,
2008). While evidence remains mixed (Gordon, Salkovskis, & Bream,
2015), OCPD has been associated with poor treatment response to both
exposure and response prevention (EX/RP) (Pinto, Liebowitz, Foa, &
Simpson, 2011) and SRI medications (Cavedini, Erzegovesi, Ronchi, &
Bellodi, 1997).
Due to limitations in categorical definitions of personality disorders
(Clark, 2007), a dimensional approach to personality, reflecting a
comprehensive explanatory model, may be more informative.
Determining the nature of the relationship between personality traits
and OCD may prove helpful in clarifying the disorder's etiology, based
on the theoretical view that certain personality traits may make
individuals vulnerable to the onset of the disorder. As personality
and psychopathology have a pathoplastic relationship (Widiger, 2011),
in which they can influence the presentation of each other, relating
personality dimensions to OCD symptoms may provide a means of
identifying more homogeneous phenotypes of the disorder (i.e., sub-
typing OCD based on the presence or absence of key personality traits),
relevant given recent work suggesting perfectionism may have a genetic
component (Di Nocera, Colazingari, Trabalza, Mamazza, &
Bevilacqua, 2014). Identifying homogenous subtypes of OCD with a
genetic component might enable individualized treatment recommen-
dations, in line with the goals of personalized medicine.
Perfectionism, as a maladaptive trait dimension, has been impli-
cated in understanding OCD since it is highly prevalent in patients with
OCD (Pinto et al., 2006) and has been shown to impede OCD treatment
(Pinto et al., 2011). Perfectionism is defined as the tendency to set and
pursue unrealistically high standards and to employ overly critical self-
evaluations (Frost, Marten, Lahart, & Rosenblate, 1990). While a
prominent feature of OCPD, perfectionism is also a distinct clinical
presentation. The Obsessive Compulsive Cognitions Working Group
(OCCWG, 1997) considers perfectionism to be a risk factor for the
development of OCD, and others consider it to be a necessary, but
insufficient, predisposing trait for the disorder (Rhéaume, Freeston,
Dugas, Letarte, & Ladoucer, 1995).
Some theoretical and empirical work suggests that perfectionism
may be a maintaining factor in OCD symptoms. This view is based on
several lines of evidence that will be reviewed here, including perfec-
tionism as a transdiagnostic process driving various pathologies (Egan,
Wade, & Shafran, 2011), the correlation between obsessive compul-
sive symptoms and perfectionism in both clinical and non-clinical
samples, and the positive effect of explicitly treating perfectionism on
comorbidities. Considering the impact of perfectionism on OCD
treatment outcome provides a new direction for research into evidence
based approaches for this population, including adapting evidence
based treatments for clinical perfectionism, which are reviewed here.
Although perfectionism itself has been increasingly researched and
recently reviewed (Egan et al., 2011), the present paper focused on the
co-occurrence of perfectionism within OCD. In particular, we sought to
review recent empirical work with implications for clinicians treating
OCD. We feel that this is an important endeavour for several reasons.
Based on high rates of co-occurrence, treating clinicians are highly
likely to encounter patients with OCD (and OCD-related disorders)
who demonstrate clinically significant perfectionism. The nature of
OCD symptoms can make it difficult to disentangle what is OCD and
what is best conceptualized as a separate issue with perfectionism; thus
reviewing the current conceptualization of perfectionism could help
clinicians make diagnostic determinations. In addition, recent data
suggests that perfectionism may represent a complicating factor in
OCD treatment, which treating clinicians should be aware of. Finally,
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Journal of Obsessive-Compulsive and Related Disorders 12 (2017) 102–108
evidence supports specifically-tailored CBT to target perfectionism,
perhaps offering clinicians an additional treatment option in such
cases.
To identify relevant empirical reports, we conducted a search of the
electronic databases PsycINFO, PsycARTICLES, Medline,
ScienceDirect and PubMed using the following key words: Obsessive-
Compulsive Disorder or OCD and perfectionism; Obsessive-
Compulsive Personality Disorder or OCPD and perfectionism; OCD,
perfectionism and treatment; perfectionism, treatment and outcome.
Article relevance was determined by screening titles and abstracts.
Reference lists of relevant articles were further screened for potentially
relevant studies. This review begins by defining perfectionism as both a
construct and transdiagnostic process. We then organized the results of
our literature review to focus on empirical studies of perfectionism in
OCD and OCD-related disorders, followed by the impact of perfection-
ism on treatment of these conditions. Next, we discuss treatments
focusing on perfectionism itself and how these may be incorporated
into OCD treatment. Finally, we review conclusions and offer directions
for future research in this area.
1.1. Perfectionism as a construct
While there has been increasing interest in the role perfectionism
plays in the etiology, maintenance, and treatment of a variety of
disorders, considerable debate continues regarding how perfectionism
should be defined. The multidimensional perspective (Frost et al.,
1990; Hewitt & Flett, 1991) considers perfectionism as being com-
prised of various intrapersonal and interpersonal domains. Hewitt and
Flett (1991) developed a multidimensional perfectionism scale, the
Hewitt-Flett Multidimensional Perfectionism Scale (HMPS), composed
of three dimensions: self-oriented perfectionism, in which one sets
stringent standards for oneself and focuses on perceived failures;
socially-prescribed perfectionism, or the perception that others have
unrealistically high standards for them; and other-oriented perfection-
ism, wherein one's own demanding standards and stern evaluations are
reflected onto others. Frost et al. (1990) developed another measure of
multidimensional perfectionism, the Frost Multidimensional
Perfectionism Scale (FMPS), which encompassed five dimensions:
concern over mistakes, setting high personal standards, perceiving
high parental expectations, parental criticism, and doubting the quality
of one's performance or actions. A comparison of these scales showed
that the FMPS global measure of perfectionism correlated highly with
the HMPS self-oriented and socially-prescribed subscales, and to a
lesser extent, the other-oriented scale (Frost, Heimberg, Holt, Mattia,
& Neubauer, 1993). Moreover, a factor analysis of the nine subscales
between the two questionnaires parsed out two distinct factors:
maladaptive evaluative concerns and positive striving, with only the
former contributing to perfectionism-associated psychopathology
(Frost et al., 1993).
Shafran, Cooper, and Fairburn (2002) proposed an alternative
construct informed by a cognitive-behavioral view of perfectionism:
clinical perfectionism is “the overdependence of self-evaluation on the
determined pursuit of personally demanding, self-imposed standards
despite adverse consequences” (p. 778). In emphasizing the valuation
of self-worth being tied to striving and success as the central tenet of
clinical perfectionism and proposing distinct cognitive mechanisms
that maintain this schema, they identify potential domains for treat-
ment focus (Riley & Shafran, 2005; Shafran et al., 2002). In response,
the Clinical Perfectionism Questionnaire (CPQ; Shafran et al., 2002)
was developed to measure perfectionism through striving for achieve-
ment and the effect of perceived success or failure on self-evaluation.
The CPQ is correlated with the personal standards and concern over
mistakes subscales of the FMPS (Egan, Piek, Dyck, Rees, & Hagger,
2013; Chang & Sanna, 2012; Egan et al., 2015), indicating notable
overlap between definitions of perfectionism.
A. Pinto et al.
1.2. Perfectionism as a transdiagnostic process in psychopathology
Perfectionism has been implicated across disorders and clinical
presentations. A clinical review by Egan, Wade, and Shafran (2011)
found elevated rates of perfectionism among participants with eating
disorders, as well as patients with anxiety disorders and mood
disorders. They argued that clinical perfectionism is a transdiagnostic
feature of these disorders, contributing to their onset and maintenance.
In addition to being a core symptom of OCPD, perfectionism has also
been implicated across personality disorders (Stoeber, 2014), offering
further evidence for the transdiagnostic role of perfectionism.
Research suggests that maladaptive perfectionism is a significant
vulnerability factor for depression (Rice & Aldea, 2006) and perfec-
tionism has been shown to impede the treatment of depression (Blatt,
Quinlan, Pilkonis, & Shea, 1995; Blatt, Zuroff, Bondi, Sanislow, &
Pilkonis, 1998). Further, socially prescribed perfectionism has been
uniquely associated with greater likelihood of suicidal ideation (Hewitt,
Flett, & Weber, 1994; Hewitt, Newton, Flett, & Callander, 1997) and
poorer marital adjustment for both the individual and the partner
(Haring, Hewitt, & Flett, 2003).
Perfectionism has been suggested as a maintaining mechanism for
eating disorders (Fairburn, Cooper, & Shafran, 2003), as the self-
appraisal and self-evaluation of patients with eating disorders are
contingent on striving to attain goals of controlling one's eating, weight,
and shape. In addition, treatment for perfectionism has been shown to
result in symptom reduction across comorbid conditions, including
those which were not directly targeted in treatment (Egan et al., 2011;
Egan, Wade, & Shafran, 2012). This is particularly evident when
considering the results of Steele and Wade (2008), who found that CBT
for perfectionism had the same impact on reducing eating disorder
behaviors as CBT for bulimia nervosa. Additionally, CBT for perfec-
tionism resulted in trends of larger effect size reductions in anxiety and
depression. These results reinforce the view that perfectionism is a core
feature driving symptomatology and a worthy target of intervention.
1.3. Perfectionism in OCD
Perfectionism is considered an important potential feature in OCD,
as it has been shown to impact treatment response (Kyrios, Hordern,
& Fassnacht, 2015; Pinto et al., 2011) and may contribute to the
maintenance of debilitating symptoms.
The role of perfectionism in OCD was highlighted by the OCCWG
(1997) as one of six belief domains in OCD. In addition to responsi-
bility, overestimation of threat, importance of thoughts, control of
thoughts, and intolerance of uncertainty, the OCCWG described
perfectionism as a cognitive process that is central to the etiology
and maintenance of OCD. Patients with OCD have been described as
being tormented by a need for certainty and perfection, which results in
overwhelming doubt about performing actions correctly (Rasmussen
& Eisen, 1992). When compared with nonclinical controls, patients
with OCD display significantly higher levels of perfectionism (Antony,
Downie, & Swinson, 1998; Antony, Purdon, Huta, & Swinson, 1998).
This elevation relative to healthy controls extends to several dimen-
sions of perfectionism, including socially prescribed perfectionism,
high personal standards, and concern over mistakes (Antony et al.,
1998; Boisseau, Thompson-Brenner, Pratt, Farchione, & Barlow,
2013; Frost & Steketee, 1997; Sassaroli et al., 2008). Measures of
perfectionism are positively correlated with measures of obsessive
compulsive symptoms in both nonclinical (Frost, Steketee, Cohn, &
Griess, 1994; Rhéaume, Freeston, Dugas, Letarte, & Ladouceur, 1995)
and clinical (Ferrari, 1995) samples, particularly with regard to
excessive concern over mistakes and doubts about actions. In addition,
perfectionism has been linked to specific types of OCD symptoms,
including ordering (Tolin, Woods, & Abramowitz, 2003), checking
(Gershunny & Sher, 1995), cleaning (Tallis, 1996), and hoarding
(Frost & Gross, 1993). Wu and Cortesi (2009) found that perfection-
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Journal of Obsessive-Compulsive and Related Disorders 12 (2017) 102–108
ism predicted checking, washing, and ordering symptoms in a student
sample.
Calvo et al. (2009) studied OCPD symptoms among parents of
children with OCD and healthy controls. They found perfectionism, as
well as hoarding and preoccupation with details, to occur significantly
more frequently in parents of children with OCD. Counting, ordering,
and cleaning compulsions in OCD children predicted elevated odds of
perfectionism and rigidity in their parents. Studies of samples of
children and adolescents with OCD have also reported positive
associations between perfectionism and OCD symptom severity. In a
study of 94 youth (aged 9–17 years old) Soreni et al. (2014) reported
that perfectionism predicted severity of both OCD and depressive
symptoms. In another recent study, Park et al. (2015) reported that a
measure of OCPD traits (including perfectionism) predicted checking,
symmetry, and contamination symptoms in a large sample of youth
with OCD.
Perfectionism in OCD may also clarify incompleteness, or ‘Not Just
Right Experiences’ (NJREs), which refer to feelings of tension or
discomfort that result from a desire to perform tasks perfectly or
completely (Coles, Frost, Heimberg, & Rhéaume, 2003).
Incompleteness and NJREs often exist in the context of OCD features
such as symmetry, counting, and repeating. In a large clinical sample of
individuals with OCD, Ecker and Gonner (2008) reported that incom-
pleteness was uniquely associated to the symmetry/ordering dimension
of OCD. Believed to also underlie obsessive compulsive personality
traits, particularly maladaptive perfectionism and indecisiveness, high
incompleteness scores in OCD predict meeting criteria for OCPD, and
OCD symptoms motivated by feelings of incompleteness are more
strongly related to OCPD than OCD symptoms motivated by harm
avoidance (Summerfeldt, Antony, & Swinson, 2000). More research is
needed to better understand the role of incompleteness in OCD and
OCPD.
For individuals with OCD, perfectionism appears to be a major
factor in NJREs, whereby a person performs a ritual in a highly specific
manner until they feel “just right” (Moretz & McKay, 2009), and
indeed, incompleteness has been found to be strongly correlated to
socially and personally prescribed perfectionism (Pietrefessa & Coles,
2008). In three studies conducted on large, undergraduate, non-clinical
samples, NJREs were significantly correlated with both OC symptoms
and facets of perfectionism (Coles, Frost, Heimberg, & Rheaume,
2003; Coles, Heimberg, Frost, & Steketee, 2005; Pietrefesa & Coles,
2008). In patients with OCD and perfectionism, perfectionism is often
seen through patients’ need to perform compulsions in “exactly the
right way” in response to their obsessions. Additionally, the absence of
perfect certainty may lead patients to doubt whether they have
correctly performed an action. Indeed, in a study of 51 residential
patients with OCD, Wetterneck al. (2011) found a significant relation-
ship between OCD severity and the doubt over actions domain of
perfectionism. They suggested that NJREs may occur when individuals
have high doubt over actions, combined with low levels of flexibility. A
subsequent investigation in residential OCD patients replicated results
that the doubts about actions domain of perfectionism predicted OCD
severity (particularly checking symptoms) and also revealed that the
organizational domain of perfectionism specifically related to ordering
symptoms (Martinelli et al., 2014)
1.4. Perfectionism in OCD-related disorders
Perhaps not surprisingly, perfectionism has been linked to many of
the OCD-related disorders, including body dysmorphic disorder
(BDD), hoarding disorder (HD), trichotillomania and skin picking
disorder. With regards to BDD, conceptual accounts of the disorder
suggest that some individuals’ dysmorphic concerns may be motivated
by an internal drive for perfectionism (Veale, 2004) and some empirical
work supports this notion. In an unscreened student survey, the
presence of BDD symptoms was significantly predicted by both self-
A. Pinto et al.
oriented perfectionism and socially prescribed perfectionism (Bartsch,
2007). Patients with BDD also evidence heightened levels of perfec-
tionism. For example, Buhlmann et al. (2008) compared BDD (N=19)
and OCD (N=21) patients with healthy controls (N=21) and reported
that both clinical groups evidenced elevated perfectionistic thinking
(measured with the Frost Multidimensional Perfectionism Scale)
relative to controls. Moreover, the BDD and OCD groups had equiva-
lent scores on five of the six subscales of perfectionism (with the
exception being that OCD patients endorsed greater perfectionism
relating to doubting actions), suggesting similar degrees of perfectio-
nistic thinking in the two disorders. In addition, relatively high rates of
comorbid OCPD have also been reported in BDD samples (12–28%;
Philips & McElory, 2000; Neziroglu et al., 1996), though avoidant
personality disorder appears to be more common. Importantly comor-
bid personality disorders have been linked to worse outcomes during a
naturalistic longitudinal study (Philips et al., 2005), though this study
did not examine perfectionism or OCPD in particular.
Perfectionism has also been consistently linked with hoarding
problems. In fact, difficulty discarding worn out or unneeded items
has been included as a criterion for OCPD, along with maladaptive
perfectionism, creating a historical association between the two
(Mataix-Cols et al., 2010). Cognitive-behavioral conceptualizations of
hoarding problems suggest that perfectionism and fear of making a
mistake may motivate excessive saving behavior for some individuals
(Frost & Gross, 1993). In line with this hypothesis, epidemiological
surveys have also found hoarding symptoms are associated with
perfectionism (Timpano et al., 2011). High rates of OCPD have also
been reported in HD (e.g., 45% in Samuels et al., 2002; 56.8% in
Landau et al., 2011). Importantly, perfectionism has been found to be a
complicating factor in CBT for HD (Muroff, Steketee, Frost, & Tolin,
2013).
Trichotillomania involves the recurrent pulling out of one's hair
resulting in noticeable hair loss, and some conceptual models of the
disorder cite perfectionism as a contributing factor for the disorder. For
example, some patients pluck eyebrow hairs because they want them to
be perfectly similar, and clinical reports note perfectionistic thinking as
a characteristic in the disorder (Duke, Keeley, Geffken, & Storch,
2010). However, little empirical work has been done in order to
determine whether perfectionism is a risk factor for trichotillomania,
although a single case report details a treatment course that utilized
CBT targeting perfectionism to successfully reduce hairpulling
(Pelissier & O'Connor, 2004). Perfectionism is also cited as a
contributing factor to pathological skin picking, in that many sufferers
begin picking at an area of imperfection/blemish that they fixate on
(Deckersbach, Wilhelm & Keuthen, 2003). In line with this observa-
tion, OCPD was found to be the most common personality disorder in
pathological skin picking, with 48% of sufferers meeting DSM-IV
criteria for OCPD in one study (Wilhelm et al., 1999).
1.5. Treatment outcome in OCD and OCD-related disorders when
perfectionism is present
Cognitive Behavioral Therapy (CBT) including EX/RP is the
psychotherapy of choice for OCD, with a number of controlled trials
(e.g., Foa et al., 2005) and meta-analytic studies (e.g., McKay et al.,
2014) supporting its efficacy. Despite this demonstrated efficacy, only
about 25% of patients achieve full recovery (Fisher & Wells, 2005) and
an estimated 25% refuse EX/RP or drop out of treatment (Foa et al.,
2005). Perfectionism has been suggested as a factor that may interfere
with treatment outcome in OCD (Frost, Novara, & Rheaume, 2002).
Higher scores on the doubt over actions subscale of the FMPS
predicted poorer outcome to both group and individual treatment for
OCD (Chik, Whittal, & O’Neill, 2008). Furthermore, Kyrios, Hordern,
& Fassnacht (2015) found that the perfectionism subscale of the
Obsessive Beliefs Questionnaire (OBQ) was the only subscale that
was a significant predictor of treatment outcome in OCD. In a study of
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Journal of Obsessive-Compulsive and Related Disorders 12 (2017) 102–108
patients with a principal diagnosis of OCD, comorbid OCPD and OCPD
severity each predicted poorer response to EX/RP. However, when
each OCPD criterion was tested separately, only perfectionism pre-
dicted worse treatment outcome (Pinto, Liebowitz, Foa, & Simpson,
2011).
In treating depression, perfectionism has been found to interfere
with response to treatment and the therapeutic relationship (Blatt
et al., 1995, 1998), perhaps explaining why individuals with OCD and
perfectionism have poorer responses to EX/RP. Data based on the
Treatment of Depression Collaborative Research Program (Elkin et al.,
1989) show perfectionism predicts poorer treatment outcome across
CBT, interpersonal therapy, and antidepressant medication at post
treatment (Blatt et al., 1995) and at 18 month follow-up (Blatt et al.,
1998). This pattern of poorer treatment response has also been shown
in adolescents with perfectionism receiving treatment for depression
(Jacobs et al., 2009). A study by Zuroff et al. (2000) found that patients
identified as high in perfectionism had smaller, if any, increases in
therapeutic alliance across therapy sessions than patients identified as
low in perfectionism. Additionally, the inability of patients high in
perfectionism to develop stronger therapeutic alliances mediated the
negative relationship between perfectionism and treatment outcome.
The authors suggest that perfectionistic patients may have more
difficulty moving beyond a certain level of openness with their
therapists and may not respond as constructively to inevitable disrup-
tions, strains, and fluctuations in the therapy process. Blatt and Zuroff
(2002) concluded that perfectionistic patients have greater interperso-
nal difficulty both in and out of treatment, which may clarify why many
clients with OCD and perfectionism have poorer responses to EX/RP.
Although EX/RP is the gold-standard psychotherapy treatment for
OCD, it is well-accepted that this treatment can be very stressful and
challenging for patients (Lee & Rees, 2011). Thus, if patients with
perfectionism become distressed about not progressing ‘perfectly’, they
may have difficulty eliciting the support of the therapist and may avoid
going to sessions, or even drop out of therapy (Frost, Novara, &
Rheaume, 2002).
Consistent with this view, Pinto et al. (2011) outlined four factors
through which perfectionism may interfere with treatment outcomes in
OCD: (1) The patient tries too hard to do treatment perfectly, (2) The
patient avoids or does not adhere to EX/RP tasks assigned between
sessions due to fear of not doing the tasks correctly, (3) The patient has
a narrow view of EX/RP and does not generalize exposures to new
situations, and (4) The patient gives up on trying in treatment if they
believe they are not making perfect progress (e.g., “If the treatment is
not going perfectly, why bother at all?”). In summary, perfectionism
can have a detrimental effect on treatment outcome in OCD. However,
the exact mechanism for this relationship has not yet been identified.
In studies involving psychotherapy for depression, perfectionism
appears to lead to worse therapy outcomes by impairing the therapeu-
tic alliance. This may also be true for psychotherapy for OCD, but no
published reports have yet investigated this possibility. In addition,
perfectionism appears to predict worse OCD treatment response with
medications (Cavedini et al., 1997) perhaps suggesting that perfectio-
nistic OCD patients are more refractory at a biological level.
Much less is known about the effect of perfectionism in the
treatment of OCD-related disorders. Muroff et al. (2013) examined
predictors of response in a sample of 37 patients with HD who received
26 sessions of individual CBT. Adjusting for baseline hoarding symp-
toms, perfectionism (as measured by the perfectionism subscale of the
Obsessive Beliefs Questionnaire) was a significant predictor of post-
treatment symptoms, suggesting that more perfectionistic patients had
less benefit from CBT for HD. Moreover, the authors speculated that
future therapy protocols for HD be adapted to more directly target
perfectionism (Muroff et al., 2013). Other research has been less clear
on the relationship between perfectionism and treatment outcome for
OCD-related disorders. Neziroglu et al. (1996) found no relationship
between Axis II diagnoses (including OCPD) and response to intensive
A. Pinto et al.
CBT in BDD, but did not investigate the role of perfectionism
specifically. Future research is needed in this area before firm conclu-
sions can be drawn.
1.6. Changes in perfectionism during OCD treatment
Recent studies report that obsessive beliefs related to perfectionism
significantly decrease following CBT for OCD, raising the possibility
that changes in perfectionism might be a mechanism of therapeutic
action. In a recent study of 36 adult OCD patients who underwent 24
weeks of cognitive therapy (including behavioral experiments, but
without systematic prolonged exposures), lagged mediational analyses
found that perfectionism and certainty beliefs predicted subsequent
reduction in OCD symptoms, suggesting that changes in perfectionism
mediated treatment response (Kyrios, Horden, & Fassnacht, 2015).
However, changes in beliefs (including those related to perfectionism)
accounted for a relatively small portion of change in OCD symptoms
(16%). Another study found partial support for the hypothesis that
changes in beliefs (including perfectionism) mediate reductions in OCD
symptoms during CBT, as significant mediator effects were found for
one analytic technique (traditional mediational analysis with Sobel
test), but not another more sophisticated test of mediation (bivariate
dual change score analysis) (Woody, Whittal, & McLean, 2011).
Importantly, a subsequent study in a sample of patients receiving
EX/RP found that although obsessive beliefs regarding perfectionism/
certainty did decrease significantly across EX/RP, reductions in these
beliefs did not mediate subsequent improvement in OCD symptoms
(Su, Carpenter, Zandberg, Simpson, & Foa, 2016). It is possible that
cognitive therapy and EX/RP for OCD work via different mechanisms
and more work is needed to investigate whether changes in perfection-
ism might lead to subsequent improvement in OCD symptoms.
1.7. Treatment for perfectionism
Given the potential that reducing perfectionism might improve
OCD treatment, the next section reviews recent work on treatments for
perfectionism broadly (i.e., outside of the specific OCD context). In
light of the significant consequences of perfectionism and its purported
role in contributing to a range of psychiatric conditions and their
treatment, interventions that explicitly target perfectionism have been
developed. The most thoroughly tested approach involves relatively
short term CBT (8–14 sessions) which meta-analysis suggests is
effective in reducing perfectionism (Lloyd, Schmidt, Khondoker, &
Tchanturia, 2015).
Fairburn, Cooper, and Shafran (2003) developed a protocol for
perfectionism from a cognitive behavioral treatment for eating dis-
orders, targeting four elements: (1) identifying perfectionism as a
problem and establishing its maintaining mechanisms (e.g., repeated
performance checking and avoidance); (2) conducting behavioral
experiments to challenge perfectionism-related beliefs (e.g., reducing
the frequency of checking behavior, exposure to avoided situations); (3)
cognitive-behavioral methods to address the individual's personal
standards, rigidity, and self-criticism; (4) broadening the individual's
self-evaluation by adopting alternative ways of thinking and behaving.
Importantly this protocol shares some similarities to CBT for OCD,
particularly in that some behavioral experiments to complete tasks
imperfectly resemble exposures in standard EX/RP (particularly those
targeting incompleteness or not just right experiences). However, CBT-
P typically involves targeting a broader class of behaviors and situa-
tions designed to fundamentally alter the patient's relationship to the
outside world so that he or she responds in a more flexible manner. In
light of these similarities CBT-P and EX/RP are compatible with one
another and can be deployed to focus narrowly on OCD-specific
situations or on tolerating imperfection more broadly.
Fairbun et al. (2002) tested this protocol implemented in ten
sessions over eight weeks in a randomized control trial (RCT) evaluat-
106
Journal of Obsessive-Compulsive and Related Disorders 12 (2017) 102–108
ing twenty participants who met criteria for clinical perfectionism,
fifteen of whom demonstrated significant reductions in clinical perfec-
tionism post-treatment (Riley, Lee, Cooper, Fairburn, & Shafran,
2007). The gains were maintained at eight and sixteen weeks after
the intervention, and the number of participants meeting criteria for
depressive and anxiety disorders was reduced from ten to four.
Pleva and Wade (2007) tested the effectiveness of self-help, CBT-
based therapy on perfectionism, OC, and depressive symptoms. The
interventions, based on the self-help book, When Perfect Isn’t Good
Enough (Antony & Swinson, 1998), took the form of guided self-help
(GSH, n=24) or pure self-help (PSH, n=25) therapy, with participants
being randomized to receive one or the other. At post-treatment
assessment, GSH was found to be superior to PSH in reducing
perfectionism, OC, and depressive symptoms, with effect sizes ranging
from 1.3 to 1.9. For the most part, gains in the GSH group persisted at
three-month follow-up suggesting that CBT-based self-help is an
effective treatment for perfectionism and associated OC symptoms.
Group format interventions were examined in a case study design
that compared group CBT versus psychoeducation for perfectionism
(Steele et al., 2013). Twenty-one participants from an outpatient
community psychiatry sample received eight 2 hour sessions conducted
over an 8-week period, derived from the manual Overcoming
Perfectionism (Shafran, Egan, & Wade, 2010). Both perfectionism
and negative affect were found to be significantly improved both
immediately post-treatment and at three month follow-up in the CBT
group, but not for psychoeducation alone (Steele et al., 2012). Further
evidence of group based CBT for perfectionism has also been shown in
a recent RCT (Handley, Egan, Kane, & Rees, 2015).
The effectiveness of CBT for perfectionism holds across treatment
formats. Egan and colleagues (2014) conducted an RCT that compared
face-to-face CBT for perfectionism (CBT-P; n=18), online self-help
CBT-P (n=16), and a waitlist control period (n=18). There was no
significant change for the waitlist control group on any of the outcome
measures at the end of treatment. Both in-person and online groups
reported significant reductions in perfectionism variables at the end of
treatment and at 6-month follow-up; however, effect sizes were more
robust for the face-to-face group. In addition, only face-to-face CBT-P
showed a significant decrease in depression, anxiety, and stress, and an
increase in self-esteem (Egan et al., 2014).
1.8. Implications for treatment of perfectionism in OCD
In this review, we present evidence that in addition to being
dysfunctional in its own right, perfectionism may complicate effective
treatment for OCD, due to cognitive styles inherent in clinical
perfectionism and the interpersonal difficulty associated with it.
Some data suggest that reductions in perfectionism precede change
in OCD symptoms, suggesting the benefit of incorporating therapy
elements directly targeting perfectionism in OCD treatment. While
short-term therapies for perfectionism have been developed and
demonstrated to be effective, there are no evidence-based guidelines
to suggest which treatment package to use when an individual has
comorbid disorders, a common occurrence in clinical practice (Craske,
2012). Guidelines have recently been outlined (Egan, Wade, &
Shafran, 2012) regarding selecting the most appropriate treatment
for a patient who has elevated perfectionism. These guidelines suggest
that the decision to proceed with disorder-specific or perfectionism-
specific treatment should be based on a functional analysis that
delineates the role of the perfectionism in the maintenance of the
specific disorder. It has also been suggested that disorder-specific
protocols should continue to be utilized unless the functional analysis
indicates that perfectionism is the primary maintaining factor across
disorders, or that it is impeding with treatment progress, for example,
through the patient trying to be ‘perfect’ in therapy (Egan, Wade, &
Shafran, 2012). Given the success of CBT-P in reducing OC sympto-
matology, it may be appropriate to integrate this intervention in the
A. Pinto et al.
event that perfectionism is interfering in EX/RP therapy. Further
research is needed to clarify treatment guidelines for individuals with
perfectionism and OCD.
1.9. Conclusions and future directions
Given the heterogeneity of the OCD phenotype, understanding
other possible confounding variables may aid research and clinical
outcomes. Evidence supports the relationship between OCD and
perfectionism, specifically regarding doubt about actions and concern
over mistake domains of perfectionism. When implicated, integrating
treatment for perfectionism with EX/RP for OCD may lead to greater
treatment response, though further research is needed to address this
directly.
This review also highlights important directions for future research
on the connection between perfectionism and OCD. Although fre-
quently cited as a factor in the development and maintenance of OCD,
much of the research conducted to-date has involved cross-sectional
methods. Thus future research with longitudinal methods is necessary
to determine the temporal relationship among these variables. In
particular, studies that manipulate perfectionism (for example by
specifically targeting it with CBT treatment) might be used to deter-
mine whether perfectionism contributes to OCD later in life and
whether such a strategy could be used for prevention. In addition,
our search results highlighted the potential role of perfectionism in the
other OCD-related disorders. Due to the relative novelty of this class of
disorders, research on the common factors across OCD-related dis-
orders remains in its nascent stages. Future research is needed to
continue to investigate why OCD and related disorders seem to be
particularly linked with perfectionism. Once sufficient research has
accumulated, quantitative reviews employing meta-analytic methods
would be helpful.
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