Nurse Educator
Vol. 37, No. 5, pp. 202-205
Nurse Educator
Understanding Maladaptive Perfectionism in
College Students
Elizabeth Christman, BSN, RN
Admission to nursing programs is highly competitive. Students strive for excellence, but their pursuit of perfectionism may
become unhealthy. The author explores current literature to help faculty understand differences in adaptive perfectionism
versus maladaptive perfectionism, recognize the signs of maladaptive perfectionism, be aware of the influencing forces,
distinguish common effects from critical manifestations, and explore intervention strategies.
S
tudents enter college facing unique and challeng-
ing opportunities and confront unexpected daily
stressors. Many are in unfamiliar communities, with
little or no support system and are first-generation college
students. They may be uncertain of the work necessary to
be successful. Whatever each student’s circumstance, col-
lege provides a beginning taste of freedom that is tempered
with a steady dose of pressure and responsibility.
To understand maladaptive perfectionism among col-
lege students, an extensive literature search using search
terms ‘‘maladaptive perfectionism’’ and ‘‘perfectionism’’ in
‘‘college students’’ produced research in the areas of
sociology, psychology, and medicine. When the search
was limited to PubMed’s nursing journals from present to
1990, 2 articles addressing perfectionism were found. The
editorial was excluded; the nursing research–based article
is included here.
Perfectionism: Adaptive
Versus Maladaptive
Although striving for excellence is important and admira-
ble, this perfectionism can become a problem for stu-
dents. Because it is positive and negative, it is necessary to
distinguish between adaptive and maladaptive perfection-
ism. Maladaptive perfectionists are those who ‘‘set high
standards but view themselves as never seeming to meet
their own high expectations’’1(p21) and involves pursuing
excellence to an unhealthy extreme.2 For example, students
who received an ‘‘A’’ on an examination may be fixated on
a small point deduction. These students perceive the assign-
ment as a failure because they did not achieve perfection.
As a result, they may perceive themselves as a failure.
Author Affiliation: Graduate Student, College of Nursing and Health
Sciences, University of Wisconsin–Eau Claire, Eau Claire, Wisconsin.
The author declares no conflict of interest.
Correspondence: Ms Christman, University of Wisconsin-Eau Claire,
105 GarfieldAve., Eau Claire, WI 54702-4004 (harelsei@uwec.edu).
DOI: 10.1097/NNE.0b013e318262aba3
202 Volume 37 & Number 5 & September/October 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Copyright * 2012 Wolters Kluwer Health |
Lippincott Williams & Wilkins
Maladaptive perfectionists are also prone to narcis-
sism, which has been described as a fragile self-esteem
hidden by a ‘‘veneer of self-confidence.’’3(p188) These per-
fectionists have an unhealthy sense of purpose that is fo-
cused on being superior to others.
Students with adaptive perfectionism wish to excel,
set goals, and feel ‘‘pride and accomplishment’’ when the
goal is achieved.1(p22) Adaptive perfectionists’ ambition for
achievement is a motivating, not paralyzing force.4 They
differ from maladaptive perfectionists as they self-evaluate
less than perfect results. Maladaptive perfectionists set forth
unreasonable standards and exhibit less self-worth when
imperfect outcomes are achieved, whereas adaptive perfec-
tionists see the positive results of their hard work, despite
the less than perfect results.5
Signs of Maladaptive Perfectionism
Maladaptive perfectionism is characterized by an attitude
of being unreasonable. Maladaptive perfectionists experi-
ence a sense of persistent dissatisfaction that culminates in
a feeling of ‘‘unrelenting distress.’’5(p223) This distress is
seen in various ways. Maladaptive perfectionist expression
can include depression, performance anxiety, social anxiety,
writer’s block, procrastination, study inefficiency, overcom-
mitting, and obsessive-compulsive characteristics.4-6 They
may exhibit increased psychological distress, have less so-
cial support, be less agreeable, and react with aggressive-
ness.3 Faculty must be aware of these signs, indicating
students may be struggling with maladaptive perfectionism.
In addition, maladaptive perfectionists may be more
stubborn, have more difficulty engaging in group activities,
and challenge faculty.7 They also may have increased stress
levels and exhibit persistent signs of worry or fear of fail-
ure.1 Increased stress was also examined by O’Brien and
Page8 in a study examining the perfectionism and stress
among Canadian nurses. They found a correlation between
socially prescribed perfectionism and life/job satisfaction.
Striving for perfectionism in the workplace appeared to
affect nurses’ ability to enjoy activities in day-to-day life.
Nurse Educator
 Although maladaptive perfectionism may be seen across
the life span, research suggests college students are at an
increased risk. Students set high standards for success, which
are valued in the academic environment.9 Students strive for
validation by peers and professors and look for success in
their future. They experience pressures that are self-imposed
and pressures imposed by others.
Influencing Forces
Various influencing forces trigger maladaptive perfection-
ism. Frost et al10 suggested that perfectionist behavior is
generated from personal standards, concern over mistakes,
parental expectations and criticism, doubts about actions,
and an overemphasis on organization. These factors do not
lead inherently to maladaptive perfectionism but may in-
crease the potential for maladaptive behaviors.
Childhood relationships, emotional functioning, and
personality11 seem to influence perfectionist behaviors.
Hamachek2 proposed that perfectionism develops in re-
sponse to parental approval, whereas Sorotzkin12(pp87-89)
found that ‘‘parents of maladaptive perfectionists tend to
be nonapproving or inconsistently approving.’’ Bandura’s
social learning model also provides a valuable approach
to examine the origin of perfectionist behavior. He pro-
posed that children learn behavior by ‘‘observing and imi-
tating the behavior of others.’’11(p120) Two studies showed
a positive correlation between perfectionist behavior in
parents and children.13,14 Despite the correlation, it is not
known if perfectionist behavior has a genetic or learned
component. Regardless of cause, the relationship between
parents and students provides important clues about the
development of maladaptive perfectionism.
Other research emphasized the importance of attach-
ment bonds in maladaptive versus adaptive perfectionists.
Insecure attachment bonds are most often seen in mal-
adaptive perfectionists.15 Insecure attachment (eg, indif-
ference, overindulgence, and excessive criticism) is linked
to negative experiences with parental figures.11 In contrast,
secure attachment is seen with parents who are supportive
and encourage autonomy. Examples of secure attachment
include positive reinforcement, independent skill building,
and constructive critique.11
In addition to parental attachment bonds, social in-
fluence may affect perfectionist tendencies. Flett et al16
proposed a social reaction model where people develop
perfectionist tendencies that result from disturbing family
or social circumstances. This model contends that perfec-
tionist behavior stems from coping with difficult situations.
For example, a student may develop an eating disorder in
response to perfectionist pressures from her family as she
prepares for a competitive nursing school application. Striv-
ing for physical perfection manifests the pressures of this
high-stakes review.
Besides family pressures, the model helps describe the
social pressures found in a college environment. Emphasis
on achievement is a foundational aspect of the educational
environment that sets high standards and may create per-
fectionist tendencies. Additional environmental pressures,
such as culture as well as peer and occupational pressure,
may also influence perfectionist tendencies.1,4
Nurse Educator
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Common Effects of Perfectionism
Educators are becoming increasingly concerned with the
common effects of maladaptive perfectionism. Because of
an initial fear of failure, students try to prevent failure to
avoid the shame of disappointment. This stems from ‘‘fear
of experiencing shame and embarrassment, fear of de-
valuing one’s self-estimate, fear of having an uncertain
future, fear of important other’s losing interest, and fear of
upsetting important others.’’17(p603) Students overcome
with fear of failure may challenge educators for increased
direction. For example, students may request examples of
‘‘A’’ assignments from previous classes despite instructions
detailed in the course syllabus. The students may also re-
quest to submit assignments for feedback prior to receiv-
ing the final assignment grade. Educators must recognize
these types of behaviors may demonstrate maladaptive
perfectionism. That is, students desire assurance that their
assignment is perfect to avoid the fear of point deductions
and self-imposed failure.
Fear of failure may also escalate to greater levels of
maladaptive perfectionism including poor self-esteem and
decline in self-worth. When their high performance is less
than perfect, maladaptive perfectionists’ self-esteem remains
low, and they experience vulnerability.2
Educators may see this vulnerability as students com-
pare their performance to a peer group. Students’ self-
visualized success is often marked by competition with other
high performers in their class. Students may visualize them-
selves as succeeding only if receiving the top score in the
class. For example, educators may witness a student with
maladaptive perfectionist tendencies obsessively questioning
peers regarding their score on an assignment. Maladaptive
perfectionists gauge their sense of personal accomplish-
ment in comparison with peers. When maladaptive perfec-
tionists perform at a more moderate level, they may feel a
decline in self-esteem and self-worth. This places maladap-
tive perfectionists at risk for depression.
Depression in college-age students is manifested by
disruption in self-development and difficulties with college
adjustment. Anxiety, as one outcome of depression, is often
overwhelming and beyond individual control.1 It can lead
to apprehension, concern, and worry regarding both major
and minor life events. Educators must closely monitor stu-
dents for signs of depression and excessive anxiety in order
to offer early intervention. For example, nursing educators
expect students to have a degree of anxiety when entering
a new clinical environment. However, if a student appears
late, disheveled, and tearful the first day of a clinical rota-
tion, the amount of anxiety demonstrated by the student
warrants further investigation by the educator.
Two studies examined the relationship between de-
pression and maladaptive perfectionism. Although their study
was conducted with a small sample, Preusser et al18 found
a strong correlation between maladaptive perfectionist be-
havior and self-esteem with resultant depressive symptoms.
When additional examination of self-esteem and depression
was completed in a larger sample of university students
(N = 400), the correlation of self-esteem and depression was
less strongly supported.19 Further investigation between
these 2 facets is needed before making strong assertions.
Volume 37 & Number 5 & September/October 2012 203
Critical Manifestations
Maladaptive perfectionist manifestations may escalate from
fear of failure, depression, and anxiety into more serious
conditions. These include eating disorders, substance abuse,
and suicidal ideation.3
Eating Patterns
Researchers have examined the connection between per-
fectionist behaviors and disordered eating patterns. Forbush
et al20 conducted a large quantitative study (N = 2,482) with
college students in northeast United States and found that
women and men with a lifetime history of disordered eat-
ing (eg, fasting, binging, self-induced vomiting, diuretic or
laxative abuse) had higher levels of perfectionism than
those who did not report an eating disorder. Associations
showed the strongest correlation for fasting and purging.
Miller-Day and Marks21 also found a strong correlation be-
tween college students’ perfectionist behavior and subsequent
disordered eating. They also found a significant relationship
between perfectionist behaviors and parental communica-
tion patterns. This suggests that college students desiring
to conform to high parental standards may be at increased
risk for exhibiting maladaptive eating behaviors.
Substance Abuse
In addition to disordered eating, substance abuse may also
be a critical manifestation of maladaptive perfectionism. Flett
et al22 identified certain personality traits that place college
students at increased risk for binge drinking. Several traits
were found to be predictors of alcohol disorders including
anxiety, neuroticism, impulsiveness, and perfectionism.23
The self-induced pressure by maladaptive perfectionist stu-
dents may lead to substance use as a type of stress release.
Students may use chemicals as a way to numb themselves
to the emotion associated with their fear of failure or anx-
iety. When educators are cognizant of this potential risk
among perfectionist students, they are better able to offer
early intervention such as referral to campus or community
counseling services.
Suicidal Ideation
Suicidal ideation and behavior emerge as the most critical
manifestations. Research surrounding suicide and perfec-
tionism is complicated by other contributing factors such
as depression and anxiety; however, many recent studies
have begun to examine the correlation. In a recent system-
atic review by O’Conner,23 30 studies were reviewed that
measured perfectionism and self-criticism in relation to
suicidality in adults. He reported that the evidence sug-
gested perfectionist behavior was strongly correlated with
suicidality.23
Several researchers have studied the relationship be-
tween suicide and perfectionist behaviors in young adult
and college-age populations. Cross et al,24 as well as Hamilton
and Schweitzer,4 found the connection between perfec-
tionism and suicide to be especially high among academ-
ically gifted and high-achieving students. It may be that this
population has been conditioned for success, and anything
less than perfection is difficult to accept. In a case study
analysis of 20 suicides in the United Kingdom, Bell et al9
204 Volume 37 & Number 5 & September/October 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
also examined the role of perfectionism in student suicide.
They determined, through family interview, that 10 of the
20 students had maladaptive perfectionist behavior prior to
committing suicide. Closer examination of 3 of the cases
found that individuals were caught in peak psychological
turmoil with unrealistically high standards that resulted in
great frustration and disappointment.
Critical manifestations may emerge as a result of a neg-
ative decision during a high-stakes situation. Educator short-
age and funding challenges have led to a competitive
nursing program admission. For example, a student with a
3.6 GPA may be turned away because of a strong candidate
pool. If the student’s advisor recognizes this individual as
a gifted high performer, careful attention to counseling is
warranted. It is important for educators and advisors to
support and guide students during significantly disappoint-
ing times.
Intervention Strategies
When educators are aware of maladaptive perfectionist
behaviors, they are better able to intervene. Many per-
fectionist students will not seek out assistance because
they see this as an admission of failure,1,4 it is even more
important for those who witness perfectionist behavior to
offer guidance.
There is limited research regarding interventions for
maladaptive perfectionists. In a small study by Ferguson
and Rodway,25 7 of 9 participants who underwent cog-
nitive behavioral therapy such as restructuring, role play-
ing, and relaxation showed a reduction in the levels of
perfectionism. In addition, there have been many recom-
mended, but not tested, interventions. Kearns et al1 described
these interventions, which include identifying advantages
and disadvantages of perfectionism, finding other sources
of pleasure and self-worth, keeping a perfectionist diary,
identifying triggers, and developing goals and plans for
change.
Halgin and Leahy5 described the importance of re-
ferring individuals with maladaptive perfectionism for ex-
pert mental health evaluation. Mental health professionals
address maladaptive perfectionism by helping the individ-
ual ‘‘(a) develop insight about developmental determinants
of his/her perfectionism, (b) formulate more effective and
more realistic reinforcements for his/her accomplishments,
(c) discover a sense of self-worth that is engendered by the
counselor’s concern, empathy, and positive regard.’’5(p224)
The treatment plan is tailored to individual circumstance and
manifestation. Educators who recognize important warning
signs are then able to refer students for individualized ex-
pert intervention in a timely way.
If nursing educators are aware of maladaptive per-
fectionist behaviors, they can take action to help students
address them. For example, nurse educators can stress the
importance of learning from one’s errors. An activity that
may invite this would be to engage students in correcting
mistakes following an examination and offering a per-
centage of points back to students who correct mistakes
with supporting rationale. Stressing the value of learning
from one’s mistakes is the key component of this activity.
Because students look to educators as practice experts,
role modeling is crucial. Educators must remind students
Nurse Educator
that nursing is a profession requiring lifelong learning, and
they too started as novice nurses and made mistakes along
the way. Acknowledging the universal inability to achieve
perfection demystifies the notion that to be an excellent
nurse one must be fault-free. Rather, educators must stress
the importance of acknowledging uncertainty and seeking
out resources.
Educators can also challenge maladaptive perfection-
ist students’ mindset with role-play activities. Role playing
may be valuable when discussing emotionally charged
issues such as ethical practice dilemmas. Educators may
present an ethical dilemma and have students write down
their viewpoint/argument regarding the issue. The educa-
tor would then collect all of the arguments and match stu-
dents with a partner who shared an opposing viewpoint.
Each participant would then debate the issue taking the
opposing person’s viewpoint. This activity focuses on col-
laboration and shared learning. It negates the sense that
there is only one ‘‘right’’ and everyone else is ‘‘wrong.’’ This
activity helps diminish the superiority mindset held by some
maladaptive perfectionists.
Conclusion
Students face pressures as they enter the college environ-
ment. These pressures can lead to unhealthy expression in
the form of maladaptive perfectionism, especially in com-
petitive disciplines such as nursing. When educators under-
stand differences in maladaptive versus adaptive perfectionism,
are aware of maladaptive signs of perfectionism, recognize
influencing forces, and distinguish common effects from crit-
ical manifestations, they are well positioned to intervene
using teaching strategies and refer students for additional
intervention. In this way, college students can balance learn-
ing and stimulation with pressure and responsibilities.
References
1. Kearns H, Forbes A, Gardiner M, Marshall K. When a high dis-
tinction isn’t good enough: a review of perfectionism and
self-handicapping. Aust Educ Res. 2008;35(3):21-36.
2. Hamachek DE. Psychodynamics of normal and neurotic per-
fectionism. Psychology. 1978;15:27-33.
3. Rice KG, Dellwo JP. Perfectionism and self-development: im-
plications for college adjustment. J Couns Dev. 2002;80:188-196.
4. Hamilton TK, Schweitzer RD. The cost of being perfect: per-
fectionism and suicide ideation in university students. Aust N
Z J Psychiatry. 2000;34:829-835.
5. Halgin RP, Leahy P. Understanding and treating perfectionist
college students. J Couns Dev. 1989;68:222-225.
6. Boice R, Jones F. Why academians don’t write. J High Educ.
1984;55:567-582.
Nurse Educator
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
7. Ferrari JR, Mautz WT. Predicting perfectionism: applying tests
of rigidity. J Clin Psychol. 1997:531-536.
8. O’Brien S, Page S. Self-efficacy, perfectionism, and stress in
Canadian nurses. Can J Nurs Res. 1994;26(3):49-61.
9. Bell J, Stanley N, Mallon S, Manthorpe J. The role of per-
fectionism in student suicide: three case studies from the UK.
OMEGA. 2010;61(3):251-267.
10. Frost RO, Marten P, Lahart C, Rosenblate R. The dimensions
of perfectionism. Cogn Ther Res. 1990;14:449-468.
11. Rice KG, Lopez FG. Maladaptive perfectionism, adult attach-
ment, and self-esteem in college students. J Coll Counsel. 2004;7:
118-128.
12. Sorotzkin B. Understanding and treating perfectionism in reli-
gious adolescents. Psychotherapy. 1998;35:85-89.
13. Frost RO, Marten P, Lahart C, Rosenblate R. The development
of perfectionism: a study of daughters and their parents. Cogn
Ther Res. 1991;15:469-489.
14. Chang EC. Perfectionism as a predictor of positive and neg-
ative psychological outcomes: examining a mediation model
in younger and older adults. J Couns Psychol. 2000;47:18-26.
15. Rice KG, Mirzadeh SA. Perfectionism, attachment, and adjust-
ment. J Couns Psychol. 2000;47:238-250.
16. Flett GL, Hewitt PL, Oliver JL, MacDonald S. Perfectionism in
children and their parents: a developmental analysis. In: Flett
GL, HewittPL, eds. Perfectionism: Theory, Research, and Treat-
ment. Washington, DC: American Psychological Association; 2002.
17. Sagar SS, Stoebel J. Perfectionism fear of failure, and affective
responses to success and failure: the central role of gear and
experiencing shame and embarrassment. J Sport Exerc Psychol.
2009;31:602-627.
18. Preusser KJ, Rice KG, Ashby JS. The role of self-esteem in
mediating perfectionism-depression connection. J Coll Stud
Dev. 1994;35:88-93.
19. Rice KG, Ashby JS, Slaney R. Self-esteem as a mediator be-
tween perfectionism and depression: a structural equations
analysis. J Couns Psychol. 1998;45:304-314.
20. Forbush K, Heatherton TF, Keel PK. Relationship between
perfectionism and specific disordered eating behaviors. Int J
Eat Disord. 2007;40(1):37-41.
21. Miller-Day M, Marks JD. Perceptions of parental communication
orientation, perfectionism, and disordered eating behaviors of
sons and daughters. Health Commun. 2006;19(2):153-163.
22. Flett GL, Goldstein A, Wall A, Hewitt PL, Wekerle C, Azzi N.
Perfectionism and binge drinking in Canadian students making
the transition to university. J Am Coll Health. 2008;57(2):249-253.
23. O’Conner R. The relations between perfectionism and sui-
cidality: a systematic review. Suicide Life Threat Behav. 2007;
37(6):698-714.
24. Cross TL, Gust-Brey K, Ball PB. A psychological autopsy of
the suicide of an academically gifted student: researchers’ and
parents’ perspectives. Gifted Child Q. 2002;46(4):247-264.
25. Ferguson K, Rodway M. Cognitive behavioral treatment of
perfectionism: initial evaluation studies. Res Soc Work Pract.
1994;4:283-308.
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