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Background: Over 50 years of theory and research implicates perfectionism in anxiety. However, it is unclear which (if any) perfectionism dimensions are risk factors for anxiety. Objective: To address this, we conducted a meta-analysis testing whether socially prescribed perfectionism, concern over mistakes, doubts about actions, self-oriented perfectionism, and personal standards predict increases in anxiety. Method: Our literature search yielded 11 relevant studies for inclusion, composed of children, adolescents, undergraduates, community adults, and psychiatric patients. Results: Meta-analysis using random-effects models revealed concern over mistakes (r+ = .11), doubts about actions (r+ = .13), and personal standards (r+ = .08), but not socially prescribed perfectionism or self-oriented perfectionism, displayed significant small positive relationships with follow-up anxiety, after controlling for baseline anxiety. Conclusion: Research is needed to understand the conditions under which the connection between perfectionism and anxiety becomes stronger (e.g., stress).
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Running head: PERFECTIONISM AND ANXIETY 1
Are Perfectionism Dimensions Risk Factors for Anxiety Symptoms?
A Meta-Analysis of 11 Longitudinal Studies
Martin M. Smith
University of Western Ontario
Vanja Vidovic, Simon B. Sherry and Sherry H. Stewart
Dalhousie University
Donald H. Saklofske
University of Western Ontario
Author Note
Martin M. Smith and Donald H. Saklofske, Department of Psychology, University of Western
Ontario. Vanja Vidovic and Simon B. Sherry, Department of Psychology and Neuroscience,
Dalhousie University. Sherry H. Stewart, Department of Psychology and Neuroscience,
Dalhousie University, and Department of Psychiatry, Dalhousie University.
Correspondence concerning this article should be addressed to Martin M. Smith, Department of
Psychology, University of Western Ontario, London N6A 5C2, Canada.
E-mail: msmit454@uwo.ca.
Smith, M. M., Vidovic, V., Sherry, S. B., Stewart, S. H., & Saklofske, D. H. (accepted).
Are perfectionism dimensions risk factors for anxiety symptoms? A meta-analysis of 11
longitudinal studies. Anxiety, Stress, & Coping.
PERFECTIONISM AND ANXIETY 2
Abstract
Background: Over 50 years of theory and research implicates perfectionism in anxiety.
However, it is unclear which (if any) perfectionism dimensions are risk factors for anxiety.
Objective: To address this, we conducted a meta-analysis testing whether socially prescribed
perfectionism, concern over mistakes, doubts about actions, self-oriented perfectionism, and
personal standards predict increases in anxiety. Method: Our literature search yielded 11
relevant studies for inclusion, composed of children, adolescents, undergraduates, community
adults, and psychiatric patients. Results: Meta-analysis using random-effects models revealed
concern over mistakes (r+ = .11), doubts about actions (r+ = .13), and personal standards (r+ =
.08), but not socially prescribed perfectionism or self-oriented perfectionism, displayed
significant small positive relationships with follow-up anxiety, after controlling for baseline
anxiety. Conclusion: Research is needed to understand the conditions under which the
connection between perfectionism and anxiety becomes stronger (e.g., stress).
Keywords: perfectionism; anxiety; longitudinal; meta-analysis
PERFECTIONISM AND ANXIETY 3
Are Perfectionism Dimensions Risk Factors for Anxiety Symptoms?
A Meta-Analysis of 11 Longitudinal Studies
Everyone is anxious sometimes (Salunke, 2013), but pathological anxiety is characterized
by persistent and excessive fear, worry, physical arousal, and avoidance (Benson-Martin, Stein,
& Hollander, 2009). These anxiety symptoms cause profound distress for affected individuals
and negatively impact their social relationships, occupational function, and family dynamics
(Benson-Martin et al., 2009). Unfortunately, anxiety is one of the most common mental health
problems (Lépine, 2002; Spinhoven et al., 2016), and co-occurs with many other undesirable
experiences and outcomes, including depressive symptoms, substance abuse, and eating
disorders (Benson-Martin et al., 2009; Swinbourne & Touyz, 2007). Hence, given the personal
disability and the economic burden associated with anxiety (e.g., Lépine, 2002), there is clearly
merit in advancing our understanding of anxiety’s etiology.
To this end, there is increased interest in advancing our understanding of the pre-morbid
personality of anxious individuals (e.g., Calkins et al., 2009; Weinstock & Whisman, 2006). One
personality trait linked to anxiety is perfectionism, with Moser et al. (2012) proposing the
association between anxiety and perfectionism is partially due to genetic factors. Another theory
(e.g., Dunkley et al., 2003) states the relation between perfectionism and anxiety is primarily
attributable to unhealthy coping strategies, such as escape-avoidance (Gnilka, Ashby, & Noble,
2012). Finally, a third theory rests on cognitive explanations (Klibert et al., 2015). As proposed
by Ellis (2002), perfectionists are vulnerable to experiences of anxiety because of maladaptive
approaches to happiness and survival (e.g., they vigorously pursue accomplishment and
approval, while negatively appraising failures and set-backs; Klibert et al., 2015).
Despite these theories, there is a paucity of research directly examining relations between
PERFECTIONISM AND ANXIETY 4
perfectionism and longitudinal changes in anxiety symptoms, while controlling for baseline
anxiety. In fact, most investigators use cross-sectional designs which, unlike longitudinal
designs, cannot address temporal precedence. Accordingly, whether perfectionism leads to
increases in anxiety is unclear, and clinicians can only speculate as to whether reducing
perfectionism reduces anxiety symptoms. Moreover, given evidence that correlations do not
stabilize until N > 250 (Schönbrodt & Perugini, 2013), several studies on perfectionism and
anxiety are underpowered and limited in their ability to draw firm conclusions (e.g., Joiner &
Schmidt, 1995). As such, the field would benefit from a single analysis that coherently organizes
extant findings and addresses limitations associated with small samples. Accordingly, we
conducted a rigorous meta-analytic review testing the extent to which different perfectionism
dimensions predict longitudinal increases in anxiety symptoms over time.
Perfectionism Dimensions and Anxiety Symptoms
The majority of common variance among several core perfectionism dimensions is
accounted for by two higher-order factors: perfectionistic concerns and perfectionistic strivings
(Stoeber & Otto, 2006). Traits comprising perfectionistic concerns include socially prescribed
perfectionism (perceiving that others demand perfection; Hewitt & Flett, 1991), concern over
mistakes (highly negative reactions to perceived failures; Frost, Marten, Lahart, & Rosenblate,
1990), and doubts about actions (uncertainty regarding performance abilities; Frost et al., 1990).
Similarly, perfectionistic strivings consist of a family of traits, including self-oriented
perfectionism (demanding perfection of oneself; Hewitt & Flett, 1991) and personal standards
(holding unreasonably high standards; Frost et al., 1990).
Facets of perfectionistic concerns, such as concern over mistakes and doubts about
actions (Minarik & Ahrens, 1996), as well as socially prescribed perfectionism (Antony, Purdon,
PERFECTIONISM AND ANXIETY 5
Huta, & Swinson, 1998; Hewitt & Flett, 1991), are linked to increases in anxiety. In contrast, the
literature on perfectionistic strivings and anxiety reports less consistent findings, with some
studies suggesting perfectionistic strivings are beneficial and others warning that they confer
vulnerability for anxiety. For instance, Joiner and Schmidt (1995) found that, although socially
prescribed perfectionism predicted both depression and anxiety, self-oriented perfectionism
predicted only depression (and not anxiety). Similarly, Antony and colleagues (1998) observed
that anxious and non-anxious groups in their study did not differ on ratings of self-oriented
perfectionism, and Klibert et al. (2015) failed to find an association between self-oriented
perfectionism and generalized anxiety symptoms. This lack of association is inconsistent with
Hewitt and Flett’s (2002) contention that individuals with high self-oriented perfectionism are
vulnerable to psychopathology, including generalized anxiety (Klibert et al., 2015). The absence
of significant correlations between perfectionistic strivings and anxiety is also at odds with
recent research providing evidence of both perfectionistic concerns and perfectionistic strivings
being transdiagnostic factors, given their association with various forms of psychopathology
(Limburg et al., 2016; Egan, Wade, & Shafran, 2011). Accordingly, the relationship between
perfectionistic strivings and anxiety remains unclear and contentiously debated.
Advancing Research on Perfectionism and Anxiety Symptoms Using Meta-Analysis
A meta-analysis could elucidate between-study inconsistencies and address questions of
which specific dimensions of perfectionism confer risk for anxiety by providing a quantitative
synthesis of extant literature and allowing for an overall conclusion to be reached (Smith et al.,
2016). Advantages of a meta-analysis will help overcome limitations associated with small
sample sizes (Card, 2012), facilitating understanding of the longitudinal effects of perfectionism
dimensions on anxiety. This approach will be particularly useful in clarifying inconsistencies in
PERFECTIONISM AND ANXIETY 6
longitudinal research concerning perfectionistic strivings and anxiety. Meta-analysis will also
provide a more inclusive and generalizable conclusion regarding the effects of perfectionism
dimensions on anxiety symptoms, which is hard to establish through a single longitudinal study.
Objectives and Hypotheses
Are certain perfectionistic traits part of a premorbid personality structure that confers risk
for anxiety symptoms? We answered this question by comprehensively meta-analyzing
longitudinal research on this important topic. Informed by theoretical accounts (e.g., Ellis, 2002)
and by empirical evidence (e.g., Flaxman et al., 2012), we hypothesized baseline perfectionistic
concerns (socially prescribed perfectionism, concern over mistakes, doubts about actions) would
predict increased anxiety symptoms at follow-up, after controlling for baseline anxiety. We also
tested if perfectionistic strivings (self-oriented perfectionism, personal standards) predicts
longitudinal increases in anxiety symptoms. However, given inconsistencies in findings, we
considered our investigation into the perfectionistic strivings-anxiety link to be exploratory.
Method
Selection of Studies
A literature search using PsycINFO, PubMed, Cochrane, Cinahl, Educational Resource
Information Center (ERIC), Embase, ProQuest Dissertations and Theses, Scopus, SPORTDiscus,
and Web of Science was conducted to locate longitudinal studies of perfectionism and anxiety.
Each search used the keywords and Boolean search terms (perfection*) AND (anxiety OR
anxious OR nervous OR avoid* OR selective mutism OR phobia OR fear OR agoraphobia OR
intolerance of uncertainty OR obsession OR excessive concern) AND (Longitudinal OR repeated
measure OR serial measure OR prospective OR multi-wave OR (over time)). This search yielded
511 studies. After removing duplicates, 316 studies remained. A backward citation search was
PERFECTIONISM AND ANXIETY 7
then conducted and resulted in the addition of one journal article: Einstein, Lovibond, and
Gaston (2000). Next, the first and the second authors reviewed the abstract and method of each
article identified and determined inclusion based on the following pre-determined criteria. A
study was included if (a) it had a longitudinal design, (b) anxiety symptoms were assessed on
more than one occasion, and (c) perfectionism was assessed concurrently with symptoms of
anxiety on at least one occasion that preceded the ultimate measure of anxiety. Our literature
search and numbers associated with each stage appear in Figure 1. Daily diary studies were
excluded, as daily diary studies assess daily processes and do not satisfy the conventional
definition of a longitudinal design. Likewise, perfectionism measures used in two or less studies
were excluded. No restrictions were placed on study characteristics regarding age, gender, or
ethnicity. Studies from any nation and any time period were considered relevant.
Our search yielded 24 studies for inclusion. Interrater agreement on inclusion or
exclusion of studies in the meta-analysis was 100%. For any studies where the reported
information was insufficient for computing effect sizes, the primary author was contacted (N =
5). All contacted authors provided us with the needed information. On January 11, 2017, all
search strategies were terminated and we instigated data reduction and analysis. In total, 13
studies were excluded (see Supplemental Material A for justification). The final sample of
included studies was comprised of 11 studies (see Table 1).
Coding of Studies
The first and second author coded each study based on the following 10 characteristics:
sample size at baseline, sample type, mean age of participants at baseline, percent female
participants at baseline, percent ethnic minority (i.e., non-Caucasian) at baseline, time lag
between assessments, percent attrition, publication status, measures used to assess perfectionism,
PERFECTIONISM AND ANXIETY 8
and measures used to assess anxiety.
Meta-Analytic Procedure
Random-effects analyses were performed using Comprehensive Meta-Analysis software
(Version 3.3; Borenstein, Hedges, Higgins, & Rothstein, 2005). We used random-effects models,
over fixed-effects models, as the selected studies varied widely in design (see Table 1). Weighted
mean effect sizes were computed following Hunter and Schmidt’s recommendations (1990). This
allowed for estimation of mean effect sizes and variance in observed scores after considering
sampling error (Card, 2012). Effect size estimates were weighted by sample size and aggregated.
We chose to weigh effects by sample size because studies with larger sample sizes have greater
precision than studies with smaller sample sizes (Borenstein, Hedges, Higgins, & Rothstein,
2009). To test the extent to which perfectionism dimensions predict follow-up anxiety, after
controlling for baseline anxiety, we computed semi-partial correlations using Mplus 6 (Muthén
& Muthén, 1998-2010) with maximum likelihood estimation. Specifically, for each study, we
calculated semi-partial correlations by imputing bivariate correlation matrices into Mplus and
using path analysis with follow-up anxiety regressed on the perfectionism dimensions of interest
and baseline anxiety.
When more than one measure was used to assess anxiety, effects were averaged such that
only one effect was included in the analysis (Card, 2012). This strategy is utilized in meta-
analyses to guard against overrepresentation of studies that include multiple effects (Borenstein
et al., 2009). Likewise, in an effort to minimize heterogeneity, when studies included the
variables of interest across three or more waves of data collection, we averaged across effect
sizes for all time lags. Before averaging, correlations were transformed into Fisher’s Z (Card,
2012). Correlations for each individual study are in Table 2. Overall weighted mean effect sizes
PERFECTIONISM AND ANXIETY 9
between baseline perfectionism dimensions and follow-up anxiety symptoms, controlling for
baseline anxiety symptoms, are in Table 3.
The total heterogeneity of weighted mean effect sizes (QT) was assessed for each analysis
(see Table 3). A significant QT indicates the variance evident in the weighted mean effect sizes is
greater than would be expected by sampling error; a non-significant QT suggests a weak basis for
moderation (Card, 2012). The inconsistency in observed relationships across studies (I2) was also
computed for each analysis. I2 indicates the total variation across studies due to heterogeneity,
and values of 25%, 50%, and 75% correspond to low, medium, and high heterogeneity,
respectively (Higgins & Thompson, 2002).
To assess publication bias, we examined funnel plots with observed and imputed studies
(see Supplemental Material B). Funnel plots allow for a visual inspection of publication bias. In
the absence of publication bias, studies are distributed symmetrically about the mean (Borenstein
et al., 2009). In the presence of publication bias, there is expected to be symmetry at the top of
the plot and asymmetry near to bottom of the plot (Borenstein et al., 2009). Funnel plots with
observed and imputed studies also allow for inspection of how effect sizes shift when missing
studies are included. Additionally, we calculated Egger’s test of regression to the intercept
(Egger, Smith, Schneider, & Minder, 1997; see Table 3). In the absence of publication bias,
Egger’s regression intercept does not differ significantly from zero (Egger et al., 1997).
Description of Studies
Our literature search identified 11 studies containing relevant effect size data (Table 1).
These 11 studies varied in size between 40 and 515, with an average sample size of 285.8 (SD =
197.8). The total number of participants pooled across studies was 3,144. Samples were available
between 1995 and 2017, with a median year of 2013. There was one sample of youth, three
PERFECTIONISM AND ANXIETY 10
samples of adolescents, two samples of undergraduates, four samples of community adults, and
one sample of psychiatric patients. The mean age of participants was 24.0 years (SD = 12.4; age
range = 6.2-46.1 years). The average percentage of female participants was 67.6%; the average
percentage of ethnic minority participants was 30.5%.
Measures
Perfectionism. Trait perfectionism was assessed using seven measures (see Table 1).
Concern over mistakes, doubts about actions, and personal standards were assessed with Frost et
al.’s (1990) Multidimensional Perfectionism Scale (MPS). Oddo-Sommerfeld et al. (2016) used
Altstötter-Gleichand and Bergemann’s (2006) German version of the MPS. Self-oriented
perfectionism and socially prescribed perfectionism were assessed with Hewitt and Flett’s (1991)
Multidimensional Perfectionism Scale (HMPS). Self-oriented and socially prescribed
perfectionism were also assessed with Flett et al.’s (2000) Child and Adolescent Perfectionism
Scale (CAPS), O’Connor, Dixon, and Rasmussen’s (2009) 14-item version of the CAPS (CAPS-
14) and the modified self-oriented and socially prescribed perfectionism subscales of Garner et
al.’s (1983) Eating Disorder Inventory (EDI; see Joiner & Schmidt, 1995). Additionally, one
study used the 5-item short form of the MPS concern over mistakes subscale and the 5-item short
form of the HMPS socially prescribed perfectionism subscale: Sherry et al. (2014). Evidence
suggests these subscales assess stable traits. Rice and Dellwo (2001) administered the MPS twice
over a 10-week period in a sample of undergraduates and reported test-retest coefficients across
subscales ranging from .62 to .88. Similarly, Hewitt and Flett (1991) administered the HMPS
twice over a three-month interval in a sample of outpatients and reported test-retest correlations
across subscales ranging from .60 to .69.
Anxiety. Anxiety was assessed using nine measures (see Table 1): the anxiety subscale of
PERFECTIONISM AND ANXIETY 11
Zigmond and Snaith’s (1983) Anxiety and Depression Scale (HADS-Anx); the self-report
version of Birmaher et al.’s (1999) Screen for Child Anxiety Related Emotional Disorders
(SCARED); the anxiety subscale of Lovibond and Lovibond’s (1995) Depression Anxiety and
Stress Scale (DASS-Anx); the anxiety subscale of Warr’s (1990) Affective Well-Being Scale
(AWBS-Anx); the anxiety subscale of Ialongo, Kellam, and Poduska’s (1999) Baltimore How I
Feel-Young Child Version Child Report (BHIF-YC-C-Anx); Beck et al.’s (1988) Beck Anxiety
Inventory (BAI); the general distress anxious symptoms scale of Watson and Clark’s (1991)
Mood and Anxiety Symptom Questionnaire Short Form (MASQ-GDA); the anxious arousal
scale of Watson and Clark’s (1991) Mood and Anxiety Symptom Questionnaire Short Form
(MASQ-AA); and the State Anxiety subscale of Laux et al.’s (2013) State-Trait Anxiety
Depression Inventory (STADI-Anx).
Results
Overall Effect Sizes
The weighted mean effect sizes between perfectionism at baseline and anxiety symptoms
at follow-up, while controlling for baseline levels of anxiety, are in Table 2. To facilitate
interpretation of effect sizes, we followed Gignac and Szodorai’s (2016) guidelines for small,
medium, and large effect sizes (r = .10, .30, .50, respectively). In addition, we considered effect
sizes below .10 to be marginal in size and non-substantive. All longitudinal perfectionism-
anxiety effects were marginal-to-small in magnitude. For facets of perfectionistic concerns, small
positive significant effects were found between concern over mistakes, and doubts about actions
predicting follow-up up anxiety, while controlling for baseline anxiety. Likewise, for facets of
perfectionistic strivings, a marginal positive, significant effect was observed between baseline
personal standards and follow up anxiety, controlling for baseline anxiety. Conversely, socially
PERFECTIONISM AND ANXIETY 12
prescribed perfectionism’s and self-oriented perfectionism’s relationships with follow-up
anxiety, controlling for baseline anxiety, were non-significant.
The test of the total heterogeneity of weighted mean effect sizes corresponding to
perfectionism dimensions effects on follow-up anxiety were non-significant. For facets of
perfectionistic concerns, I2 estimates were 0.0% for concern over mistakes, 32.6% for socially
prescribed perfectionism, and 19.2% for doubts about actions (see Table 3). I2 estimates for both
facets of perfectionistic strivings were 0.0% (see Table 3). This suggests the assumption of
homogeneity should be retained and indicates common study effects (Card, 2012). Results also
indicate differences in relevant effect sizes were not greater than would be expected based on
sample variation alone.
Publication Bias
Egger’s test of regression to the intercept (see Table 3) was not significant for any of the
relationships between perfectionism dimensions and follow-up anxiety symptoms, controlling for
baseline anxiety. Likewise, funnel plots (see Supplemental Material B) revealed that after
imputing missing studies using “Trim and Fill” (see Table 3), adjusted point estimates provided
the same substantive implications as observed point estimates. As such, we found limited
evidence of publication bias.
Discussion
Case histories, theoretical accounts, and empirical studies suggest an important
relationship between perfectionism and anxiety (e.g., Antony et al., 1998; Kawamura, Hunt,
Frost, & DiBartolo, 2001; Minarik & Ahrens, 1996; O’Connor, Rasmussen, & Hawton, 2010).
However, it is unclear which perfectionism dimensions (if any) are risk factors for anxiety.
Hence, we comprehensively meta-analyzed extant findings to test which perfectionism
PERFECTIONISM AND ANXIETY 13
dimensions confer risk for anxiety. Findings, derived from 11 longitudinal studies, including
adolescent, undergraduate, community, and clinical samples, revealed concern over mistakes,
doubts about actions, and to a lesser extent personal standards, predicted longitudinal increases
in anxiety. However, all observed effects were marginal-to-small in magnitude. Moreover,
neither socially prescribed perfectionism nor self-oriented perfectionism, predicted change in
anxiety.
Perfectionistic Concerns
Consistent with hypotheses, concern over mistakes and doubts about actions at baseline
predicted increased anxiety at follow-up, even after controlling for baseline anxiety. This
suggests people with high concern over mistakes and people with high doubts about actions are
prone to experiencing anxiety. Indeed, for people with high concern over mistakes, intense
anxiety might arise from perceived or actual failures. Likewise, for people with high doubts
about actions, nagging uncertainty about performance abilities may trigger anxiety in
performance or evaluative situations. And this sense of personal inadequacy may make everyday
life more anxiety-provoking for people with high concern over mistakes and people with high
doubts about actions. Confidence in our results is augmented by the longitudinal nature of
studies included in our meta-analysis, and by convergence with theoretical accounts positing that
concern over mistakes and doubts about actions are stable personality traits that predispose
emotional distress (Smith et al., 2016).
Even so, contrary to hypotheses, socially prescribed perfectionism’s relationship with
follow-up anxiety, after controlling for baseline anxiety, was non-significant. Accordingly, our
results highlight a need for additional studies to elucidate this relationship. Although cross-
sectional relationships suggest socially prescribed perfectionism and anxiety symptoms co-occur,
PERFECTIONISM AND ANXIETY 14
our study found limited support for the contention that socially prescribed perfectionism confers
risk for anxiety. Nonetheless, a relationship between socially prescribed perfectionism and
anxiety may only emerge under certain conditions. This assertion is consistent with Hewitt and
Flett’s (2002) view of daily stressors as triggering emotional distress in perfectionistic
individuals (Klibert et al., 2015). Indeed, analyses accounting for daily stressors, negative life
events, and other potential moderators (e.g., coping) of the perfectionism-anxiety relationship
may be essential for clarifying the link between socially prescribed perfectionism and anxiety
(Dunkley, Sanislow, Grilo, & McGlashan, 2006).
Perfectionistic Strivings
Given inconsistent findings (e.g., Antony et al., 1998), and the contentiously debated
suggestion that perfectionistic strivings are adaptive (e.g., Stoeber & Otto, 2006), we attempted
to answer the question, “Do personal standards and self-oriented perfectionism protect against, or
increase risk for, anxiety symptoms?” Our data provided an equivocal answer to this question,
with a non-significant relationship between self-oriented perfectionism and follow-up anxiety
and a significant, but non-substantive, positive associations between personal standards and
follow up anxiety. Accordingly, as with socially prescribed perfectionism, our findings highlight
the need for additional studies testing whether perfectionistic strivings confer risk for anxiety.
In particular, our equivocal findings regarding the perfectionistic strivings-anxiety link
may stem from the included studies assessing perfectionistic strivings and perfectionistic
concerns in the realm of their separate, rather than combined, contribution (Gaudreau & Verner-
Filion, 2012). Indeed, perfectionistic strivings may only confer risk for anxiety in the presence of
high perfectionistic concerns. Similarly, ample evidence suggests perfectionistic concerns
suppress the relationship between perfectionistic strivings and positive outcomes (see Hill,
PERFECTIONISM AND ANXIETY 15
Huelsman, & Araujo, 2010). As such, failure to control of perfectionistic concerns when
investigating the extent to which perfectionistic strivings predict change in anxiety could obscure
distinct, possibly negative, relationships (Stoeber & Gaudreau, 2017). Nonetheless,
perfectionistic strivings were recently posited as a transdiagnostic factor in psychopathology
(Egan et al., 2011; Limburg et al., 2016). Hence, it is advisable to be wary of perfectionistic
strivings in clinical settings. Even so, for now our results suggest that perfectionistic strivings are
relatively benign with regard to anxiety.
Limitations of Overall Literature
Meta-analysis offers insight into the current state of a body of knowledge, as limitations
in empirical studies are translated into limitations of the meta-analysis, and directions for future
research become apparent. One such limitation in the perfectionism-anxiety literature is a heavy
reliance on cross-sectional studies. This is problematic given that cross-sectional studies are not
adequate for assessing temporal precedence and have the potential to obscure relationships that
emerge over time. Research in this area would benefit from more longitudinal studies, which are
able to make conclusions about risk for developing anxiety over time. Additionally, increased
consideration of potential confounding variables, by the assessment and the inclusion of
covariates in analyses (e.g., neuroticism), would be advantageous in ensuring variables outside of
the research questions do not confound analyses and misguide interpretation of results.
Our search of the literature on perfectionism and longitudinal changes in anxiety showed
an overwhelming reliance on mono-source designs. Conclusions based on data collected from a
single source (e.g., self-report questionnaires) are limited. This is especially problematic in the
study of traits such as perfectionism, where individuals might be motivated to conceal socially
undesirable tendencies (i.e., self-presentational biases could invalidate results; Klonsky &
PERFECTIONISM AND ANXIETY 16
Oltmanns, 2002). The potential for such biases can be minimized using additional or alternative
methods of data collection, such as informant reports or physiological data (Sherry et al., 2013).
Lastly, since three longitudinal studies in our meta-analysis had sample sizes below 150,
it appears that a portion of studies examining the link between perfectionism and anxiety are
underpowered. Moving forward, it would be advisable for researchers to ensure all sample sizes
are sufficiently large to detect small to moderate effects in longitudinal designs.
Limitations of the Present Study and Future Directions
Despite the advantages of meta-analysis and the strengths of our investigation, this study
is not without limitations. One limitation is inherent in conceptualizing perfectionism as having
two dimensions: Perfectionistic concerns were comprised of three facets (socially prescribed
perfectionism, concern over mistakes, and doubts about actions) and perfectionistic strivings
were comprised of two facets (self-oriented perfectionism and personal standards). It is possible
perfectionistic concerns were more completely and comprehensively captured than
perfectionistic strivings, and this may have influenced the magnitude of observed effects in
unexpected ways. In future, analyses of perfectionism including an equivalent number of
dimensions within each of the two dimensions may be preferable. As with any meta-analysis, the
validity of our results also largely depends on the quality of measures used in studies included in
our meta-analysis. Because of variability in questionnaires assessing perfectionism and anxiety,
interpretation of results might not be as straightforward as if all studies had measured these
constructs in the same way. Similarly, additional research on the perfectionism-anxiety link
using the 2 X 2 model of perfectionism to examine the unique, combined, and interactive effects
of perfectionistic strivings and perfectionistic concerns is needed (Gaudreau & Thomson, 2010;
see also Gaudreau, 2012, 2013). Finally, included samples were diverse in terms of clinical
PERFECTIONISM AND ANXIETY 17
versus nonclinical status and age. As such, the extent to which our results are generalizable to
specific populations (e.g., ethnic minorities) is unclear.
Conclusions
Our findings suggest concern over mistakes and doubts about actions confer risk for
anxiety over time and highlight the need for additional research on how socially prescribed
perfectionism and perfectionistic strivings may influence anxiety.
PERFECTIONISM AND ANXIETY 18
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PERFECTIONISM AND ANXIETY 26
Table 1
Characteristics of longitudinal studies included in the meta-analysis
Sample
N
Sample
type
Mean
age
Time
lag
Attrition
%
Female
%
Ethnic
%
Status
Perfectionism
Anxiety
Akram et al. (2015)
76
community
members
25.30
12.00
25.00
80.00
7.90
A
FMPS-COM
FMPS-DAA
HMPS-SPP
FMPS-PS
HMPS-SOP
HADS-Anx
Damian et al. (2016)
489
middle and high
school students
15.90
9.00
52.00
54.00
0.00
A
FMPS-COM
FMPS-DAA
CAPS-SPP
FMPS-PS
CAPS-SOP
SCARED
Einstein et al. (2000)
508
high school
students
17.60
2.00
21.85
65.80
NR
A
HMPS-SPP
HMPS-SOP
DASS-Anx
Flaxman et al. (2012)
77
university
academics
46.00
2.00
30.63
64.00
NR
A
FMPS-DAA
AWBS-Anx
Herman et al. (2013)
547
elementary school
students
6.22
72.00
NR
NR
100.00
A
CAPS-SPP
CAPS-SOP-critical
BHIF-YC-C-
Anx
Joiner and Schmidt (1995)
174
university
undergraduates
19.80
0.75
NR
62.64
40.00
A
EDI-PS-SPP
EDI-PS-SOP
BAI
Mandel et al. (2015)
150
community
members
41.02
48.00
32.74
70.00
25.00
A
FMPS-COM
HMPS-SPP
FMPS-PS
HMPS-SOP
MASQ-GDA
MASQ-AA
O’Connor et al. (2010)
515
high school
students
15.20
6.00
30.12
49.80
NR
A
CAPS-14-SPP
CAPS-14-SOP-critical
CAPS-14-SOP-
striving
HADS-Anx
PERFECTIONISM AND ANXIETY 27
Oddo-Sommerfeld et al. (2016)
266
community
members
32.35
4.50
10.44
100.00
NR
A
MPS-German-COM
MPS-German-DAA
MPS-German-PS
STADI-Anx
Rasmussen (2005) study 4
40
psychiatric
patients
NR
1.50
37.50
57.50
NR
D
HMPS-SPP
HMPS-SOP
HADS-Anx
Sherry et al. (2014)
302
university
undergraduates
20.84
6.00 /
12.00
27.80
72.60
9.90
A
FMPS-SF-COM
FMPS-DAA
HMPS-SF-SPP
MASQ-AA
Note. NR = not reported; N = total number of participants; time lag is expressed in months; Ethnic % = percentage ethnic minority; status = publication status
of study; A = article; D = dissertation; FMPS = Frost’s et al.’s (1990) Multidimensional Perfectionism Scale; COM = concern over mistakes; DAA = doubts
about actions; PS = personal standards; HMPS = Hewitt and Flett’s (1991) Multidimensional Perfectionism Scale; SOP = self-oriented perfectionism; SPP =
socially prescribed perfectionism; CAPS = Flett et al.’s (2000) Child and Adolescent Perfectionism Scale; SOP-critical = self-oriented perfectionism critical
subscale; SOP-striving = self-oriented perfectionism striving subscale; EDI-PS= Garner et al.’s (1983) Eating Disorder Inventory Perfectionism Subscale;
MPS-German = Mehrdimensionale Perfektionismus-Skala von Frost et al. (1990) and Altstötter-Gleichand and Bergemann (2006), the German version of
Frost’s et al.’s (1990) Multidimensional Perfectionism Scale; CAPS-14 = O’Connor et al.’s (2009) Child and Adolescent Perfectionism Scale 14-item version;
HADS-Anx = anxiety subscale of Zigmond and Snaith’s (1983) Anxiety and Depression Scale; SCARED = self-report version of Birmaher et al.’s (1999)
Screen for Child Anxiety Related Emotional Disorders; DASS-Anx = anxiety subscale of Lovibond and Lovibond’s (1995) Depression Anxiety Stress Scales;
AWBS-Anx = anxiety subscale of Warr’s (1990) Affective Well-Being scales; BHIF-YC-C-Anx = Ialongo et al.’s (1999) Baltimore How I Feel-Young Child
Version, Child Report, anxiety scale; BAI = Beck et al.’s (1988) Beck Anxiety Inventory; MASQ = Watson and Clark’s (1991) Mood and Anxiety Symptom
Questionnaire Short Form; GDA = general distress anxious subscale; AA = anxious arousal subscale; STADI-Anx = Laux et al.’s (2013) State-Trait Anxiety
Depression Inventory, state anxiety subscale; SF = short form.
PERFECTIONISM AND ANXIETY 28
Table 2
Relationships between perfectionism dimensions and anxiety symptoms
Concern over mistakes
Outcome
rCM1,A1
rCM2,A2
A1A2
A1A3
A2A3
CM1A2
CM1A3
CM2A3
CMAav
Akram et al. (2015)
HADS
Overall
.35
.35
.83
.83
.01
.01
.01
.01
Damian et al. (2016)
SCA
Overall
.48
.48
.51
.51
.55
.55
.48
.48
.65
.65
.20
.20
.16
.16
.04
.04
.13
.13
Mandel et al. (2015)
MAS-G
MAS-A
Overall
.33
.36
.35
.49
.55
.52
.09
.05
.07
.09
.05
.07
Oddo-Sommerfeld et al. (2016)
STADI
Overall
.39
.39
.37
.37
.17
.17
.17
.17
Sherry et al. (2014)
MAS-A
Overall
.23
.23
.30
.30
.67
.67
.60
.60
.69
.69
.04
.04
.13
.13
.05
.05
.07
.07
Doubts about actions
Outcome
rDA1,A1
rDA2,A2
A1A2
A1A3
A2A3
DA1A2
DA1A3
DA2A3
DAAav
Akram et al. (2015)
HADS
Overall
.39
.39
.76
.76
.17
.17
.17
.17
Damian et al. (2016)
SCA
Overall
.55
.55
.54
.54
.54
.54
.46
.46
.63
.63
.18
.18
.19
.19
.07
.07
.15
.15
Flaxman et al. (2012)
AWBS
Overall
.34
.34
.43
.43
.25
.25
.25
.25
Oddo-Sommerfeld et al. (2016)
STADI
Overall
.44
.44
.36
.36
.16
.16
.16
.16
Sherry et al. (2014)
MAS-A
Overall
.35
.35
.34
.34
.66
.66
.64
.64
.72
.72
.06
.06
-.01
-.01
-.02
-.02
.01
.01
Socially prescribed perfectionism
Outcome
rSP1,A1
rSP2,A2
A1A2
A1A3
A2A3
SP1A2
SP1A3
SP2A3
SPAav
Akram et al. (2015)
HADS
Overall
.30
.30
.80
.80
.10
.10
.10
.10
Damian et al. (2016)
SCA
Overall
.34
.34
.34
.34
.64
.64
.52
.52
.64
.64
.01
.01
.11
.11
.08
.08
.07
.07
Einstein et al. (2000)
DASS
Overall
.29
.29
.54
.54
.09
.09
.09
.09
Herman et al. (2013)
BHIF
Overall
.31
.31
.18
.18
-.01
-.01
-.01
-.01
Joiner and Schmidt (1995)
BAI
Overall
-.01
-.01
.49
.49
-.12
-.12
-.12
-.12
PERFECTIONISM AND ANXIETY 29
Mandel et al. (2015)
MAS-G
MAS-A
Overall
.28
.32
.30
.49
.52
.51
.11
.14
.13
.11
.14
.13
O’Connor et al. (2010)
HADS
Overall
.36
.36
.60
.60
.08
.08
.08
.08
Rasmussen (2005)
HADS
Overall
.33
.33
.63
.63
-.10
-.10
-.10
-.10
Sherry et al. (2014)
MAS-A
Overall
.20
.20
.26
.26
.69
.69
.63
.63
.69
.69
-.05
-.05
.04
.04
.07
.07
.01
.02
Personal standards
Outcome
rPS1,A1
rPS2,A2
A1A2
A1A3
A2A3
PS1A2
PS1A3
PS2A3
PSAav
Akram et al. (2015)
HADS
Overall
.23
.23
.83
.83
.00
.00
.00
.00
Damian et al. (2016)
SCA
Overall
.23
.23
.23
.23
.62
.62
.54
.54
.66
.66
.11
.11
.10
.10
.05
.05
.09
.09
Mandel et al. (2015)
MAS-G
MAS-A
Overall
.13
.09
.11
.50
.56
.53
.14
.12
.13
.14
.12
.13
Oddo-Sommerfeld et al. (2016)
STADI
Overall
.20
.20
.42
.42
.07
.07
.07
.07
Self-oriented perfectionism
Outcome
rSO1,A1
rSO2,A2
A1A2
A1A3
A2A3
SO1A2
SO1A3
SO2A3
SOAav
Akram et al. (2015)
HADS
Overall
.23
.23
.82
.82
.05
.05
.05
.05
Damian et al. (2016)
SCA
Overall
.33
.33
.27
.27
.62
.62
.54
.54
.66
.66
.06
.06
.05
.05
.02
.02
.04
.04
Einstein et al. (2000)
DASS
Overall
.08
.08
.56
.56
.02
.02
.02
.02
Joiner and Schmidt (1995)
BAI
Overall
.06
.06
.50
.50
-.11
-.11
-.11
-.11
Mandel et al. (2015)
MAS-G
MAS-A
Overall
.14
.13
.14
.50
.56
.53
.16
.12
.14
.16
.12
.14
Rasmussen (2005)
HADS
Overall
.18
.18
.60
.60
.01
.01
.01
.01
Self-oriented perfectionism critical
Outcome
rSO1,A1
rSO2,A2
A1A2
A1A3
A2A3
SO1A2
SO1A3
SO2A3
SOAav
Herman et al. (2013)
BHIF
Overall
.40
.40
.17
.17
.02
.02
.02
.02
PERFECTIONISM AND ANXIETY 30
O’Connor et al. (2010)
HADS
Overall
.35
.35
.59
.59
.11
.11
.11
.11
Self-oriented perfectionism striving
Outcome
rSO1,A1
rSO2,A2
A1A2
A1A3
A2A3
SO1A2
SO1A3
SO2A3
SOAav
O’Connor et al. (2010)
HADS
Overall
.00
.00
.63
.63
.01
.01
.01
.01
Note. CM = concern over mistakes; A = anxiety; DA = doubts about actions; SP = socially prescribed perfectionism; PS = personal standards; SO = self-
oriented perfectionism; x1 = time 1 variable; x2 = time 2 variable; x3 = time 3 variable; rx1,ry1= bivariate correlation between time 1 variables; rx2,ry2= bivariate
correlation between time 2 variables; COM1ANX2 = standardized beta for time 1 concern over mistakes predicting time 2 anxiety symptoms; COM1ANX3
= standardized beta for time 1 concern over mistakes predicting time 3 anxiety symptoms; COM2ANX3 = standardized beta for time 2 concern over mistakes
predicting time 3 anxiety symptoms; COMANXAV = the standardized weighted average for concern over mistakes predicting future anxiety symptoms
averaged across all waves; ANX1ANX2 = standardized beta for time 1 anxiety symptoms predicting time 2 anxiety symptoms; ANX1ANX3 = standardized
beta for time 1 anxiety symptoms predicting time 3 anxiety symptoms; ANX2ANX3 = standardized beta for time 2 anxiety symptoms predicting time 3
anxiety symptoms; HADS = anxiety subscale of Zigmond and Snaith’s (1983) Anxiety and Depression Scale; SCA = self-report version of Birmaher et al’s
(1999) Screen for Child Anxiety Related Emotional Disorders; MAS = Watson and Clark’s (1991) Mood and Anxiety Symptom Questionnaire Short Form;
MAS-G = MAS general distress anxious subscale; MAS-A = MAS anxious arousal subscale; STADI = state anxiety subscale of Laux et al.’s (2013) State-Trait
Anxiety Depression Inventory; AWBS = anxiety subscale of Warr’s (1990) Affective Well-Being scales; DASS = anxiety subscale of Lovibond and Lovibond’s
(1995) Depression Anxiety Stress Scales; BAI = Beck et al.’s (1988) Beck Anxiety Inventory; BHIF = anxiety scale of Ialongo et al.’s (1999) Baltimore How I
Feel-Young Child Version, Child Report.
PERFECTIONSIM AND ANXIETY 31
Table 3
Summary of effect sizes for the relationship between perfectionism dimensions and anxiety symptoms
Variable
k
N
r+
95% CI
QT
I2 (%)
Egger’s
intercept
95% CI
KTF
Trim and fill
estimates
r+ [95% CI]
Perfectionistic Concerns
Concern over mistakes
rCOM,ANX
5
1,283
.38***
[.28, .47]
14.56**
72.55
-2.84
[-12.35, 6.66]
0
.38 [.28, .47]
ANXANX
5
1,264
.60***
[.47, .70]
39.14***
89.78
3.75
[-11.09, 18.60]
0
.60 [.47, .70]
COMANX
5
1,264
.11***
[.06, .17]
2.44
0.00
-1.36
[-4.59, 1.88]
0
.11 [.06, .17]
Doubts about actions
rDAA,ANX
5
1,210
.43***
[.33, .52]
14.97**
73.28
-3.00
[-10.56, 4.56]
0
.43 [.33, .52]
ANXANX
5
1,191
.57***
[.42, .68]
36.35***
89.00
1.05
[-12.52, 14.63]
0
.55 [.42, .68]
DAAANX
5
1,191
.13**
[.05, .20]
5.94
32.61
1.01
[-4.21, 6.23]
2
.11 [.04, .18]
Socially prescribed perfectionisma
r SPP,ANX
9
2,797
.27***
[.21, .33]
23.38**
64.25
-2.02
[-5.52, 1.48]
0
.27 [.21, .33]
ANXANX
9
2,655
.57***
[.45, .67]
130.45***
93.87
3.20
[-5.32, 11.72]
3
.50 [.38, .60]
SPPANX
9
2,665
.04
[.00, .09]
9.91
19.24
-0.45
[-2.89, 1.99]
0
.04 [.00, .09]
Perfectionistic Strivings
Personal Standards
r PS,ANX
4
981
.20***
[.14, .26]
1.79
0.00
-0.96
[-6.55, 4.62]
0
.20 [.14, .26]
ANXANX
4
962
.70***
[.50, .83]
63.35
95.26
6.98
[-20.27, 34.23]
0
.70 [.50, 83]
PSANX
4
962
.08*
[.02, .15]
0.76
0.00
-0.44
[-3.97, 3.08]
0
.08 [.02, .15]
Self-oriented perfectionismb
r SOP,ANX
8
2,495
.20***
[.10, .30]
42.05***
83.36
-1.53
[-7.39, 4.31]
0
.20 [.10, .30]
ANXANX
8
2,363
.56***
[.42, .68]
130.35***
94.63
3.20
[-6.33, 12.73]
3
.47 [.34, .58]
SOPANX
8
2,363
.03
[-.01, .07]
5.85
0.00
-0.14
[-2.27, 1.98]
0
.03 [-.01, .07]
Note. k = number of studies; N = total number of participants in the k samples; r+ = weighted mean r; CI = confident interval; QT = measure of heterogeneity of
effect sizes; I2 = percentage of heterogeneity; Egger’s intercept = Egger’s test of regression to the intercept; kTF = number of imputed studies as part of trim and
fill method; COM = concern over mistakes; DAA = doubts about actions; SPP = socially prescribed perfectionism; PS = personal standards; SOP = self-oriented
perfectionism; ANX = anxiety; rCOM,ANX = bivariate correlation between concern over mistakes and anxiety; ANXANX = standardized beta for baseline
anxiety symptoms predicting follow-up anxiety symptoms; COMANX = standardized beta for concern over mistakes predicting follow-up anxiety symptoms;
HMPS = Hewitt and Flett’s (1991) Multidimensional Perfectionism Scale; CAPS = Flett et al.’s (2000) Child and Adolescent Perfectionism Scale; SOP-C = self-
oriented perfectionism critical; SOP-S = self-oriented perfectionism striving; EDI = Garner et al.’s (1983) Eating Disorder Inventory Perfectionism Subscale.
aAggregate of HMPS-SPP, CAPS-SPP, and EDI-SPP; bAggregate of HMPS-SOP, CAPS-SOP, CAPS-SOP-C, CAPS-SOP-S, CAPS-SOP, and EDI-SOP
*p < .05; **p < .01; ***p < .001.
SUPPLEMENTAL MATERIAL
32
Supplemental Material A: Excluded Studies
Studies marked with an asterisk were excluded from the present meta-analysis.
Beck, A., Epstein, N., Brown, G., & Steer, R. (1988). An inventory for measuring clinical
anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56,
893-897.
Blatt, S. J., D’Afflitti, J. P., & Quinlan, D. M. (1976). Experiences of depression in normal
young adults. Journal of Abnormal Psychology, 85, 383389.
*Bonvanie, I. J., Rosmalen, J. G., van Rhede van der Kloot, C. M., Oldehinkel, A. J., & Janssens,
K. A. (2015). Short report: Functional somatic symptoms are associated with
perfectionism in adolescents. Journal of Psychosomatic Research, 79, 328-330.
Burns, D. D. (1980). The perfectionist’s script for self-defeat. Psychology Today, 14, 3452.
Burns, D. D. (1983). The spouse who is a perfectionist. Medical Aspects of Human Sexuality, 17,
219230.
Cochrane, R., & Robertson, A. (1973). The life events inventory: A measure of the relative
severity of psychosocial stressors. Journal of Psychosomatic Research, 17, 135139.
Derogatis, L. R., Lipman, R. S., Rickels, K., Uhlenhuth, E. H., & Covi, L. (1974). The Hopkins
Symptom Checklist (HSCL): A self-report symptom inventory. Behavioral Science, 19,
115.
*Dunkley, D. M., Mandel, T., & Ma, D. (2014). Perfectionism, neuroticism, and daily stress
reactivity and coping effectiveness 6 months and 3 years later. Journal of Counseling
Psychology, 61, 616-633.
Dunkley, D. M., Zuroff, D. C., & Blankstein, K. R. (2003). Self-critical perfectionism and daily
affect: Dispositional and situational influences on stress and coping. Journal of
SUPPLEMENTAL MATERIAL
33
Personality and Social Psychology, 84, 234252.
*Egan, S. J., van Noort, E., Chee, A., Kane, R. T., Hoiles, K. J., Shafran, R., & Wade, T. D.
(2014). A randomized controlled trial of face to face versus pure online self-help
cognitive behavioural treatment for perfectionism. Behaviour Research and Therapy, 63,
107-113.
*Enns, M. W., Cox, B. J., & Clara, I. P. (2005). Perfectionism and neuroticism: A longitudinal
study of specific vulnerability and diathesis-stress models. Cognitive Therapy and
Research, 29, 463-478.
Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating
disorders: A 'transdiagnostic' theory and treatment. Behaviour Research and Therapy, 41,
509-528.
Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism.
Cognitive Therapy and Research, 14, 449-468.
Garner, D. M., Olmsted, M. P., & Polivy, J. (1983). Development and validation of a
multidimensional eating disorder inventory for anorexia nervosa and bulimia.
International Journal of Eating Disorders, 2, 15-34.
*Gautreau, C. M., Sherry, S. B., Mushquash, A. R., & Stewart, S. H. (2015). Is self-critical
perfectionism an antecedent of or a consequence of social anxiety, or both? A 12-month,
three-wave longitudinal study. Personality and Individual Differences, 82, 125-130.
*Glover, D. S., Brown, G. P., Fairburn, C. G., & Shafran, R. (2007). A preliminary evaluation of
cognitive-behaviour therapy for clinical perfectionism: A case series. British Journal of
Clinical Psychology, 46, 85-94.
Hart, T. A., Mora, D. B., Palyo, S. A., Fresco, D. M., Holle, C., & Heimberg, R. G. (2008).
SUPPLEMENTAL MATERIAL
34
Development and examination of the social appearance anxiety scale. Assessment,
15, 48-59.
Hewitt, P. L., & Flett, G. L. (1991). Perfectionism in the self and social contexts. Journal of
Personality and Social Psychology, 60, 456-470.
*Holm-Denoma, J. M., Gordon, K. H., Bardone-Cone, A. M., Vohs, K. D., Abramson, L. Y.,
Heatherton, T. F., & Joiner, T. E. (2005). A test of an interactive model of bulimic
symptomatology in adult women. Behavior Therapy, 36, 311-321.
Leary, M. R. (1983). A brief version of the fear of negative evaluation scale. Personality
and Social Psychology Bulletin, 9, 371-375.
*Levinson, C. A., & Rodebaugh, T. L. (2016). Clarifying the prospective relationships between
social anxiety and eating disorder symptoms and underlying vulnerabilities. Appetite, 107,
38-46.
Liebowitz, M. R. (1987). Social phobia. Modern Problems of Pharmacopsychiatry, 22,
141173.
Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states:
Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression
and Anxiety Inventories. Behaviour Research and Therapy, 33, 335-343.
Mandel, T., Dunkley, D. M., & Moroz, M. (2015). Self-critical perfectionism and depressive and
anxious symptoms over 4 years: The mediating role of daily stress reactivity. Journal of
counseling psychology, 62, 703-717.
Mattick, R. P., & Clarke, J. C. (1998). Development and validation of measures of social phobia
scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455-
470.
SUPPLEMENTAL MATERIAL
35
*Procopio, C. A., Holm-Denoma, J. M., Gordon, K. H., & Joiner, T. E. (2006). Twothree-year
stability and interrelations of bulimotypic indicators and depressive and anxious
symptoms in middle-aged women. International Journal of Eating Disorders, 39, 312-
319.
Sakurai, S., & Otani, Y. (1994). Kanzen-shugi to yokuutu-keikou no kankei ni tuite no kenkyu:
Burns ni yoru kanzenshugi-shakudo wo motiite [A study of relationship between
perfectionism and depression using the perfectionism scale constructed by Burns]. Bulletin
of Nara University of Education, 43, 213223.
Sherry, S. B., Hewitt, P. L., Besser, A., McGee, B. J., & Flett, G. L. (2004). Selforiented and
socially prescribed perfectionism in the Eating Disorder Inventory Perfectionism
subscale. International Journal of Eating Disorders, 35, 69-79.
Slaney, R. B., Rice, K., Mobley, M., Trippi, J., & Ashby, J. (2001). The Revised Almost Perfect
Scale. Measurement and Evaluation in Counseling and Development, 34, 130-145.
Snell, W. E., Jr. (1997). The Multidimensional Sexual Perfectionism Questionnaire (MSPQ),
Section I. Retrieved from http://www4.semo.edu/snell/scales/MSPQ.htm.
Snell, W. E., Jr. (2011). Multidimensional Sexual Self-Concept Questionnaire. In T. D. Fisher,
C. M. Davis, W. L. Yarber, & S. L. Davis (Eds.), Handbook of sexuality-related measures
(3rd ed., pp. 537540). New York: Routledge.
*Steele, A. L, & Wade, T. D. (2008). A randomised trial investigating guided self-help to reduce
perfectionism and its impact on bulimia nervosa: A pilot study. Behaviour Research and
Therapy, 46, 1316-1323.
*Stoeber, J., & Harvey, L. N. (2016). Multidimensional sexual perfectionism and female sexual
function: A longitudinal investigation. Archives of Sexual Behavior, 45, 2003-2014.
SUPPLEMENTAL MATERIAL
36
Sumi, K. (1997). Optimism, social support, stress and physical and psychological well-being in
Japanese women. Psychological Reports, 81, 299306.
*Sumi, K., & Kanda, K. (2002). Relationship between neurotic perfectionism, depression,
anxiety, and psychosomatic symptoms: A prospective study among Japanese men.
Personality and Individual Differences, 32, 817-826.
*Vohs, K. D., Voelz, Z. R., Pettit, J. W., Bardone, A. M., Katz, J., Abramson, L. Y., ... & Joiner,
T. E. (2001). Perfectionism, body dissatisfaction, and self-esteem: An interactive model
of bulimic symptom development. Journal of Social and Clinical Psychology, 20, 476-
497.
Watson, D., & Clark, L. A. (1991). The Mood and Anxiety Symptom Questionnaire. Iowa City,
IA: Department of Psychology, University of Iowa.
Weissman, A. N., & Beck, A. T. (1978, March). Development and validation of the
Dysfunctional Attitude Scale: A preliminary investigation. Paper presented at the 62nd
annual meeting of the American Educational Research Association, Toronto, ON,
Canada.
SUPPLEMENTAL MATERIAL
37
Table A1
Characteristics of studies excluded from the meta-analysis
Sample
Measures
Reason for exclusion
N
Sample
type
Mean
age
Female
%
Ethnic
%
Status
Perfectionism
Anxiety
Bonvanie et al. (2015)
1,878
adolescent
16.2
NR
NR
A
YSR-Perfect
AD-YSR
Perfectionism assessed
with one item: “I have
the feeling I have to be
perfect.”
Dunkley et al. (2014)
85
communitya
NR
71.8
NR
A
MPS-SOP
MPS-SPP
FMPS-COM
APS-R-DIS
DEQ-SC
DAS-SC
ES
Measured event stress.
Egan et al. (2014)
52
treatmentb
39.9
58.0
NR
A
MPS-COM
CPQ
DAS-SC
DASS-A
Treatment study.
Enns et al. (2005)
139
universityc
23.5
43.2
NR
A
MPS-SF-SOP
MPS-SF-OOP
MPS-SF-SPP
MPS-COM
MPS-DAA
LEI
Measured life event
stress.
Gautreau et al. (2015)
301
universityc
20.9
71.1
10.0
A
MPS-COM
MPS-DAA
LSAS-A
SIAS
SPS
Measured social
anxiety.
Glover et al. (2007)
9
psychiatricd
33.0
77.8
NR
A
MPS-SOP
MPS-OOP
MPS-SPP
CPQ
DAS-P
BAI
Treatment study.
Holm-Denoma et al. (2005)
150
health
workerse
47.4
100.0
10.0
A
EDIP
BAI-SF
Used the EDIP.f
SUPPLEMENTAL MATERIAL
38
Levinson and Rodebaugh (2016)
300
universityc
18.0g
100.0
39.3
A
FMPS-COM
FMPS-DAA
FMPS-PC
FMPS-PE
FMPS-PPS
BFNE
SAAS
SIAS
Measured social
anxiety.
Procopio et al. (2006)
150
health
workerse
45.2
100.0
10.0
A
EDIP
BAI-SF
Same sample as Holm-
Denoma et al. (2005).
Steele and Wade (2008)
48
psychiatricd
26.0
98.0
NR
A
FMPS-COM
FMPS-PS
DASS-A
Treatment study.
Stoeber and Harvey (2016)
366
universityc
communitya
23.5
100.0
27.3
A
MSPQ-SO
MSPQ-PO
MSPQ-PP
MSPQ-SP
MSSCQ-SA
Measured sexual
perfectionism and
sexual anxiety.
Sumi and Kanda (2002)
138
universityc
21.5
0.0
100.0
A
BPS-J
HSC-Anx
BPS-J used in only
one study.
Vohs et al. (2001)
70
universityc
NR
100.0
28.0
A
EDIP
BAI
Used the EDIP.e
Note. NR = not reported; N = total number of participants; Ethnic % = percentage ethnic minority; status = publication status of the study; A = article; D =
dissertation; YSRPerfect = one item of the Youth Self-Report measuring perfection; ADYSR = Anxious/Depressed scale of the Youth Self-Report; MPS =
Hewitt and Flett’s (1991) Multidimensional Perfectionism Scale; SOP = self-oriented perfectionism; OOP = other-oriented perfectionism; SPP = socially prescribed
perfectionism; FMPS = Frost et al.’s (1990) Multidimensional Perfectionism Scale; COM = concern over mistakes; DAA = doubts about actions; PC = parental
criticism; PE = parental expectations; PS = personal standards; PPS = pure personal standards; APSR = Slaney et al.’s (2001) Almost Perfect Scale-Revised; DIS =
discrepancy; HS = high standards; DEQ = Blatt et al.’s (1976) Depressive Experiences Questionnaire; SC = self-criticism; DAS = Weissman and Beck’s (1978)
Dysfunctional Attitude Scale; P = perfectionism; ES = event stress question from measure of daily bothersome events (Dunkley et al., 2003); MASQ = Watson and
Clark’s (1991) Mood and Anxiety Symptom Questionnaire Short Form; GDA = MASQ general distress anxious symptoms scale; AA = MASQ anxious arousal
scale; CPQ = Fairburn et al.’s (2003) Clinical Perfectionism Questionnaire; DASSA = Lovibond and Lovibond’s (1995) Depression Anxiety Stress Scale anxiety
subscale; SF = short form of measure; LEI = Cochrane and Robertson’s (1973) Life Events Inventory; LSASA = Liebowitz’ (1987) Liebowitz Social Anxiety
Scale avoidance subscale; SIAS = Mattick and Clarke’s (1998) Social Interaction Anxiety Scale; SPS = Mattick and Clarke’s (1998) Social Phobia Scale; BAI =
Beck et al.’s (1988) Beck Anxiety Inventory; EDIP = Garner et al.’s (1983) Eating Disorder Inventory perfectionism subscale; BFNE = Leary’s (1983) Brief Fear of
Negative Evaluation scale; SAAS = Hart et al.’s (2008) Social Appearance Anxiety Scale; MSPQ = Snell’s (1997) Multidimensional Sexual Perfectionism
Questionnaire; SO = self-oriented; PO = partner-oriented; PP = partner-prescribed; SP = socially-prescribed; MSSCQSA = Snell’s (2011) Multidimensional
Sexual Self-Concept Questionnaire sexual anxiety subscale; BPSJ = Sakurai and Otani’s (1994) Japanese version of Burns Perfectionism Scale (Burns 1980, 1983);
HSCAnx = Sumi’s (1997) Japanese version of Derogatis et al.’s (1974) Hopkins Symptom Checklist anxiety subscale.
aCommunity adults
bPeople seeking treatment for difficulties with perfectionism
SUPPLEMENTAL MATERIAL
39
cUniversity undergraduates
dPsychiatric patients
eHealth professionals (e.g., social workers, dentists, nurses, counselors, etc.)
fThe EDIP was excluded from the present meta-analysis in consideration of research suggesting the EDIP is problematic due to a factor structure composed of self-
oriented perfectionism items and social prescribed perfectionism items (see Sherry, Hewitt, Besser, McGee, & Flett, 2004).
gThe mean age was not reported; the median age is recorded here.
SUPPLEMENTAL MATERIAL 40
Supplemental Material B: Funnel Plots with Imputed Studies
B1. Funnel plot for the relationship between baseline concern over mistakes and follow up
anxiety, controlling for baseline anxiety. Open circles correspond to observed point estimates. The
open diamond corresponds to the overall observed point estimates. The filled in circles correspond
to overall imputed point estimates. The filled in diamond corresponds to the imputed point
estimate. The expected direction of missing studies was specified as being to the left of the mean.
-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0
0.00
0.05
0.10
0.15
0.20
Standard Error
Fisher's Z
Funnel Plot of Standard Error by Fisher's Z
SUPPLEMENTAL MATERIAL 41
B2. Funnel plot for the relationship between baseline doubts about actions and follow up anxiety,
controlling for baseline anxiety. Open circles correspond to observed point estimates. The open
diamond corresponds to the overall observed point estimates. The filled in circles correspond to
overall imputed point estimates. The filled in diamond corresponds to the imputed point estimate.
The expected direction of missing studies was specified as being to the left of the mean.
-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0
0.00
0.05
0.10
0.15
0.20
Standard Error
Fisher's Z
Funnel Plot of Standard Error by Fisher's Z
SUPPLEMENTAL MATERIAL 42
B3. Funnel plot for the relationship between baseline socially prescribed perfectionism and follow
up anxiety, controlling for baseline anxiety. Open circles correspond to observed point estimates.
The open diamond corresponds to the overall observed point estimates. The filled in circles
correspond to overall imputed point estimates. The filled in diamond corresponds to the imputed
point estimate. The expected direction of missing studies was specified as being to the left of the
mean.
-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0
0.0
0.1
0.2
0.3
0.4
Standard Error
Fisher's Z
Funnel Plot of Standard Error by Fisher's Z
SUPPLEMENTAL MATERIAL 43
B4. Funnel plot for the relationship between baseline personal standards and follow up anxiety,
controlling for baseline anxiety. Open circles correspond to observed point estimates. The open
diamond corresponds to the overall observed point estimates. The filled in circles correspond to
overall imputed point estimates. The filled in diamond corresponds to the imputed point
estimate. The expected direction of missing studies was specified as being to the left of the mean.
-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0
0.00
0.05
0.10
0.15
0.20
Standard Error
Fisher's Z
Funnel Plot of Standard Error by Fisher's Z
SUPPLEMENTAL MATERIAL 44
B5. Funnel plot for the relationship between baseline self-oriented perfectionism and follow up
anxiety, controlling for baseline anxiety. Open circles correspond to observed point estimates. The
open diamond corresponds to the overall observed point estimates. The filled in circles correspond
to overall imputed point estimates. The filled in diamond corresponds to the imputed point
estimate. The expected direction of missing studies was specified as being to the left of the mean.
-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0
0.0
0.1
0.2
0.3
0.4
Standard Error
Fisher's Z
Funnel Plot of Standard Error by Fisher's Z
SUPPLEMENTAL MATERIAL 45
Supplemental Material C: Forest Plots
C1. Forest plot of baseline concern over mistakes predicting follow up anxiety (controlling for
baseline anxiety). Random effects weights with prediction interval are shown. Boxes represent
effect sizes and are proprotional in area to a study’s weight.
SUPPLEMENTAL MATERIAL 46
C2. Forest plot of baseline doubts about actions predicting follow up anxiety (controlling for
baseline anxiety). Random effects weights with prediction interval are shown. Boxes represent
effect sizes and are proprotional in area to a study’s weight.
SUPPLEMENTAL MATERIAL 47
C3. Forest plot of baseline socially prescribed perfectionism predicting follow up anxiety
(controlling for baseline anxiety). Random effects weights with prediction interval are shown.
Boxes represent effect sizes and are proprotional in area to a study’s weight.
SUPPLEMENTAL MATERIAL 48
C4. Forest plot of baseline personal standards predicting follow up anxiety (controlling for
baseline anxiety). Random effects weights with prediction interval are shown. Boxes represent
effect sizes and are proprotional in area to a study’s weight.
SUPPLEMENTAL MATERIAL 49
C5. Forest plot of baseline self-oriented perfectionism predicting follow up anxiety (controlling
for baseline anxiety). Random effects weights with prediction interval are shown. Boxes
represent effect sizes and are proprotional in area to a study’s weight.
... There has been a long-standing debate in the scientific literature about whether striving for perfection can, in some cases, be considered adaptive (Lo and Abbott 2013;Stoeber, Madigan, and Gonidis 2020). For example, in a recent meta-analysis of longitudinal studies on the effects of both aspects of perfectionism on anxiety, Smith et al. (2018) revealed that both high personal standards and concerns/doubts are predictors of higher anxiety over time. Similar results were also observed for the relationship between both aspects of perfectionism and eating disorders (Stackpole et al. 2023). ...
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... Identifying bridge symptoms has significant clinical implications, such as targeted treatment of bridge symptoms. While network analysis studies have examined depressive and anxiety symptoms (e.g., Van den Bergh et al., 2021), none have done so including putative predictors like perfectionism Smith et al., 2018Smith et al., , 2021. ...
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... Zero-order correlations (p < 0.01) were found for this single item with perfectionism domains, such as worry-distress (0.30), reactions to failure (0.21) and also depression domain (0.16). These associations were in the same direction as indicated by a meta-analysis study, where perfectionism and anxiety positively correlated in samples of various ages (Smith et al., 2018). ...
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