Module 18 — CPQ — Clinical Perfectionism, When Your Standards Run You

 

The difference between having high standards and being run by them, where the twelve-item Clinical Perfectionism Questionnaire came from, how far its psychometrics can be trusted, and how the whole idea reads differently when the standard you are holding is appearing normal.

 

Autistic Self-Discovery · Part Six — Traveling Companions · 13 min read, about 26 min with the workbook

 

The big idea

 

If you have ever rewritten a three-line message six times, stayed up finishing something nobody was going to check, or hit the target you set and immediately decided the target had been too easy — this module is about a twelve-question measure that tries to separate having high standards from being run by them, and about how much weight the number it gives you can actually carry.

 

Be careful here, because this is where an honest module has to stop short. Nobody has validated this questionnaire in autistic adults. The closest published study compared 41 autistic boys with 42 typically developing boys and found more dysfunctional attitudes and higher emotional symptoms in the autistic group, but a weak relationship between the cognitive and emotional measures in both groups.¹³ Boys, not adults, and a mixed result. The overlap described above is a reasonable reading of separate literatures, not a finding.

 

Step 1 — The lesson

 

A. The standard that moves

 

Most people arrive at this word already labeled. Someone at work calls you a perfectionist, usually while asking you to do something quickly, and it lands somewhere between a compliment and a complaint. The questionnaire on this page is not built on that word. It is built on a much narrower idea, and the narrowness is the whole point.

 

In 2002 Roz Shafran, Zafra Cooper and Christopher Fairburn proposed that the defining feature of clinically significant perfectionism is the overdependence of self-evaluation on the determined pursuit and achievement of personally demanding standards in at least one salient domain, despite the occurrence of adverse consequences.¹ Strip the academic wording and there are two halves. Where your sense of being an acceptable person is coming from. And what it is costing you that you keep paying anyway.

 

Diagram — A · The standard that moves. The left column is a preference. The right column is a mechanism: the standard is doing the work of telling you whether you are all right. That is why encouragement bounces off it, and why hitting the target so rarely settles anything.

 

The same paper described how the thing keeps itself going. If you fall short of your standard, you respond with self-criticism. If you meet it, the standard is re-evaluated as having been insufficiently demanding, so it moves up.¹ Both outcomes feed the same conclusion. There is no result you can get that ends the argument, because success is quietly reclassified as evidence that the bar was too low.

 

This is why the research calls it a maintaining mechanism rather than a personality trait. Perfectionism has been argued to act as a risk and maintaining factor across eating disorders, anxiety disorders and depression rather than sitting inside any one of them,² and the largest meta-analysis in the area — 284 studies yielding 2,047 effect sizes — supports treating it as a transdiagnostic factor.³

 

The distinction matters more than it sounds. A trait is a description of you. A mechanism is something that runs, and things that run can be interrupted. Almost everything useful in this module follows from that sentence.

 

B. Twelve questions, or fourteen

 

The measure itself is short and unglamorous. Twelve items, each answered on a four-point scale running from not at all to all of the time, asking about the past month. It was written by Fairburn, Cooper and Shafran in 2003 as a companion to the theory.⁴ Twelve items scored one to four gives a lowest possible total of 12 and a highest of 48.

 

Hold on to that arithmetic, because there is a contradiction on the screener page you are about to use and we would rather point at it than tidy it away. The page says fourteen questions. It then gives a total range of 12 to 48, which is exactly a twelve-item range. Both cannot be right. Count the questions as you answer them: if there really are fourteen scored items, the total you get is not the total any of the research below is describing, and the bands will be sitting on the wrong scale.

 

Diagram — B · Twelve questions, or fourteen. The measure was written to capture one thing. Almost every independent team that has factor-analyzed it since has found two, and several have found the twelve items fit better once two of them are removed.

 

The first substantial psychometric paper came in 2016. A non-clinical internet sample of 206 adults was followed by 129 people in treatment for an eating disorder and 80 community participants. Factor analysis pointed to a two-factor structure in both studies, internal consistency was acceptable, and the questionnaire separated the eating disorder group from the controls. The authors also checked its readability and put it at a US grade four reading level.⁵ That last detail is not trivial. Short, plain items are why this measure gets used in ordinary clinics.

 

The two factors that keep appearing are usually named perfectionistic strivings and perfectionistic concerns — roughly, how much you chase the standard and how much you dread falling short of it. Then the picture got more complicated. In 211 eating disorder patients, a revised ten-item bifactor model fitted best: one general perfectionism factor plus two smaller group factors covering overvaluation of striving and concern over mistakes. Only the general factor predicted eating disorder symptoms.⁶ A community sample of 397 adults reached the same shape, and found something sharper still: the general factor was positively associated with depression, anxiety and stress, while the strivings group factor was negatively associated with depression.⁷

 

Read that twice. Once you account for the general factor, the striving part of perfectionism pointed the other way. Your total mixes together two components that do not behave the same, which is one reason a single number is a blunt instrument here.

 

Two of the twelve items are reverse-scored, and they misbehave. When a Swedish team tested the questionnaire in 223 treatment-seeking adults, the model fitted inadequately until the two reverse-scored items were excluded; internal consistency was 0.72 after their removal, and the eight-week test-retest correlation was 0.62.⁸ Reverse-scored items are meant to catch people who tick straight down the page. In practice they often catch nothing except confusion, and in this questionnaire they are the items independent teams keep dropping.

 

One finding is worth setting against all that. In 243 adults, the questionnaire accounted for additional variance in depressive symptoms, anxious symptoms and stress beyond both multidimensional perfectionism scales and general negative affectivity.⁹ It is not simply a slower way of asking whether you feel bad.

 

C. Autistic, and holding a standard nobody set

 

Clinical perfectionism only requires one salient domain. The literature usually pictures that domain as work, sport, study or eating and shape. For a great many late-identified autistic adults the domain is something else entirely: appearing normal.

 

When 92 autistic adults were asked about camouflaging, they described motivations of fitting in and building connection, a mix of masking and compensation techniques, and consequences that included exhaustion, challenging stereotypes and threats to self-perception.¹⁰ Look at that through the definition in section A. A demanding standard, in one salient domain, that you go on meeting despite the costs, where falling short feels like a verdict on you rather than a difficult afternoon. The structure is the same. The domain is just not one the questionnaire's authors had in mind.

 

Diagram — C · Autistic, and holding a standard nobody set. The instrument asks about standards without asking which domain they live in. For many autistic adults the answer is not achievement at all. It is passing as ordinary, which is a standard with no visible finish line and no day off.

 

There is a second overlap that gets read as perfectionism from the outside and is not. Insistence on sameness — the rule kept exactly, the route not varied, the process done in the same order — can look identical to a demanding standard. In 426 autistic adults, sensory processing differences were linked to insistence on sameness through intolerance of uncertainty, with alexithymia and anxiety in the chain for repetitive motor behaviors.¹¹ That is a different engine. One is about self-worth. The other is about not being able to bear the unknown. They call for different responses, and this questionnaire cannot tell them apart.

 

Then there is the over-preparation. Rehearsing a phone call. Arriving forty minutes early to avoid arriving flustered. Reading the entire agenda twice because being caught out is unbearable. Interviews with autistic adults about burnout describe chronic exhaustion, loss of skills and reduced tolerance to stimulus, arising from chronic life stress and a mismatch between expectations and abilities — with acceptance, reduced expectations and unmasking among the things that helped recovery.¹² Over-preparation is often the price of a standard, and the bill arrives late.

 

D. What the number does and does not mean

 

The screener returns a total between 12 and 48 and sorts it into three bands: 12 to 23 is labeled Low Perfectionism, 24 to 35 Moderate Perfectionism, and 36 to 48 High Perfectionism. Here is what sits underneath those numbers.

 

Diagram — D · What the number does and does not mean. The overall range matches the published twelve-item measure exactly. The two boundaries inside it do not come from the published literature, which reports factor structure, reliability and correlations rather than cut-off scores.

 

We looked for a published derivation for the cuts at 23 and 35 and did not find one. The psychometric papers on this questionnaire report what it is made of, how internally consistent it is and how it correlates with other measures. They do not supply a threshold that separates clinical from non-clinical perfectionism, and there is no normative table you can look your score up in. So a band here is a way of describing your answers back to you. It is not a line you have crossed.

 

The item-count problem compounds this. If the version you take really has fourteen scored items, the same three bands are being applied to a scale that runs from 14 to 56, and a total of 35 no longer means what the band says it means. Before you give the number any weight at all, count the questions.

 

The total also flattens the two components. Because the strivings component ran the opposite way to the general factor once that factor was accounted for,⁷ two people with an identical total of 34 can be in genuinely different situations — one carrying mostly ambition, the other mostly dread. The questionnaire as delivered here does not split them out.

 

Nothing in a score points at autism, and nothing in it rules autism out. Perfectionism is elevated across depression, anxiety disorders, obsessive-compulsive disorder, eating disorders and general distress alike,³ which is the entire reason researchers describe it as transdiagnostic. A high total tells you a mechanism is running. It does not tell you which road brought it.

 

Finally, this is a self-report about the past month, from a twelve-item questionnaire with a test-retest correlation of 0.62 over eight weeks in the one study that measured it.⁸ That is moderate stability, not high. A score taken during a difficult month is a score about a difficult month.

 

INSIDE THE INSTRUMENT

 

CPQ — Clinical Perfectionism Questionnaire

 

Where it came from

 

Shafran, Cooper and Fairburn's 2002 cognitive-behavioral analysis redefined clinically significant perfectionism as the overdependence of self-evaluation on the pursuit and achievement of personally demanding standards in at least one salient domain, despite adverse consequences, maintained by self-criticism after failure and by re-evaluating met standards as insufficiently demanding.¹ The questionnaire followed in 2003, authored by Fairburn, Cooper and Shafran: twelve items, a four-point scale from not at all to all of the time, referenced to the past month.⁴ It was designed as a change-sensitive measure for treatment, not as a case-finding tool.

 

What it is made of

 

Twelve items, total 12 to 48, two of them reverse-scored. It was intended to be unidimensional. Independent factor analyses have not agreed with that. Two-factor solutions — usually labeled perfectionistic strivings and perfectionistic concerns — recur in community, clinical and adolescent samples,⁵ a two-factor higher-order solution has been reported in general and clinical samples with McDonald's omega for the subscales between 0.75 and 0.86,⁴ and bifactor models with a strong general factor have outperformed both one- and two-factor alternatives.^6,7

 

How well it performs

 

In the 2016 validation, a non-clinical internet sample of 206 and a clinical study of 129 eating disorder patients plus 80 community controls both yielded acceptable internal consistency, construct and incremental validity, and discrimination between clinical and control groups; readability was US grade four.⁵ In 243 adults it explained variance in depressive, anxious and stress symptoms over and above multidimensional perfectionism scales and negative affectivity.⁹ The Swedish validation of 223 treatment-seeking adults reported alpha of 0.72 after excluding the two reverse-scored items and an eight-week test-retest correlation of 0.62 (95% CI 0.45 to 0.74, n = 72).⁸

 

Where it was validated

 

Eating disorder outpatients, community and student adults, treatment-seeking adults screened for internet CBT, and adolescent girls. It has been translated and psychometrically examined in Swedish, German, Italian, Persian, Russian, Arabic and Turkish, mostly by teams with no connection to the original authors. There is no published validation in an autistic sample, and no autistic normative data of any kind.

 

What it cannot do

 

It has no published cut-off and no normative table. The literature reports structure, reliability and correlations. The band boundaries at 23 and 35 used on this screener page have no derivation we could locate in the published work, so they should be read as descriptive language rather than as thresholds.

 

Its factor structure is genuinely unsettled. Designed as unidimensional, measured repeatedly as two factors,⁵ and best fitted in two independent samples by bifactor models on a reduced ten-item set.^6,7 In one of those samples the strivings group factor related negatively to depression once the general factor was accounted for,⁷ so a total score sums components that do not point the same way.

 

The two reverse-scored items behave poorly. A Swedish confirmatory factor analysis achieved acceptable fit only after removing items 2 and 8, and reported structural validity as still poor.⁸ Reduced ten-item versions are now common in the literature, which means published psychometrics and this twelve-item scoring are not always describing the same instrument.

 

It carries no diagnostic specificity. A meta-analysis of 284 studies producing 2,047 effect sizes found both perfectionism dimensions associated with depression, anxiety disorders, obsessive-compulsive disorder, eating disorders, deliberate self-harm, suicidal ideation and general distress.³ An elevated score is not evidence for or against any diagnosis, autism included.

 

The live page states 14 questions and a total range of 12 to 48. Those are inconsistent: 12 to 48 is a twelve-item range at one to four points per item. Until the live form is checked, treat the total as provisional and do not compare it to published figures. The page also does not state its per-item response scale; the four-point scale described here is the published instrument's, not a claim about this implementation.

 

What a clinician does with it

 

Use it as a repeated measure, which is what it was built for, and score the two components separately where possible rather than relying on the total. The treatment evidence is the strong part of this literature: a meta-analysis of 15 randomised controlled trials of CBT for perfectionism (N = 912, mean pooled age 23) found Hedges g of 0.87 for clinical perfectionism, 0.89 for concern over mistakes and 0.57 for personal standards, with 0.61 for eating disorder symptoms, 0.60 for depression and 0.42 for anxiety, and no evidence of publication bias.¹⁴ A UK randomised trial of guided internet CBT in 120 adults found a between-group effect of d = 1.04 on this questionnaire, but 71% of participants completed fewer than half the modules and completion moderated the rate of change.¹⁵ Engagement, not efficacy, is the bottleneck.

 

Validity tier: 2 — peer-reviewed and independently examined, but uncalibrated. Multiple unaffiliated labs have tested it across languages and populations, which is more than most screeners can claim; there is still no published cut-off, no normative sample, no settled factor structure and no autistic validation, so the bands are descriptive rather than diagnostic.

 

Diagram — E · One high total, many roads to it. This is the caveat to carry away. A high score is good evidence that a demanding standard is doing work in your life. It is no evidence at all about why, and it does not point at autism.

 

STRENGTHS LENS

 

The standard is not the problem. The tax on it is.

 

The care that produces a document with no errors in it, the preparation that means you have already thought of the question nobody else thought of, the refusal to hand over something you know is not finished — these are real capabilities, and the people who benefit from them rarely say so out loud. Nothing in this module asks you to become careless.

 

What the research points at is narrower and more hopeful than that. It is not the standard that carries the cost. It is self-worth being wired to the standard, so that meeting it brings no relief and missing it brings a verdict. Those two things can be unhooked from each other. The treatment trials that reduce clinical perfectionism do not turn people into sloppier workers — they reduce the concern over mistakes, which is the part that hurts, considerably more than they touch personal standards.

 

F. What helps

 

This is one of the few areas in the course with a proper evidence base behind the intervention rather than only behind the description. Cognitive behavioral work on perfectionism has been tested in randomised trials, and it moves both the perfectionism and the mood symptoms that travel with it. What follows is the shape of that work, plus two adjustments that matter if you are autistic.

 

1. Run one small experiment against the standard.

 

Pick something low-stakes and deliberately do it to eighty per cent. Send the email after one read. Leave the report without the third pass. Then write down, the same day, what you predicted would happen and what actually happened. This is the core move in CBT for perfectionism, and across fifteen randomised trials it produced large reductions in clinical perfectionism and concern over mistakes.

 

2. Name the domain your worth is plugged into.

 

Clinical perfectionism needs only one salient area, and it is usually obvious once you look for the place where failing feels like a verdict rather than an inconvenience. Write the actual domain down in your own words — not "work" but "never being the one who slows the team down". You cannot widen a base you have not located.

 

3. Ask whether it is a standard or a need for sameness.

 

For the next rigid rule you notice, ask one question: if I break this, is the feeling shame or is it dread? Shame usually means self-worth is attached and the perfectionism work applies. Dread usually means uncertainty is the driver, which responds to graded, predictable exposure and to building in slack, not to lowering your standards. The questionnaire cannot make this distinction for you.

 

4. Put a hard limit on preparation.

 

Decide in advance how long you will rehearse the call, check the route or reread the agenda, and stop when the time is up rather than when the anxiety drops. Over-preparation is invisible labour that shows up later as exhaustion, and autistic adults describing burnout point at exactly this mismatch between expectations and capacity as the thing that empties the tank.

 

5. Catch the moment the bar moves.

 

The maintaining loop lives in a single instant: you achieve the thing and, within about a minute, decide it did not count, or was easier than it looked, or that anyone could have done it. Write that instant down when it happens, in your own words. Seeing it in your handwriting four or five times does more to loosen it than any amount of being told you are too hard on yourself.

 

Step 2 — Take the screener

 

Three to five minutes, free and confidential. You get one total between 12 and 48 and one of three bands. One honest steer before you start: the page says fourteen questions but gives a total range of 12 to 48, which is the range of the published twelve-item version, so count the questions as you answer them — and read the band as a description of what you said, not as a threshold you have crossed.

 

Take the CPQ

 

Before you start

 

The Clinical Perfectionism Questionnaire is a published twelve-item measure written by Fairburn, Cooper and Shafran in 2003 and examined since by several independent labs across seven languages, so it is better supported than most free quizzes. It also has real limits: no published cut-off score, no normative table, a factor structure researchers still disagree about, two reverse-scored items that other teams routinely delete, and no validation of any kind in autistic adults. Note too that this page states fourteen questions while giving a twelve-item score range, so treat the total as provisional. Perfectionism is transdiagnostic and runs high across depression, anxiety, OCD and eating disorders alike, so no score here indicates that you are or are not autistic. This is a screen, not a diagnosis, and only a clinician can diagnose.

 

Step 3 — Your workbook

 

Your answers save to this device only — we cannot see a word of what you write. This module lets you record your total, name the one domain your self-worth is plugged into, catch the moment the bar moves after you achieve something, tell a demanding standard apart from a need for sameness, and set up one small experiment against the standard.

 

Your CPQ results

 

Took the screener? Put the number in below. Read section D first if you can — the bands are descriptive language, not thresholds, and the page's item count does not match its own score range. Entirely optional — skip it if you would rather just read.

 

Score bands: 12–23 = Low Perfectionism; 24–35 = Moderate Perfectionism; 36–48 = High Perfectionism

 

Fields: CPQ · Clinical Perfectionism Questionnaire; Total score (12–48); My total (enter 12–48); How many questions did the screener actually ask you?: Twelve / Fourteen / Some other number / I did not count

 

The domain your worth is plugged into

 

Section F, item 2. Clinical perfectionism only needs one salient area — the one where falling short feels like a verdict rather than an inconvenience.

 

Fields: The domain, in my own words; What falling short in that domain says about me, in the moment; What else counts, on a good day, that I never give credit for

 

The moment the bar moves

 

Section F, item 5. The maintaining loop lives in about sixty seconds: you hit the target and immediately discount it.

 

Fields: Something I achieved recently; What I said to myself within a minute of achieving it; Which move was it?: It did not really count / It was easier than it looked / Anyone could have done that / I should have done it sooner / I did not discount it this time

 

Standard, or sameness

 

Section F, item 3. Shame usually means self-worth is attached. Dread usually means uncertainty is the driver. Different engines, different fixes.

 

Fields: A rigid rule I keep; If I break it, the feeling is closer to: Shame — a verdict on me / Dread — the unknown is unbearable / Genuinely both / Not sure yet; What that suggests I should work on first

 

One experiment against the standard

 

Section F, item 1. Low stakes, done deliberately to eighty per cent, with the prediction written down before you start.

 

Fields: The task I will do to eighty per cent; What I predict will happen; What actually happened; Tick: I did it and nothing I predicted came true

 

The preparation budget

 

Section F, item 4. Over-preparation is invisible labour, and the bill arrives as exhaustion later in the week.

 

Fields: What I over-prepare for; How long I will give it, decided in advance; What the preparation is protecting me from, if I am honest

 

Appendix — Research companion

 

Peer-reviewed research

 

9. Chang EC, Sanna LJ (2012). Evidence for the validity of the Clinical Perfectionism Questionnaire in a nonclinical population: more than just negative affectivity. Journal of Personality Assessment, 94(1), 102-108. DOI 10.1080/00223891.2011.627962. View the paper Examined the questionnaire in a non-clinical sample of 61 men and 182 women. Scores were positively associated with depressive symptoms, anxious symptoms and stress, and regression analyses showed the measure accounted for additional variance in all three beyond both multidimensional perfectionism scales and negative affectivity, which counters the objection that it is only an indirect measure of distress. Limitation: a cross-sectional non-clinical sample of unequal sex composition with no clinical comparison group, so it speaks to incremental validity rather than to clinical utility or cut-offs.

 

5. Egan SJ, Shafran R, Lee M, Fairburn CG, Cooper Z, Doll HA, Palmer RL, Watson HJ (2016). The reliability and validity of the Clinical Perfectionism Questionnaire in eating disorder and community samples. Behavioural and Cognitive Psychotherapy, 44(1), 79-91. DOI 10.1017/S1352465814000629. View the paper The main psychometric paper for the 12-item questionnaire, co-authored by its developers. Study 1 used a non-clinical internet sample of 206 adults and found a two-factor structure with strong correlations with other perfectionism and psychopathology measures, acceptable internal consistency and discriminative and incremental validity; Study 2 used 129 people in treatment for an eating disorder and 80 community participants, reproduced the two-factor structure, and showed the measure discriminating between the groups. Readability was assessed at a US grade four reading level. Limitation: the authors include the instrument's developers, both community samples were self-selected, and the two-factor result contradicts the unidimensional construct the measure was designed to capture.

 

14. Galloway R, Watson H, Greene D, Shafran R, Egan SJ (2022). The efficacy of randomised controlled trials of cognitive behaviour therapy for perfectionism: a systematic review and meta-analysis. Cognitive Behaviour Therapy, 51(2), 170-184. DOI 10.1080/16506073.2021.1952302. View the paper Systematic review and meta-analysis of 15 randomised controlled trials of self-help and face-to-face CBT for perfectionism (N = 912, mean pooled age 23). Effects were medium to large on perfectionism measures - personal standards g = 0.57, concern over mistakes g = 0.89, clinical perfectionism g = 0.87 - with medium effects on eating disorder symptoms (g = 0.61) and depression (g = 0.60) and a small to medium effect on anxiety (g = 0.42), and no publication bias detected. Limitation: a small number of trials, largely against wait-list rather than active comparators, with mostly young non-clinical or mildly symptomatic samples and no autistic participants identified.

 

13. Greenaway R, Howlin P (2010). Dysfunctional attitudes and perfectionism and their relationship to anxious and depressive symptoms in boys with autism spectrum disorders. Journal of Autism and Developmental Disorders, 40(10), 1179-1187. DOI 10.1007/s10803-010-0977-z. View the paper Compared 41 autistic boys with 42 typically developing boys on dysfunctional attitudes, perfectionism and emotional symptoms, to test whether the cognitive model behind CBT applies in this group. The autistic group endorsed more dysfunctional attitudes and reported higher emotional symptoms, but the relationship between cognitive and emotional variables was weak in both groups, with dysfunctional attitudes in the autistic group significantly associated only with reported obsessive-compulsive symptoms. Limitation: boys only, small groups, and self-report cognitive measures never validated in autistic populations, so it cannot be extended to autistic adults or to clinical perfectionism specifically.

 

7. Howell J, Anderson R, Egan S, McEvoy P (2020). One factor? Two factor? Bi-factor? A psychometric evaluation of the Frost Multidimensional Scale and the Clinical Perfectionism Questionnaire. Cognitive Behaviour Therapy, 49(6), 518-530. DOI 10.1080/16506073.2020.1790645. View the paper Compared one-factor, two-factor and bifactor models of both the Frost Multidimensional Perfectionism Scale and the Clinical Perfectionism Questionnaire in a community sample of 397 adults. Bifactor models were better supported than either alternative for both instruments; the general factor was positively associated with depression, anxiety and stress symptoms, while the perfectionistic strivings group factor was negatively associated with depression. The authors recommend using general factor scores in research and treatment. Limitation: a cross-sectional community sample with no clinical group and no test-retest data, and bifactor models are known to fit well for statistical reasons even when the substantive case for them is weak.

 

10. Hull L, Petrides KV, Allison C, Smith P, Baron-Cohen S, Lai MC, Mandy W (2017). Putting on my best normal: social camouflaging in adults with autism spectrum conditions. Journal of Autism and Developmental Disorders, 47(8), 2519-2534. DOI 10.1007/s10803-017-3166-5. View the paper Qualitative study of 92 autistic adults asked about the nature, motivations and consequences of social camouflaging, analysed thematically into a three-stage model. Motivations centred on fitting in and increasing connection with others; techniques combined masking and compensation; consequences included exhaustion, challenging stereotypes and threats to self-perception, with effects on both immediate wellbeing and longer-term quality of life. Limitation: a self-selected sample recruited online and analysed qualitatively, with no measure of perfectionism and no comparison group, so the parallel with clinical perfectionism drawn in this module is interpretive rather than tested.

 

3. Limburg K, Watson HJ, Hagger MS, Egan SJ (2017). The relationship between perfectionism and psychopathology: a meta-analysis. Journal of Clinical Psychology, 73(10), 1301-1326. DOI 10.1002/jclp.22435. View the paper Meta-analysis of 284 studies producing 2,047 effect sizes, examining perfectionistic strivings and perfectionistic concerns against clinical diagnoses of depression, anxiety disorders, obsessive-compulsive disorder and eating disorders, symptoms of those conditions, and related outcomes including deliberate self-harm, suicidal ideation and general distress. Both dimensions were associated with multiple forms of psychopathology, supporting perfectionism as a transdiagnostic factor. Limitation: overwhelmingly cross-sectional and correlational, so it establishes association rather than causal or maintaining status, and it pools many different perfectionism instruments.

 

4. Moloodi R, Pourshahbaz A, Mohammadkhani P, Fata L, Ghaderi A (2021). Two-factor higher-order model of perfectionism in Iranian general and clinical samples. BMC Psychology, 9(1), 30. DOI 10.1186/s40359-021-00529-2. View the paper Tested the structure of the Clinical Perfectionism Questionnaire in an Iranian general population sample of 384 adults and a clinical sample of 152 patients with major depression, obsessive-compulsive disorder, social anxiety disorder or eating disorders. It records the instrument as 12 items developed by Fairburn, Cooper and Shafran in 2003, answered on a four-point scale from not at all to all of the time about the past month, and supports a two-factor higher-order solution with McDonald's omega for the subscales between 0.75 and 0.86. Limitation: single-country samples with unequal group sizes and no test-retest data, and the clinical sample pools four diagnostic groups too small to analyse separately.

 

11. Moore HL, Brice S, Powell L, Ingham B, Freeston M, Parr JR, Rodgers J (2022). The mediating effects of alexithymia, intolerance of uncertainty, and anxiety on the relationship between sensory processing differences and restricted and repetitive behaviours in autistic adults. Journal of Autism and Developmental Disorders, 52(10), 4384-4396. DOI 10.1007/s10803-021-05312-1. View the paper Serial mediation analysis in 426 autistic adults examining routes from sensory processing differences to repetitive motor behaviours and to insistence on sameness. There were significant direct effects to both, with indirect effects running through alexithymia, intolerance of uncertainty and anxiety for repetitive motor behaviours, and through intolerance of uncertainty alone, and alexithymia with intolerance of uncertainty, for insistence on sameness. The authors conclude that different mechanisms underpin the two behaviour classes. Limitation: cross-sectional self-report data, so the mediation models describe statistical pathways rather than demonstrated causal sequences.

 

8. Parks A, van de Leur JC, Straat M, Elfving F, Andersson G, Carlbring P, Shafran R, Rozental A (2021). A self-report measure of perfectionism: a confirmatory factor analysis of the Swedish version of the Clinical Perfectionism Questionnaire. Clinical Psychology in Europe, 3(4), e4581. DOI 10.32872/cpe.4581. View the paper Translated the questionnaire into Swedish and tested it in 223 treatment-seeking adults screened for eligibility for internet-based CBT. Fit was inadequate initially; a two-factor structure excluding the reverse-scored items 2 and 8 fitted better and produced Cronbach's alpha of 0.72, with an eight-week test-retest correlation of 0.62 (95% CI 0.45 to 0.74) in 72 wait-list controls, although the authors describe structural validity as still poor. Correlations with depression, anxiety, self-criticism, quality of life and self-compassion ran in the expected directions. Limitation: one treatment-seeking Swedish sample, and the reported solution requires deleting two items, so the resulting scale is not the twelve-item version scored on most screener pages.

 

6. Prior KL, Erceg-Hurn DM, Raykos BC, Egan SJ, Byrne S, McEvoy PM (2018). Validation of the clinical perfectionism questionnaire in an eating disorder sample: a bifactor approach. International Journal of Eating Disorders, 51(10), 1176-1184. DOI 10.1002/eat.22892. View the paper Confirmatory factor analysis of the questionnaire in 211 patients presenting for eating disorder treatment. A revised 10-item bifactor model fitted best, with a strong general perfectionism factor plus two group factors covering overvaluation of striving and concern over mistakes, and only the general factor predicted eating disorder symptoms, which the authors read as justifying use of a total score in this population. Limitation: a single treatment-seeking eating disorder sample, and the best-fitting model discards two of the twelve items, so its findings do not straightforwardly transfer to a twelve-item total scored elsewhere.

 

15. Shafran R, Wade TD, Egan SJ, Kothari R, Allcott-Watson H, Carlbring P, Rozental A, Andersson G (2017). Is the devil in the detail? A randomised controlled trial of guided internet-based CBT for perfectionism. Behaviour Research and Therapy, 95, 99-106. DOI 10.1016/j.brat.2017.05.014. View the paper Randomised 120 UK adults (mean age 28.9, 79% female) to guided internet CBT for perfectionism or a wait-list over 12 weeks. Between-group effects were d = 0.98 on concern over mistakes and d = 1.04 on the Clinical Perfectionism Questionnaire on intent-to-treat analysis, but 71% of participants completed fewer than half the modules and the number of modules completed moderated the rate of change in clinical perfectionism. Limitation: a wait-list comparator rather than an active treatment, a self-selected largely female sample, and engagement problems severe enough that the effect estimates rest on substantial non-completion.

 

Clinical frameworks and position statements

 

2. Egan SJ, Wade TD, Shafran R (2011). Perfectionism as a transdiagnostic process: a clinical review. Clinical Psychology Review, 31(2), 203-212. DOI 10.1016/j.cpr.2010.04.009. View the source Clinical review arguing that perfectionism functions as a risk and maintaining factor across eating disorders, anxiety disorders and depression rather than belonging to any single diagnosis, and setting out the case for treating it directly as a transdiagnostic target. It is the paper most often cited as the rationale for CBT for perfectionism as a stand-alone intervention. Limitation: a narrative clinical review rather than a systematic one, with no pooled effect sizes and no quality appraisal of the studies it draws on.

 

Lived experience

 

12. Raymaker DM, Teo AR, Steckler NA, Lentz B, Scharer M, Delos Santos A, Kapp SK, Hunter M, Joyce A, Nicolaidis C (2020). Having all of your internal resources exhausted beyond measure and being left with no clean-up crew: defining autistic burnout. Autism in Adulthood, 2(2), 132-143. DOI 10.1089/aut.2019.0079. View the source Community-based participatory research using thematic analysis of 19 interviews with autistic adults and 19 public internet sources to define autistic burnout. It characterises the syndrome as chronic exhaustion, loss of skills and reduced tolerance to stimulus arising from chronic life stress and a mismatch between expectations and abilities, with impacts on health, independent living, quality of life and suicidal behaviour, and identifies acceptance and social support, time off and reduced expectations, and doing things in an autistic way including unmasking as aids to recovery. Limitation: a qualitative definitional study with a small interview sample of professionally diagnosed adults, offering no prevalence estimate and no validated measure of the construct.

 

Emerging or contested

 

1. Shafran R, Cooper Z, Fairburn CG (2002). Clinical perfectionism: a cognitive-behavioural analysis. Behaviour Research and Therapy, 40(7), 773-791. DOI 10.1016/S0005-7967(01)00059-6. View the paper The originating theoretical paper for the whole clinical perfectionism literature and for the questionnaire this module covers. It proposes that the defining feature of clinically significant perfectionism is the overdependence of self-evaluation on the determined pursuit and achievement of self-imposed personally demanding standards in at least one salient domain, despite the occurrence of adverse consequences, and that it is maintained by self-criticism after perceived failure and by re-evaluating met standards as insufficiently demanding. It argues that anorexia nervosa and bulimia nervosa are often direct expressions of this mechanism. Limitation: a conceptual and review paper with no empirical sample and no data of its own, so it establishes a definition rather than testing one.

 

Further reading — general background

 

Cobbaert L, Millichamp AR, Elwyn R, Silverstein S, Schweizer K, Thomas E, Miskovic-Wheatley J (2024). Neurodivergence, intersectionality, and eating disorders: a lived experience-led narrative review. Journal of Eating Disorders, 12(1), 187. DOI 10.1186/s40337-024-01126-5. View the source Lived experience-led narrative review of why autistic and ADHD people are at high risk of developing eating disorders, offering a thematic framework of psychosocial, environmental and biological factors and a critical appraisal of current eating disorder research and care, including poorer treatment outcomes for neurodivergent people. Included here as further reading for anyone whose perfectionism sits closest to food, shape or control. Limitation: a narrative rather than systematic review, with no pooled data and no quality appraisal of the studies it summarises.

 

Peer-reviewed = checked by independent experts before publication. Clinical model = an established professional framework, not a single study.

 

Up next

 

Module 19 - FMPS — Six Faces of Perfectionism

 

All modules in Autistic Self-Discovery

 

Standards are not the problem. The tax is. This course was built by clinicians who are part of the New Path Family. Perfectionism is one of the few things in this course with proper randomised trial evidence behind the treatment, and unhooking self-worth from the standard is work that responds well to having someone alongside you. Therapy for clients in California and coaching worldwide, all by telehealth, are offered by our sister company New Path Family of Therapy Centers, Inc. A conversation costs nothing and there is no pressure. Saving this for later counts too. Talk with the New Path team