Perfectionism and Anxiety: Addressing the Root Causes With RO DBT

Think back to when you were a young child visiting a local park. Did you notice the beauty of the flowers, hear the laughter of children playing and join in the fun without worry? Or did you notice the bugs in the air and the thorns in the bushes, and choose to keep to yourself, worried you wouldn’t be good at the games other children were playing?

The answer may come down to your biotemperament, explains Ellen Astrachan-Fletcher, PhD, FAED, CEDS-S (she/her/hers), regional clinical director at Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight):

“Biotemperament is the biological basis of emotion that impacts two things: how we perceive the world and how we regulate our emotions."

An individual’s biotemperament is tied to conditions like maladaptive perfectionism and anxiety, which are also triggers for eating disorders, depression and other mood disorders. For providers, untangling this web of symptoms and behaviors has been challenging historically. Today, however, an emerging evidence-based approach called radically open dialectical behavior therapy (RO DBT) can help providers identify clients’ biotemperamental tendencies and help them develop a mindful awareness around how perfectionism shows up for them.

Identifying perfectionism

Before we explore RO DBT, let’s first examine perfectionism. By definition, an individual who is a perfectionist constantly strives to achieve a state of “perfection” -- something that, in reality, isn’t feasible.

“Individuals with perfectionism believe they need to appear perfect, but they never believe they are actually good enough,” Dr. Astrachan-Fletcher says.

What’s fascinating is that perfectionism, like many other biotemperamental traits, can be both good and bad. It can, for example, make people excellent employees because they strive to put their best foot forward whenever they’re asked to complete a task. However, perfectionism often has a shadow side. Individuals with maladaptive perfectionism find themselves in an endless loop striving to achieve the unachievable, with a potentially devastating impact on their mental health.

“Maladaptive perfectionism can lead to self-disappointment, disgust, even self-hatred,” Dr. Astrachan-Fletcher says. “It can even lead to the view that ‘I need to punish myself because I’m not good enough.’”

How perfectionism and anxiety intersect

When perfectionistic tendencies develop, anxiety often isn’t far behind.

One study found that more recent generations of college students scored higher for specific types of perfectionism than students from earlier generations ^[1]. Additional research showed a correlation between perfectionism and higher risks for depression ^[2].

To see how this can occur, consider the example of a student writing a paper for class. They stay up all night trying to make their paper “perfect.” They write and rewrite, but never feel it’s good enough. This triggers feelings of anxiety. Then the student begins questioning themselves.

“What if I didn’t understand the assignment correctly? What if my writing is garbage? What if my teacher thinks less of me after this assignment?”

As the anxiety grows, the perfectionism gets even louder. This could lead to the student not turning in the paper out of fear that it’s “not perfect,” and even failing the class.

Slippery slope: Perfectionism and eating disorders

Because perfectionism is closely related to anxiety disorders, it can also be a contributing factor leading to eating disorders.

Research from the National Institute of Mental Health ^[3] shows that anxiety disorders and eating disorders often coexist. According to their data, anxiety disorders are identified in:

• 80.6% of adults with bulimia nervosa
• 65.1% of adults with binge eating disorder
• 47.9% of adults with anorexia nervosa

Laura Hill, PhD, FAED, an eating disorders specialist and adjunct associate professor of psychiatry and behavioral health at The Ohio State University, shed more light on the relationship between perfectionism and eating disorders during our Mental Note podcast.

“One of the traits that is common to anorexia is perfectionism,” explains Dr. Hill. “Some people tend to avoid or pull back and inhibit themselves when something seems overwhelming. Others may show inhibition and avoidance perfectionism, which is an inability to trust your decisions. And that is a very common trait among those with anorexia and binge eating disorder.”

The perfectionism trait and threat sensitivity

The roots of perfectionism can often be traced back to biotemperament, the forces that help people perceive and regulate emotions.

Take the example of the child at the park who would rather not engage with other children. It’s likely that one of their biotemperamental traits is threat sensitivity. So, they perceive threats (bugs, thorns, not being “as good as” the other kids at playing games) differently than others.

“A higher threat sensitivity often leads to the experience of anxiety,” Dr. Astrachan-Fletcher says.

Now, experts are addressing the relationship between biotemperament and mental health, including maladaptive perfectionism.

RO DBT for maladaptive perfectionism

An innovative approach to treating mood and anxiety disorders is RO DBT. It’s a transdiagnostic methodology that’s specifically designed for individuals who exhibit signs of emotional overcontrol, such as maladaptive perfectionism.

“The theory behind RO DBT is that overcontrolled people are better off pursuing what they are missing in their lives, which is true connection with at least one other person,” Dr. Astrachan-Fletcher says.

The RO DBT framework is structured to help individuals learn from their environments, make meaningful changes to connect with others and improve their relationships through a focus on three areas:

• Openness: Receptiveness to feedback in order to learn and grow (which can be difficult for people with a high threat sensitivity)
• Flexibility: Adaptability in different situations
• Connectedness: Emotional recognition and expression (valuable skills that support intimacy and healthy relationships)

“The goal,” explains Dr. Astrachan-Fletcher, “is to help overcontrolled clients get to their ‘safety cue’ state so they can grow more comfortable in the vulnerability of a therapy session.”

Encouraging a mindful relationship with perfectionism

When working with an individual who exhibits perfectionistic traits, it’s important for clinicians to acknowledge that their perfectionism can sometimes be a good thing, Dr. Astrachan-Fletcher explains. The key is to help your client develop a mindful awareness of their perfectionism, recognizing when it’s helpful and when it’s not.

“Many people think that if they loosen their reigns on perfectionism, they will make constant mistakes and experience constant failure, but that’s not true,” Dr. Astrachan-Fletcher says. “By using RO DBT, we can teach our clients how to approach perfectionism with kindness, acceptance and curiosity so they can see both the good and bad side of perfectionism and get more comfortable with their genuine selves.”

Related Resources 
A Mindfulness Exercise to Reduce Perfectionism 
High-Functioning Anxiety: What It Is and When to Get Help 
How to Let Go of Perfectionism in Eating Disorder Recovery