Perfectionism as a risk factor for suicide – the most comprehensive test to date

According to the World Health Organisation, someone takes their own life every 45 seconds. To help prevent future tragedies, we need to know more about the factors that make some people especially vulnerable to suicidal thoughts and acting on those thoughts. One candidate is perfectionism: the tendency some people have to hold themselves to consistently impossible standards and/or feeling the need to meet or surpass the lofty expectations of others.

In 1995 the late psychologist Sidney Blatt highlighted the apparent link between perfectionism and suicide in an influential article for American Psychologist titled "The Destructiveness of Perfectionism" in which he profiled three highly talented, ambitious but harshly self-critical individuals all of whom took their own lives: Vincent Foster, a deputy counsel to President Bill Clinton; writer, singer and broadcaster Alasdair Clayre; and athlete and scholar Roger D Hansen.

"Because of the need to maintain a personal and public image of strength and perfection, [perfectionists] are constantly trying to prove themselves, are always on trial, feel vulnerable to any possible implication of failure or criticism, and often are unable to turn to others, even the closest of confidants, for help or to share their anguish" Blatt wrote.

However, since Blatt's paper, research progress on the topic has been slow, hampered in part by a confusing multitude of definitions of perfectionism and a paucity of studies with the longitudinal methodology needed to establish that perfectionist tendencies increase suicidal risk. But now, writing in Journal of Personality, a team led by Martin Smith at the University of Western Ontario say there is enough data to conduct a "meta-analysis", which is what they've done, producing "the most comprehensive test of the perfectionism-suicidality link to date".

The researchers found 45 relevant, suitably robust studies involving collectively 54 samples, totalling 11,747 participants. Forty-eight of the samples were cross-sectional (measures were only taken at a single point in time) while six had the all-important longitudinal design, granting insight into whether perfectionism may precede suicidal thoughts or behaviours. Collectively, the studies covered 15 of the different definitions and ways of measuring perfectionism that exist, most falling under the main categories of either placing excessive expectations on oneself, feeling pressure from others (including parents or society at large), or holding other people to perfectionistic standards.

Overall, the analysis showed that 13 of the 15 different measures of perfectionism had associations with increased suicidal thoughts (in statistical terms the effect size was small to moderate). Aspects of perfectionism related to concerns about meeting others' expectations were additionally associated with making more suicide attempts. Meanwhile, holding others to high standards, and being perfectionist in terms of tidiness and organisation, were not related to suicidal thoughts or attempts.

"Perfectionists," the researchers explained, "are their own worst critics … locked in an endless loop of self-defeating over-striving in which each new task is another opportunity for harsh self-rebuke, disappointment, and failure."

But the most pernicious form of perfectionism seems to be feeling the weight of meeting other people's expectations – this was related to increased suicidal thoughts in longitudinal studies that followed the same participants over time and that controlled for their baseline levels of suicidal thought.  "Our findings lend credence to the long-standing notion that feeling incapable of living up to the lofty standards of others is a part of the premorbid personality of people at risk for suicide," the researchers said.

It's notable that past research has found trait conscientiousness (one of the Big Five personality traits associated with self-discipline and orderliness) is associated with reduced risk of suicide. This suggests perfectionism as defined here – holding oneself to unrealistic standards, or seeking to meet the unrealistic standards of others – is not simply a form of excessive conscientiousness.

Although this is the most thorough examination of the links between perfectionism and suicide to date, and the data suggests that perfectionism is a relevant risk factor, it's important to note that the research base is still lacking. There is especially a need for more longitudinal research, more research with diverse groups (most of the studies to date have involved White Western people) and more research that tests whether perfectionism adds risk even after other factors are taken into account, such as depression.

For now, the researchers said the data are consistent with "case histories and theoretical accounts suggesting people high in perfectionism appear to think, behave, perceive, and relate in ways that have suicidogenic consequences". Perfectionism is associated with "intense psychological pain" they said. Perfectionists have a "harsh way of relating to a self they find deficient". Their lives are typically stressful and they often have a "prickly, conflictual style of relating to others," leaving them isolated and lacking support. "Amid such pain," Smith and his colleagues conclude," perfectionists may think about, or engage in, suicide as a means of escaping a life they find unbearable."