The problem of overcontrol: Perfectionism, emotional inhibition, and personality disorders
Introduction
Some patients with psychiatric disorders use overcontrolling strategies to manage their emotions and behaviors [1]. Overcontrol is associated with negative social outcomes, including reduced spontaneity [2], avoidance, social withdrawal, aversion to novel situations and lack of assertiveness [3,4]. The tendency to control one's affects, interpersonal behavior and social expression has been characterized as a hallmark of a number of personality disorders (PD), including obsessive-compulsive, avoidant, schizoid and paranoid presentations [[5], [6], [7], [8], [9]]. Individuals diagnosed with these PD's tend to control emotional expression, for reasons such as fear of being considered inappropriate or weak. They also report anxiety that if others know what they experience will judge them, for example if they display anxiety others will consider them inept, or showing signs of vulnerability will enable others to control or subjugate them [10]. Emotional overcontrol may have different functions in different PDs. For example, persons with avoidant PD may use over-control because they fear the social consequences of displaying emotion, whereas persons with obsessive-compulsive PD may think it is morally inappropriate. Alternatively, persons with paranoid PD may fear that the others can use information about their feelings in order to cheat or humiliate them. Consequently, individuals with these PDs hesitate making decisions in the social domain. They may fear negative social evaluation that may in turn trigger feelings of shame and humiliation. Alternatively, they may predict that they will hurt others if they do not act appropriately and consequently avoid making choices or worry and postpone decisions. These negative expectations lead these individuals to limit their affective displays and social behaviors, that in turn impact upon social functioning.
Lynch and colleagues [9] list the core features of these PDs as limited awareness and expression of affect; a tendency to minimize distress; high levels of perfectionism; the need to control the environment; limited social interactions; and problems with intimacy. These individuals are also risk adverse and avoid novelty. However, despite the relevance of overcontrol in PD, research is largely lacking in this domain [9]. Studies tend to focus on dysregulation of affect and behavior, leaving the impact of inhibitive strategies and affect suppression largely unexplored. Therefore, the current study focuses on perfectionism and emotional inhibition as two potential candidate psychological mechanisms underlying PD.
Perfectionism reflects the tendency to set high standards and strive to reach highly valued personal goals in a variety of fields. Following Frost and colleagues [11], self-oriented perfectionism is multidimensional and comprises setting high standards for performance; fear of making mistakes; enhanced focus on parents' criticism; doubts about one's own performance, and finally a preference for organization and order. Hewitt and Flett [12] add an interpersonal dimension to this definition, including other-oriented perfectionism (the setting of unrealistically high standards on others and the belief that others hold unrealistically high expectations about the self that one should meet). There is substantial evidence that maladaptive perfectionism underlies many psychopathologies including eating disorders [13,14], mood disturbance [15,16] and anxiety disorders [17,18]. It has been observed that perfectionism can be an aspect of PD [19].
Most literature to date focuses on obsessive-compulsive PD (OCPD), where perfectionism is one of its main features [20,21]. OCPD involves high personal standards and procrastination, as a by-product of the fear of making mistakes [12,22,23]. Perfectionism in OCPD has also been conceptualized as a core vulnerability in eating disorders [24] and has also been associated with tendencies to delay reward in OCPD [25]. It has been observed that perfectionism may be relevant in many other PDs [26,27], such as narcissism [28] and depressive PDs, (the latter characterized by a tendency to blame the self excessively for any setbacks and to harshly judge others [29]). Heightened socially prescribed perfectionism has also been associated, in nonclinical samples, with PD-related traits linked to borderline, avoidant and dependent PD's [12,30]. Of note, although the current study mostly focuses on the importance of the connection between perfectionism and emotional inhibition, perfectionism may also be a feature of dysregulated PDs, e.g. BPD. In this case, patients may have unrelenting standards but poor capacity to regulate their actions thus increasing their sense of worthlessness.
Recently, Dimaggio and colleagues [31] have explored the associations of perfectionism with PD in clinical samples and reported that maladaptive perfectionism was correlated with number of PD criteria. Specific aspects such as concern over mistakes [11] were associated with most PD traits, with the exception of schizotypal and antisocial, whist doubts about one's own actions [11] were correlated with specific PD traits, including obsessive-compulsive, avoidant and dependent PD's. Maladaptive perfectionism was also related to symptoms and interpersonal problems (including inability to cooperate or excessive striving for approval). These findings support the proposition that aspects of perfectionism such as fear of criticism over one's mistakes and tendency to doubt whether one's action is correct are aspects of PDs not captured in current classifications [8,26]. Further exploration of the role of perfectionism in PD is merited given its potential as a focus for treatment [9,19,32] in many PD's. This would expand knowledge of perfectionism as a transdiagnostic candidate mechanism underlying a broad array of psychiatric disorders [32].
Humans constantly regulate their social display of emotions for a multitude of reasons. For example, one may amplify the display of positive and reduce display of negative emotions or, on the contrary, one may wish to display negative affect to influence another's' behavior (e.g. displaying anger to frighten someone). Consequently, affect regulation is important for well-being, as individuals strive to reduce the impact of negative emotions or increase the impact of positive feelings. One oft-used strategy is emotional inhibition or suppression [[34], [35], [36], [37]]. Emotion inhibition includes strategies such as verbal inhibition of expressing feelings, self-control (e.g. being polite when others are rude), disguising ones' own feelings and shyness [34]. Expressive suppression refers to “ongoing efforts to inhibit one's emotion-expressive behavior” [38,p. 9]. Research consistently shows that over-reliance on inhibition has detrimental effects on psychological well-being [39,40], and increases the negative impact of feelings such as disgust [41]. Inhibition also correlates with overeating [42], depression [43], post-traumatic symptoms [44] and has adverse effects on physical health, including increased risk of premature mortality [[45], [46], [47], [48], [49]]. Suppression in relationships contributes to reduced closeness, less satisfaction in relationships, including marital satisfaction, perception of social support and reduced quality of parenting [9,40,[50], [51], [52], [53], [54], [55]]. However, despite the evidence for the pervasive impact of emotional inhibition within PDs, and the evidence for inhibition being one of the core traits underlying PDs [7], this area has been largely under-investigated. Chapman and colleagues [56] found that individuals high in BPD traits reported improved functioning when invited to suppress emotions during an experiencing sampling task, whereas persons low in BPD traits felt worse when asked to suppress feelings. These data support the idea that BPD is more associated to impaired capacity to tone down affects, and not of diminished emotional display. Also these authors suggest that both suppression and expression of feelings are not healthy or pathological per se, but reflect a balance between expression and regulation. Contrasting findings reported that patients with borderline PD tended to suppress both positive and negative emotions [57]. Popolo and colleagues [10] reported that avoidant, and to a lesser degree dependent, PD traits were correlated with inhibition. Borderline traits were inversely connected with inhibition and, contrary to expectations, no associations were found between inhibition and OCPD traits.
Based on the above evidence, in selected PDs interpersonal problems and symptoms may stem from high perfectionism, whilst for other PD's the same problems may associate with emotional inhibition. Moreover, perfectionism and emotional inhibition can be both present and their combined interaction associates with symptom severity, interpersonal problems and global severity of PD as measured with total number of SCID-II criteria.
In the current study we sought to explore these mechanisms in a treatment-seeking sample of individuals with PD diagnoses. We hypothesized that: 1) maladaptive perfectionism would be associated with most PDs; 2) emotional inhibition would be prominent in PD such as avoidant, dependent and OCPD; 3) both perfectionism and emotional inhibition would be associated with severity of global symptomatology, interpersonal problems and PD severity; and 4) perfectionism and emotional inhibition interact with each other resulting in an association between them. Also, their combined presence should help predict specific PD and PD severity. Finally, through mediation analyses, we explored the differential impact of perfectionism and emotional inhibition on PD severity.
Section snippets
Participants and procedures
The sample consisted of 578 treatment-seeking outpatients. All participants gave informed consent to the study. All measures were administered by trained clinical psychologists, psychiatrists or psychotherapists at patient intake as part of the standard assessment procedure at each site involved. Interviews were conducted by four clinical psychologists trained in administering the interview. The results of the interview were discussed with the referring clinician and, when treatment had
Sample characteristics and measures
The total number of participants was N = 578. Participants had a mean age 35.8 (SD = 11.4). The gender distribution of the population was 54.3% (n = 314) female, with no significant differences between genders (t (475) = 0.523, p > 0.05). Demographic and measurement characteristics of the sample are displayed in Table 1. Mean scores for each measure were indicative of moderate levels of distress in the sample based on depressive, anxiety and personality disorder symptomatology. Proportions of
Discussion
Given the paucity of research into aspects of overcontrol in PD in general, and perfectionism and emotional inhibition in particular, we investigated the role of these variables in a large sample of treatment-seeking outpatients. Consistent with our first hypothesis and supporting previous findings [31], maladaptive perfectionism was associated with most PDs and with overall PD severity. Secondly, consistent with our hypothesis, emotional inhibition was most strongly associated with avoidant
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