Is There a Connection Between Perfectionism and Severe Alcohol Use Disorder?

By Lori Ryland, Ph.D., LP, CAADC, CCS, BCBA-D, Chief Clinical Officer, Pinnacle Treatment Centers

Practice makes perfect.

That’s what we’ve heard our entire lives.

Most of us have also heard about the 10,000-hour rule proposed by Malcom Gladwell in his 2008 book Outliers. The rule goes like this: to achieve mastery over a complex skill, it takes at least ten thousand hours of practice.

That’s a lot of practice.

It seems excessive.

However, we live in a culture that celebrates individual achievement and mastery of skills. The concept of exceptionalism is embedded in our worldview. Our heroes are individuals who buck trends. And if they don’t buck trends or set new ones themselves, they put their nose to the grindstone, work hard, and strive for excellence in everything they do. In business, in personal life, and in social life we idolize people who rise to the top.

In other words, we place a premium on perfection. Not just perfection itself, but also on the pursuit of perfection.

At school, we encourage our students to get high grades in classes, on exams, and on the standardized tests that determine their college choices, if they choose the college route. In the workplace, we encourage employees to break performance records and seek recognition like “employee of the month” and “top earner of the year.” In family life, we often compete with older siblings or other family members: if everyone in the family has a Ph.D., then we feel compelled to go at least that far in our educational endeavors.

And in our social lives, the advent of social media platforms elevated this compare-and-surpass to a rare height. Today – in contrast to twenty years ago – we can glance down at our smartphones and see examples of a thousand different types of perfection that we may want to strive to achieve.

But at what cost?

The Downside of Perfectionism

Recent research shows this drive toward perfection may have consequences we never considered.

A study published in Belgium in August 2022 called “Greater Self-Oriented and Socially Prescribed Perfectionism in Severe Alcohol Use Disorder” examined the relationship between people with perfectionist personalities and severe alcohol use disorder (SAUD). Previous research identifies connections between perfectionism and disorders such as anxiety, depression, and eating disorders. This study, however, was the first to explore the possible connection between perfectionism and severe alcohol addiction.

To understand the results of this research, we need to understand two things:

1. How mental health experts define perfectionism
2. How mental health experts define alcohol use disorder (AUD)

We also need to understand how common perfectionist tendencies are in people, and how common alcohol use disorder is in the U.S.

We’ll start with perfectionism.

Perfectionism: Changes Over Time

In a meta-analysis published in 2017 called “Perfectionism Is Increasing Over Time: A Meta-Analysis of Birth Cohort Differences From 1989 to 2016,” researchers indicate that our current understanding of perfectionism revolves around of the direction of perfection-oriented belief and behavior. Based on this model, research identifies three types of perfectionism.

The Three Types of Perfectionism

1. Self-directed perfectionism:

• • When directed inward, individuals attach extreme, irrational value on being perfect. They have unrealistic expectations of themselves and are extremely critical and punitive in their evaluation of themselves. This is also known as self-oriented perfectionism.

2. Social perfectionism:

• • When an expectation of perfection is perceived to come from other people, perfectionist individuals see their social milieu as excessively demanding. They think others judge them critically at all times. They think must be perfect to attain social approval. This is also known as socially prescribed perfectionism.

3. Outward-directed perfectionism:

• • When an individual directs perfectionistic expectations toward others, they impose irrational and unrealistic expectations on the people around them. They evaluate others critically. This is also known as other-oriented perfectionism.

Those are the three types of perfectionism. The study examined a sample of 41,641 college students in birth cohorts from 1989-2016 to determine whether levels of perfectionism have increased, decreased, or stayed the same over the past twenty-seven years, which roughly coincides with the time period we think of a generation.

In this study – which compared the average college student in 1989 with the average college student in 2017 – researchers found increases in all three areas of perfectionism. The following data refers to the increase in terms of change from a standard average – the 50^th percentile – assigned in 1989.

Here’s what the researchers found.

Perfectionism: A Generational Change

• Self-directed perfectionism increased over time:
  • In 2017, the average college student scored in the 55^th percentile
  • That’s a 10% increase from the 1989 baseline
• Social perfectionism increased over time:
  • In 2017, the average college student scored in the 66^th percentile
  • That’s a 10% increase from the 1989 baseline
• Other-directed perfectionism increased over time:
  • In 2017, the average college student scored in the 58^th percentile
  • That’s a 16% increase from the 1989 baseline

That gives us a solid understanding of what perfectionism is and teaches us that perfectionism is a personality trait that’s increasing over time. That’s important information, considering the topic of this article and the study we’ll discuss in a moment.

First, we need to define alcohol use disorder and learn how common it is among people in the U.S.

Alcohol Use Disorder (AUD) in the U.S.: Facts and Figures

Here’s how the National Institute on Alcohol Abuse and Alcoholism defines AUD:

“Alcohol use disorder (AUD) is a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences. It encompasses the conditions that some people refer to as alcohol abuse, alcohol dependence, alcohol addiction, and the colloquial term, alcoholism. Considered a brain disorder, AUD can be mild, moderate, or severe.”

To learn more about AUD, please read our article “Defining Alcohol Use Disorder.” To learn about the latest evidence-based treatment for AUD, please visit our Alcohol Use Disorder treatment page.

Now let’s look at the prevalence of AUD, how many people with AUD received treatment, and the difference between the number of people who needed treatment for AUD and the number of people who received treatment for AUD, which is called the treatment gap.

We retrieved the following data from the 2017, 2018, 2019, and 2020 iterations of the National Surveys on Drug Use and Health (NSDUH), a nationwide, annual survey that collects data from over 70,000 participants from around the country.

Alcohol Use Disorder Among Adults Age 18+

• Alcohol Use Disorder:
  • 2017: 14,062,000
  • 2018: 14,418,00
  • 2019: 14,100,000
  • 2020: 27,615,000

Received Treatment for Alcohol Use Disorder Adults Age 18+

• Treatment for Alcohol Use Disorder:
  • 2017: 2,368,000
  • 2018: 2,269,000
  • 2019: 2,465,000
  • 2020: 1,929,000

Received Treatment for AUD/SUD at Specialized Facility Adults Age 18+

• Treatment at Specialized Facility for AUD:
  • 2017: 1,323,000
  • 2018: 1,361,000
  • 2019: 1,425,000
  • 2020: 1,069,000

The Treatment Gap in 2020: Age 18+

• People with AUD: 27,615,000
  • Received treatment for AUD: 1,929,000
  • Received specialized treatment for AUD: 1,355,000

The takeaway from this data: millions of adults in the U.S. have AUD that meets a clinical threshold, but over 90 percent of people who need treatment for AUD did not get the treatment they needed – specialized or otherwise.

It’s time to put everything together. The information above tells what perfectionism is, including all three types, and that it’s increased over time.  The information above also tells us what alcohol use disorder is, and its prevalence among adults in the U.S.

What we’ll share now are the results of the study on the relationship between perfectionism and severe alcohol use disorder (SAUD).

Perfectionism and Severe Alcohol Use Disorder

In this study, researchers matched 65 participants diagnosed with severe alcohol use disorder (SAUD) with 65 control participants without any diagnosis of alcohol use disorder. Next, they administered a well-respected perfectionism questionnaire – called the Hewitt Multidimensional Perfectionism Scale – and asked questions about the presence or absence of symptoms of anxiety and depression.

Here’s what they found:

• High self-directed perfectionism was associated with SAUD:
  • Unrealistic personal standards contributed to this association
  • This type of perfectionism was more prevalent in males with SAUD
  • This type of perfectionism was more prevalent in participants with higher educational attainment
• High socially prescribed perfectionism was associated with SAUD:
  • Increased sensitivity to the expectations of others contributed to this association
• Compared to the control group, participants with SAUD had a higher prevalence of:
  • Symptoms of anxiety
  • Symptoms of depression

Researchers indicate these results align with previous research that shows specific traits associated with SAUD, including:

• High levels of self-blame
• Reduced levels self-esteem
• Unrealistic social standards
• Greater degrees of social isolation

The data make it clear that there’s a connection between two types of perfectionism and severe alcohol use disorder: self-directed perfectionism and socially prescribed perfectionism. When we look closer at the data and reflect upon its meaning, we realize that the emotions related to these types of perfectionism may lead to self-medication with alcohol.

Self-medication is the practice of using alcohol or drugs to manage difficult, challenging, painful, or overwhelming emotions. Perfectionism is associated with self-blame and reduced self-esteem, which are both related to elevated levels of shame, self-doubt, and increased sensitivity to what other people think.

How This Information Helps

When we understand perfectionism in this way, we see that it may be a potential risk factor for the misuse and/or disordered use of alcohol. That means when we screen for alcohol use disorder in the future – when more research confirms these findings – perfectionism might be added as a significant risk factor for AUD.

In addition, it may mean that during treatment for AUD or SAUD, screening for and addressing perfectionism – if present – may facilitate healing and recovery. Although perfectionism is not a mental health disorder, the data shows that the thoughts and emotions associated with perfectionism contribute to AUD. Therefore, exploring and resolving the issues related to perfectionism may help with resolving AUD, and help people achieve long-term, sustainable sobriety.

This is a new development in addiction research. We’re ready to use this new knowledge to help our patients in any way we can.