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OR I G I N A L ART I C L E
The perniciousness of perfectionism A meta-analytic reviewof the perfectionismndashsuicide relationship
Martin M Smith1 | Simon B Sherry2 | Samantha Chen1 | Donald H Saklofske1 |
Christopher Mushquash3 | Gordon L Flett4 | Paul L Hewitt5
1University of Western Ontario2Dalhousie University3Lakehead University4York University5University of British Columbia
CorrespondenceMartin M Smith Department ofPsychology University of WesternOntario London N6A 5C2 CanadaEmail msmit454uwoca
Funding informationCanada Graduate Scholarship from theSocial Sciences and Humanities ResearchCouncil (752-2016-2229) to Martin MSmith Social Sciences and HumanitiesResearch Council of Canada InsightGrant (35154) to Simon Sherry MichaelPratt Sherry Stewart and Dayna Lee-Baggley
Abstract
Objective Over 50 years of research implicates perfectionism in suicide Yet therole of perfectionism in suicide needs clarification due to notable between-studyinconsistencies in findings underpowered studies and uncertainty about whether per-fectionism confers risk for suicide We addressed this by meta-analyzingperfectionismrsquos relationship with suicide ideation and attempts We also testedwhether self-oriented other-oriented and socially prescribed perfectionism predictedincreased suicide ideation beyond baseline ideation
Method Our literature search yielded 45 studies (N5 11747) composed of under-graduates medical students community adults and psychiatric patients
Results Meta-analysis using random effects models revealed perfectionistic con-cerns (socially prescribed perfectionism concern over mistakes doubts about actionsdiscrepancy perfectionistic attitudes) perfectionistic strivings (self-oriented perfec-tionism personal standards) parental criticism and parental expectations displayedsmall-to-moderate positive associations with suicide ideation Socially prescribed per-fectionism also predicted longitudinal increases in suicide ideation Additionallyperfectionistic concerns parental criticism and parental expectations displayed smallpositive associations with suicide attempts
Conclusions Results lend credence to theoretical accounts suggesting self-generatedand socially based pressures to be perfect are part of the premorbid personality ofpeople prone to suicide ideation and attempts Perfectionistic strivingsrsquo associationwith suicide ideation also draws into question the notion that such strivings arehealthy adaptive or advisable
KEYWORD S
meta-analysis perfectionism suicide
1 | INTRODUCTION
Suicide is a major public health concern with wide-reachingconsequences Suicide claims more lives than homicide andwar combined is the second-leading cause of death amongAmerican adolescents and costs the US economy $51 bil-lion annually (Center for Disease Control and Prevention2015) By 2020 suicide is predicted to account for 24 of
the global burden of disease (World Health Organization2012) Worldwide 10 to 20 million people attempt suicideeach year and nearly 1 million people complete suicide eachyear (World Health Organization 2012) Furthermore eachsuicide seriously affects at least six people (McIntosh ampDrapeau 2014) Even so the global suicide rate decreased26 from 2000 to 2012 suggesting some forms of suicideare preventable (World Health Organization 2012)
522 | VC 2017 Wiley Periodicals Inc wileyonlinelibrarycomjournaljopy J Pers 201886522ndash542
Received 11 November 2016 | Revised 17 May 2017 | Accepted 12 July 2017
DOI 101111jopy12333
Accordingly researchers and clinicians are increasinglyinterested in identifying reliable markers of suicide to sup-port prevention and intervention strategies Although suicideis seldom attributable to any single factor personality traitscan play a very important role (Bogg amp Roberts 2004Brezo Paris amp Turecki 2006) The present study focuses onone such traitmdashperfectionism
The Alaska Suicide Follow-Back Study (Alaska InjuryPrevention Center Critical Illness and Trauma FoundationInc amp American Association of Suicidology 2007) helpsillustrate the perniciousness of perfectionism In that studyresearchers interviewed family and friends of people whocompleted suicide and found 56 of decedents weredescribed as perfectionistic (Alaska Injury Prevention Centeret al 2007 p 32) Similarly when Teuroornblom Werbart andRydelius (2013 p 248) conducted interviews with parents ofadolescents who completed suicide 681 reported theirchildrsquos ldquohigh demands and expectationsrdquomdashhallmarks of per-fectionismmdashwere contributing factors As these examplessuggest perfectionism can be pernicious Even so the roleof perfectionism in suicide may be underappreciated under-recognized and misunderstood due to notable inconsisten-cies in findings between studies underpowered studies anduncertainty about whether perfectionism confers longitudinalrisk for suicide ideation and attempts We addressed theseissues by conducting a rigorous comprehensive meta-analytic review of the perfectionismndashsuicide relationship Inconducting this empirical synthesis our goal was to bringgreater clarity to this important literature
11 | Conceptualizing perfectionism
The most widely adopted conceptualizations of perfectionismare associated with two measures both titled the Multidi-mensional Perfectionism Scale (FMPS Frost MartenLahart amp Rosenblate 1990 MPS Hewitt amp Flett 1991)Frost et al (1990) defined perfectionism as ldquohigh standardsof performance which are accompanied by overly criticalevaluations of onersquos behaviorrdquo (p 450) and introduced sixdimensionsmdashconcern over mistakes doubts about actionsparental criticism parental expectations personal standardsand organization Concern over mistakes involves a preoccu-pation with mistakes to such an extent that performance iseither perfect or worthless Doubts about actions characterizea nagging sense of doubt regarding the quality of onersquos per-formance Personal standards reflect setting unreasonablyhigh personal standards and goals Parental criticism andparental expectations encompass perceptions of onersquos parentsas excessively critical and holding unrealistically highexpectations Organization includes an overemphasis onorder precision and neatness Hewitt and Flettrsquos (1991)model underscored the personal and interpersonal aspects of
perfectionism and introduced three dimensionsmdashself-oriented perfectionism (demanding perfection of one-self) other-oriented perfectionism (demanding perfection ofothers) and socially prescribed perfectionism (perceivingothers are demanding perfection of oneself)
Other notable conceptualizations of perfectionism existSlaney Rice Mobley Trippi and Ashbyrsquos (2001) AlmostPerfect Scale-Revised (APS-R) conceptualizes perfectionismas having positive and negative features with the APS-RrsquosDiscrepancy subscale reflecting a perceived gap betweenhow one is and how one would like to be and the APS-RrsquosStandards subscale reflecting striving for excellence (BlasbergHewitt Flett Sherry amp Chen 2016) Alternatively Beckand associates (Imber et al 1990) view perfectionism as aunitary cognitive style which we label perfectionistic atti-tudes These attitudes include cognitive distortions with per-fectionistic themes (eg black-and-white dichotomousthinking) and social difficulties with perfectionistic themes(eg social evaluative concerns Sherry Hewitt Flett ampHarvey 2003) Finally Garner Olmstead and Polivyrsquos(1983) Eating Disorder Inventory (EDI) conceptualizes per-fectionism as a unidimensional construct characterized byboth perfectionistic standards and evaluative concerns(Sherry Hewitt Besser McGee amp Flett 2004)
12 | Perfectionistic concerns perfectionisticstrivings other forms of perfectionism andcorrelates of perfectionism
The number of perfectionism dimensions makes studyingperfectionism challenging However this challenge can bemitigated by adopting the two-factor model (eg SmithSherry Chen et al 2016) This model asserts the majorityof common variance among lower-order perfectionismdimensions is attributable to two higher-order factors perfec-tionistic concerns and strivings (Stoeber amp Otto 2006) Per-fectionistic concerns encompass a family of traits involvingsocially prescribed perfectionism concern over mistakesdoubts about actions discrepancy and perfectionistic atti-tudes (Dunkley Sanislow Grilo amp McGlashan 2004Smith Sherry Rnic et al 2016) In contrast perfectionisticstrivings encompass a constellation of traits involving self-oriented perfectionism and personal standards (Stoeber ampOtto 2006)
Yet the two-factor model is unable to integrate all formsof perfectionismmdashparticularly other-oriented perfectionismThe two-factor model is also incapable of accommodatingtotal scores Although the use of total scores is discouragedby some (Hewitt Flett Besser Sherry amp McGee 2003)several studies use them (eg Chang 2002) To deal withsuch issues we refer to other-oriented perfectionism and totalperfectionism scores as measured by Frost et al (1990) and
SMITH ET AL | 523
by Garner et al (1983) as ldquoother forms of perfectionismrdquoWe also considered three of Frost and colleaguesrsquo (1990) sixfacets (parental criticism parental expectations and organi-zation) as ldquocorrelates of perfectionismrdquo as opposed to corecharacteristics of perfectionism (Stoeber amp Otto 2006)Parental criticism and expectations assess childhood antece-dents of perfectionism (Sherry amp Hall 2009) and organiza-tion does not appear definitional to the perfectionismconstruct (Frost et al 1990) Given Cox Enns and Clararsquos(2002) factor-analytic findings we also combined parentalcriticism and parental expectations to form parentalperceptions
13 | Suicide ideation and suicide attempts
Suicide ideation involves thoughts intent threats and othernonphysical actions suicide attempts involve physicalbehaviors in which an individual attempts to end his or herlife but survives (Kessler Berglund Borges Nock ampWang 2005) Research suggests suicide ideation and suicideattempts lie along a continuum such that risk for completedsuicide increases as one progresses from passive thoughtsabout suicide to seriously thinking about suicide to activelyattempting suicide (Joiner 2005) Indeed suicide ideationand even passive thoughts about wanting to be dead predictsuicide completion (Brown Beck Steer amp Grisham 2000Brown Steer Henriques amp Beck 2005) Likewise suicideattempts are robustly tied to suicide completion (Oquendoet al 2004) And the best predictor of completed suicide is ahistory of attempts (Nordstreuroom Samuelsson amp Asberg1995 Joiner et al 2005) Given these links we refer to thecontinuum of possible suicide thoughts (ideation) and actions(attempts) as suicidality
14 | The perfectionismndashsuicidalityrelationship
Public outcry over the perfectionismndashsuicide link aroselargely from media accounts of Sidney Blattrsquos (1995) articleldquoThe Destructiveness of Perfectionismrdquo Blattrsquos (1995) arti-cle described how perfectionism led three remarkably tal-ented individuals to end their lives (ie Vincent FosterAlasdair Clayre and Denny Hansen) Five years earlier Bau-meister (1990) also sounded the same alarm with his escapetheory of suicide Baumeister (1990) posited lofty personalstandards can trigger a causal chain cumulating in suicideBuilding on these accounts most researchers conceptualizeperfectionism as a vulnerability factor for suicide (eg FlettHewitt amp Heisel 2014 Hewitt Flett Sherry amp Caelian2006 Roxborough et al 2012)
So why is perfectionism associated with thinking aboutattempting and even completing suicide Perfectionists are
their own worst criticsmdashgood enough is never enough(Hewitt amp Flett 1991) Consequently the typical perfection-ist is locked in an endless loop of self-defeating over-strivingin which each new task is another opportunity for harsh self-rebuke disappointment and failure (DiBartolo FrostChang LaSota amp Grills 2004 Dunkley amp Grilo 2007Sturman Flett Hewitt amp Rudolph 2009) In additionblack-and-white thinking can lead perfectionists to interpretfailures as catastrophes that in extreme circumstances areseen as warranting death (Blatt 1995 Flett et al 2014Hewitt et al 2006) Many perfectionists also struggle to par-ticipate in and to benefit from stable positive interpersonalrelationships (Sherry Mackinnon amp Gautreau 2015) Thisinability to partake in harmonious relationships may leaveperfectionists at risk for suicidality (see Hewitt et al 2006)Similarly the stress-diathesis model of perfectionism (Hewittamp Flett 2002) asserts ego-involving stressors place perfec-tionists at risk for suicide Flamenbaum and Holden (2007)for instance found perfectionists are prone to psychache(ie profound psychological pain) if they perceive unfilledneeds in areas of achievement and affiliation All toldresearch suggests an important relationship between perfec-tionism and suicide Yet this literature has not been meta-analyzed
Hewitt and colleaguesrsquo (2006) OrsquoConnorrsquos (2007) andFlett and colleaguesrsquo (2014) nonempirical reviews capablysummarized the perfectionismndashsuicide literature and con-cluded perfectionistic concerns were related to suicidalityHowever due to notable inconsistencies between studies infindings none of these authors reached concrete conclusionsregarding perfectionistic strivingsrsquo link with suicidalityIndeed some studies report perfectionistic strivings are nega-tively related to suicidality (eg Stoeber amp Otto 2006)some studies report perfectionistic strivings are unrelated tosuicidality (eg Hewitt Norton Flett Callander amp Cowan1998) and other studies report perfectionistic strivings arepositively related to suicidality (eg Flamenbaum amp Holden2007) Likewise OrsquoConnor (2007 p 709) concludedldquoThere are insufficient studies to draw any firm conclusionabout [other-oriented perfectionism]rdquo Other-oriented perfec-tionism was altogether absent from reviews by Hewitt et al(2006) and Flett et al (2014) Additionally as with perfec-tionistic strivings inconsistent findings between studies haverendered our understanding of other-oriented perfectionismrsquosrelationship with suicidality equivocal Some investigatorsreport other-oriented perfectionism is negatively related tosuicidality (Hunter amp OrsquoConnor 2003) some investigatorsreport other-oriented perfectionism is unrelated to suicidality(Hewitt Caelian Chen amp Flett 2014) and other investiga-tors report other-oriented perfectionism is positively relatedto suicidality in Asian but not Caucasian samples (ChenHewitt amp Flett 2017) Nonetheless as of 2017 there are 12
524 | SMITH ET AL
TABLE1
Characteristicsof
studiesincluded
inthemeta-analysis
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Adkins(1994)
129
university
aNR
NR
101
dissertatio
ncross-sectional
FMPS
-total
ASIQ
mdash
Adkinsamp
Parker
(1996)
129
university
a218
650
110
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
AAHS-ST
eattemptsf
Becket
al(1993)
908
psychiatricb
364
550
NR
article
cross-sectional
DAS-P
SSI
attemptsf
Beevers
ampMiller
(200
4)tim
e1
121
psychiatricb
380
744
66
article
long
itudinal
DAS-P
MSS
Imdash
Beevers
ampMiller
(200
4)tim
e2
100
psychiatricb
380
744
66
article
long
itudinal
DAS-P
MSS
Imdash
Blanksteinet
al(2007)
wom
en144
university
a221
1000
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
CSI
mdash
Blanksteinet
al(2007)
men
61un
iversity
a221
00
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
CSI
mdash
Blasberget
al(2016)
371
university
a210
610
NR
article
cross-sectional
FMPS
-PS
SSI
mdash
Caelian(2005)
55psychiatricb
155
745
255
dissertatio
ncross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
attemptsf
Chang
(2002)
371
university
a235
806
70
article
cross-sectional
FMPS
-total
ASIQ
mdash
Chen(2012)
wom
en279
community
c586
1000
135
dissertatio
nlongitu
dinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
mdash
Chen(2012)
men
157
community
c586
00
135
dissertatio
nlongitu
dinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
mdash
Chenet
al(2017)
240
university
a189
638
500
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
ASIQ
mdash (Contin
ues)
SMITH ET AL | 525
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Deanamp
Range
(1996)
168
university
a219
690
280
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SBQ
mdash
Deanamp
Range
(1999)
132
psychiatricb
355
712
333
article
cross-sectional
MPS
-SOP
MPS
-SPP
SSI
mdash
Deanet
al(1996)
114
university
a244
842
281
article
cross-sectional
MPS
-SPP
SSI
mdash
Enn
set
al(2001)
96medicald
251
417
NR
article
long
itudinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
SIQ
mdash
Fedorowiczet
al(20
07)
940
psychiatricb
260
00
NR
article
cross-sectional
EDI
mdashattemptsg
Flam
enbaum
ampHolden(2007)
264
university
a189
758
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
BSS
-MBSS
-Pintent
hattemptsf
Foulon
etal(2007)
304
psychiatricb
223
977
NR
article
cross-sectional
EDI
mdashattemptsi
Franko
etal(2004)
246
psychiatricb
NR
1000
NR
article
cross-sectional
EDI
mdashattemptsi
Freudenstein
etal(2012)
100
psychiatricb
166
470
120
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
CSP
Sattemptsi
Ham
ilton
ampSchw
eitzer
(2000)
389
university
a227
743
NR
article
cross-sectional
FMPS
-PS
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-total
GHQ-ST
mdash
Hew
ittet
al(1992)
87psychiatricb
357
529
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
BDI-SI
mdash (Contin
ues)
526 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Hew
ittet
al(1994)
study1
91psychiatricb
355
538
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
RST
-past
RST
-future
mdash
Hew
ittet
al(1994)
study2
160
university
a217
656
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
RST
-past
RST
-future
mdash
Hew
ittet
al(1997)
wom
en33
psychiatricb
154
1000
NR
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
mdash
Hew
ittet
al(1997)
men
33psychiatricb
154
00
NR
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
mdash
Hew
ittet
al(1998)
78psychiatricb
328
538
308
article
cross-sectionali
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Hew
ittet
al(2014)
55psychiatricb
155
745
255
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
attemptsi
Hunteramp
OrsquoConnor(2003)
sample1
43psychiatricb
346
534
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Hunteramp
OrsquoConnor(2003)
sample2
44psychiatricb
346
477
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Izadi(2015)
50community
c270
740
420
dissertatio
ncross-sectional
MPS
-SPP
FMPS
-COM
FMPS
-PC
FMPS
-PE
SBQ-SI
attemptsf
Jacobs
etal(2009)
439
psychiatricb
146
540
260
article
cross-sectional
DAS-P
SIQ-JR
mdash
Jeglic
(2003)
97university
a184
732
330
dissertatio
ncross-sectional
FMPS
-total
mdashattemptsi
Jeglic
etal(2007)
study2
440
university
a185
620
400
article
cross-sectional
FMPS
-total
mdashattemptsi
(Contin
ues)
SMITH ET AL | 527
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Muyan
ampChang
(2015)
288
university
a213
590
NR
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
FSII
mdash
OrsquoConnoramp
Forgan
(2007)
255
university
a220
780
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
GHQ-ST
mdash
OrsquoConnorRC
et
al(2007)
study2
151
university
a240
722
NR
article
long
itudinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
OrsquoConnorDB
et
al(2007)
sample1
65psychiatricb
241
722
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
OrsquoConnorDB
et
al(2007)
sample2
61psychiatricb
241
722
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Pisetsky
etal(2013)
635
psychiatricb
317
NR
NR
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PS
mdashattemptsi
Portzkyet
al(2014)
1436
psychiatricb
242
954
NR
article
cross-sectional
EDI
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
mdashattemptsi
Ranieriet
al(1987)
sample1
50psychiatricb
443
560
80
article
cross-sectional
DAS-P
BSS
Iattemptsf
Ranieriet
al(1987)
sample2
25psychiatricb
417
600
NR
article
cross-sectional
DAS-P
BSS
Iattemptsf
(Contin
ues)
528 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Rasmussenet
al(2008)
sample1
17psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussenet
al(2008)
sample2
23psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussen
Elliotet
al(2012)
161
psychiatricb
337
590
NR
article
cross-sectional
MPS
-SPP
SPS-SI
mdash
Rasmussen
Slish
etal(2012)
214
university
a201
570
257
article
cross-sectional
APS
-DDSI-SS
mdash
Roxboroughet
al(2012)
152
psychiatricb
129
454
285
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
intent
hmdash
Slish(2006)
48university
a201
521
625
dissertatio
ncross-sectional
APS
-DDSI-SS
mdash
Wallack
(2007)
181
university
a198
796
260
dissertatio
ncross-sectional
APS
-DSIS
mdash
Wanget
al(2013)
466
university
a264
496
NR
article
cross-sectional
APS
-DSIS
mdash
Yam
aguchi
etal(2000)
51psychiatricb
212
961
NR
article
cross-sectional
EDI
mdashattemptsi
Note
N5totalnumberof
participantsNR5
notreportedFemale5percentage
female
Ethnic5percentage
ethnic
minority
Status
5publicationstatus
ofthestudy
FMPS
5Frostandcolleaguesrsquo
(1990)
Multid
imen-
sional
Perfectio
nism
Scale
total5
totalscore
ASIQ5
Reynoldsrsquos(1991)
AdultSu
icideIdeatio
nQuestionnaireCOM
5concernover
mistakesDAA5
doubtsaboutactio
nsPC
5parental
criticism
PE
5parental
expecta-
tionsPS
5personal
standardsORG5organizatio
nAAHS-ST
5NationalAdolescentHealth
Survey
Suicidal
Thinkingmodifiedversion(1989)DAS-P5Weissman
andBeckrsquos(1978)
Dysfunctio
nalAttitude
Scale-
Perfectio
nism
subscaleSS
I5Beck
SteerandRanierirsquos
(1988)
ScaleforSu
icidal
Ideatio
nMSS
I5MillerNormanBishop
andDow
rsquos(1986)
ModifiedScaleforSu
icidal
Ideatio
nMPS
5Hew
ittandFlettrsquos
(1991)
Multi-
dimensional
Perfectio
nism
Scale
SOP5self-orientedperfectio
nism
OOP5other-oriented
perfectio
nism
SP
P5socially
prescribed
perfectio
nism
CSI
5Blanksteinrsquos(2007)
Current
SuicideIdeatio
nScale
CAPS
5Flett
andcolleaguesrsquo
(2016)
Child-A
dolescentPerfectio
nism
Scale
SIQ5
Reynoldsrsquos(1987b)Su
icidal
Ideatio
nQuestionnaireEDI5
Garnerandcolleaguesrsquo
(1983)
EatingDisorderInventory-Perfectio
nism
subscaleBSS
5Beck
andSteerrsquos
(1993)
SuicideIdeatio
nScale
M5
motivation
P5preparation
Intent5suicidal
intentCSP
S5Pfefferrsquos
(1986)
Child
SuicidePo
tentialScale
GHQ-ST5
GoldbergandWilliamsrsquos(1988)
General
Health
Questionnaire-SuicidalThinkingsubscaleBDI-SI
5Beckrsquos(1979)
DepressionInventoryitem-9
(SuicidalIntent)RST
-past5
ratin
gof
thefrequencyof
pastsuicidal
thoughtsRST
-future5ratin
gof
thefrequencyof
future
suicidal
thoughtsSB
Q5
Linehanrsquos
(1981)
Suicidal
BehaviorQuestionnaireSI
5suicidal
ideatio
nSIQ-JR5
Reynoldsrsquos(1987a)Su
icidal
Ideatio
nQuestionnaire-G
rades7ndash9
FSII5
Chang
andChang
rsquos(2016)
Frequency
ofSu
icideIdeatio
nInventory
SPS5CullandGillrsquos
(1982)
SuicideProbability
Scale
BSS
I5Beck
KovacsandWeissmanrsquos
(1979)
ScaleforSu
icidal
Ideatio
nAPS
-D5
Slaney
andcolleaguesrsquo
(2001)
Alm
ostPerfect
Scale-Revised
Discrepancy
subscaleDSI-SS5
MetalskyandJoinerrsquos
(1997)
DepressiveSy
mptom
sInventory-Su
icidality
subscaleSIS5Ruddrsquos(1989)
Suicidal
Ideatio
nScale
a University
undergraduates
b Psychiatric
patients
c Com
munity
adults
d Medical
students
e Participants
reported
whether
they
hadever
seriouslythoughtaboutattemptingsuicide
f Self-reported
numberof
priorsuicideattempts
g Prior
numberof
suicideattemptsassessed
byaclinician
h Participants
asked
ldquoHow
likelyisitthat
youwill
attempt
suicidesomedayrdquo
i Com
paredsuicideattemptersandnon-attempters
SMITH ET AL | 529
studies examining other-oriented perfectionism and suicidal-ity (see Table 1) meaning this literature is now suitable formeta-analysis In sum though perfectionistic concernsrsquo linkwith suicidality is clear (Flett al 2014 Hewitt et al 2006OrsquoConnor 2007) perfectionistic strivingsrsquo and other-oriented perfectionismrsquos link with suicidality is unclear
15 | Advancing research on theperfectionismndashsuicidality relationship usingmeta-analysis
Over 50 years of case reports theoretical accounts andempirical research implicate perfectionism in suicide (egBlatt 1995 Hassan Flett Ganguli amp Hewitt 2014 Hewittet al 2014 Kiamanesh Dyregrov Haavind amp Dieserud2014 Shaffer 1974) And yet there is much to learn aboutthe perfectionismndashsuicidality relationship (Flett et al 2014)First noteworthy inconsistencies between studies in findings(eg Flamenbaum amp Holden 2007 Hewitt et al 19982014 Hunter amp OrsquoConnor 2003) have clouded our under-standing of perfectionistic strivingsrsquo and other-oriented per-fectionismrsquos relationships with suicidality A quantitativesynthesis is needed for overall conclusions to be reachedSuch a quantitative synthesis could also allow for tests ofmoderating variables (eg gender) that might explain whenthe strength or the direction of the perfectionismndashsuicidalityrelationship changes Second despite evidence that correla-tions do not stabilize until N 250 (Scheuroonbrodt amp Perugini2013) most research on perfectionism and suicide attemptsis underpowered (cf Flamenbaum amp Holden 2007) How-ever meta-analysis could overcome limitations of small sam-ples (Borenstein Hedges Higgins amp Rothstein 2009) andbring greater clarity to our understanding of perfectionismrsquosrelationship with suicide attempts Third as noted by Flettet al (2014) and OrsquoConnor (2007) the extent to which per-fectionism dimensions confer risk for suicide has yet to bedetermined Indeed most investigators use cross-sectionaldesigns which unlike longitudinal designs cannot addresstemporal precedence As such whether perfectionism leadsto increases in suicidality is unclear and researchers andclinicians can only speculate as to whether reducing perfec-tionism reduces suicidality Nevertheless there is now suffi-cient data to test whether self-oriented other-oriented andsocially prescribed perfectionism predict follow-up suicideideation beyond baseline suicide ideation (Chen 2012Enns Cox Sareen amp Freeman 2001 R C OrsquoConnorWhyte et al 2007) Fourth due to limitations of nonempiri-cal reviews the strength of the relation between perfection-ism dimensions suicide ideation and suicide attempts isunclear A meta-analysis could shed light on which perfec-tionism dimensions display the strongest relations with sui-cide ideation and suicide attempts which in time might
inform the development of interventions designed to targetand to modify perfectionismrsquos most pernicious aspects
16 | Objectives and hypothesis
Our primary aim was to bring greater clarity to our under-standing of the perfectionismndashsuicidality relationship bycomprehensively synthesizing empirical research on perfec-tionism suicide ideation and suicide attempts To date thereis no meta-analysis of findings from this long-standing andimportant literature We also aimed to test the contentiouslydebated relation between perfectionistic strivings suicideideation and suicide attempts Such evidence would informdebate on the pros and cons of demanding perfection of one-self (eg Stoeber amp Otto 2006 Sherry Hewitt SherryFlett amp Graham 2010) Another aim was to test whetherself-oriented other-oriented and socially prescribed perfec-tionism predicted longitudinal increases in suicide ideationover time Controlling for baseline suicide ideation repre-sents a stringent test of the perfectionismndashsuicidality relation-ship as baseline suicide ideation is a strong predictor ofsubsequent suicide ideation (eg Joiner et al 2005)
Building on theory and research (Flett et al 2014Hewitt et al 2006 OrsquoConnor 2007) we hypothesized per-fectionistic concerns (socially prescribed perfectionism con-cern over mistakes doubts about action discrepancy andperfectionistic attitudes) would display positive relationshipswith suicide ideation and attempts We also hypothesizedsocially prescribed perfectionism would place people at riskfor longitudinal increases in suicide ideation However giventhe inconsistency of research on suicidality in relation to per-fectionistic strivings (self-oriented perfectionism personalstandards) other forms of perfectionism (other-oriented per-fectionism EDI-perfectionism total scores FMPS-perfectionism total scores) and correlates of perfectionism(parental criticism parental expectations organization) weconsidered our investigation into these questions to be moreexploratory
2 | METHOD
21 | Selection of studies
In 2016 a literature search using PsycINFO Medline Webof Science ERIC and ProQuest Dissertations and Theseswas conducted using the keywords and Boolean search termsldquoperfectrdquo and ldquosuicidrdquo This search yielded 100 studiesfrom PsycINFO 122 studies from Medline 226 studies fromWeb of Science and 38 studies from ProQuest We alsocompiled a list of 353 authors who had published on perfec-tionism We then contacted each author individually andrequested unpublished findings However none of the
530 | SMITH ET AL
authors contacted provided relevant data Additionally wemonitored the Perfectionism Network Mailing List to iden-tify studies that were accepted but not published at the timeof our literature search This yielded one study Chen et al(2017) Both the first and the third author then reviewedabstracts of all studies identified selecting studies meetinginclusion criteria Studies were included that (a) containeddata on perfectionism and suicidality (ideation and attempts)and (b) were in English Included studies also (c) reported aneffect size or enough information for computing an effectsize or effect size information was obtained from a studyauthor All authors contacted (N5 1) provided the requestedinformation
This literature search yielded 57 studies for inclusionInter-rater agreement on inclusion or exclusion in the meta-analysis was 95 Disagreement was resolved by revisitingarticles and coming to a consensus The reference lists ofincluded articles were also examined to locate additional rel-evant literature On August 7 2016 we terminated all searchstrategies and started data reduction and analysis Weexcluded 12 studies (see Supplemental Material A) The finalsample of included studies was composed of 45 studies with54 samples
22 | Coding of studies
The first and the third author coded each study based on ninecharacteristics sample size sample type mean age of partici-pants percentage of female participants percentage of ethnicminority participants publication status measure used toassess perfectionism measure used to assess suicide ideationand measure used to assess suicide attempts
23 | Meta-analytic procedures
Random effects analyses were conducted using Comprehen-sive Meta-Analysis software (Borenstein et al 2005) Wechose random effects models over fixed effects models asthe 45 included studies varied widely in design We alsoweighed mean effects following the procedure suggested byHunter and Schmidt (1990) This allowed us to estimatemean effect sizes and variance in observed scores after con-sidering sampling error (Card 2012) Next effect size esti-mates were weighted by sample size and aggregated Forstudies with more than one measure of suicide ideation weaveraged effect sizes so only one effect was included (Boren-stein et al 2009 Card 2012) Effect sizes presented in met-rics other than r (ie means t-tests d or F scores) wereconverted and expressed as correlations following formulasprovided by Borenstein et al (2009) We also used Boren-stein and colleaguesrsquo (2009) formula to calculate powerunder the random effects model for each weighted mean
effect Additionally most included studies measured perfec-tionism and suicide ideation with imperfect reliability Asthis can attenuate the magnitude of observed correlationseffects were adjusted by dividing the observed correlation bythe square root of the product of the two corresponding reli-ability coefficients (Card 2012) When reported the actualreliability statistics for a study were used when not reportedthe corresponding meta-analyzed mean reliability was used(Card 2012) However we were unable to adjust for unreli-ability in suicide attempts Thus in the interest of methodo-logical consistency we used the common albeitconservative strategy of interpreting observed effects whichgenerally underestimates the true magnitude of effect sizes(Borenstein et al 2009) Nonetheless for readers who dis-agree with this strategy effect sizes adjusted for unreliabilityare presented in our supplementary material
To examine the extent to which baseline self-orientedother-oriented and socially prescribed perfectionism predictfollow-up suicide ideation after controlling for baseline idea-tion we computed partial correlations using the ldquocorpcorrdquopackage (Schafer Opgen-Rhein Zuber Silvia amp Strimmer2015) for R (R Core Team 2013) Although there was insuf-ficient data to examine unique effects between perfectionismdimensions and suicide attempts there was sufficient data toexamine unique effects between perfectionism dimensionsand suicide ideation Thus again using the ldquocorpcorrdquo pack-age (Schafer et al 2015) we computed partial correlationsfor MPS-perfectionism dimensions by residualizing self-oriented other-oriented and socially prescribed perfection-ism based on their overlap with each other prior to being cor-related with suicide ideation Likewise for FMPS-perfectionism dimensions we computed partial correlationsby residualizing concern over mistakes doubts about actionparental criticism parental expectations personal standardsand organization based on their overlap with each other priorto being correlated with suicide ideation
To assess moderation we evaluated the total heterogene-ity of weighted mean effect sizes (QT) A significant QT indi-cates variance in weighted mean effect sizes is greater thanexpected by sampling error (Card 2012) a nonsignificantQT suggests a weak basis for moderation For each analysiswe also computed the inconsistency in observed effects (I2)across studies I2 indicates the percentage of total varianceacross studies due to heterogeneity Values of 25 50and 75 correspond to low medium and high heterogene-ity respectively
When QT was significant we stipulated a categoricalstructure and the total heterogeneity explained by the catego-rization (QB) was calculated (Card 2012) A significant QB
indicates meaningful differences in effects between catego-ries and provides a firm basis for moderation (Borensteinet al 2009) When QB was significant we examined
SMITH ET AL | 531
differences in effect sizes between studies grouped by publi-cation status (articles and dissertations) age (adult youngadult adolescent) and sample (community adults under-graduate students psychiatric patients) by performing aseries of all possible two-group comparisons to test whichgroup differed significantly in effect size (Card 2012) Foreach group comparison the resultant QB from the twogroups was tested using a v2 test with one degree of freedomWe also recorded gender (percentage female) and ethnicity(percentage ethnic minority) as continuous variables andused mixed effects meta-regression to test the potential mod-erating effects of gender and ethnicity
To assess publication bias we inspected funnel plotswith observed and imputed studies and computed Eggerrsquostest of regression to the intercept (Egger Smith Schneideramp Minder 1997) Such funnel plots allow for visual inspec-tion of how the effect size shifts when imputed studies areincluded (Borenstein et al 2009) In the absence of publica-tion bias Eggerrsquos regression intercept does not differ signifi-cantly from zero (Egger et al 1997)
24 | Description of studies
Our search identified 45 studies and 54 samples containingrelevant effect size data (see Table 1) The total number ofparticipants pooled across studies was 11747 Relevant datawere obtained from 38 journal articles and seven disserta-tions There were 21 samples of university undergraduates29 samples of psychiatric patients one sample of medicalstudents and three samples of community adults There were48 cross-sectional samples and six longitudinal samplesSample size varied between 17 and 1436 with an averageof 2175 (SD5 2598) The mean age of participants was268 years (SD5 102 range5 129ndash586) The average per-centage of female participants was 633 the average per-centage of ethnic minority participants was 244 Effectsize information for each individual study is presented inSupplemental Material B Adjusted effect size informationfor each individual study is presented in Supplemental Mate-rial C
25 | Measures
251 | Perfectionism
Following theory and research (eg Dunkley et al 2004Stoeber amp Otto 2006) personal standards (FMPS) and self-oriented perfectionism (MPS Child-Adolescent Perfection-ism Scale [CAPS] Flett et al 2016) were considered facetsof perfectionistic strivings concern over mistakes (FMPS)doubts about actions (FMPS) socially prescribed perfection-ism (MPS CAPS) discrepancy (APS-R) and perfectionistic
attitudes (Dysfunctional Attitude Scale-Perfectionism sub-scale [DAS-P] Weissman amp Beck 1978) were consideredfacets of perfectionistic concerns Parental criticism parentalexpectations and organization were designated correlates ofperfectionism As well parental criticism and parentalexpectations were combined and labeled as parental percep-tions (see Cox et al 2002) Other-oriented perfectionism(MPS) FMPS-perfectionism and EDI-perfectionism weredesignated other forms of perfectionism
252 | Suicide ideation and suicide attempts
Suicide ideations were assessed via self-reported suicidalthinking Suicide attempts were assessed via self-reportednumber of prior suicide attempts (eg Adkins amp Parker1996) clinicianrsquos ratings of the number of prior suicideattempts (eg Fedorowicz et al 2007) and group compari-sons between suicide attempters and non-attempters (egHewitt et al 2014) Although Pfefferrsquos (1986) Child SuicidePotential Scale (CSPS) and Linehanrsquos (1981) Suicide Behav-ior Questionnaire (SBQ) assess suicidal ideation and suicideattempts we categorized the CPS and SBQ as measures ofsuicide ideation given the majority of CSPS and SBQ itemsassess suicidal thoughts
3 | RESULTS
31 | Overall effect sizes
Weighted mean effect sizes between perfectionism corre-lates of perfectionism and suicide ideation and suicideattempts are in Table 2 (see Supplemental Material D foradjusted effect sizes) Following Cohenrsquos (1992) guidelinesfor small medium and large effects (r5 10 30 and 50respectively) perfectionistic concerns socially prescribedperfectionism concern over mistakes doubts about actionsdiscrepancy perfectionistic attitudes perfectionistic striv-ings self-oriented perfectionism personal standards parentalperceptions parental criticism parental expectations andFMPS-perfectionism displayed small-to-moderate positiverelationships with suicide ideation Other-oriented perfection-ismrsquos and organizationrsquos relationships with suicide ideationwere nonsignificant Perfectionistic concerns socially pre-scribed perfectionism concern over mistakes doubts aboutaction FMPS-perfectionism parental perceptions parentalcriticism and parental expectations displayed small positiverelationships with suicide attempts perfectionistic attitudesrsquoperfectionistic strivingsrsquo self-oriented perfectionismrsquos perso-nal standardsrsquo other-oriented perfectionismrsquos EDI-perfectionismrsquos and organizationrsquos relationships with suicideattempts were nonsignificant
532 | SMITH ET AL
TABLE2
Summaryof
overalleffect
sizesfortherelatio
nshipbetweenperfectio
nism
andsuicidality
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Suicideideatio
n
Perfectio
nistic
concerns
a42
7936
28
[24
32]
9910
5863
175
[076
273]
028[2
431]
99
Socially
prescribed
perfectio
nism
303640
28
[25
32]
3704
2171
035
[2100169]
028[2
532]
99
Concern
over
mistakes
5952
25
[13
36]
1219
6720
251
[2436938]
025[1
336]
98
Doubtsaboutactio
ns4
902
27
[18
35]
514
4162
294
[25671158
220[1
130]
99
Discrepancy
4904
26
[14
38]
917
6727
338
[24791154]
124[1
235]
98
Perfectio
nistic
attitudes
51533
37
[19
52]
3355
8808
407
[2033848]
226[0
941]
98
Perfectio
nistic
strivingsb
314588
10
[07
13]
3214
665
018
[2094130]
010[0
713]
99
Self-orientedperfectio
nism
273315
11
[08
15]
2096
000
ndash046
[2156064]
011[0
815]
99
Personal
standards
51273
10
[00
19]
1033
6127
334
[24711139]
010[0
019]
52
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
202755
01
[204
06]
3287
4219
027
[2178230]
101[2
04
06]
08
FMPS
totalscore
41018
31
[15
45]
1971
8477
472
[21692
2636]
127[1
240]
96
EDI-perfectio
nism
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdash
Correlatesof
perfectio
nism
Parental
perceptio
nsc
51904
19
[10
27]
1279
6871
204
[2558966]
019[1
027]
98
Parental
criticism
5952
20
[11
29]
798
4987
092
[2556740]
020[1
029]
98
Parental
expectations
5952
16
[06
26]
842
5247
196
[2391784]
113[0
323]
88
Organization
3513
ndash02
[220
17]
792
7475
253
[27738
8243]
0ndash02
[220
17]
05
Suicideattempts
Perfectio
nistic
concerns
d15
5275
12
[07
17]
2448
4281
115
[021
208]
508[0
314]
99
Socially
prescribed
perfectio
nism
8689
19
[08
29]
1257
4432
021
[2365407]
019[0
829]
93
Concern
over
mistakes
51827
09
[04
14]
012
000
008
[2035052]
109[0
413]
97
Doubtsaboutactio
n3
1777
06
[01
11]
276
000
100
[2201401]
205[2
02
11]
71
Discrepancy
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdashPerfectio
nistic
attitudes
3983
09
[203
22]
254
2126
142
[2155440]
205[2
07
17]
32
(Contin
ues)
SMITH ET AL | 533
TABLE2
(Contin
ued)
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Perfectio
nistic
strivingsa
101436
02
[202
06]
525
000
ndash010
[2110087]
002[2
01
06]
19
Self-orientedperfectio
nism
6539
07
[201
16]
304
000
ndash161
[2320ndash0
02]
007[2
01
15]
37
Personal
standards
41777
01
[204
06]
060
000
ndash049
[2182083]
001[2
04
05]
06
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
4429
ndash03
[213
06]
126
000
ndash142
[2258ndash0
28]
0ndash03
[213
06]
11
FMPS
totalscore
3666
14
[07
21]
130
000
ndash031
[2055ndash0
07]
016[0
823]
99
EDI-perfectio
nism
52975
03
[201
06]
183
000
106
[2098273]
103[2
01
06]
33
Correlatesof
perfectio
nism
Parental
perceptio
nsc
33230
07
[04
11]
053
000
045
[2643733]
007[0
411]
98
Parental
criticism
31615
08
[03
12]
065
000
063
[2523650]
207[0
211]
85
Parental
expectations
31615
07
[02
12]
010
000
001
[2386387]
007[0
211]
79
Organization
21565
ndash01
[206
04]
082
000
mdashmdash
mdashmdash
mdash
Note
k5numberof
studiesN5totalnumberof
participantsin
theksamplesr1
5weightedmeanbivariatecorrelation
CI5
confidence
intervalQT5measure
ofheterogeneity
ofeffect
sizesI25percentage
ofheteroge-
neity
kT
F5numberof
imputedstudiesas
partof
ldquotrim
andfillrdquo
method
FMPS
5Frostrsquos
andcolleaguesrsquo
(1990)
Multid
imensional
Perfectio
nism
Scale
EDI-perfectio
nism
5Garnerandcolleaguesrsquo
(1983)
EatingDisorder
Inventory-Perfectio
nism
subscale
a Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesdoubtsaboutactio
nsanddiscrepancy
b Perfectionistic
strivingsassessed
asaggregateof
self-orientedperfectio
nism
andpersonal
standards
c Parentalperceptio
nsassessed
asaggregateof
parental
criticism
andparental
expectations
(Cox
etal2002)
d Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesanddoubtsaboutactio
ns
plt05
plt01
p
lt001
534 | SMITH ET AL
Weighted mean effect sizes for the relationships betweenself-oriented other-oriented and socially prescribed perfec-tionism at baseline and suicide ideation at follow-up whilecontrolling for ideation at baseline are in SupplementalMaterial E (see Supplemental Material F for adjusted longi-tudinal effect sizes) Despite the large positive relationshipbetween baseline and follow-up suicide ideation sociallyprescribed perfectionism still displayed a small positive rela-tionship with follow-up suicide ideation after controlling forbaseline suicide ideation Self-oriented and other-orientedperfectionismrsquos relationships with follow-up suicide ideationafter controlling for baseline ideation were nonsignificant
MPS-perfectionism dimensions displayed small-to-largepositive correlations with each other (see SupplementalMaterial G for observed effects and Supplemental MaterialH for adjusted effects) After controlling for overlap in MPSdimensions self-oriented perfectionism ceased to signifi-cantly predict suicide ideation other-oriented perfectionismhad a small unique negative association with suicide idea-tion and socially prescribed perfectionism had a smallunique positive relationship with suicide ideation FMPS-perfectionism dimensions had marginal-to-large correlationswith each other (see Supplemental Material G for observedeffects and Supplemental Material H for adjusted effects)After controlling for overlap in FMPS dimensions the rela-tionships among suicide ideation and concern over mistakespersonal standards parental expectations and organizationwere nonsignificant However after controlling for overlapamong FMPS dimensions doubts about actions and parentalcriticism displayed small unique positive relationships withideation (see Supplemental Material G for observed effectsand Supplemental Material H for adjusted effects)
The test of the total heterogeneity of variance of weightedmean effect sizes (QT) was significant for suicide ideationrsquosrelations with perfectionistic concerns concern over mistakesdiscrepancy personal standards perfectionistic attitudesother-oriented perfectionism FMPS-perfectionism and orga-nization (see Table 2) QT was also significant for the linkbetween suicide attempts and perfectionistic concerns (seeTable 2) The percentage of total variance owing to heteroge-neity (I2) ranged from small to large suggesting possiblemoderators
32 | Moderator analyses
Moderator analyses (see Supplemental Material I) testedwhether effect sizes with significant heterogeneity (QT) weremoderated by publication status (peer-reviewed articles dis-sertations) age (adolescent samples 13 and 17 yearsyoung adult samples 18 and 25 years adultsamples 25 years) sample (university undergraduatescommunity adults psychiatric patients) or perfectionism
measure Perfectionistic concernsrsquo relationship with suicideattempts was nonsignificant for the CAPS but significant forthe FMPS and the MPS Meta-regression also revealed thestrength of the relationship between perfectionistic concernsand suicide attempts decreased as the proportion of femalesin a sample increased However we advise caution in inter-preting our moderator analyses given the small number ofstudies per subgroup
33 | Publication bias
Funnel plots (see Supplemental Material J) and Eggerrsquosregression intercept (see Table 2) provided mixed evidencefor publication bias Eggerrsquos regression intercept was signifi-cant for perfectionistic concernsrsquo relationship with suicideideation and suicide attempts Moreover the funnel plot forperfectionistic concerns and suicide attempts was asymmetri-cal Accordingly for perfectionistic concernsrsquo relationshipwith suicide ideation and suicide attempts trim and fill esti-mates may provide more accurate estimates Nonethelessafter imputing missing studies the adjusted point estimatesfor perfectionistic concernsrsquo relationships with suicide idea-tion and suicide attempts provided the same substantiveimplications (see Table 2)
4 | DISCUSSION
Suicide claims one life every 45 seconds (World HealthOrganization 2012) Given the wide-reaching personal andsocietal costs of suicide it is vital to identify contributingfactors One such factor supported by over 50 years of casehistories theoretical accounts and empirical research is per-fectionism (Blatt 1995 Hassan et al 2014 Hewitt et al2014 Kiamanesh et al 2014 Shaffer 1974) Yet despitethe abundance of research the role of perfectionism in sui-cide remains underappreciated under-recognized and mis-understood due to inconsistencies between studies infindings underpowered studies and uncertainty surroundingwhether perfectionism dimensions predict longitudinalincreases in suicidality We aimed to rectify this by rigor-ously conducting the first meta-analytic review of the perfec-tionismndashsuicidality relationship
41 | An improved understanding of theperfectionismndashsuicidality relationship
Our meta-analysis of 45 studies 54 samples and 11747 par-ticipants represents the most comprehensive test of the per-fectionismndashsuicidality link to date All dimensions orcorrelates of perfectionism (except for other-oriented perfec-tionism and organization) were positively related to suicideideation and these effect sizes were generally consistent
SMITH ET AL | 535
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
Accordingly researchers and clinicians are increasinglyinterested in identifying reliable markers of suicide to sup-port prevention and intervention strategies Although suicideis seldom attributable to any single factor personality traitscan play a very important role (Bogg amp Roberts 2004Brezo Paris amp Turecki 2006) The present study focuses onone such traitmdashperfectionism
The Alaska Suicide Follow-Back Study (Alaska InjuryPrevention Center Critical Illness and Trauma FoundationInc amp American Association of Suicidology 2007) helpsillustrate the perniciousness of perfectionism In that studyresearchers interviewed family and friends of people whocompleted suicide and found 56 of decedents weredescribed as perfectionistic (Alaska Injury Prevention Centeret al 2007 p 32) Similarly when Teuroornblom Werbart andRydelius (2013 p 248) conducted interviews with parents ofadolescents who completed suicide 681 reported theirchildrsquos ldquohigh demands and expectationsrdquomdashhallmarks of per-fectionismmdashwere contributing factors As these examplessuggest perfectionism can be pernicious Even so the roleof perfectionism in suicide may be underappreciated under-recognized and misunderstood due to notable inconsisten-cies in findings between studies underpowered studies anduncertainty about whether perfectionism confers longitudinalrisk for suicide ideation and attempts We addressed theseissues by conducting a rigorous comprehensive meta-analytic review of the perfectionismndashsuicide relationship Inconducting this empirical synthesis our goal was to bringgreater clarity to this important literature
11 | Conceptualizing perfectionism
The most widely adopted conceptualizations of perfectionismare associated with two measures both titled the Multidi-mensional Perfectionism Scale (FMPS Frost MartenLahart amp Rosenblate 1990 MPS Hewitt amp Flett 1991)Frost et al (1990) defined perfectionism as ldquohigh standardsof performance which are accompanied by overly criticalevaluations of onersquos behaviorrdquo (p 450) and introduced sixdimensionsmdashconcern over mistakes doubts about actionsparental criticism parental expectations personal standardsand organization Concern over mistakes involves a preoccu-pation with mistakes to such an extent that performance iseither perfect or worthless Doubts about actions characterizea nagging sense of doubt regarding the quality of onersquos per-formance Personal standards reflect setting unreasonablyhigh personal standards and goals Parental criticism andparental expectations encompass perceptions of onersquos parentsas excessively critical and holding unrealistically highexpectations Organization includes an overemphasis onorder precision and neatness Hewitt and Flettrsquos (1991)model underscored the personal and interpersonal aspects of
perfectionism and introduced three dimensionsmdashself-oriented perfectionism (demanding perfection of one-self) other-oriented perfectionism (demanding perfection ofothers) and socially prescribed perfectionism (perceivingothers are demanding perfection of oneself)
Other notable conceptualizations of perfectionism existSlaney Rice Mobley Trippi and Ashbyrsquos (2001) AlmostPerfect Scale-Revised (APS-R) conceptualizes perfectionismas having positive and negative features with the APS-RrsquosDiscrepancy subscale reflecting a perceived gap betweenhow one is and how one would like to be and the APS-RrsquosStandards subscale reflecting striving for excellence (BlasbergHewitt Flett Sherry amp Chen 2016) Alternatively Beckand associates (Imber et al 1990) view perfectionism as aunitary cognitive style which we label perfectionistic atti-tudes These attitudes include cognitive distortions with per-fectionistic themes (eg black-and-white dichotomousthinking) and social difficulties with perfectionistic themes(eg social evaluative concerns Sherry Hewitt Flett ampHarvey 2003) Finally Garner Olmstead and Polivyrsquos(1983) Eating Disorder Inventory (EDI) conceptualizes per-fectionism as a unidimensional construct characterized byboth perfectionistic standards and evaluative concerns(Sherry Hewitt Besser McGee amp Flett 2004)
12 | Perfectionistic concerns perfectionisticstrivings other forms of perfectionism andcorrelates of perfectionism
The number of perfectionism dimensions makes studyingperfectionism challenging However this challenge can bemitigated by adopting the two-factor model (eg SmithSherry Chen et al 2016) This model asserts the majorityof common variance among lower-order perfectionismdimensions is attributable to two higher-order factors perfec-tionistic concerns and strivings (Stoeber amp Otto 2006) Per-fectionistic concerns encompass a family of traits involvingsocially prescribed perfectionism concern over mistakesdoubts about actions discrepancy and perfectionistic atti-tudes (Dunkley Sanislow Grilo amp McGlashan 2004Smith Sherry Rnic et al 2016) In contrast perfectionisticstrivings encompass a constellation of traits involving self-oriented perfectionism and personal standards (Stoeber ampOtto 2006)
Yet the two-factor model is unable to integrate all formsof perfectionismmdashparticularly other-oriented perfectionismThe two-factor model is also incapable of accommodatingtotal scores Although the use of total scores is discouragedby some (Hewitt Flett Besser Sherry amp McGee 2003)several studies use them (eg Chang 2002) To deal withsuch issues we refer to other-oriented perfectionism and totalperfectionism scores as measured by Frost et al (1990) and
SMITH ET AL | 523
by Garner et al (1983) as ldquoother forms of perfectionismrdquoWe also considered three of Frost and colleaguesrsquo (1990) sixfacets (parental criticism parental expectations and organi-zation) as ldquocorrelates of perfectionismrdquo as opposed to corecharacteristics of perfectionism (Stoeber amp Otto 2006)Parental criticism and expectations assess childhood antece-dents of perfectionism (Sherry amp Hall 2009) and organiza-tion does not appear definitional to the perfectionismconstruct (Frost et al 1990) Given Cox Enns and Clararsquos(2002) factor-analytic findings we also combined parentalcriticism and parental expectations to form parentalperceptions
13 | Suicide ideation and suicide attempts
Suicide ideation involves thoughts intent threats and othernonphysical actions suicide attempts involve physicalbehaviors in which an individual attempts to end his or herlife but survives (Kessler Berglund Borges Nock ampWang 2005) Research suggests suicide ideation and suicideattempts lie along a continuum such that risk for completedsuicide increases as one progresses from passive thoughtsabout suicide to seriously thinking about suicide to activelyattempting suicide (Joiner 2005) Indeed suicide ideationand even passive thoughts about wanting to be dead predictsuicide completion (Brown Beck Steer amp Grisham 2000Brown Steer Henriques amp Beck 2005) Likewise suicideattempts are robustly tied to suicide completion (Oquendoet al 2004) And the best predictor of completed suicide is ahistory of attempts (Nordstreuroom Samuelsson amp Asberg1995 Joiner et al 2005) Given these links we refer to thecontinuum of possible suicide thoughts (ideation) and actions(attempts) as suicidality
14 | The perfectionismndashsuicidalityrelationship
Public outcry over the perfectionismndashsuicide link aroselargely from media accounts of Sidney Blattrsquos (1995) articleldquoThe Destructiveness of Perfectionismrdquo Blattrsquos (1995) arti-cle described how perfectionism led three remarkably tal-ented individuals to end their lives (ie Vincent FosterAlasdair Clayre and Denny Hansen) Five years earlier Bau-meister (1990) also sounded the same alarm with his escapetheory of suicide Baumeister (1990) posited lofty personalstandards can trigger a causal chain cumulating in suicideBuilding on these accounts most researchers conceptualizeperfectionism as a vulnerability factor for suicide (eg FlettHewitt amp Heisel 2014 Hewitt Flett Sherry amp Caelian2006 Roxborough et al 2012)
So why is perfectionism associated with thinking aboutattempting and even completing suicide Perfectionists are
their own worst criticsmdashgood enough is never enough(Hewitt amp Flett 1991) Consequently the typical perfection-ist is locked in an endless loop of self-defeating over-strivingin which each new task is another opportunity for harsh self-rebuke disappointment and failure (DiBartolo FrostChang LaSota amp Grills 2004 Dunkley amp Grilo 2007Sturman Flett Hewitt amp Rudolph 2009) In additionblack-and-white thinking can lead perfectionists to interpretfailures as catastrophes that in extreme circumstances areseen as warranting death (Blatt 1995 Flett et al 2014Hewitt et al 2006) Many perfectionists also struggle to par-ticipate in and to benefit from stable positive interpersonalrelationships (Sherry Mackinnon amp Gautreau 2015) Thisinability to partake in harmonious relationships may leaveperfectionists at risk for suicidality (see Hewitt et al 2006)Similarly the stress-diathesis model of perfectionism (Hewittamp Flett 2002) asserts ego-involving stressors place perfec-tionists at risk for suicide Flamenbaum and Holden (2007)for instance found perfectionists are prone to psychache(ie profound psychological pain) if they perceive unfilledneeds in areas of achievement and affiliation All toldresearch suggests an important relationship between perfec-tionism and suicide Yet this literature has not been meta-analyzed
Hewitt and colleaguesrsquo (2006) OrsquoConnorrsquos (2007) andFlett and colleaguesrsquo (2014) nonempirical reviews capablysummarized the perfectionismndashsuicide literature and con-cluded perfectionistic concerns were related to suicidalityHowever due to notable inconsistencies between studies infindings none of these authors reached concrete conclusionsregarding perfectionistic strivingsrsquo link with suicidalityIndeed some studies report perfectionistic strivings are nega-tively related to suicidality (eg Stoeber amp Otto 2006)some studies report perfectionistic strivings are unrelated tosuicidality (eg Hewitt Norton Flett Callander amp Cowan1998) and other studies report perfectionistic strivings arepositively related to suicidality (eg Flamenbaum amp Holden2007) Likewise OrsquoConnor (2007 p 709) concludedldquoThere are insufficient studies to draw any firm conclusionabout [other-oriented perfectionism]rdquo Other-oriented perfec-tionism was altogether absent from reviews by Hewitt et al(2006) and Flett et al (2014) Additionally as with perfec-tionistic strivings inconsistent findings between studies haverendered our understanding of other-oriented perfectionismrsquosrelationship with suicidality equivocal Some investigatorsreport other-oriented perfectionism is negatively related tosuicidality (Hunter amp OrsquoConnor 2003) some investigatorsreport other-oriented perfectionism is unrelated to suicidality(Hewitt Caelian Chen amp Flett 2014) and other investiga-tors report other-oriented perfectionism is positively relatedto suicidality in Asian but not Caucasian samples (ChenHewitt amp Flett 2017) Nonetheless as of 2017 there are 12
524 | SMITH ET AL
TABLE1
Characteristicsof
studiesincluded
inthemeta-analysis
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Adkins(1994)
129
university
aNR
NR
101
dissertatio
ncross-sectional
FMPS
-total
ASIQ
mdash
Adkinsamp
Parker
(1996)
129
university
a218
650
110
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
AAHS-ST
eattemptsf
Becket
al(1993)
908
psychiatricb
364
550
NR
article
cross-sectional
DAS-P
SSI
attemptsf
Beevers
ampMiller
(200
4)tim
e1
121
psychiatricb
380
744
66
article
long
itudinal
DAS-P
MSS
Imdash
Beevers
ampMiller
(200
4)tim
e2
100
psychiatricb
380
744
66
article
long
itudinal
DAS-P
MSS
Imdash
Blanksteinet
al(2007)
wom
en144
university
a221
1000
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
CSI
mdash
Blanksteinet
al(2007)
men
61un
iversity
a221
00
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
CSI
mdash
Blasberget
al(2016)
371
university
a210
610
NR
article
cross-sectional
FMPS
-PS
SSI
mdash
Caelian(2005)
55psychiatricb
155
745
255
dissertatio
ncross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
attemptsf
Chang
(2002)
371
university
a235
806
70
article
cross-sectional
FMPS
-total
ASIQ
mdash
Chen(2012)
wom
en279
community
c586
1000
135
dissertatio
nlongitu
dinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
mdash
Chen(2012)
men
157
community
c586
00
135
dissertatio
nlongitu
dinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
mdash
Chenet
al(2017)
240
university
a189
638
500
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
ASIQ
mdash (Contin
ues)
SMITH ET AL | 525
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Deanamp
Range
(1996)
168
university
a219
690
280
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SBQ
mdash
Deanamp
Range
(1999)
132
psychiatricb
355
712
333
article
cross-sectional
MPS
-SOP
MPS
-SPP
SSI
mdash
Deanet
al(1996)
114
university
a244
842
281
article
cross-sectional
MPS
-SPP
SSI
mdash
Enn
set
al(2001)
96medicald
251
417
NR
article
long
itudinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
SIQ
mdash
Fedorowiczet
al(20
07)
940
psychiatricb
260
00
NR
article
cross-sectional
EDI
mdashattemptsg
Flam
enbaum
ampHolden(2007)
264
university
a189
758
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
BSS
-MBSS
-Pintent
hattemptsf
Foulon
etal(2007)
304
psychiatricb
223
977
NR
article
cross-sectional
EDI
mdashattemptsi
Franko
etal(2004)
246
psychiatricb
NR
1000
NR
article
cross-sectional
EDI
mdashattemptsi
Freudenstein
etal(2012)
100
psychiatricb
166
470
120
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
CSP
Sattemptsi
Ham
ilton
ampSchw
eitzer
(2000)
389
university
a227
743
NR
article
cross-sectional
FMPS
-PS
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-total
GHQ-ST
mdash
Hew
ittet
al(1992)
87psychiatricb
357
529
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
BDI-SI
mdash (Contin
ues)
526 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Hew
ittet
al(1994)
study1
91psychiatricb
355
538
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
RST
-past
RST
-future
mdash
Hew
ittet
al(1994)
study2
160
university
a217
656
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
RST
-past
RST
-future
mdash
Hew
ittet
al(1997)
wom
en33
psychiatricb
154
1000
NR
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
mdash
Hew
ittet
al(1997)
men
33psychiatricb
154
00
NR
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
mdash
Hew
ittet
al(1998)
78psychiatricb
328
538
308
article
cross-sectionali
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Hew
ittet
al(2014)
55psychiatricb
155
745
255
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
attemptsi
Hunteramp
OrsquoConnor(2003)
sample1
43psychiatricb
346
534
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Hunteramp
OrsquoConnor(2003)
sample2
44psychiatricb
346
477
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Izadi(2015)
50community
c270
740
420
dissertatio
ncross-sectional
MPS
-SPP
FMPS
-COM
FMPS
-PC
FMPS
-PE
SBQ-SI
attemptsf
Jacobs
etal(2009)
439
psychiatricb
146
540
260
article
cross-sectional
DAS-P
SIQ-JR
mdash
Jeglic
(2003)
97university
a184
732
330
dissertatio
ncross-sectional
FMPS
-total
mdashattemptsi
Jeglic
etal(2007)
study2
440
university
a185
620
400
article
cross-sectional
FMPS
-total
mdashattemptsi
(Contin
ues)
SMITH ET AL | 527
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Muyan
ampChang
(2015)
288
university
a213
590
NR
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
FSII
mdash
OrsquoConnoramp
Forgan
(2007)
255
university
a220
780
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
GHQ-ST
mdash
OrsquoConnorRC
et
al(2007)
study2
151
university
a240
722
NR
article
long
itudinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
OrsquoConnorDB
et
al(2007)
sample1
65psychiatricb
241
722
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
OrsquoConnorDB
et
al(2007)
sample2
61psychiatricb
241
722
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Pisetsky
etal(2013)
635
psychiatricb
317
NR
NR
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PS
mdashattemptsi
Portzkyet
al(2014)
1436
psychiatricb
242
954
NR
article
cross-sectional
EDI
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
mdashattemptsi
Ranieriet
al(1987)
sample1
50psychiatricb
443
560
80
article
cross-sectional
DAS-P
BSS
Iattemptsf
Ranieriet
al(1987)
sample2
25psychiatricb
417
600
NR
article
cross-sectional
DAS-P
BSS
Iattemptsf
(Contin
ues)
528 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Rasmussenet
al(2008)
sample1
17psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussenet
al(2008)
sample2
23psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussen
Elliotet
al(2012)
161
psychiatricb
337
590
NR
article
cross-sectional
MPS
-SPP
SPS-SI
mdash
Rasmussen
Slish
etal(2012)
214
university
a201
570
257
article
cross-sectional
APS
-DDSI-SS
mdash
Roxboroughet
al(2012)
152
psychiatricb
129
454
285
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
intent
hmdash
Slish(2006)
48university
a201
521
625
dissertatio
ncross-sectional
APS
-DDSI-SS
mdash
Wallack
(2007)
181
university
a198
796
260
dissertatio
ncross-sectional
APS
-DSIS
mdash
Wanget
al(2013)
466
university
a264
496
NR
article
cross-sectional
APS
-DSIS
mdash
Yam
aguchi
etal(2000)
51psychiatricb
212
961
NR
article
cross-sectional
EDI
mdashattemptsi
Note
N5totalnumberof
participantsNR5
notreportedFemale5percentage
female
Ethnic5percentage
ethnic
minority
Status
5publicationstatus
ofthestudy
FMPS
5Frostandcolleaguesrsquo
(1990)
Multid
imen-
sional
Perfectio
nism
Scale
total5
totalscore
ASIQ5
Reynoldsrsquos(1991)
AdultSu
icideIdeatio
nQuestionnaireCOM
5concernover
mistakesDAA5
doubtsaboutactio
nsPC
5parental
criticism
PE
5parental
expecta-
tionsPS
5personal
standardsORG5organizatio
nAAHS-ST
5NationalAdolescentHealth
Survey
Suicidal
Thinkingmodifiedversion(1989)DAS-P5Weissman
andBeckrsquos(1978)
Dysfunctio
nalAttitude
Scale-
Perfectio
nism
subscaleSS
I5Beck
SteerandRanierirsquos
(1988)
ScaleforSu
icidal
Ideatio
nMSS
I5MillerNormanBishop
andDow
rsquos(1986)
ModifiedScaleforSu
icidal
Ideatio
nMPS
5Hew
ittandFlettrsquos
(1991)
Multi-
dimensional
Perfectio
nism
Scale
SOP5self-orientedperfectio
nism
OOP5other-oriented
perfectio
nism
SP
P5socially
prescribed
perfectio
nism
CSI
5Blanksteinrsquos(2007)
Current
SuicideIdeatio
nScale
CAPS
5Flett
andcolleaguesrsquo
(2016)
Child-A
dolescentPerfectio
nism
Scale
SIQ5
Reynoldsrsquos(1987b)Su
icidal
Ideatio
nQuestionnaireEDI5
Garnerandcolleaguesrsquo
(1983)
EatingDisorderInventory-Perfectio
nism
subscaleBSS
5Beck
andSteerrsquos
(1993)
SuicideIdeatio
nScale
M5
motivation
P5preparation
Intent5suicidal
intentCSP
S5Pfefferrsquos
(1986)
Child
SuicidePo
tentialScale
GHQ-ST5
GoldbergandWilliamsrsquos(1988)
General
Health
Questionnaire-SuicidalThinkingsubscaleBDI-SI
5Beckrsquos(1979)
DepressionInventoryitem-9
(SuicidalIntent)RST
-past5
ratin
gof
thefrequencyof
pastsuicidal
thoughtsRST
-future5ratin
gof
thefrequencyof
future
suicidal
thoughtsSB
Q5
Linehanrsquos
(1981)
Suicidal
BehaviorQuestionnaireSI
5suicidal
ideatio
nSIQ-JR5
Reynoldsrsquos(1987a)Su
icidal
Ideatio
nQuestionnaire-G
rades7ndash9
FSII5
Chang
andChang
rsquos(2016)
Frequency
ofSu
icideIdeatio
nInventory
SPS5CullandGillrsquos
(1982)
SuicideProbability
Scale
BSS
I5Beck
KovacsandWeissmanrsquos
(1979)
ScaleforSu
icidal
Ideatio
nAPS
-D5
Slaney
andcolleaguesrsquo
(2001)
Alm
ostPerfect
Scale-Revised
Discrepancy
subscaleDSI-SS5
MetalskyandJoinerrsquos
(1997)
DepressiveSy
mptom
sInventory-Su
icidality
subscaleSIS5Ruddrsquos(1989)
Suicidal
Ideatio
nScale
a University
undergraduates
b Psychiatric
patients
c Com
munity
adults
d Medical
students
e Participants
reported
whether
they
hadever
seriouslythoughtaboutattemptingsuicide
f Self-reported
numberof
priorsuicideattempts
g Prior
numberof
suicideattemptsassessed
byaclinician
h Participants
asked
ldquoHow
likelyisitthat
youwill
attempt
suicidesomedayrdquo
i Com
paredsuicideattemptersandnon-attempters
SMITH ET AL | 529
studies examining other-oriented perfectionism and suicidal-ity (see Table 1) meaning this literature is now suitable formeta-analysis In sum though perfectionistic concernsrsquo linkwith suicidality is clear (Flett al 2014 Hewitt et al 2006OrsquoConnor 2007) perfectionistic strivingsrsquo and other-oriented perfectionismrsquos link with suicidality is unclear
15 | Advancing research on theperfectionismndashsuicidality relationship usingmeta-analysis
Over 50 years of case reports theoretical accounts andempirical research implicate perfectionism in suicide (egBlatt 1995 Hassan Flett Ganguli amp Hewitt 2014 Hewittet al 2014 Kiamanesh Dyregrov Haavind amp Dieserud2014 Shaffer 1974) And yet there is much to learn aboutthe perfectionismndashsuicidality relationship (Flett et al 2014)First noteworthy inconsistencies between studies in findings(eg Flamenbaum amp Holden 2007 Hewitt et al 19982014 Hunter amp OrsquoConnor 2003) have clouded our under-standing of perfectionistic strivingsrsquo and other-oriented per-fectionismrsquos relationships with suicidality A quantitativesynthesis is needed for overall conclusions to be reachedSuch a quantitative synthesis could also allow for tests ofmoderating variables (eg gender) that might explain whenthe strength or the direction of the perfectionismndashsuicidalityrelationship changes Second despite evidence that correla-tions do not stabilize until N 250 (Scheuroonbrodt amp Perugini2013) most research on perfectionism and suicide attemptsis underpowered (cf Flamenbaum amp Holden 2007) How-ever meta-analysis could overcome limitations of small sam-ples (Borenstein Hedges Higgins amp Rothstein 2009) andbring greater clarity to our understanding of perfectionismrsquosrelationship with suicide attempts Third as noted by Flettet al (2014) and OrsquoConnor (2007) the extent to which per-fectionism dimensions confer risk for suicide has yet to bedetermined Indeed most investigators use cross-sectionaldesigns which unlike longitudinal designs cannot addresstemporal precedence As such whether perfectionism leadsto increases in suicidality is unclear and researchers andclinicians can only speculate as to whether reducing perfec-tionism reduces suicidality Nevertheless there is now suffi-cient data to test whether self-oriented other-oriented andsocially prescribed perfectionism predict follow-up suicideideation beyond baseline suicide ideation (Chen 2012Enns Cox Sareen amp Freeman 2001 R C OrsquoConnorWhyte et al 2007) Fourth due to limitations of nonempiri-cal reviews the strength of the relation between perfection-ism dimensions suicide ideation and suicide attempts isunclear A meta-analysis could shed light on which perfec-tionism dimensions display the strongest relations with sui-cide ideation and suicide attempts which in time might
inform the development of interventions designed to targetand to modify perfectionismrsquos most pernicious aspects
16 | Objectives and hypothesis
Our primary aim was to bring greater clarity to our under-standing of the perfectionismndashsuicidality relationship bycomprehensively synthesizing empirical research on perfec-tionism suicide ideation and suicide attempts To date thereis no meta-analysis of findings from this long-standing andimportant literature We also aimed to test the contentiouslydebated relation between perfectionistic strivings suicideideation and suicide attempts Such evidence would informdebate on the pros and cons of demanding perfection of one-self (eg Stoeber amp Otto 2006 Sherry Hewitt SherryFlett amp Graham 2010) Another aim was to test whetherself-oriented other-oriented and socially prescribed perfec-tionism predicted longitudinal increases in suicide ideationover time Controlling for baseline suicide ideation repre-sents a stringent test of the perfectionismndashsuicidality relation-ship as baseline suicide ideation is a strong predictor ofsubsequent suicide ideation (eg Joiner et al 2005)
Building on theory and research (Flett et al 2014Hewitt et al 2006 OrsquoConnor 2007) we hypothesized per-fectionistic concerns (socially prescribed perfectionism con-cern over mistakes doubts about action discrepancy andperfectionistic attitudes) would display positive relationshipswith suicide ideation and attempts We also hypothesizedsocially prescribed perfectionism would place people at riskfor longitudinal increases in suicide ideation However giventhe inconsistency of research on suicidality in relation to per-fectionistic strivings (self-oriented perfectionism personalstandards) other forms of perfectionism (other-oriented per-fectionism EDI-perfectionism total scores FMPS-perfectionism total scores) and correlates of perfectionism(parental criticism parental expectations organization) weconsidered our investigation into these questions to be moreexploratory
2 | METHOD
21 | Selection of studies
In 2016 a literature search using PsycINFO Medline Webof Science ERIC and ProQuest Dissertations and Theseswas conducted using the keywords and Boolean search termsldquoperfectrdquo and ldquosuicidrdquo This search yielded 100 studiesfrom PsycINFO 122 studies from Medline 226 studies fromWeb of Science and 38 studies from ProQuest We alsocompiled a list of 353 authors who had published on perfec-tionism We then contacted each author individually andrequested unpublished findings However none of the
530 | SMITH ET AL
authors contacted provided relevant data Additionally wemonitored the Perfectionism Network Mailing List to iden-tify studies that were accepted but not published at the timeof our literature search This yielded one study Chen et al(2017) Both the first and the third author then reviewedabstracts of all studies identified selecting studies meetinginclusion criteria Studies were included that (a) containeddata on perfectionism and suicidality (ideation and attempts)and (b) were in English Included studies also (c) reported aneffect size or enough information for computing an effectsize or effect size information was obtained from a studyauthor All authors contacted (N5 1) provided the requestedinformation
This literature search yielded 57 studies for inclusionInter-rater agreement on inclusion or exclusion in the meta-analysis was 95 Disagreement was resolved by revisitingarticles and coming to a consensus The reference lists ofincluded articles were also examined to locate additional rel-evant literature On August 7 2016 we terminated all searchstrategies and started data reduction and analysis Weexcluded 12 studies (see Supplemental Material A) The finalsample of included studies was composed of 45 studies with54 samples
22 | Coding of studies
The first and the third author coded each study based on ninecharacteristics sample size sample type mean age of partici-pants percentage of female participants percentage of ethnicminority participants publication status measure used toassess perfectionism measure used to assess suicide ideationand measure used to assess suicide attempts
23 | Meta-analytic procedures
Random effects analyses were conducted using Comprehen-sive Meta-Analysis software (Borenstein et al 2005) Wechose random effects models over fixed effects models asthe 45 included studies varied widely in design We alsoweighed mean effects following the procedure suggested byHunter and Schmidt (1990) This allowed us to estimatemean effect sizes and variance in observed scores after con-sidering sampling error (Card 2012) Next effect size esti-mates were weighted by sample size and aggregated Forstudies with more than one measure of suicide ideation weaveraged effect sizes so only one effect was included (Boren-stein et al 2009 Card 2012) Effect sizes presented in met-rics other than r (ie means t-tests d or F scores) wereconverted and expressed as correlations following formulasprovided by Borenstein et al (2009) We also used Boren-stein and colleaguesrsquo (2009) formula to calculate powerunder the random effects model for each weighted mean
effect Additionally most included studies measured perfec-tionism and suicide ideation with imperfect reliability Asthis can attenuate the magnitude of observed correlationseffects were adjusted by dividing the observed correlation bythe square root of the product of the two corresponding reli-ability coefficients (Card 2012) When reported the actualreliability statistics for a study were used when not reportedthe corresponding meta-analyzed mean reliability was used(Card 2012) However we were unable to adjust for unreli-ability in suicide attempts Thus in the interest of methodo-logical consistency we used the common albeitconservative strategy of interpreting observed effects whichgenerally underestimates the true magnitude of effect sizes(Borenstein et al 2009) Nonetheless for readers who dis-agree with this strategy effect sizes adjusted for unreliabilityare presented in our supplementary material
To examine the extent to which baseline self-orientedother-oriented and socially prescribed perfectionism predictfollow-up suicide ideation after controlling for baseline idea-tion we computed partial correlations using the ldquocorpcorrdquopackage (Schafer Opgen-Rhein Zuber Silvia amp Strimmer2015) for R (R Core Team 2013) Although there was insuf-ficient data to examine unique effects between perfectionismdimensions and suicide attempts there was sufficient data toexamine unique effects between perfectionism dimensionsand suicide ideation Thus again using the ldquocorpcorrdquo pack-age (Schafer et al 2015) we computed partial correlationsfor MPS-perfectionism dimensions by residualizing self-oriented other-oriented and socially prescribed perfection-ism based on their overlap with each other prior to being cor-related with suicide ideation Likewise for FMPS-perfectionism dimensions we computed partial correlationsby residualizing concern over mistakes doubts about actionparental criticism parental expectations personal standardsand organization based on their overlap with each other priorto being correlated with suicide ideation
To assess moderation we evaluated the total heterogene-ity of weighted mean effect sizes (QT) A significant QT indi-cates variance in weighted mean effect sizes is greater thanexpected by sampling error (Card 2012) a nonsignificantQT suggests a weak basis for moderation For each analysiswe also computed the inconsistency in observed effects (I2)across studies I2 indicates the percentage of total varianceacross studies due to heterogeneity Values of 25 50and 75 correspond to low medium and high heterogene-ity respectively
When QT was significant we stipulated a categoricalstructure and the total heterogeneity explained by the catego-rization (QB) was calculated (Card 2012) A significant QB
indicates meaningful differences in effects between catego-ries and provides a firm basis for moderation (Borensteinet al 2009) When QB was significant we examined
SMITH ET AL | 531
differences in effect sizes between studies grouped by publi-cation status (articles and dissertations) age (adult youngadult adolescent) and sample (community adults under-graduate students psychiatric patients) by performing aseries of all possible two-group comparisons to test whichgroup differed significantly in effect size (Card 2012) Foreach group comparison the resultant QB from the twogroups was tested using a v2 test with one degree of freedomWe also recorded gender (percentage female) and ethnicity(percentage ethnic minority) as continuous variables andused mixed effects meta-regression to test the potential mod-erating effects of gender and ethnicity
To assess publication bias we inspected funnel plotswith observed and imputed studies and computed Eggerrsquostest of regression to the intercept (Egger Smith Schneideramp Minder 1997) Such funnel plots allow for visual inspec-tion of how the effect size shifts when imputed studies areincluded (Borenstein et al 2009) In the absence of publica-tion bias Eggerrsquos regression intercept does not differ signifi-cantly from zero (Egger et al 1997)
24 | Description of studies
Our search identified 45 studies and 54 samples containingrelevant effect size data (see Table 1) The total number ofparticipants pooled across studies was 11747 Relevant datawere obtained from 38 journal articles and seven disserta-tions There were 21 samples of university undergraduates29 samples of psychiatric patients one sample of medicalstudents and three samples of community adults There were48 cross-sectional samples and six longitudinal samplesSample size varied between 17 and 1436 with an averageof 2175 (SD5 2598) The mean age of participants was268 years (SD5 102 range5 129ndash586) The average per-centage of female participants was 633 the average per-centage of ethnic minority participants was 244 Effectsize information for each individual study is presented inSupplemental Material B Adjusted effect size informationfor each individual study is presented in Supplemental Mate-rial C
25 | Measures
251 | Perfectionism
Following theory and research (eg Dunkley et al 2004Stoeber amp Otto 2006) personal standards (FMPS) and self-oriented perfectionism (MPS Child-Adolescent Perfection-ism Scale [CAPS] Flett et al 2016) were considered facetsof perfectionistic strivings concern over mistakes (FMPS)doubts about actions (FMPS) socially prescribed perfection-ism (MPS CAPS) discrepancy (APS-R) and perfectionistic
attitudes (Dysfunctional Attitude Scale-Perfectionism sub-scale [DAS-P] Weissman amp Beck 1978) were consideredfacets of perfectionistic concerns Parental criticism parentalexpectations and organization were designated correlates ofperfectionism As well parental criticism and parentalexpectations were combined and labeled as parental percep-tions (see Cox et al 2002) Other-oriented perfectionism(MPS) FMPS-perfectionism and EDI-perfectionism weredesignated other forms of perfectionism
252 | Suicide ideation and suicide attempts
Suicide ideations were assessed via self-reported suicidalthinking Suicide attempts were assessed via self-reportednumber of prior suicide attempts (eg Adkins amp Parker1996) clinicianrsquos ratings of the number of prior suicideattempts (eg Fedorowicz et al 2007) and group compari-sons between suicide attempters and non-attempters (egHewitt et al 2014) Although Pfefferrsquos (1986) Child SuicidePotential Scale (CSPS) and Linehanrsquos (1981) Suicide Behav-ior Questionnaire (SBQ) assess suicidal ideation and suicideattempts we categorized the CPS and SBQ as measures ofsuicide ideation given the majority of CSPS and SBQ itemsassess suicidal thoughts
3 | RESULTS
31 | Overall effect sizes
Weighted mean effect sizes between perfectionism corre-lates of perfectionism and suicide ideation and suicideattempts are in Table 2 (see Supplemental Material D foradjusted effect sizes) Following Cohenrsquos (1992) guidelinesfor small medium and large effects (r5 10 30 and 50respectively) perfectionistic concerns socially prescribedperfectionism concern over mistakes doubts about actionsdiscrepancy perfectionistic attitudes perfectionistic striv-ings self-oriented perfectionism personal standards parentalperceptions parental criticism parental expectations andFMPS-perfectionism displayed small-to-moderate positiverelationships with suicide ideation Other-oriented perfection-ismrsquos and organizationrsquos relationships with suicide ideationwere nonsignificant Perfectionistic concerns socially pre-scribed perfectionism concern over mistakes doubts aboutaction FMPS-perfectionism parental perceptions parentalcriticism and parental expectations displayed small positiverelationships with suicide attempts perfectionistic attitudesrsquoperfectionistic strivingsrsquo self-oriented perfectionismrsquos perso-nal standardsrsquo other-oriented perfectionismrsquos EDI-perfectionismrsquos and organizationrsquos relationships with suicideattempts were nonsignificant
532 | SMITH ET AL
TABLE2
Summaryof
overalleffect
sizesfortherelatio
nshipbetweenperfectio
nism
andsuicidality
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Suicideideatio
n
Perfectio
nistic
concerns
a42
7936
28
[24
32]
9910
5863
175
[076
273]
028[2
431]
99
Socially
prescribed
perfectio
nism
303640
28
[25
32]
3704
2171
035
[2100169]
028[2
532]
99
Concern
over
mistakes
5952
25
[13
36]
1219
6720
251
[2436938]
025[1
336]
98
Doubtsaboutactio
ns4
902
27
[18
35]
514
4162
294
[25671158
220[1
130]
99
Discrepancy
4904
26
[14
38]
917
6727
338
[24791154]
124[1
235]
98
Perfectio
nistic
attitudes
51533
37
[19
52]
3355
8808
407
[2033848]
226[0
941]
98
Perfectio
nistic
strivingsb
314588
10
[07
13]
3214
665
018
[2094130]
010[0
713]
99
Self-orientedperfectio
nism
273315
11
[08
15]
2096
000
ndash046
[2156064]
011[0
815]
99
Personal
standards
51273
10
[00
19]
1033
6127
334
[24711139]
010[0
019]
52
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
202755
01
[204
06]
3287
4219
027
[2178230]
101[2
04
06]
08
FMPS
totalscore
41018
31
[15
45]
1971
8477
472
[21692
2636]
127[1
240]
96
EDI-perfectio
nism
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdash
Correlatesof
perfectio
nism
Parental
perceptio
nsc
51904
19
[10
27]
1279
6871
204
[2558966]
019[1
027]
98
Parental
criticism
5952
20
[11
29]
798
4987
092
[2556740]
020[1
029]
98
Parental
expectations
5952
16
[06
26]
842
5247
196
[2391784]
113[0
323]
88
Organization
3513
ndash02
[220
17]
792
7475
253
[27738
8243]
0ndash02
[220
17]
05
Suicideattempts
Perfectio
nistic
concerns
d15
5275
12
[07
17]
2448
4281
115
[021
208]
508[0
314]
99
Socially
prescribed
perfectio
nism
8689
19
[08
29]
1257
4432
021
[2365407]
019[0
829]
93
Concern
over
mistakes
51827
09
[04
14]
012
000
008
[2035052]
109[0
413]
97
Doubtsaboutactio
n3
1777
06
[01
11]
276
000
100
[2201401]
205[2
02
11]
71
Discrepancy
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdashPerfectio
nistic
attitudes
3983
09
[203
22]
254
2126
142
[2155440]
205[2
07
17]
32
(Contin
ues)
SMITH ET AL | 533
TABLE2
(Contin
ued)
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Perfectio
nistic
strivingsa
101436
02
[202
06]
525
000
ndash010
[2110087]
002[2
01
06]
19
Self-orientedperfectio
nism
6539
07
[201
16]
304
000
ndash161
[2320ndash0
02]
007[2
01
15]
37
Personal
standards
41777
01
[204
06]
060
000
ndash049
[2182083]
001[2
04
05]
06
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
4429
ndash03
[213
06]
126
000
ndash142
[2258ndash0
28]
0ndash03
[213
06]
11
FMPS
totalscore
3666
14
[07
21]
130
000
ndash031
[2055ndash0
07]
016[0
823]
99
EDI-perfectio
nism
52975
03
[201
06]
183
000
106
[2098273]
103[2
01
06]
33
Correlatesof
perfectio
nism
Parental
perceptio
nsc
33230
07
[04
11]
053
000
045
[2643733]
007[0
411]
98
Parental
criticism
31615
08
[03
12]
065
000
063
[2523650]
207[0
211]
85
Parental
expectations
31615
07
[02
12]
010
000
001
[2386387]
007[0
211]
79
Organization
21565
ndash01
[206
04]
082
000
mdashmdash
mdashmdash
mdash
Note
k5numberof
studiesN5totalnumberof
participantsin
theksamplesr1
5weightedmeanbivariatecorrelation
CI5
confidence
intervalQT5measure
ofheterogeneity
ofeffect
sizesI25percentage
ofheteroge-
neity
kT
F5numberof
imputedstudiesas
partof
ldquotrim
andfillrdquo
method
FMPS
5Frostrsquos
andcolleaguesrsquo
(1990)
Multid
imensional
Perfectio
nism
Scale
EDI-perfectio
nism
5Garnerandcolleaguesrsquo
(1983)
EatingDisorder
Inventory-Perfectio
nism
subscale
a Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesdoubtsaboutactio
nsanddiscrepancy
b Perfectionistic
strivingsassessed
asaggregateof
self-orientedperfectio
nism
andpersonal
standards
c Parentalperceptio
nsassessed
asaggregateof
parental
criticism
andparental
expectations
(Cox
etal2002)
d Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesanddoubtsaboutactio
ns
plt05
plt01
p
lt001
534 | SMITH ET AL
Weighted mean effect sizes for the relationships betweenself-oriented other-oriented and socially prescribed perfec-tionism at baseline and suicide ideation at follow-up whilecontrolling for ideation at baseline are in SupplementalMaterial E (see Supplemental Material F for adjusted longi-tudinal effect sizes) Despite the large positive relationshipbetween baseline and follow-up suicide ideation sociallyprescribed perfectionism still displayed a small positive rela-tionship with follow-up suicide ideation after controlling forbaseline suicide ideation Self-oriented and other-orientedperfectionismrsquos relationships with follow-up suicide ideationafter controlling for baseline ideation were nonsignificant
MPS-perfectionism dimensions displayed small-to-largepositive correlations with each other (see SupplementalMaterial G for observed effects and Supplemental MaterialH for adjusted effects) After controlling for overlap in MPSdimensions self-oriented perfectionism ceased to signifi-cantly predict suicide ideation other-oriented perfectionismhad a small unique negative association with suicide idea-tion and socially prescribed perfectionism had a smallunique positive relationship with suicide ideation FMPS-perfectionism dimensions had marginal-to-large correlationswith each other (see Supplemental Material G for observedeffects and Supplemental Material H for adjusted effects)After controlling for overlap in FMPS dimensions the rela-tionships among suicide ideation and concern over mistakespersonal standards parental expectations and organizationwere nonsignificant However after controlling for overlapamong FMPS dimensions doubts about actions and parentalcriticism displayed small unique positive relationships withideation (see Supplemental Material G for observed effectsand Supplemental Material H for adjusted effects)
The test of the total heterogeneity of variance of weightedmean effect sizes (QT) was significant for suicide ideationrsquosrelations with perfectionistic concerns concern over mistakesdiscrepancy personal standards perfectionistic attitudesother-oriented perfectionism FMPS-perfectionism and orga-nization (see Table 2) QT was also significant for the linkbetween suicide attempts and perfectionistic concerns (seeTable 2) The percentage of total variance owing to heteroge-neity (I2) ranged from small to large suggesting possiblemoderators
32 | Moderator analyses
Moderator analyses (see Supplemental Material I) testedwhether effect sizes with significant heterogeneity (QT) weremoderated by publication status (peer-reviewed articles dis-sertations) age (adolescent samples 13 and 17 yearsyoung adult samples 18 and 25 years adultsamples 25 years) sample (university undergraduatescommunity adults psychiatric patients) or perfectionism
measure Perfectionistic concernsrsquo relationship with suicideattempts was nonsignificant for the CAPS but significant forthe FMPS and the MPS Meta-regression also revealed thestrength of the relationship between perfectionistic concernsand suicide attempts decreased as the proportion of femalesin a sample increased However we advise caution in inter-preting our moderator analyses given the small number ofstudies per subgroup
33 | Publication bias
Funnel plots (see Supplemental Material J) and Eggerrsquosregression intercept (see Table 2) provided mixed evidencefor publication bias Eggerrsquos regression intercept was signifi-cant for perfectionistic concernsrsquo relationship with suicideideation and suicide attempts Moreover the funnel plot forperfectionistic concerns and suicide attempts was asymmetri-cal Accordingly for perfectionistic concernsrsquo relationshipwith suicide ideation and suicide attempts trim and fill esti-mates may provide more accurate estimates Nonethelessafter imputing missing studies the adjusted point estimatesfor perfectionistic concernsrsquo relationships with suicide idea-tion and suicide attempts provided the same substantiveimplications (see Table 2)
4 | DISCUSSION
Suicide claims one life every 45 seconds (World HealthOrganization 2012) Given the wide-reaching personal andsocietal costs of suicide it is vital to identify contributingfactors One such factor supported by over 50 years of casehistories theoretical accounts and empirical research is per-fectionism (Blatt 1995 Hassan et al 2014 Hewitt et al2014 Kiamanesh et al 2014 Shaffer 1974) Yet despitethe abundance of research the role of perfectionism in sui-cide remains underappreciated under-recognized and mis-understood due to inconsistencies between studies infindings underpowered studies and uncertainty surroundingwhether perfectionism dimensions predict longitudinalincreases in suicidality We aimed to rectify this by rigor-ously conducting the first meta-analytic review of the perfec-tionismndashsuicidality relationship
41 | An improved understanding of theperfectionismndashsuicidality relationship
Our meta-analysis of 45 studies 54 samples and 11747 par-ticipants represents the most comprehensive test of the per-fectionismndashsuicidality link to date All dimensions orcorrelates of perfectionism (except for other-oriented perfec-tionism and organization) were positively related to suicideideation and these effect sizes were generally consistent
SMITH ET AL | 535
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
by Garner et al (1983) as ldquoother forms of perfectionismrdquoWe also considered three of Frost and colleaguesrsquo (1990) sixfacets (parental criticism parental expectations and organi-zation) as ldquocorrelates of perfectionismrdquo as opposed to corecharacteristics of perfectionism (Stoeber amp Otto 2006)Parental criticism and expectations assess childhood antece-dents of perfectionism (Sherry amp Hall 2009) and organiza-tion does not appear definitional to the perfectionismconstruct (Frost et al 1990) Given Cox Enns and Clararsquos(2002) factor-analytic findings we also combined parentalcriticism and parental expectations to form parentalperceptions
13 | Suicide ideation and suicide attempts
Suicide ideation involves thoughts intent threats and othernonphysical actions suicide attempts involve physicalbehaviors in which an individual attempts to end his or herlife but survives (Kessler Berglund Borges Nock ampWang 2005) Research suggests suicide ideation and suicideattempts lie along a continuum such that risk for completedsuicide increases as one progresses from passive thoughtsabout suicide to seriously thinking about suicide to activelyattempting suicide (Joiner 2005) Indeed suicide ideationand even passive thoughts about wanting to be dead predictsuicide completion (Brown Beck Steer amp Grisham 2000Brown Steer Henriques amp Beck 2005) Likewise suicideattempts are robustly tied to suicide completion (Oquendoet al 2004) And the best predictor of completed suicide is ahistory of attempts (Nordstreuroom Samuelsson amp Asberg1995 Joiner et al 2005) Given these links we refer to thecontinuum of possible suicide thoughts (ideation) and actions(attempts) as suicidality
14 | The perfectionismndashsuicidalityrelationship
Public outcry over the perfectionismndashsuicide link aroselargely from media accounts of Sidney Blattrsquos (1995) articleldquoThe Destructiveness of Perfectionismrdquo Blattrsquos (1995) arti-cle described how perfectionism led three remarkably tal-ented individuals to end their lives (ie Vincent FosterAlasdair Clayre and Denny Hansen) Five years earlier Bau-meister (1990) also sounded the same alarm with his escapetheory of suicide Baumeister (1990) posited lofty personalstandards can trigger a causal chain cumulating in suicideBuilding on these accounts most researchers conceptualizeperfectionism as a vulnerability factor for suicide (eg FlettHewitt amp Heisel 2014 Hewitt Flett Sherry amp Caelian2006 Roxborough et al 2012)
So why is perfectionism associated with thinking aboutattempting and even completing suicide Perfectionists are
their own worst criticsmdashgood enough is never enough(Hewitt amp Flett 1991) Consequently the typical perfection-ist is locked in an endless loop of self-defeating over-strivingin which each new task is another opportunity for harsh self-rebuke disappointment and failure (DiBartolo FrostChang LaSota amp Grills 2004 Dunkley amp Grilo 2007Sturman Flett Hewitt amp Rudolph 2009) In additionblack-and-white thinking can lead perfectionists to interpretfailures as catastrophes that in extreme circumstances areseen as warranting death (Blatt 1995 Flett et al 2014Hewitt et al 2006) Many perfectionists also struggle to par-ticipate in and to benefit from stable positive interpersonalrelationships (Sherry Mackinnon amp Gautreau 2015) Thisinability to partake in harmonious relationships may leaveperfectionists at risk for suicidality (see Hewitt et al 2006)Similarly the stress-diathesis model of perfectionism (Hewittamp Flett 2002) asserts ego-involving stressors place perfec-tionists at risk for suicide Flamenbaum and Holden (2007)for instance found perfectionists are prone to psychache(ie profound psychological pain) if they perceive unfilledneeds in areas of achievement and affiliation All toldresearch suggests an important relationship between perfec-tionism and suicide Yet this literature has not been meta-analyzed
Hewitt and colleaguesrsquo (2006) OrsquoConnorrsquos (2007) andFlett and colleaguesrsquo (2014) nonempirical reviews capablysummarized the perfectionismndashsuicide literature and con-cluded perfectionistic concerns were related to suicidalityHowever due to notable inconsistencies between studies infindings none of these authors reached concrete conclusionsregarding perfectionistic strivingsrsquo link with suicidalityIndeed some studies report perfectionistic strivings are nega-tively related to suicidality (eg Stoeber amp Otto 2006)some studies report perfectionistic strivings are unrelated tosuicidality (eg Hewitt Norton Flett Callander amp Cowan1998) and other studies report perfectionistic strivings arepositively related to suicidality (eg Flamenbaum amp Holden2007) Likewise OrsquoConnor (2007 p 709) concludedldquoThere are insufficient studies to draw any firm conclusionabout [other-oriented perfectionism]rdquo Other-oriented perfec-tionism was altogether absent from reviews by Hewitt et al(2006) and Flett et al (2014) Additionally as with perfec-tionistic strivings inconsistent findings between studies haverendered our understanding of other-oriented perfectionismrsquosrelationship with suicidality equivocal Some investigatorsreport other-oriented perfectionism is negatively related tosuicidality (Hunter amp OrsquoConnor 2003) some investigatorsreport other-oriented perfectionism is unrelated to suicidality(Hewitt Caelian Chen amp Flett 2014) and other investiga-tors report other-oriented perfectionism is positively relatedto suicidality in Asian but not Caucasian samples (ChenHewitt amp Flett 2017) Nonetheless as of 2017 there are 12
524 | SMITH ET AL
TABLE1
Characteristicsof
studiesincluded
inthemeta-analysis
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Adkins(1994)
129
university
aNR
NR
101
dissertatio
ncross-sectional
FMPS
-total
ASIQ
mdash
Adkinsamp
Parker
(1996)
129
university
a218
650
110
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
AAHS-ST
eattemptsf
Becket
al(1993)
908
psychiatricb
364
550
NR
article
cross-sectional
DAS-P
SSI
attemptsf
Beevers
ampMiller
(200
4)tim
e1
121
psychiatricb
380
744
66
article
long
itudinal
DAS-P
MSS
Imdash
Beevers
ampMiller
(200
4)tim
e2
100
psychiatricb
380
744
66
article
long
itudinal
DAS-P
MSS
Imdash
Blanksteinet
al(2007)
wom
en144
university
a221
1000
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
CSI
mdash
Blanksteinet
al(2007)
men
61un
iversity
a221
00
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
CSI
mdash
Blasberget
al(2016)
371
university
a210
610
NR
article
cross-sectional
FMPS
-PS
SSI
mdash
Caelian(2005)
55psychiatricb
155
745
255
dissertatio
ncross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
attemptsf
Chang
(2002)
371
university
a235
806
70
article
cross-sectional
FMPS
-total
ASIQ
mdash
Chen(2012)
wom
en279
community
c586
1000
135
dissertatio
nlongitu
dinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
mdash
Chen(2012)
men
157
community
c586
00
135
dissertatio
nlongitu
dinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
mdash
Chenet
al(2017)
240
university
a189
638
500
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
ASIQ
mdash (Contin
ues)
SMITH ET AL | 525
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Deanamp
Range
(1996)
168
university
a219
690
280
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SBQ
mdash
Deanamp
Range
(1999)
132
psychiatricb
355
712
333
article
cross-sectional
MPS
-SOP
MPS
-SPP
SSI
mdash
Deanet
al(1996)
114
university
a244
842
281
article
cross-sectional
MPS
-SPP
SSI
mdash
Enn
set
al(2001)
96medicald
251
417
NR
article
long
itudinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
SIQ
mdash
Fedorowiczet
al(20
07)
940
psychiatricb
260
00
NR
article
cross-sectional
EDI
mdashattemptsg
Flam
enbaum
ampHolden(2007)
264
university
a189
758
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
BSS
-MBSS
-Pintent
hattemptsf
Foulon
etal(2007)
304
psychiatricb
223
977
NR
article
cross-sectional
EDI
mdashattemptsi
Franko
etal(2004)
246
psychiatricb
NR
1000
NR
article
cross-sectional
EDI
mdashattemptsi
Freudenstein
etal(2012)
100
psychiatricb
166
470
120
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
CSP
Sattemptsi
Ham
ilton
ampSchw
eitzer
(2000)
389
university
a227
743
NR
article
cross-sectional
FMPS
-PS
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-total
GHQ-ST
mdash
Hew
ittet
al(1992)
87psychiatricb
357
529
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
BDI-SI
mdash (Contin
ues)
526 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Hew
ittet
al(1994)
study1
91psychiatricb
355
538
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
RST
-past
RST
-future
mdash
Hew
ittet
al(1994)
study2
160
university
a217
656
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
RST
-past
RST
-future
mdash
Hew
ittet
al(1997)
wom
en33
psychiatricb
154
1000
NR
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
mdash
Hew
ittet
al(1997)
men
33psychiatricb
154
00
NR
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
mdash
Hew
ittet
al(1998)
78psychiatricb
328
538
308
article
cross-sectionali
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Hew
ittet
al(2014)
55psychiatricb
155
745
255
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
attemptsi
Hunteramp
OrsquoConnor(2003)
sample1
43psychiatricb
346
534
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Hunteramp
OrsquoConnor(2003)
sample2
44psychiatricb
346
477
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Izadi(2015)
50community
c270
740
420
dissertatio
ncross-sectional
MPS
-SPP
FMPS
-COM
FMPS
-PC
FMPS
-PE
SBQ-SI
attemptsf
Jacobs
etal(2009)
439
psychiatricb
146
540
260
article
cross-sectional
DAS-P
SIQ-JR
mdash
Jeglic
(2003)
97university
a184
732
330
dissertatio
ncross-sectional
FMPS
-total
mdashattemptsi
Jeglic
etal(2007)
study2
440
university
a185
620
400
article
cross-sectional
FMPS
-total
mdashattemptsi
(Contin
ues)
SMITH ET AL | 527
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Muyan
ampChang
(2015)
288
university
a213
590
NR
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
FSII
mdash
OrsquoConnoramp
Forgan
(2007)
255
university
a220
780
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
GHQ-ST
mdash
OrsquoConnorRC
et
al(2007)
study2
151
university
a240
722
NR
article
long
itudinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
OrsquoConnorDB
et
al(2007)
sample1
65psychiatricb
241
722
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
OrsquoConnorDB
et
al(2007)
sample2
61psychiatricb
241
722
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Pisetsky
etal(2013)
635
psychiatricb
317
NR
NR
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PS
mdashattemptsi
Portzkyet
al(2014)
1436
psychiatricb
242
954
NR
article
cross-sectional
EDI
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
mdashattemptsi
Ranieriet
al(1987)
sample1
50psychiatricb
443
560
80
article
cross-sectional
DAS-P
BSS
Iattemptsf
Ranieriet
al(1987)
sample2
25psychiatricb
417
600
NR
article
cross-sectional
DAS-P
BSS
Iattemptsf
(Contin
ues)
528 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Rasmussenet
al(2008)
sample1
17psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussenet
al(2008)
sample2
23psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussen
Elliotet
al(2012)
161
psychiatricb
337
590
NR
article
cross-sectional
MPS
-SPP
SPS-SI
mdash
Rasmussen
Slish
etal(2012)
214
university
a201
570
257
article
cross-sectional
APS
-DDSI-SS
mdash
Roxboroughet
al(2012)
152
psychiatricb
129
454
285
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
intent
hmdash
Slish(2006)
48university
a201
521
625
dissertatio
ncross-sectional
APS
-DDSI-SS
mdash
Wallack
(2007)
181
university
a198
796
260
dissertatio
ncross-sectional
APS
-DSIS
mdash
Wanget
al(2013)
466
university
a264
496
NR
article
cross-sectional
APS
-DSIS
mdash
Yam
aguchi
etal(2000)
51psychiatricb
212
961
NR
article
cross-sectional
EDI
mdashattemptsi
Note
N5totalnumberof
participantsNR5
notreportedFemale5percentage
female
Ethnic5percentage
ethnic
minority
Status
5publicationstatus
ofthestudy
FMPS
5Frostandcolleaguesrsquo
(1990)
Multid
imen-
sional
Perfectio
nism
Scale
total5
totalscore
ASIQ5
Reynoldsrsquos(1991)
AdultSu
icideIdeatio
nQuestionnaireCOM
5concernover
mistakesDAA5
doubtsaboutactio
nsPC
5parental
criticism
PE
5parental
expecta-
tionsPS
5personal
standardsORG5organizatio
nAAHS-ST
5NationalAdolescentHealth
Survey
Suicidal
Thinkingmodifiedversion(1989)DAS-P5Weissman
andBeckrsquos(1978)
Dysfunctio
nalAttitude
Scale-
Perfectio
nism
subscaleSS
I5Beck
SteerandRanierirsquos
(1988)
ScaleforSu
icidal
Ideatio
nMSS
I5MillerNormanBishop
andDow
rsquos(1986)
ModifiedScaleforSu
icidal
Ideatio
nMPS
5Hew
ittandFlettrsquos
(1991)
Multi-
dimensional
Perfectio
nism
Scale
SOP5self-orientedperfectio
nism
OOP5other-oriented
perfectio
nism
SP
P5socially
prescribed
perfectio
nism
CSI
5Blanksteinrsquos(2007)
Current
SuicideIdeatio
nScale
CAPS
5Flett
andcolleaguesrsquo
(2016)
Child-A
dolescentPerfectio
nism
Scale
SIQ5
Reynoldsrsquos(1987b)Su
icidal
Ideatio
nQuestionnaireEDI5
Garnerandcolleaguesrsquo
(1983)
EatingDisorderInventory-Perfectio
nism
subscaleBSS
5Beck
andSteerrsquos
(1993)
SuicideIdeatio
nScale
M5
motivation
P5preparation
Intent5suicidal
intentCSP
S5Pfefferrsquos
(1986)
Child
SuicidePo
tentialScale
GHQ-ST5
GoldbergandWilliamsrsquos(1988)
General
Health
Questionnaire-SuicidalThinkingsubscaleBDI-SI
5Beckrsquos(1979)
DepressionInventoryitem-9
(SuicidalIntent)RST
-past5
ratin
gof
thefrequencyof
pastsuicidal
thoughtsRST
-future5ratin
gof
thefrequencyof
future
suicidal
thoughtsSB
Q5
Linehanrsquos
(1981)
Suicidal
BehaviorQuestionnaireSI
5suicidal
ideatio
nSIQ-JR5
Reynoldsrsquos(1987a)Su
icidal
Ideatio
nQuestionnaire-G
rades7ndash9
FSII5
Chang
andChang
rsquos(2016)
Frequency
ofSu
icideIdeatio
nInventory
SPS5CullandGillrsquos
(1982)
SuicideProbability
Scale
BSS
I5Beck
KovacsandWeissmanrsquos
(1979)
ScaleforSu
icidal
Ideatio
nAPS
-D5
Slaney
andcolleaguesrsquo
(2001)
Alm
ostPerfect
Scale-Revised
Discrepancy
subscaleDSI-SS5
MetalskyandJoinerrsquos
(1997)
DepressiveSy
mptom
sInventory-Su
icidality
subscaleSIS5Ruddrsquos(1989)
Suicidal
Ideatio
nScale
a University
undergraduates
b Psychiatric
patients
c Com
munity
adults
d Medical
students
e Participants
reported
whether
they
hadever
seriouslythoughtaboutattemptingsuicide
f Self-reported
numberof
priorsuicideattempts
g Prior
numberof
suicideattemptsassessed
byaclinician
h Participants
asked
ldquoHow
likelyisitthat
youwill
attempt
suicidesomedayrdquo
i Com
paredsuicideattemptersandnon-attempters
SMITH ET AL | 529
studies examining other-oriented perfectionism and suicidal-ity (see Table 1) meaning this literature is now suitable formeta-analysis In sum though perfectionistic concernsrsquo linkwith suicidality is clear (Flett al 2014 Hewitt et al 2006OrsquoConnor 2007) perfectionistic strivingsrsquo and other-oriented perfectionismrsquos link with suicidality is unclear
15 | Advancing research on theperfectionismndashsuicidality relationship usingmeta-analysis
Over 50 years of case reports theoretical accounts andempirical research implicate perfectionism in suicide (egBlatt 1995 Hassan Flett Ganguli amp Hewitt 2014 Hewittet al 2014 Kiamanesh Dyregrov Haavind amp Dieserud2014 Shaffer 1974) And yet there is much to learn aboutthe perfectionismndashsuicidality relationship (Flett et al 2014)First noteworthy inconsistencies between studies in findings(eg Flamenbaum amp Holden 2007 Hewitt et al 19982014 Hunter amp OrsquoConnor 2003) have clouded our under-standing of perfectionistic strivingsrsquo and other-oriented per-fectionismrsquos relationships with suicidality A quantitativesynthesis is needed for overall conclusions to be reachedSuch a quantitative synthesis could also allow for tests ofmoderating variables (eg gender) that might explain whenthe strength or the direction of the perfectionismndashsuicidalityrelationship changes Second despite evidence that correla-tions do not stabilize until N 250 (Scheuroonbrodt amp Perugini2013) most research on perfectionism and suicide attemptsis underpowered (cf Flamenbaum amp Holden 2007) How-ever meta-analysis could overcome limitations of small sam-ples (Borenstein Hedges Higgins amp Rothstein 2009) andbring greater clarity to our understanding of perfectionismrsquosrelationship with suicide attempts Third as noted by Flettet al (2014) and OrsquoConnor (2007) the extent to which per-fectionism dimensions confer risk for suicide has yet to bedetermined Indeed most investigators use cross-sectionaldesigns which unlike longitudinal designs cannot addresstemporal precedence As such whether perfectionism leadsto increases in suicidality is unclear and researchers andclinicians can only speculate as to whether reducing perfec-tionism reduces suicidality Nevertheless there is now suffi-cient data to test whether self-oriented other-oriented andsocially prescribed perfectionism predict follow-up suicideideation beyond baseline suicide ideation (Chen 2012Enns Cox Sareen amp Freeman 2001 R C OrsquoConnorWhyte et al 2007) Fourth due to limitations of nonempiri-cal reviews the strength of the relation between perfection-ism dimensions suicide ideation and suicide attempts isunclear A meta-analysis could shed light on which perfec-tionism dimensions display the strongest relations with sui-cide ideation and suicide attempts which in time might
inform the development of interventions designed to targetand to modify perfectionismrsquos most pernicious aspects
16 | Objectives and hypothesis
Our primary aim was to bring greater clarity to our under-standing of the perfectionismndashsuicidality relationship bycomprehensively synthesizing empirical research on perfec-tionism suicide ideation and suicide attempts To date thereis no meta-analysis of findings from this long-standing andimportant literature We also aimed to test the contentiouslydebated relation between perfectionistic strivings suicideideation and suicide attempts Such evidence would informdebate on the pros and cons of demanding perfection of one-self (eg Stoeber amp Otto 2006 Sherry Hewitt SherryFlett amp Graham 2010) Another aim was to test whetherself-oriented other-oriented and socially prescribed perfec-tionism predicted longitudinal increases in suicide ideationover time Controlling for baseline suicide ideation repre-sents a stringent test of the perfectionismndashsuicidality relation-ship as baseline suicide ideation is a strong predictor ofsubsequent suicide ideation (eg Joiner et al 2005)
Building on theory and research (Flett et al 2014Hewitt et al 2006 OrsquoConnor 2007) we hypothesized per-fectionistic concerns (socially prescribed perfectionism con-cern over mistakes doubts about action discrepancy andperfectionistic attitudes) would display positive relationshipswith suicide ideation and attempts We also hypothesizedsocially prescribed perfectionism would place people at riskfor longitudinal increases in suicide ideation However giventhe inconsistency of research on suicidality in relation to per-fectionistic strivings (self-oriented perfectionism personalstandards) other forms of perfectionism (other-oriented per-fectionism EDI-perfectionism total scores FMPS-perfectionism total scores) and correlates of perfectionism(parental criticism parental expectations organization) weconsidered our investigation into these questions to be moreexploratory
2 | METHOD
21 | Selection of studies
In 2016 a literature search using PsycINFO Medline Webof Science ERIC and ProQuest Dissertations and Theseswas conducted using the keywords and Boolean search termsldquoperfectrdquo and ldquosuicidrdquo This search yielded 100 studiesfrom PsycINFO 122 studies from Medline 226 studies fromWeb of Science and 38 studies from ProQuest We alsocompiled a list of 353 authors who had published on perfec-tionism We then contacted each author individually andrequested unpublished findings However none of the
530 | SMITH ET AL
authors contacted provided relevant data Additionally wemonitored the Perfectionism Network Mailing List to iden-tify studies that were accepted but not published at the timeof our literature search This yielded one study Chen et al(2017) Both the first and the third author then reviewedabstracts of all studies identified selecting studies meetinginclusion criteria Studies were included that (a) containeddata on perfectionism and suicidality (ideation and attempts)and (b) were in English Included studies also (c) reported aneffect size or enough information for computing an effectsize or effect size information was obtained from a studyauthor All authors contacted (N5 1) provided the requestedinformation
This literature search yielded 57 studies for inclusionInter-rater agreement on inclusion or exclusion in the meta-analysis was 95 Disagreement was resolved by revisitingarticles and coming to a consensus The reference lists ofincluded articles were also examined to locate additional rel-evant literature On August 7 2016 we terminated all searchstrategies and started data reduction and analysis Weexcluded 12 studies (see Supplemental Material A) The finalsample of included studies was composed of 45 studies with54 samples
22 | Coding of studies
The first and the third author coded each study based on ninecharacteristics sample size sample type mean age of partici-pants percentage of female participants percentage of ethnicminority participants publication status measure used toassess perfectionism measure used to assess suicide ideationand measure used to assess suicide attempts
23 | Meta-analytic procedures
Random effects analyses were conducted using Comprehen-sive Meta-Analysis software (Borenstein et al 2005) Wechose random effects models over fixed effects models asthe 45 included studies varied widely in design We alsoweighed mean effects following the procedure suggested byHunter and Schmidt (1990) This allowed us to estimatemean effect sizes and variance in observed scores after con-sidering sampling error (Card 2012) Next effect size esti-mates were weighted by sample size and aggregated Forstudies with more than one measure of suicide ideation weaveraged effect sizes so only one effect was included (Boren-stein et al 2009 Card 2012) Effect sizes presented in met-rics other than r (ie means t-tests d or F scores) wereconverted and expressed as correlations following formulasprovided by Borenstein et al (2009) We also used Boren-stein and colleaguesrsquo (2009) formula to calculate powerunder the random effects model for each weighted mean
effect Additionally most included studies measured perfec-tionism and suicide ideation with imperfect reliability Asthis can attenuate the magnitude of observed correlationseffects were adjusted by dividing the observed correlation bythe square root of the product of the two corresponding reli-ability coefficients (Card 2012) When reported the actualreliability statistics for a study were used when not reportedthe corresponding meta-analyzed mean reliability was used(Card 2012) However we were unable to adjust for unreli-ability in suicide attempts Thus in the interest of methodo-logical consistency we used the common albeitconservative strategy of interpreting observed effects whichgenerally underestimates the true magnitude of effect sizes(Borenstein et al 2009) Nonetheless for readers who dis-agree with this strategy effect sizes adjusted for unreliabilityare presented in our supplementary material
To examine the extent to which baseline self-orientedother-oriented and socially prescribed perfectionism predictfollow-up suicide ideation after controlling for baseline idea-tion we computed partial correlations using the ldquocorpcorrdquopackage (Schafer Opgen-Rhein Zuber Silvia amp Strimmer2015) for R (R Core Team 2013) Although there was insuf-ficient data to examine unique effects between perfectionismdimensions and suicide attempts there was sufficient data toexamine unique effects between perfectionism dimensionsand suicide ideation Thus again using the ldquocorpcorrdquo pack-age (Schafer et al 2015) we computed partial correlationsfor MPS-perfectionism dimensions by residualizing self-oriented other-oriented and socially prescribed perfection-ism based on their overlap with each other prior to being cor-related with suicide ideation Likewise for FMPS-perfectionism dimensions we computed partial correlationsby residualizing concern over mistakes doubts about actionparental criticism parental expectations personal standardsand organization based on their overlap with each other priorto being correlated with suicide ideation
To assess moderation we evaluated the total heterogene-ity of weighted mean effect sizes (QT) A significant QT indi-cates variance in weighted mean effect sizes is greater thanexpected by sampling error (Card 2012) a nonsignificantQT suggests a weak basis for moderation For each analysiswe also computed the inconsistency in observed effects (I2)across studies I2 indicates the percentage of total varianceacross studies due to heterogeneity Values of 25 50and 75 correspond to low medium and high heterogene-ity respectively
When QT was significant we stipulated a categoricalstructure and the total heterogeneity explained by the catego-rization (QB) was calculated (Card 2012) A significant QB
indicates meaningful differences in effects between catego-ries and provides a firm basis for moderation (Borensteinet al 2009) When QB was significant we examined
SMITH ET AL | 531
differences in effect sizes between studies grouped by publi-cation status (articles and dissertations) age (adult youngadult adolescent) and sample (community adults under-graduate students psychiatric patients) by performing aseries of all possible two-group comparisons to test whichgroup differed significantly in effect size (Card 2012) Foreach group comparison the resultant QB from the twogroups was tested using a v2 test with one degree of freedomWe also recorded gender (percentage female) and ethnicity(percentage ethnic minority) as continuous variables andused mixed effects meta-regression to test the potential mod-erating effects of gender and ethnicity
To assess publication bias we inspected funnel plotswith observed and imputed studies and computed Eggerrsquostest of regression to the intercept (Egger Smith Schneideramp Minder 1997) Such funnel plots allow for visual inspec-tion of how the effect size shifts when imputed studies areincluded (Borenstein et al 2009) In the absence of publica-tion bias Eggerrsquos regression intercept does not differ signifi-cantly from zero (Egger et al 1997)
24 | Description of studies
Our search identified 45 studies and 54 samples containingrelevant effect size data (see Table 1) The total number ofparticipants pooled across studies was 11747 Relevant datawere obtained from 38 journal articles and seven disserta-tions There were 21 samples of university undergraduates29 samples of psychiatric patients one sample of medicalstudents and three samples of community adults There were48 cross-sectional samples and six longitudinal samplesSample size varied between 17 and 1436 with an averageof 2175 (SD5 2598) The mean age of participants was268 years (SD5 102 range5 129ndash586) The average per-centage of female participants was 633 the average per-centage of ethnic minority participants was 244 Effectsize information for each individual study is presented inSupplemental Material B Adjusted effect size informationfor each individual study is presented in Supplemental Mate-rial C
25 | Measures
251 | Perfectionism
Following theory and research (eg Dunkley et al 2004Stoeber amp Otto 2006) personal standards (FMPS) and self-oriented perfectionism (MPS Child-Adolescent Perfection-ism Scale [CAPS] Flett et al 2016) were considered facetsof perfectionistic strivings concern over mistakes (FMPS)doubts about actions (FMPS) socially prescribed perfection-ism (MPS CAPS) discrepancy (APS-R) and perfectionistic
attitudes (Dysfunctional Attitude Scale-Perfectionism sub-scale [DAS-P] Weissman amp Beck 1978) were consideredfacets of perfectionistic concerns Parental criticism parentalexpectations and organization were designated correlates ofperfectionism As well parental criticism and parentalexpectations were combined and labeled as parental percep-tions (see Cox et al 2002) Other-oriented perfectionism(MPS) FMPS-perfectionism and EDI-perfectionism weredesignated other forms of perfectionism
252 | Suicide ideation and suicide attempts
Suicide ideations were assessed via self-reported suicidalthinking Suicide attempts were assessed via self-reportednumber of prior suicide attempts (eg Adkins amp Parker1996) clinicianrsquos ratings of the number of prior suicideattempts (eg Fedorowicz et al 2007) and group compari-sons between suicide attempters and non-attempters (egHewitt et al 2014) Although Pfefferrsquos (1986) Child SuicidePotential Scale (CSPS) and Linehanrsquos (1981) Suicide Behav-ior Questionnaire (SBQ) assess suicidal ideation and suicideattempts we categorized the CPS and SBQ as measures ofsuicide ideation given the majority of CSPS and SBQ itemsassess suicidal thoughts
3 | RESULTS
31 | Overall effect sizes
Weighted mean effect sizes between perfectionism corre-lates of perfectionism and suicide ideation and suicideattempts are in Table 2 (see Supplemental Material D foradjusted effect sizes) Following Cohenrsquos (1992) guidelinesfor small medium and large effects (r5 10 30 and 50respectively) perfectionistic concerns socially prescribedperfectionism concern over mistakes doubts about actionsdiscrepancy perfectionistic attitudes perfectionistic striv-ings self-oriented perfectionism personal standards parentalperceptions parental criticism parental expectations andFMPS-perfectionism displayed small-to-moderate positiverelationships with suicide ideation Other-oriented perfection-ismrsquos and organizationrsquos relationships with suicide ideationwere nonsignificant Perfectionistic concerns socially pre-scribed perfectionism concern over mistakes doubts aboutaction FMPS-perfectionism parental perceptions parentalcriticism and parental expectations displayed small positiverelationships with suicide attempts perfectionistic attitudesrsquoperfectionistic strivingsrsquo self-oriented perfectionismrsquos perso-nal standardsrsquo other-oriented perfectionismrsquos EDI-perfectionismrsquos and organizationrsquos relationships with suicideattempts were nonsignificant
532 | SMITH ET AL
TABLE2
Summaryof
overalleffect
sizesfortherelatio
nshipbetweenperfectio
nism
andsuicidality
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Suicideideatio
n
Perfectio
nistic
concerns
a42
7936
28
[24
32]
9910
5863
175
[076
273]
028[2
431]
99
Socially
prescribed
perfectio
nism
303640
28
[25
32]
3704
2171
035
[2100169]
028[2
532]
99
Concern
over
mistakes
5952
25
[13
36]
1219
6720
251
[2436938]
025[1
336]
98
Doubtsaboutactio
ns4
902
27
[18
35]
514
4162
294
[25671158
220[1
130]
99
Discrepancy
4904
26
[14
38]
917
6727
338
[24791154]
124[1
235]
98
Perfectio
nistic
attitudes
51533
37
[19
52]
3355
8808
407
[2033848]
226[0
941]
98
Perfectio
nistic
strivingsb
314588
10
[07
13]
3214
665
018
[2094130]
010[0
713]
99
Self-orientedperfectio
nism
273315
11
[08
15]
2096
000
ndash046
[2156064]
011[0
815]
99
Personal
standards
51273
10
[00
19]
1033
6127
334
[24711139]
010[0
019]
52
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
202755
01
[204
06]
3287
4219
027
[2178230]
101[2
04
06]
08
FMPS
totalscore
41018
31
[15
45]
1971
8477
472
[21692
2636]
127[1
240]
96
EDI-perfectio
nism
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdash
Correlatesof
perfectio
nism
Parental
perceptio
nsc
51904
19
[10
27]
1279
6871
204
[2558966]
019[1
027]
98
Parental
criticism
5952
20
[11
29]
798
4987
092
[2556740]
020[1
029]
98
Parental
expectations
5952
16
[06
26]
842
5247
196
[2391784]
113[0
323]
88
Organization
3513
ndash02
[220
17]
792
7475
253
[27738
8243]
0ndash02
[220
17]
05
Suicideattempts
Perfectio
nistic
concerns
d15
5275
12
[07
17]
2448
4281
115
[021
208]
508[0
314]
99
Socially
prescribed
perfectio
nism
8689
19
[08
29]
1257
4432
021
[2365407]
019[0
829]
93
Concern
over
mistakes
51827
09
[04
14]
012
000
008
[2035052]
109[0
413]
97
Doubtsaboutactio
n3
1777
06
[01
11]
276
000
100
[2201401]
205[2
02
11]
71
Discrepancy
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdashPerfectio
nistic
attitudes
3983
09
[203
22]
254
2126
142
[2155440]
205[2
07
17]
32
(Contin
ues)
SMITH ET AL | 533
TABLE2
(Contin
ued)
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Perfectio
nistic
strivingsa
101436
02
[202
06]
525
000
ndash010
[2110087]
002[2
01
06]
19
Self-orientedperfectio
nism
6539
07
[201
16]
304
000
ndash161
[2320ndash0
02]
007[2
01
15]
37
Personal
standards
41777
01
[204
06]
060
000
ndash049
[2182083]
001[2
04
05]
06
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
4429
ndash03
[213
06]
126
000
ndash142
[2258ndash0
28]
0ndash03
[213
06]
11
FMPS
totalscore
3666
14
[07
21]
130
000
ndash031
[2055ndash0
07]
016[0
823]
99
EDI-perfectio
nism
52975
03
[201
06]
183
000
106
[2098273]
103[2
01
06]
33
Correlatesof
perfectio
nism
Parental
perceptio
nsc
33230
07
[04
11]
053
000
045
[2643733]
007[0
411]
98
Parental
criticism
31615
08
[03
12]
065
000
063
[2523650]
207[0
211]
85
Parental
expectations
31615
07
[02
12]
010
000
001
[2386387]
007[0
211]
79
Organization
21565
ndash01
[206
04]
082
000
mdashmdash
mdashmdash
mdash
Note
k5numberof
studiesN5totalnumberof
participantsin
theksamplesr1
5weightedmeanbivariatecorrelation
CI5
confidence
intervalQT5measure
ofheterogeneity
ofeffect
sizesI25percentage
ofheteroge-
neity
kT
F5numberof
imputedstudiesas
partof
ldquotrim
andfillrdquo
method
FMPS
5Frostrsquos
andcolleaguesrsquo
(1990)
Multid
imensional
Perfectio
nism
Scale
EDI-perfectio
nism
5Garnerandcolleaguesrsquo
(1983)
EatingDisorder
Inventory-Perfectio
nism
subscale
a Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesdoubtsaboutactio
nsanddiscrepancy
b Perfectionistic
strivingsassessed
asaggregateof
self-orientedperfectio
nism
andpersonal
standards
c Parentalperceptio
nsassessed
asaggregateof
parental
criticism
andparental
expectations
(Cox
etal2002)
d Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesanddoubtsaboutactio
ns
plt05
plt01
p
lt001
534 | SMITH ET AL
Weighted mean effect sizes for the relationships betweenself-oriented other-oriented and socially prescribed perfec-tionism at baseline and suicide ideation at follow-up whilecontrolling for ideation at baseline are in SupplementalMaterial E (see Supplemental Material F for adjusted longi-tudinal effect sizes) Despite the large positive relationshipbetween baseline and follow-up suicide ideation sociallyprescribed perfectionism still displayed a small positive rela-tionship with follow-up suicide ideation after controlling forbaseline suicide ideation Self-oriented and other-orientedperfectionismrsquos relationships with follow-up suicide ideationafter controlling for baseline ideation were nonsignificant
MPS-perfectionism dimensions displayed small-to-largepositive correlations with each other (see SupplementalMaterial G for observed effects and Supplemental MaterialH for adjusted effects) After controlling for overlap in MPSdimensions self-oriented perfectionism ceased to signifi-cantly predict suicide ideation other-oriented perfectionismhad a small unique negative association with suicide idea-tion and socially prescribed perfectionism had a smallunique positive relationship with suicide ideation FMPS-perfectionism dimensions had marginal-to-large correlationswith each other (see Supplemental Material G for observedeffects and Supplemental Material H for adjusted effects)After controlling for overlap in FMPS dimensions the rela-tionships among suicide ideation and concern over mistakespersonal standards parental expectations and organizationwere nonsignificant However after controlling for overlapamong FMPS dimensions doubts about actions and parentalcriticism displayed small unique positive relationships withideation (see Supplemental Material G for observed effectsand Supplemental Material H for adjusted effects)
The test of the total heterogeneity of variance of weightedmean effect sizes (QT) was significant for suicide ideationrsquosrelations with perfectionistic concerns concern over mistakesdiscrepancy personal standards perfectionistic attitudesother-oriented perfectionism FMPS-perfectionism and orga-nization (see Table 2) QT was also significant for the linkbetween suicide attempts and perfectionistic concerns (seeTable 2) The percentage of total variance owing to heteroge-neity (I2) ranged from small to large suggesting possiblemoderators
32 | Moderator analyses
Moderator analyses (see Supplemental Material I) testedwhether effect sizes with significant heterogeneity (QT) weremoderated by publication status (peer-reviewed articles dis-sertations) age (adolescent samples 13 and 17 yearsyoung adult samples 18 and 25 years adultsamples 25 years) sample (university undergraduatescommunity adults psychiatric patients) or perfectionism
measure Perfectionistic concernsrsquo relationship with suicideattempts was nonsignificant for the CAPS but significant forthe FMPS and the MPS Meta-regression also revealed thestrength of the relationship between perfectionistic concernsand suicide attempts decreased as the proportion of femalesin a sample increased However we advise caution in inter-preting our moderator analyses given the small number ofstudies per subgroup
33 | Publication bias
Funnel plots (see Supplemental Material J) and Eggerrsquosregression intercept (see Table 2) provided mixed evidencefor publication bias Eggerrsquos regression intercept was signifi-cant for perfectionistic concernsrsquo relationship with suicideideation and suicide attempts Moreover the funnel plot forperfectionistic concerns and suicide attempts was asymmetri-cal Accordingly for perfectionistic concernsrsquo relationshipwith suicide ideation and suicide attempts trim and fill esti-mates may provide more accurate estimates Nonethelessafter imputing missing studies the adjusted point estimatesfor perfectionistic concernsrsquo relationships with suicide idea-tion and suicide attempts provided the same substantiveimplications (see Table 2)
4 | DISCUSSION
Suicide claims one life every 45 seconds (World HealthOrganization 2012) Given the wide-reaching personal andsocietal costs of suicide it is vital to identify contributingfactors One such factor supported by over 50 years of casehistories theoretical accounts and empirical research is per-fectionism (Blatt 1995 Hassan et al 2014 Hewitt et al2014 Kiamanesh et al 2014 Shaffer 1974) Yet despitethe abundance of research the role of perfectionism in sui-cide remains underappreciated under-recognized and mis-understood due to inconsistencies between studies infindings underpowered studies and uncertainty surroundingwhether perfectionism dimensions predict longitudinalincreases in suicidality We aimed to rectify this by rigor-ously conducting the first meta-analytic review of the perfec-tionismndashsuicidality relationship
41 | An improved understanding of theperfectionismndashsuicidality relationship
Our meta-analysis of 45 studies 54 samples and 11747 par-ticipants represents the most comprehensive test of the per-fectionismndashsuicidality link to date All dimensions orcorrelates of perfectionism (except for other-oriented perfec-tionism and organization) were positively related to suicideideation and these effect sizes were generally consistent
SMITH ET AL | 535
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
TABLE1
Characteristicsof
studiesincluded
inthemeta-analysis
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Adkins(1994)
129
university
aNR
NR
101
dissertatio
ncross-sectional
FMPS
-total
ASIQ
mdash
Adkinsamp
Parker
(1996)
129
university
a218
650
110
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
AAHS-ST
eattemptsf
Becket
al(1993)
908
psychiatricb
364
550
NR
article
cross-sectional
DAS-P
SSI
attemptsf
Beevers
ampMiller
(200
4)tim
e1
121
psychiatricb
380
744
66
article
long
itudinal
DAS-P
MSS
Imdash
Beevers
ampMiller
(200
4)tim
e2
100
psychiatricb
380
744
66
article
long
itudinal
DAS-P
MSS
Imdash
Blanksteinet
al(2007)
wom
en144
university
a221
1000
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
CSI
mdash
Blanksteinet
al(2007)
men
61un
iversity
a221
00
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
CSI
mdash
Blasberget
al(2016)
371
university
a210
610
NR
article
cross-sectional
FMPS
-PS
SSI
mdash
Caelian(2005)
55psychiatricb
155
745
255
dissertatio
ncross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
attemptsf
Chang
(2002)
371
university
a235
806
70
article
cross-sectional
FMPS
-total
ASIQ
mdash
Chen(2012)
wom
en279
community
c586
1000
135
dissertatio
nlongitu
dinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
mdash
Chen(2012)
men
157
community
c586
00
135
dissertatio
nlongitu
dinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
mdash
Chenet
al(2017)
240
university
a189
638
500
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
ASIQ
mdash (Contin
ues)
SMITH ET AL | 525
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Deanamp
Range
(1996)
168
university
a219
690
280
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SBQ
mdash
Deanamp
Range
(1999)
132
psychiatricb
355
712
333
article
cross-sectional
MPS
-SOP
MPS
-SPP
SSI
mdash
Deanet
al(1996)
114
university
a244
842
281
article
cross-sectional
MPS
-SPP
SSI
mdash
Enn
set
al(2001)
96medicald
251
417
NR
article
long
itudinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
SIQ
mdash
Fedorowiczet
al(20
07)
940
psychiatricb
260
00
NR
article
cross-sectional
EDI
mdashattemptsg
Flam
enbaum
ampHolden(2007)
264
university
a189
758
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
BSS
-MBSS
-Pintent
hattemptsf
Foulon
etal(2007)
304
psychiatricb
223
977
NR
article
cross-sectional
EDI
mdashattemptsi
Franko
etal(2004)
246
psychiatricb
NR
1000
NR
article
cross-sectional
EDI
mdashattemptsi
Freudenstein
etal(2012)
100
psychiatricb
166
470
120
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
CSP
Sattemptsi
Ham
ilton
ampSchw
eitzer
(2000)
389
university
a227
743
NR
article
cross-sectional
FMPS
-PS
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-total
GHQ-ST
mdash
Hew
ittet
al(1992)
87psychiatricb
357
529
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
BDI-SI
mdash (Contin
ues)
526 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Hew
ittet
al(1994)
study1
91psychiatricb
355
538
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
RST
-past
RST
-future
mdash
Hew
ittet
al(1994)
study2
160
university
a217
656
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
RST
-past
RST
-future
mdash
Hew
ittet
al(1997)
wom
en33
psychiatricb
154
1000
NR
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
mdash
Hew
ittet
al(1997)
men
33psychiatricb
154
00
NR
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
mdash
Hew
ittet
al(1998)
78psychiatricb
328
538
308
article
cross-sectionali
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Hew
ittet
al(2014)
55psychiatricb
155
745
255
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
attemptsi
Hunteramp
OrsquoConnor(2003)
sample1
43psychiatricb
346
534
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Hunteramp
OrsquoConnor(2003)
sample2
44psychiatricb
346
477
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Izadi(2015)
50community
c270
740
420
dissertatio
ncross-sectional
MPS
-SPP
FMPS
-COM
FMPS
-PC
FMPS
-PE
SBQ-SI
attemptsf
Jacobs
etal(2009)
439
psychiatricb
146
540
260
article
cross-sectional
DAS-P
SIQ-JR
mdash
Jeglic
(2003)
97university
a184
732
330
dissertatio
ncross-sectional
FMPS
-total
mdashattemptsi
Jeglic
etal(2007)
study2
440
university
a185
620
400
article
cross-sectional
FMPS
-total
mdashattemptsi
(Contin
ues)
SMITH ET AL | 527
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Muyan
ampChang
(2015)
288
university
a213
590
NR
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
FSII
mdash
OrsquoConnoramp
Forgan
(2007)
255
university
a220
780
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
GHQ-ST
mdash
OrsquoConnorRC
et
al(2007)
study2
151
university
a240
722
NR
article
long
itudinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
OrsquoConnorDB
et
al(2007)
sample1
65psychiatricb
241
722
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
OrsquoConnorDB
et
al(2007)
sample2
61psychiatricb
241
722
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Pisetsky
etal(2013)
635
psychiatricb
317
NR
NR
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PS
mdashattemptsi
Portzkyet
al(2014)
1436
psychiatricb
242
954
NR
article
cross-sectional
EDI
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
mdashattemptsi
Ranieriet
al(1987)
sample1
50psychiatricb
443
560
80
article
cross-sectional
DAS-P
BSS
Iattemptsf
Ranieriet
al(1987)
sample2
25psychiatricb
417
600
NR
article
cross-sectional
DAS-P
BSS
Iattemptsf
(Contin
ues)
528 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Rasmussenet
al(2008)
sample1
17psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussenet
al(2008)
sample2
23psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussen
Elliotet
al(2012)
161
psychiatricb
337
590
NR
article
cross-sectional
MPS
-SPP
SPS-SI
mdash
Rasmussen
Slish
etal(2012)
214
university
a201
570
257
article
cross-sectional
APS
-DDSI-SS
mdash
Roxboroughet
al(2012)
152
psychiatricb
129
454
285
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
intent
hmdash
Slish(2006)
48university
a201
521
625
dissertatio
ncross-sectional
APS
-DDSI-SS
mdash
Wallack
(2007)
181
university
a198
796
260
dissertatio
ncross-sectional
APS
-DSIS
mdash
Wanget
al(2013)
466
university
a264
496
NR
article
cross-sectional
APS
-DSIS
mdash
Yam
aguchi
etal(2000)
51psychiatricb
212
961
NR
article
cross-sectional
EDI
mdashattemptsi
Note
N5totalnumberof
participantsNR5
notreportedFemale5percentage
female
Ethnic5percentage
ethnic
minority
Status
5publicationstatus
ofthestudy
FMPS
5Frostandcolleaguesrsquo
(1990)
Multid
imen-
sional
Perfectio
nism
Scale
total5
totalscore
ASIQ5
Reynoldsrsquos(1991)
AdultSu
icideIdeatio
nQuestionnaireCOM
5concernover
mistakesDAA5
doubtsaboutactio
nsPC
5parental
criticism
PE
5parental
expecta-
tionsPS
5personal
standardsORG5organizatio
nAAHS-ST
5NationalAdolescentHealth
Survey
Suicidal
Thinkingmodifiedversion(1989)DAS-P5Weissman
andBeckrsquos(1978)
Dysfunctio
nalAttitude
Scale-
Perfectio
nism
subscaleSS
I5Beck
SteerandRanierirsquos
(1988)
ScaleforSu
icidal
Ideatio
nMSS
I5MillerNormanBishop
andDow
rsquos(1986)
ModifiedScaleforSu
icidal
Ideatio
nMPS
5Hew
ittandFlettrsquos
(1991)
Multi-
dimensional
Perfectio
nism
Scale
SOP5self-orientedperfectio
nism
OOP5other-oriented
perfectio
nism
SP
P5socially
prescribed
perfectio
nism
CSI
5Blanksteinrsquos(2007)
Current
SuicideIdeatio
nScale
CAPS
5Flett
andcolleaguesrsquo
(2016)
Child-A
dolescentPerfectio
nism
Scale
SIQ5
Reynoldsrsquos(1987b)Su
icidal
Ideatio
nQuestionnaireEDI5
Garnerandcolleaguesrsquo
(1983)
EatingDisorderInventory-Perfectio
nism
subscaleBSS
5Beck
andSteerrsquos
(1993)
SuicideIdeatio
nScale
M5
motivation
P5preparation
Intent5suicidal
intentCSP
S5Pfefferrsquos
(1986)
Child
SuicidePo
tentialScale
GHQ-ST5
GoldbergandWilliamsrsquos(1988)
General
Health
Questionnaire-SuicidalThinkingsubscaleBDI-SI
5Beckrsquos(1979)
DepressionInventoryitem-9
(SuicidalIntent)RST
-past5
ratin
gof
thefrequencyof
pastsuicidal
thoughtsRST
-future5ratin
gof
thefrequencyof
future
suicidal
thoughtsSB
Q5
Linehanrsquos
(1981)
Suicidal
BehaviorQuestionnaireSI
5suicidal
ideatio
nSIQ-JR5
Reynoldsrsquos(1987a)Su
icidal
Ideatio
nQuestionnaire-G
rades7ndash9
FSII5
Chang
andChang
rsquos(2016)
Frequency
ofSu
icideIdeatio
nInventory
SPS5CullandGillrsquos
(1982)
SuicideProbability
Scale
BSS
I5Beck
KovacsandWeissmanrsquos
(1979)
ScaleforSu
icidal
Ideatio
nAPS
-D5
Slaney
andcolleaguesrsquo
(2001)
Alm
ostPerfect
Scale-Revised
Discrepancy
subscaleDSI-SS5
MetalskyandJoinerrsquos
(1997)
DepressiveSy
mptom
sInventory-Su
icidality
subscaleSIS5Ruddrsquos(1989)
Suicidal
Ideatio
nScale
a University
undergraduates
b Psychiatric
patients
c Com
munity
adults
d Medical
students
e Participants
reported
whether
they
hadever
seriouslythoughtaboutattemptingsuicide
f Self-reported
numberof
priorsuicideattempts
g Prior
numberof
suicideattemptsassessed
byaclinician
h Participants
asked
ldquoHow
likelyisitthat
youwill
attempt
suicidesomedayrdquo
i Com
paredsuicideattemptersandnon-attempters
SMITH ET AL | 529
studies examining other-oriented perfectionism and suicidal-ity (see Table 1) meaning this literature is now suitable formeta-analysis In sum though perfectionistic concernsrsquo linkwith suicidality is clear (Flett al 2014 Hewitt et al 2006OrsquoConnor 2007) perfectionistic strivingsrsquo and other-oriented perfectionismrsquos link with suicidality is unclear
15 | Advancing research on theperfectionismndashsuicidality relationship usingmeta-analysis
Over 50 years of case reports theoretical accounts andempirical research implicate perfectionism in suicide (egBlatt 1995 Hassan Flett Ganguli amp Hewitt 2014 Hewittet al 2014 Kiamanesh Dyregrov Haavind amp Dieserud2014 Shaffer 1974) And yet there is much to learn aboutthe perfectionismndashsuicidality relationship (Flett et al 2014)First noteworthy inconsistencies between studies in findings(eg Flamenbaum amp Holden 2007 Hewitt et al 19982014 Hunter amp OrsquoConnor 2003) have clouded our under-standing of perfectionistic strivingsrsquo and other-oriented per-fectionismrsquos relationships with suicidality A quantitativesynthesis is needed for overall conclusions to be reachedSuch a quantitative synthesis could also allow for tests ofmoderating variables (eg gender) that might explain whenthe strength or the direction of the perfectionismndashsuicidalityrelationship changes Second despite evidence that correla-tions do not stabilize until N 250 (Scheuroonbrodt amp Perugini2013) most research on perfectionism and suicide attemptsis underpowered (cf Flamenbaum amp Holden 2007) How-ever meta-analysis could overcome limitations of small sam-ples (Borenstein Hedges Higgins amp Rothstein 2009) andbring greater clarity to our understanding of perfectionismrsquosrelationship with suicide attempts Third as noted by Flettet al (2014) and OrsquoConnor (2007) the extent to which per-fectionism dimensions confer risk for suicide has yet to bedetermined Indeed most investigators use cross-sectionaldesigns which unlike longitudinal designs cannot addresstemporal precedence As such whether perfectionism leadsto increases in suicidality is unclear and researchers andclinicians can only speculate as to whether reducing perfec-tionism reduces suicidality Nevertheless there is now suffi-cient data to test whether self-oriented other-oriented andsocially prescribed perfectionism predict follow-up suicideideation beyond baseline suicide ideation (Chen 2012Enns Cox Sareen amp Freeman 2001 R C OrsquoConnorWhyte et al 2007) Fourth due to limitations of nonempiri-cal reviews the strength of the relation between perfection-ism dimensions suicide ideation and suicide attempts isunclear A meta-analysis could shed light on which perfec-tionism dimensions display the strongest relations with sui-cide ideation and suicide attempts which in time might
inform the development of interventions designed to targetand to modify perfectionismrsquos most pernicious aspects
16 | Objectives and hypothesis
Our primary aim was to bring greater clarity to our under-standing of the perfectionismndashsuicidality relationship bycomprehensively synthesizing empirical research on perfec-tionism suicide ideation and suicide attempts To date thereis no meta-analysis of findings from this long-standing andimportant literature We also aimed to test the contentiouslydebated relation between perfectionistic strivings suicideideation and suicide attempts Such evidence would informdebate on the pros and cons of demanding perfection of one-self (eg Stoeber amp Otto 2006 Sherry Hewitt SherryFlett amp Graham 2010) Another aim was to test whetherself-oriented other-oriented and socially prescribed perfec-tionism predicted longitudinal increases in suicide ideationover time Controlling for baseline suicide ideation repre-sents a stringent test of the perfectionismndashsuicidality relation-ship as baseline suicide ideation is a strong predictor ofsubsequent suicide ideation (eg Joiner et al 2005)
Building on theory and research (Flett et al 2014Hewitt et al 2006 OrsquoConnor 2007) we hypothesized per-fectionistic concerns (socially prescribed perfectionism con-cern over mistakes doubts about action discrepancy andperfectionistic attitudes) would display positive relationshipswith suicide ideation and attempts We also hypothesizedsocially prescribed perfectionism would place people at riskfor longitudinal increases in suicide ideation However giventhe inconsistency of research on suicidality in relation to per-fectionistic strivings (self-oriented perfectionism personalstandards) other forms of perfectionism (other-oriented per-fectionism EDI-perfectionism total scores FMPS-perfectionism total scores) and correlates of perfectionism(parental criticism parental expectations organization) weconsidered our investigation into these questions to be moreexploratory
2 | METHOD
21 | Selection of studies
In 2016 a literature search using PsycINFO Medline Webof Science ERIC and ProQuest Dissertations and Theseswas conducted using the keywords and Boolean search termsldquoperfectrdquo and ldquosuicidrdquo This search yielded 100 studiesfrom PsycINFO 122 studies from Medline 226 studies fromWeb of Science and 38 studies from ProQuest We alsocompiled a list of 353 authors who had published on perfec-tionism We then contacted each author individually andrequested unpublished findings However none of the
530 | SMITH ET AL
authors contacted provided relevant data Additionally wemonitored the Perfectionism Network Mailing List to iden-tify studies that were accepted but not published at the timeof our literature search This yielded one study Chen et al(2017) Both the first and the third author then reviewedabstracts of all studies identified selecting studies meetinginclusion criteria Studies were included that (a) containeddata on perfectionism and suicidality (ideation and attempts)and (b) were in English Included studies also (c) reported aneffect size or enough information for computing an effectsize or effect size information was obtained from a studyauthor All authors contacted (N5 1) provided the requestedinformation
This literature search yielded 57 studies for inclusionInter-rater agreement on inclusion or exclusion in the meta-analysis was 95 Disagreement was resolved by revisitingarticles and coming to a consensus The reference lists ofincluded articles were also examined to locate additional rel-evant literature On August 7 2016 we terminated all searchstrategies and started data reduction and analysis Weexcluded 12 studies (see Supplemental Material A) The finalsample of included studies was composed of 45 studies with54 samples
22 | Coding of studies
The first and the third author coded each study based on ninecharacteristics sample size sample type mean age of partici-pants percentage of female participants percentage of ethnicminority participants publication status measure used toassess perfectionism measure used to assess suicide ideationand measure used to assess suicide attempts
23 | Meta-analytic procedures
Random effects analyses were conducted using Comprehen-sive Meta-Analysis software (Borenstein et al 2005) Wechose random effects models over fixed effects models asthe 45 included studies varied widely in design We alsoweighed mean effects following the procedure suggested byHunter and Schmidt (1990) This allowed us to estimatemean effect sizes and variance in observed scores after con-sidering sampling error (Card 2012) Next effect size esti-mates were weighted by sample size and aggregated Forstudies with more than one measure of suicide ideation weaveraged effect sizes so only one effect was included (Boren-stein et al 2009 Card 2012) Effect sizes presented in met-rics other than r (ie means t-tests d or F scores) wereconverted and expressed as correlations following formulasprovided by Borenstein et al (2009) We also used Boren-stein and colleaguesrsquo (2009) formula to calculate powerunder the random effects model for each weighted mean
effect Additionally most included studies measured perfec-tionism and suicide ideation with imperfect reliability Asthis can attenuate the magnitude of observed correlationseffects were adjusted by dividing the observed correlation bythe square root of the product of the two corresponding reli-ability coefficients (Card 2012) When reported the actualreliability statistics for a study were used when not reportedthe corresponding meta-analyzed mean reliability was used(Card 2012) However we were unable to adjust for unreli-ability in suicide attempts Thus in the interest of methodo-logical consistency we used the common albeitconservative strategy of interpreting observed effects whichgenerally underestimates the true magnitude of effect sizes(Borenstein et al 2009) Nonetheless for readers who dis-agree with this strategy effect sizes adjusted for unreliabilityare presented in our supplementary material
To examine the extent to which baseline self-orientedother-oriented and socially prescribed perfectionism predictfollow-up suicide ideation after controlling for baseline idea-tion we computed partial correlations using the ldquocorpcorrdquopackage (Schafer Opgen-Rhein Zuber Silvia amp Strimmer2015) for R (R Core Team 2013) Although there was insuf-ficient data to examine unique effects between perfectionismdimensions and suicide attempts there was sufficient data toexamine unique effects between perfectionism dimensionsand suicide ideation Thus again using the ldquocorpcorrdquo pack-age (Schafer et al 2015) we computed partial correlationsfor MPS-perfectionism dimensions by residualizing self-oriented other-oriented and socially prescribed perfection-ism based on their overlap with each other prior to being cor-related with suicide ideation Likewise for FMPS-perfectionism dimensions we computed partial correlationsby residualizing concern over mistakes doubts about actionparental criticism parental expectations personal standardsand organization based on their overlap with each other priorto being correlated with suicide ideation
To assess moderation we evaluated the total heterogene-ity of weighted mean effect sizes (QT) A significant QT indi-cates variance in weighted mean effect sizes is greater thanexpected by sampling error (Card 2012) a nonsignificantQT suggests a weak basis for moderation For each analysiswe also computed the inconsistency in observed effects (I2)across studies I2 indicates the percentage of total varianceacross studies due to heterogeneity Values of 25 50and 75 correspond to low medium and high heterogene-ity respectively
When QT was significant we stipulated a categoricalstructure and the total heterogeneity explained by the catego-rization (QB) was calculated (Card 2012) A significant QB
indicates meaningful differences in effects between catego-ries and provides a firm basis for moderation (Borensteinet al 2009) When QB was significant we examined
SMITH ET AL | 531
differences in effect sizes between studies grouped by publi-cation status (articles and dissertations) age (adult youngadult adolescent) and sample (community adults under-graduate students psychiatric patients) by performing aseries of all possible two-group comparisons to test whichgroup differed significantly in effect size (Card 2012) Foreach group comparison the resultant QB from the twogroups was tested using a v2 test with one degree of freedomWe also recorded gender (percentage female) and ethnicity(percentage ethnic minority) as continuous variables andused mixed effects meta-regression to test the potential mod-erating effects of gender and ethnicity
To assess publication bias we inspected funnel plotswith observed and imputed studies and computed Eggerrsquostest of regression to the intercept (Egger Smith Schneideramp Minder 1997) Such funnel plots allow for visual inspec-tion of how the effect size shifts when imputed studies areincluded (Borenstein et al 2009) In the absence of publica-tion bias Eggerrsquos regression intercept does not differ signifi-cantly from zero (Egger et al 1997)
24 | Description of studies
Our search identified 45 studies and 54 samples containingrelevant effect size data (see Table 1) The total number ofparticipants pooled across studies was 11747 Relevant datawere obtained from 38 journal articles and seven disserta-tions There were 21 samples of university undergraduates29 samples of psychiatric patients one sample of medicalstudents and three samples of community adults There were48 cross-sectional samples and six longitudinal samplesSample size varied between 17 and 1436 with an averageof 2175 (SD5 2598) The mean age of participants was268 years (SD5 102 range5 129ndash586) The average per-centage of female participants was 633 the average per-centage of ethnic minority participants was 244 Effectsize information for each individual study is presented inSupplemental Material B Adjusted effect size informationfor each individual study is presented in Supplemental Mate-rial C
25 | Measures
251 | Perfectionism
Following theory and research (eg Dunkley et al 2004Stoeber amp Otto 2006) personal standards (FMPS) and self-oriented perfectionism (MPS Child-Adolescent Perfection-ism Scale [CAPS] Flett et al 2016) were considered facetsof perfectionistic strivings concern over mistakes (FMPS)doubts about actions (FMPS) socially prescribed perfection-ism (MPS CAPS) discrepancy (APS-R) and perfectionistic
attitudes (Dysfunctional Attitude Scale-Perfectionism sub-scale [DAS-P] Weissman amp Beck 1978) were consideredfacets of perfectionistic concerns Parental criticism parentalexpectations and organization were designated correlates ofperfectionism As well parental criticism and parentalexpectations were combined and labeled as parental percep-tions (see Cox et al 2002) Other-oriented perfectionism(MPS) FMPS-perfectionism and EDI-perfectionism weredesignated other forms of perfectionism
252 | Suicide ideation and suicide attempts
Suicide ideations were assessed via self-reported suicidalthinking Suicide attempts were assessed via self-reportednumber of prior suicide attempts (eg Adkins amp Parker1996) clinicianrsquos ratings of the number of prior suicideattempts (eg Fedorowicz et al 2007) and group compari-sons between suicide attempters and non-attempters (egHewitt et al 2014) Although Pfefferrsquos (1986) Child SuicidePotential Scale (CSPS) and Linehanrsquos (1981) Suicide Behav-ior Questionnaire (SBQ) assess suicidal ideation and suicideattempts we categorized the CPS and SBQ as measures ofsuicide ideation given the majority of CSPS and SBQ itemsassess suicidal thoughts
3 | RESULTS
31 | Overall effect sizes
Weighted mean effect sizes between perfectionism corre-lates of perfectionism and suicide ideation and suicideattempts are in Table 2 (see Supplemental Material D foradjusted effect sizes) Following Cohenrsquos (1992) guidelinesfor small medium and large effects (r5 10 30 and 50respectively) perfectionistic concerns socially prescribedperfectionism concern over mistakes doubts about actionsdiscrepancy perfectionistic attitudes perfectionistic striv-ings self-oriented perfectionism personal standards parentalperceptions parental criticism parental expectations andFMPS-perfectionism displayed small-to-moderate positiverelationships with suicide ideation Other-oriented perfection-ismrsquos and organizationrsquos relationships with suicide ideationwere nonsignificant Perfectionistic concerns socially pre-scribed perfectionism concern over mistakes doubts aboutaction FMPS-perfectionism parental perceptions parentalcriticism and parental expectations displayed small positiverelationships with suicide attempts perfectionistic attitudesrsquoperfectionistic strivingsrsquo self-oriented perfectionismrsquos perso-nal standardsrsquo other-oriented perfectionismrsquos EDI-perfectionismrsquos and organizationrsquos relationships with suicideattempts were nonsignificant
532 | SMITH ET AL
TABLE2
Summaryof
overalleffect
sizesfortherelatio
nshipbetweenperfectio
nism
andsuicidality
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Suicideideatio
n
Perfectio
nistic
concerns
a42
7936
28
[24
32]
9910
5863
175
[076
273]
028[2
431]
99
Socially
prescribed
perfectio
nism
303640
28
[25
32]
3704
2171
035
[2100169]
028[2
532]
99
Concern
over
mistakes
5952
25
[13
36]
1219
6720
251
[2436938]
025[1
336]
98
Doubtsaboutactio
ns4
902
27
[18
35]
514
4162
294
[25671158
220[1
130]
99
Discrepancy
4904
26
[14
38]
917
6727
338
[24791154]
124[1
235]
98
Perfectio
nistic
attitudes
51533
37
[19
52]
3355
8808
407
[2033848]
226[0
941]
98
Perfectio
nistic
strivingsb
314588
10
[07
13]
3214
665
018
[2094130]
010[0
713]
99
Self-orientedperfectio
nism
273315
11
[08
15]
2096
000
ndash046
[2156064]
011[0
815]
99
Personal
standards
51273
10
[00
19]
1033
6127
334
[24711139]
010[0
019]
52
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
202755
01
[204
06]
3287
4219
027
[2178230]
101[2
04
06]
08
FMPS
totalscore
41018
31
[15
45]
1971
8477
472
[21692
2636]
127[1
240]
96
EDI-perfectio
nism
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdash
Correlatesof
perfectio
nism
Parental
perceptio
nsc
51904
19
[10
27]
1279
6871
204
[2558966]
019[1
027]
98
Parental
criticism
5952
20
[11
29]
798
4987
092
[2556740]
020[1
029]
98
Parental
expectations
5952
16
[06
26]
842
5247
196
[2391784]
113[0
323]
88
Organization
3513
ndash02
[220
17]
792
7475
253
[27738
8243]
0ndash02
[220
17]
05
Suicideattempts
Perfectio
nistic
concerns
d15
5275
12
[07
17]
2448
4281
115
[021
208]
508[0
314]
99
Socially
prescribed
perfectio
nism
8689
19
[08
29]
1257
4432
021
[2365407]
019[0
829]
93
Concern
over
mistakes
51827
09
[04
14]
012
000
008
[2035052]
109[0
413]
97
Doubtsaboutactio
n3
1777
06
[01
11]
276
000
100
[2201401]
205[2
02
11]
71
Discrepancy
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdashPerfectio
nistic
attitudes
3983
09
[203
22]
254
2126
142
[2155440]
205[2
07
17]
32
(Contin
ues)
SMITH ET AL | 533
TABLE2
(Contin
ued)
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Perfectio
nistic
strivingsa
101436
02
[202
06]
525
000
ndash010
[2110087]
002[2
01
06]
19
Self-orientedperfectio
nism
6539
07
[201
16]
304
000
ndash161
[2320ndash0
02]
007[2
01
15]
37
Personal
standards
41777
01
[204
06]
060
000
ndash049
[2182083]
001[2
04
05]
06
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
4429
ndash03
[213
06]
126
000
ndash142
[2258ndash0
28]
0ndash03
[213
06]
11
FMPS
totalscore
3666
14
[07
21]
130
000
ndash031
[2055ndash0
07]
016[0
823]
99
EDI-perfectio
nism
52975
03
[201
06]
183
000
106
[2098273]
103[2
01
06]
33
Correlatesof
perfectio
nism
Parental
perceptio
nsc
33230
07
[04
11]
053
000
045
[2643733]
007[0
411]
98
Parental
criticism
31615
08
[03
12]
065
000
063
[2523650]
207[0
211]
85
Parental
expectations
31615
07
[02
12]
010
000
001
[2386387]
007[0
211]
79
Organization
21565
ndash01
[206
04]
082
000
mdashmdash
mdashmdash
mdash
Note
k5numberof
studiesN5totalnumberof
participantsin
theksamplesr1
5weightedmeanbivariatecorrelation
CI5
confidence
intervalQT5measure
ofheterogeneity
ofeffect
sizesI25percentage
ofheteroge-
neity
kT
F5numberof
imputedstudiesas
partof
ldquotrim
andfillrdquo
method
FMPS
5Frostrsquos
andcolleaguesrsquo
(1990)
Multid
imensional
Perfectio
nism
Scale
EDI-perfectio
nism
5Garnerandcolleaguesrsquo
(1983)
EatingDisorder
Inventory-Perfectio
nism
subscale
a Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesdoubtsaboutactio
nsanddiscrepancy
b Perfectionistic
strivingsassessed
asaggregateof
self-orientedperfectio
nism
andpersonal
standards
c Parentalperceptio
nsassessed
asaggregateof
parental
criticism
andparental
expectations
(Cox
etal2002)
d Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesanddoubtsaboutactio
ns
plt05
plt01
p
lt001
534 | SMITH ET AL
Weighted mean effect sizes for the relationships betweenself-oriented other-oriented and socially prescribed perfec-tionism at baseline and suicide ideation at follow-up whilecontrolling for ideation at baseline are in SupplementalMaterial E (see Supplemental Material F for adjusted longi-tudinal effect sizes) Despite the large positive relationshipbetween baseline and follow-up suicide ideation sociallyprescribed perfectionism still displayed a small positive rela-tionship with follow-up suicide ideation after controlling forbaseline suicide ideation Self-oriented and other-orientedperfectionismrsquos relationships with follow-up suicide ideationafter controlling for baseline ideation were nonsignificant
MPS-perfectionism dimensions displayed small-to-largepositive correlations with each other (see SupplementalMaterial G for observed effects and Supplemental MaterialH for adjusted effects) After controlling for overlap in MPSdimensions self-oriented perfectionism ceased to signifi-cantly predict suicide ideation other-oriented perfectionismhad a small unique negative association with suicide idea-tion and socially prescribed perfectionism had a smallunique positive relationship with suicide ideation FMPS-perfectionism dimensions had marginal-to-large correlationswith each other (see Supplemental Material G for observedeffects and Supplemental Material H for adjusted effects)After controlling for overlap in FMPS dimensions the rela-tionships among suicide ideation and concern over mistakespersonal standards parental expectations and organizationwere nonsignificant However after controlling for overlapamong FMPS dimensions doubts about actions and parentalcriticism displayed small unique positive relationships withideation (see Supplemental Material G for observed effectsand Supplemental Material H for adjusted effects)
The test of the total heterogeneity of variance of weightedmean effect sizes (QT) was significant for suicide ideationrsquosrelations with perfectionistic concerns concern over mistakesdiscrepancy personal standards perfectionistic attitudesother-oriented perfectionism FMPS-perfectionism and orga-nization (see Table 2) QT was also significant for the linkbetween suicide attempts and perfectionistic concerns (seeTable 2) The percentage of total variance owing to heteroge-neity (I2) ranged from small to large suggesting possiblemoderators
32 | Moderator analyses
Moderator analyses (see Supplemental Material I) testedwhether effect sizes with significant heterogeneity (QT) weremoderated by publication status (peer-reviewed articles dis-sertations) age (adolescent samples 13 and 17 yearsyoung adult samples 18 and 25 years adultsamples 25 years) sample (university undergraduatescommunity adults psychiatric patients) or perfectionism
measure Perfectionistic concernsrsquo relationship with suicideattempts was nonsignificant for the CAPS but significant forthe FMPS and the MPS Meta-regression also revealed thestrength of the relationship between perfectionistic concernsand suicide attempts decreased as the proportion of femalesin a sample increased However we advise caution in inter-preting our moderator analyses given the small number ofstudies per subgroup
33 | Publication bias
Funnel plots (see Supplemental Material J) and Eggerrsquosregression intercept (see Table 2) provided mixed evidencefor publication bias Eggerrsquos regression intercept was signifi-cant for perfectionistic concernsrsquo relationship with suicideideation and suicide attempts Moreover the funnel plot forperfectionistic concerns and suicide attempts was asymmetri-cal Accordingly for perfectionistic concernsrsquo relationshipwith suicide ideation and suicide attempts trim and fill esti-mates may provide more accurate estimates Nonethelessafter imputing missing studies the adjusted point estimatesfor perfectionistic concernsrsquo relationships with suicide idea-tion and suicide attempts provided the same substantiveimplications (see Table 2)
4 | DISCUSSION
Suicide claims one life every 45 seconds (World HealthOrganization 2012) Given the wide-reaching personal andsocietal costs of suicide it is vital to identify contributingfactors One such factor supported by over 50 years of casehistories theoretical accounts and empirical research is per-fectionism (Blatt 1995 Hassan et al 2014 Hewitt et al2014 Kiamanesh et al 2014 Shaffer 1974) Yet despitethe abundance of research the role of perfectionism in sui-cide remains underappreciated under-recognized and mis-understood due to inconsistencies between studies infindings underpowered studies and uncertainty surroundingwhether perfectionism dimensions predict longitudinalincreases in suicidality We aimed to rectify this by rigor-ously conducting the first meta-analytic review of the perfec-tionismndashsuicidality relationship
41 | An improved understanding of theperfectionismndashsuicidality relationship
Our meta-analysis of 45 studies 54 samples and 11747 par-ticipants represents the most comprehensive test of the per-fectionismndashsuicidality link to date All dimensions orcorrelates of perfectionism (except for other-oriented perfec-tionism and organization) were positively related to suicideideation and these effect sizes were generally consistent
SMITH ET AL | 535
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Deanamp
Range
(1996)
168
university
a219
690
280
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SBQ
mdash
Deanamp
Range
(1999)
132
psychiatricb
355
712
333
article
cross-sectional
MPS
-SOP
MPS
-SPP
SSI
mdash
Deanet
al(1996)
114
university
a244
842
281
article
cross-sectional
MPS
-SPP
SSI
mdash
Enn
set
al(2001)
96medicald
251
417
NR
article
long
itudinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
SIQ
mdash
Fedorowiczet
al(20
07)
940
psychiatricb
260
00
NR
article
cross-sectional
EDI
mdashattemptsg
Flam
enbaum
ampHolden(2007)
264
university
a189
758
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
BSS
-MBSS
-Pintent
hattemptsf
Foulon
etal(2007)
304
psychiatricb
223
977
NR
article
cross-sectional
EDI
mdashattemptsi
Franko
etal(2004)
246
psychiatricb
NR
1000
NR
article
cross-sectional
EDI
mdashattemptsi
Freudenstein
etal(2012)
100
psychiatricb
166
470
120
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
CSP
Sattemptsi
Ham
ilton
ampSchw
eitzer
(2000)
389
university
a227
743
NR
article
cross-sectional
FMPS
-PS
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-total
GHQ-ST
mdash
Hew
ittet
al(1992)
87psychiatricb
357
529
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
BDI-SI
mdash (Contin
ues)
526 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Hew
ittet
al(1994)
study1
91psychiatricb
355
538
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
RST
-past
RST
-future
mdash
Hew
ittet
al(1994)
study2
160
university
a217
656
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
RST
-past
RST
-future
mdash
Hew
ittet
al(1997)
wom
en33
psychiatricb
154
1000
NR
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
mdash
Hew
ittet
al(1997)
men
33psychiatricb
154
00
NR
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
mdash
Hew
ittet
al(1998)
78psychiatricb
328
538
308
article
cross-sectionali
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Hew
ittet
al(2014)
55psychiatricb
155
745
255
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
attemptsi
Hunteramp
OrsquoConnor(2003)
sample1
43psychiatricb
346
534
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Hunteramp
OrsquoConnor(2003)
sample2
44psychiatricb
346
477
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Izadi(2015)
50community
c270
740
420
dissertatio
ncross-sectional
MPS
-SPP
FMPS
-COM
FMPS
-PC
FMPS
-PE
SBQ-SI
attemptsf
Jacobs
etal(2009)
439
psychiatricb
146
540
260
article
cross-sectional
DAS-P
SIQ-JR
mdash
Jeglic
(2003)
97university
a184
732
330
dissertatio
ncross-sectional
FMPS
-total
mdashattemptsi
Jeglic
etal(2007)
study2
440
university
a185
620
400
article
cross-sectional
FMPS
-total
mdashattemptsi
(Contin
ues)
SMITH ET AL | 527
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Muyan
ampChang
(2015)
288
university
a213
590
NR
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
FSII
mdash
OrsquoConnoramp
Forgan
(2007)
255
university
a220
780
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
GHQ-ST
mdash
OrsquoConnorRC
et
al(2007)
study2
151
university
a240
722
NR
article
long
itudinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
OrsquoConnorDB
et
al(2007)
sample1
65psychiatricb
241
722
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
OrsquoConnorDB
et
al(2007)
sample2
61psychiatricb
241
722
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Pisetsky
etal(2013)
635
psychiatricb
317
NR
NR
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PS
mdashattemptsi
Portzkyet
al(2014)
1436
psychiatricb
242
954
NR
article
cross-sectional
EDI
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
mdashattemptsi
Ranieriet
al(1987)
sample1
50psychiatricb
443
560
80
article
cross-sectional
DAS-P
BSS
Iattemptsf
Ranieriet
al(1987)
sample2
25psychiatricb
417
600
NR
article
cross-sectional
DAS-P
BSS
Iattemptsf
(Contin
ues)
528 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Rasmussenet
al(2008)
sample1
17psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussenet
al(2008)
sample2
23psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussen
Elliotet
al(2012)
161
psychiatricb
337
590
NR
article
cross-sectional
MPS
-SPP
SPS-SI
mdash
Rasmussen
Slish
etal(2012)
214
university
a201
570
257
article
cross-sectional
APS
-DDSI-SS
mdash
Roxboroughet
al(2012)
152
psychiatricb
129
454
285
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
intent
hmdash
Slish(2006)
48university
a201
521
625
dissertatio
ncross-sectional
APS
-DDSI-SS
mdash
Wallack
(2007)
181
university
a198
796
260
dissertatio
ncross-sectional
APS
-DSIS
mdash
Wanget
al(2013)
466
university
a264
496
NR
article
cross-sectional
APS
-DSIS
mdash
Yam
aguchi
etal(2000)
51psychiatricb
212
961
NR
article
cross-sectional
EDI
mdashattemptsi
Note
N5totalnumberof
participantsNR5
notreportedFemale5percentage
female
Ethnic5percentage
ethnic
minority
Status
5publicationstatus
ofthestudy
FMPS
5Frostandcolleaguesrsquo
(1990)
Multid
imen-
sional
Perfectio
nism
Scale
total5
totalscore
ASIQ5
Reynoldsrsquos(1991)
AdultSu
icideIdeatio
nQuestionnaireCOM
5concernover
mistakesDAA5
doubtsaboutactio
nsPC
5parental
criticism
PE
5parental
expecta-
tionsPS
5personal
standardsORG5organizatio
nAAHS-ST
5NationalAdolescentHealth
Survey
Suicidal
Thinkingmodifiedversion(1989)DAS-P5Weissman
andBeckrsquos(1978)
Dysfunctio
nalAttitude
Scale-
Perfectio
nism
subscaleSS
I5Beck
SteerandRanierirsquos
(1988)
ScaleforSu
icidal
Ideatio
nMSS
I5MillerNormanBishop
andDow
rsquos(1986)
ModifiedScaleforSu
icidal
Ideatio
nMPS
5Hew
ittandFlettrsquos
(1991)
Multi-
dimensional
Perfectio
nism
Scale
SOP5self-orientedperfectio
nism
OOP5other-oriented
perfectio
nism
SP
P5socially
prescribed
perfectio
nism
CSI
5Blanksteinrsquos(2007)
Current
SuicideIdeatio
nScale
CAPS
5Flett
andcolleaguesrsquo
(2016)
Child-A
dolescentPerfectio
nism
Scale
SIQ5
Reynoldsrsquos(1987b)Su
icidal
Ideatio
nQuestionnaireEDI5
Garnerandcolleaguesrsquo
(1983)
EatingDisorderInventory-Perfectio
nism
subscaleBSS
5Beck
andSteerrsquos
(1993)
SuicideIdeatio
nScale
M5
motivation
P5preparation
Intent5suicidal
intentCSP
S5Pfefferrsquos
(1986)
Child
SuicidePo
tentialScale
GHQ-ST5
GoldbergandWilliamsrsquos(1988)
General
Health
Questionnaire-SuicidalThinkingsubscaleBDI-SI
5Beckrsquos(1979)
DepressionInventoryitem-9
(SuicidalIntent)RST
-past5
ratin
gof
thefrequencyof
pastsuicidal
thoughtsRST
-future5ratin
gof
thefrequencyof
future
suicidal
thoughtsSB
Q5
Linehanrsquos
(1981)
Suicidal
BehaviorQuestionnaireSI
5suicidal
ideatio
nSIQ-JR5
Reynoldsrsquos(1987a)Su
icidal
Ideatio
nQuestionnaire-G
rades7ndash9
FSII5
Chang
andChang
rsquos(2016)
Frequency
ofSu
icideIdeatio
nInventory
SPS5CullandGillrsquos
(1982)
SuicideProbability
Scale
BSS
I5Beck
KovacsandWeissmanrsquos
(1979)
ScaleforSu
icidal
Ideatio
nAPS
-D5
Slaney
andcolleaguesrsquo
(2001)
Alm
ostPerfect
Scale-Revised
Discrepancy
subscaleDSI-SS5
MetalskyandJoinerrsquos
(1997)
DepressiveSy
mptom
sInventory-Su
icidality
subscaleSIS5Ruddrsquos(1989)
Suicidal
Ideatio
nScale
a University
undergraduates
b Psychiatric
patients
c Com
munity
adults
d Medical
students
e Participants
reported
whether
they
hadever
seriouslythoughtaboutattemptingsuicide
f Self-reported
numberof
priorsuicideattempts
g Prior
numberof
suicideattemptsassessed
byaclinician
h Participants
asked
ldquoHow
likelyisitthat
youwill
attempt
suicidesomedayrdquo
i Com
paredsuicideattemptersandnon-attempters
SMITH ET AL | 529
studies examining other-oriented perfectionism and suicidal-ity (see Table 1) meaning this literature is now suitable formeta-analysis In sum though perfectionistic concernsrsquo linkwith suicidality is clear (Flett al 2014 Hewitt et al 2006OrsquoConnor 2007) perfectionistic strivingsrsquo and other-oriented perfectionismrsquos link with suicidality is unclear
15 | Advancing research on theperfectionismndashsuicidality relationship usingmeta-analysis
Over 50 years of case reports theoretical accounts andempirical research implicate perfectionism in suicide (egBlatt 1995 Hassan Flett Ganguli amp Hewitt 2014 Hewittet al 2014 Kiamanesh Dyregrov Haavind amp Dieserud2014 Shaffer 1974) And yet there is much to learn aboutthe perfectionismndashsuicidality relationship (Flett et al 2014)First noteworthy inconsistencies between studies in findings(eg Flamenbaum amp Holden 2007 Hewitt et al 19982014 Hunter amp OrsquoConnor 2003) have clouded our under-standing of perfectionistic strivingsrsquo and other-oriented per-fectionismrsquos relationships with suicidality A quantitativesynthesis is needed for overall conclusions to be reachedSuch a quantitative synthesis could also allow for tests ofmoderating variables (eg gender) that might explain whenthe strength or the direction of the perfectionismndashsuicidalityrelationship changes Second despite evidence that correla-tions do not stabilize until N 250 (Scheuroonbrodt amp Perugini2013) most research on perfectionism and suicide attemptsis underpowered (cf Flamenbaum amp Holden 2007) How-ever meta-analysis could overcome limitations of small sam-ples (Borenstein Hedges Higgins amp Rothstein 2009) andbring greater clarity to our understanding of perfectionismrsquosrelationship with suicide attempts Third as noted by Flettet al (2014) and OrsquoConnor (2007) the extent to which per-fectionism dimensions confer risk for suicide has yet to bedetermined Indeed most investigators use cross-sectionaldesigns which unlike longitudinal designs cannot addresstemporal precedence As such whether perfectionism leadsto increases in suicidality is unclear and researchers andclinicians can only speculate as to whether reducing perfec-tionism reduces suicidality Nevertheless there is now suffi-cient data to test whether self-oriented other-oriented andsocially prescribed perfectionism predict follow-up suicideideation beyond baseline suicide ideation (Chen 2012Enns Cox Sareen amp Freeman 2001 R C OrsquoConnorWhyte et al 2007) Fourth due to limitations of nonempiri-cal reviews the strength of the relation between perfection-ism dimensions suicide ideation and suicide attempts isunclear A meta-analysis could shed light on which perfec-tionism dimensions display the strongest relations with sui-cide ideation and suicide attempts which in time might
inform the development of interventions designed to targetand to modify perfectionismrsquos most pernicious aspects
16 | Objectives and hypothesis
Our primary aim was to bring greater clarity to our under-standing of the perfectionismndashsuicidality relationship bycomprehensively synthesizing empirical research on perfec-tionism suicide ideation and suicide attempts To date thereis no meta-analysis of findings from this long-standing andimportant literature We also aimed to test the contentiouslydebated relation between perfectionistic strivings suicideideation and suicide attempts Such evidence would informdebate on the pros and cons of demanding perfection of one-self (eg Stoeber amp Otto 2006 Sherry Hewitt SherryFlett amp Graham 2010) Another aim was to test whetherself-oriented other-oriented and socially prescribed perfec-tionism predicted longitudinal increases in suicide ideationover time Controlling for baseline suicide ideation repre-sents a stringent test of the perfectionismndashsuicidality relation-ship as baseline suicide ideation is a strong predictor ofsubsequent suicide ideation (eg Joiner et al 2005)
Building on theory and research (Flett et al 2014Hewitt et al 2006 OrsquoConnor 2007) we hypothesized per-fectionistic concerns (socially prescribed perfectionism con-cern over mistakes doubts about action discrepancy andperfectionistic attitudes) would display positive relationshipswith suicide ideation and attempts We also hypothesizedsocially prescribed perfectionism would place people at riskfor longitudinal increases in suicide ideation However giventhe inconsistency of research on suicidality in relation to per-fectionistic strivings (self-oriented perfectionism personalstandards) other forms of perfectionism (other-oriented per-fectionism EDI-perfectionism total scores FMPS-perfectionism total scores) and correlates of perfectionism(parental criticism parental expectations organization) weconsidered our investigation into these questions to be moreexploratory
2 | METHOD
21 | Selection of studies
In 2016 a literature search using PsycINFO Medline Webof Science ERIC and ProQuest Dissertations and Theseswas conducted using the keywords and Boolean search termsldquoperfectrdquo and ldquosuicidrdquo This search yielded 100 studiesfrom PsycINFO 122 studies from Medline 226 studies fromWeb of Science and 38 studies from ProQuest We alsocompiled a list of 353 authors who had published on perfec-tionism We then contacted each author individually andrequested unpublished findings However none of the
530 | SMITH ET AL
authors contacted provided relevant data Additionally wemonitored the Perfectionism Network Mailing List to iden-tify studies that were accepted but not published at the timeof our literature search This yielded one study Chen et al(2017) Both the first and the third author then reviewedabstracts of all studies identified selecting studies meetinginclusion criteria Studies were included that (a) containeddata on perfectionism and suicidality (ideation and attempts)and (b) were in English Included studies also (c) reported aneffect size or enough information for computing an effectsize or effect size information was obtained from a studyauthor All authors contacted (N5 1) provided the requestedinformation
This literature search yielded 57 studies for inclusionInter-rater agreement on inclusion or exclusion in the meta-analysis was 95 Disagreement was resolved by revisitingarticles and coming to a consensus The reference lists ofincluded articles were also examined to locate additional rel-evant literature On August 7 2016 we terminated all searchstrategies and started data reduction and analysis Weexcluded 12 studies (see Supplemental Material A) The finalsample of included studies was composed of 45 studies with54 samples
22 | Coding of studies
The first and the third author coded each study based on ninecharacteristics sample size sample type mean age of partici-pants percentage of female participants percentage of ethnicminority participants publication status measure used toassess perfectionism measure used to assess suicide ideationand measure used to assess suicide attempts
23 | Meta-analytic procedures
Random effects analyses were conducted using Comprehen-sive Meta-Analysis software (Borenstein et al 2005) Wechose random effects models over fixed effects models asthe 45 included studies varied widely in design We alsoweighed mean effects following the procedure suggested byHunter and Schmidt (1990) This allowed us to estimatemean effect sizes and variance in observed scores after con-sidering sampling error (Card 2012) Next effect size esti-mates were weighted by sample size and aggregated Forstudies with more than one measure of suicide ideation weaveraged effect sizes so only one effect was included (Boren-stein et al 2009 Card 2012) Effect sizes presented in met-rics other than r (ie means t-tests d or F scores) wereconverted and expressed as correlations following formulasprovided by Borenstein et al (2009) We also used Boren-stein and colleaguesrsquo (2009) formula to calculate powerunder the random effects model for each weighted mean
effect Additionally most included studies measured perfec-tionism and suicide ideation with imperfect reliability Asthis can attenuate the magnitude of observed correlationseffects were adjusted by dividing the observed correlation bythe square root of the product of the two corresponding reli-ability coefficients (Card 2012) When reported the actualreliability statistics for a study were used when not reportedthe corresponding meta-analyzed mean reliability was used(Card 2012) However we were unable to adjust for unreli-ability in suicide attempts Thus in the interest of methodo-logical consistency we used the common albeitconservative strategy of interpreting observed effects whichgenerally underestimates the true magnitude of effect sizes(Borenstein et al 2009) Nonetheless for readers who dis-agree with this strategy effect sizes adjusted for unreliabilityare presented in our supplementary material
To examine the extent to which baseline self-orientedother-oriented and socially prescribed perfectionism predictfollow-up suicide ideation after controlling for baseline idea-tion we computed partial correlations using the ldquocorpcorrdquopackage (Schafer Opgen-Rhein Zuber Silvia amp Strimmer2015) for R (R Core Team 2013) Although there was insuf-ficient data to examine unique effects between perfectionismdimensions and suicide attempts there was sufficient data toexamine unique effects between perfectionism dimensionsand suicide ideation Thus again using the ldquocorpcorrdquo pack-age (Schafer et al 2015) we computed partial correlationsfor MPS-perfectionism dimensions by residualizing self-oriented other-oriented and socially prescribed perfection-ism based on their overlap with each other prior to being cor-related with suicide ideation Likewise for FMPS-perfectionism dimensions we computed partial correlationsby residualizing concern over mistakes doubts about actionparental criticism parental expectations personal standardsand organization based on their overlap with each other priorto being correlated with suicide ideation
To assess moderation we evaluated the total heterogene-ity of weighted mean effect sizes (QT) A significant QT indi-cates variance in weighted mean effect sizes is greater thanexpected by sampling error (Card 2012) a nonsignificantQT suggests a weak basis for moderation For each analysiswe also computed the inconsistency in observed effects (I2)across studies I2 indicates the percentage of total varianceacross studies due to heterogeneity Values of 25 50and 75 correspond to low medium and high heterogene-ity respectively
When QT was significant we stipulated a categoricalstructure and the total heterogeneity explained by the catego-rization (QB) was calculated (Card 2012) A significant QB
indicates meaningful differences in effects between catego-ries and provides a firm basis for moderation (Borensteinet al 2009) When QB was significant we examined
SMITH ET AL | 531
differences in effect sizes between studies grouped by publi-cation status (articles and dissertations) age (adult youngadult adolescent) and sample (community adults under-graduate students psychiatric patients) by performing aseries of all possible two-group comparisons to test whichgroup differed significantly in effect size (Card 2012) Foreach group comparison the resultant QB from the twogroups was tested using a v2 test with one degree of freedomWe also recorded gender (percentage female) and ethnicity(percentage ethnic minority) as continuous variables andused mixed effects meta-regression to test the potential mod-erating effects of gender and ethnicity
To assess publication bias we inspected funnel plotswith observed and imputed studies and computed Eggerrsquostest of regression to the intercept (Egger Smith Schneideramp Minder 1997) Such funnel plots allow for visual inspec-tion of how the effect size shifts when imputed studies areincluded (Borenstein et al 2009) In the absence of publica-tion bias Eggerrsquos regression intercept does not differ signifi-cantly from zero (Egger et al 1997)
24 | Description of studies
Our search identified 45 studies and 54 samples containingrelevant effect size data (see Table 1) The total number ofparticipants pooled across studies was 11747 Relevant datawere obtained from 38 journal articles and seven disserta-tions There were 21 samples of university undergraduates29 samples of psychiatric patients one sample of medicalstudents and three samples of community adults There were48 cross-sectional samples and six longitudinal samplesSample size varied between 17 and 1436 with an averageof 2175 (SD5 2598) The mean age of participants was268 years (SD5 102 range5 129ndash586) The average per-centage of female participants was 633 the average per-centage of ethnic minority participants was 244 Effectsize information for each individual study is presented inSupplemental Material B Adjusted effect size informationfor each individual study is presented in Supplemental Mate-rial C
25 | Measures
251 | Perfectionism
Following theory and research (eg Dunkley et al 2004Stoeber amp Otto 2006) personal standards (FMPS) and self-oriented perfectionism (MPS Child-Adolescent Perfection-ism Scale [CAPS] Flett et al 2016) were considered facetsof perfectionistic strivings concern over mistakes (FMPS)doubts about actions (FMPS) socially prescribed perfection-ism (MPS CAPS) discrepancy (APS-R) and perfectionistic
attitudes (Dysfunctional Attitude Scale-Perfectionism sub-scale [DAS-P] Weissman amp Beck 1978) were consideredfacets of perfectionistic concerns Parental criticism parentalexpectations and organization were designated correlates ofperfectionism As well parental criticism and parentalexpectations were combined and labeled as parental percep-tions (see Cox et al 2002) Other-oriented perfectionism(MPS) FMPS-perfectionism and EDI-perfectionism weredesignated other forms of perfectionism
252 | Suicide ideation and suicide attempts
Suicide ideations were assessed via self-reported suicidalthinking Suicide attempts were assessed via self-reportednumber of prior suicide attempts (eg Adkins amp Parker1996) clinicianrsquos ratings of the number of prior suicideattempts (eg Fedorowicz et al 2007) and group compari-sons between suicide attempters and non-attempters (egHewitt et al 2014) Although Pfefferrsquos (1986) Child SuicidePotential Scale (CSPS) and Linehanrsquos (1981) Suicide Behav-ior Questionnaire (SBQ) assess suicidal ideation and suicideattempts we categorized the CPS and SBQ as measures ofsuicide ideation given the majority of CSPS and SBQ itemsassess suicidal thoughts
3 | RESULTS
31 | Overall effect sizes
Weighted mean effect sizes between perfectionism corre-lates of perfectionism and suicide ideation and suicideattempts are in Table 2 (see Supplemental Material D foradjusted effect sizes) Following Cohenrsquos (1992) guidelinesfor small medium and large effects (r5 10 30 and 50respectively) perfectionistic concerns socially prescribedperfectionism concern over mistakes doubts about actionsdiscrepancy perfectionistic attitudes perfectionistic striv-ings self-oriented perfectionism personal standards parentalperceptions parental criticism parental expectations andFMPS-perfectionism displayed small-to-moderate positiverelationships with suicide ideation Other-oriented perfection-ismrsquos and organizationrsquos relationships with suicide ideationwere nonsignificant Perfectionistic concerns socially pre-scribed perfectionism concern over mistakes doubts aboutaction FMPS-perfectionism parental perceptions parentalcriticism and parental expectations displayed small positiverelationships with suicide attempts perfectionistic attitudesrsquoperfectionistic strivingsrsquo self-oriented perfectionismrsquos perso-nal standardsrsquo other-oriented perfectionismrsquos EDI-perfectionismrsquos and organizationrsquos relationships with suicideattempts were nonsignificant
532 | SMITH ET AL
TABLE2
Summaryof
overalleffect
sizesfortherelatio
nshipbetweenperfectio
nism
andsuicidality
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Suicideideatio
n
Perfectio
nistic
concerns
a42
7936
28
[24
32]
9910
5863
175
[076
273]
028[2
431]
99
Socially
prescribed
perfectio
nism
303640
28
[25
32]
3704
2171
035
[2100169]
028[2
532]
99
Concern
over
mistakes
5952
25
[13
36]
1219
6720
251
[2436938]
025[1
336]
98
Doubtsaboutactio
ns4
902
27
[18
35]
514
4162
294
[25671158
220[1
130]
99
Discrepancy
4904
26
[14
38]
917
6727
338
[24791154]
124[1
235]
98
Perfectio
nistic
attitudes
51533
37
[19
52]
3355
8808
407
[2033848]
226[0
941]
98
Perfectio
nistic
strivingsb
314588
10
[07
13]
3214
665
018
[2094130]
010[0
713]
99
Self-orientedperfectio
nism
273315
11
[08
15]
2096
000
ndash046
[2156064]
011[0
815]
99
Personal
standards
51273
10
[00
19]
1033
6127
334
[24711139]
010[0
019]
52
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
202755
01
[204
06]
3287
4219
027
[2178230]
101[2
04
06]
08
FMPS
totalscore
41018
31
[15
45]
1971
8477
472
[21692
2636]
127[1
240]
96
EDI-perfectio
nism
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdash
Correlatesof
perfectio
nism
Parental
perceptio
nsc
51904
19
[10
27]
1279
6871
204
[2558966]
019[1
027]
98
Parental
criticism
5952
20
[11
29]
798
4987
092
[2556740]
020[1
029]
98
Parental
expectations
5952
16
[06
26]
842
5247
196
[2391784]
113[0
323]
88
Organization
3513
ndash02
[220
17]
792
7475
253
[27738
8243]
0ndash02
[220
17]
05
Suicideattempts
Perfectio
nistic
concerns
d15
5275
12
[07
17]
2448
4281
115
[021
208]
508[0
314]
99
Socially
prescribed
perfectio
nism
8689
19
[08
29]
1257
4432
021
[2365407]
019[0
829]
93
Concern
over
mistakes
51827
09
[04
14]
012
000
008
[2035052]
109[0
413]
97
Doubtsaboutactio
n3
1777
06
[01
11]
276
000
100
[2201401]
205[2
02
11]
71
Discrepancy
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdashPerfectio
nistic
attitudes
3983
09
[203
22]
254
2126
142
[2155440]
205[2
07
17]
32
(Contin
ues)
SMITH ET AL | 533
TABLE2
(Contin
ued)
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Perfectio
nistic
strivingsa
101436
02
[202
06]
525
000
ndash010
[2110087]
002[2
01
06]
19
Self-orientedperfectio
nism
6539
07
[201
16]
304
000
ndash161
[2320ndash0
02]
007[2
01
15]
37
Personal
standards
41777
01
[204
06]
060
000
ndash049
[2182083]
001[2
04
05]
06
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
4429
ndash03
[213
06]
126
000
ndash142
[2258ndash0
28]
0ndash03
[213
06]
11
FMPS
totalscore
3666
14
[07
21]
130
000
ndash031
[2055ndash0
07]
016[0
823]
99
EDI-perfectio
nism
52975
03
[201
06]
183
000
106
[2098273]
103[2
01
06]
33
Correlatesof
perfectio
nism
Parental
perceptio
nsc
33230
07
[04
11]
053
000
045
[2643733]
007[0
411]
98
Parental
criticism
31615
08
[03
12]
065
000
063
[2523650]
207[0
211]
85
Parental
expectations
31615
07
[02
12]
010
000
001
[2386387]
007[0
211]
79
Organization
21565
ndash01
[206
04]
082
000
mdashmdash
mdashmdash
mdash
Note
k5numberof
studiesN5totalnumberof
participantsin
theksamplesr1
5weightedmeanbivariatecorrelation
CI5
confidence
intervalQT5measure
ofheterogeneity
ofeffect
sizesI25percentage
ofheteroge-
neity
kT
F5numberof
imputedstudiesas
partof
ldquotrim
andfillrdquo
method
FMPS
5Frostrsquos
andcolleaguesrsquo
(1990)
Multid
imensional
Perfectio
nism
Scale
EDI-perfectio
nism
5Garnerandcolleaguesrsquo
(1983)
EatingDisorder
Inventory-Perfectio
nism
subscale
a Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesdoubtsaboutactio
nsanddiscrepancy
b Perfectionistic
strivingsassessed
asaggregateof
self-orientedperfectio
nism
andpersonal
standards
c Parentalperceptio
nsassessed
asaggregateof
parental
criticism
andparental
expectations
(Cox
etal2002)
d Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesanddoubtsaboutactio
ns
plt05
plt01
p
lt001
534 | SMITH ET AL
Weighted mean effect sizes for the relationships betweenself-oriented other-oriented and socially prescribed perfec-tionism at baseline and suicide ideation at follow-up whilecontrolling for ideation at baseline are in SupplementalMaterial E (see Supplemental Material F for adjusted longi-tudinal effect sizes) Despite the large positive relationshipbetween baseline and follow-up suicide ideation sociallyprescribed perfectionism still displayed a small positive rela-tionship with follow-up suicide ideation after controlling forbaseline suicide ideation Self-oriented and other-orientedperfectionismrsquos relationships with follow-up suicide ideationafter controlling for baseline ideation were nonsignificant
MPS-perfectionism dimensions displayed small-to-largepositive correlations with each other (see SupplementalMaterial G for observed effects and Supplemental MaterialH for adjusted effects) After controlling for overlap in MPSdimensions self-oriented perfectionism ceased to signifi-cantly predict suicide ideation other-oriented perfectionismhad a small unique negative association with suicide idea-tion and socially prescribed perfectionism had a smallunique positive relationship with suicide ideation FMPS-perfectionism dimensions had marginal-to-large correlationswith each other (see Supplemental Material G for observedeffects and Supplemental Material H for adjusted effects)After controlling for overlap in FMPS dimensions the rela-tionships among suicide ideation and concern over mistakespersonal standards parental expectations and organizationwere nonsignificant However after controlling for overlapamong FMPS dimensions doubts about actions and parentalcriticism displayed small unique positive relationships withideation (see Supplemental Material G for observed effectsand Supplemental Material H for adjusted effects)
The test of the total heterogeneity of variance of weightedmean effect sizes (QT) was significant for suicide ideationrsquosrelations with perfectionistic concerns concern over mistakesdiscrepancy personal standards perfectionistic attitudesother-oriented perfectionism FMPS-perfectionism and orga-nization (see Table 2) QT was also significant for the linkbetween suicide attempts and perfectionistic concerns (seeTable 2) The percentage of total variance owing to heteroge-neity (I2) ranged from small to large suggesting possiblemoderators
32 | Moderator analyses
Moderator analyses (see Supplemental Material I) testedwhether effect sizes with significant heterogeneity (QT) weremoderated by publication status (peer-reviewed articles dis-sertations) age (adolescent samples 13 and 17 yearsyoung adult samples 18 and 25 years adultsamples 25 years) sample (university undergraduatescommunity adults psychiatric patients) or perfectionism
measure Perfectionistic concernsrsquo relationship with suicideattempts was nonsignificant for the CAPS but significant forthe FMPS and the MPS Meta-regression also revealed thestrength of the relationship between perfectionistic concernsand suicide attempts decreased as the proportion of femalesin a sample increased However we advise caution in inter-preting our moderator analyses given the small number ofstudies per subgroup
33 | Publication bias
Funnel plots (see Supplemental Material J) and Eggerrsquosregression intercept (see Table 2) provided mixed evidencefor publication bias Eggerrsquos regression intercept was signifi-cant for perfectionistic concernsrsquo relationship with suicideideation and suicide attempts Moreover the funnel plot forperfectionistic concerns and suicide attempts was asymmetri-cal Accordingly for perfectionistic concernsrsquo relationshipwith suicide ideation and suicide attempts trim and fill esti-mates may provide more accurate estimates Nonethelessafter imputing missing studies the adjusted point estimatesfor perfectionistic concernsrsquo relationships with suicide idea-tion and suicide attempts provided the same substantiveimplications (see Table 2)
4 | DISCUSSION
Suicide claims one life every 45 seconds (World HealthOrganization 2012) Given the wide-reaching personal andsocietal costs of suicide it is vital to identify contributingfactors One such factor supported by over 50 years of casehistories theoretical accounts and empirical research is per-fectionism (Blatt 1995 Hassan et al 2014 Hewitt et al2014 Kiamanesh et al 2014 Shaffer 1974) Yet despitethe abundance of research the role of perfectionism in sui-cide remains underappreciated under-recognized and mis-understood due to inconsistencies between studies infindings underpowered studies and uncertainty surroundingwhether perfectionism dimensions predict longitudinalincreases in suicidality We aimed to rectify this by rigor-ously conducting the first meta-analytic review of the perfec-tionismndashsuicidality relationship
41 | An improved understanding of theperfectionismndashsuicidality relationship
Our meta-analysis of 45 studies 54 samples and 11747 par-ticipants represents the most comprehensive test of the per-fectionismndashsuicidality link to date All dimensions orcorrelates of perfectionism (except for other-oriented perfec-tionism and organization) were positively related to suicideideation and these effect sizes were generally consistent
SMITH ET AL | 535
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Hew
ittet
al(1994)
study1
91psychiatricb
355
538
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
RST
-past
RST
-future
mdash
Hew
ittet
al(1994)
study2
160
university
a217
656
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SSI
RST
-past
RST
-future
mdash
Hew
ittet
al(1997)
wom
en33
psychiatricb
154
1000
NR
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
mdash
Hew
ittet
al(1997)
men
33psychiatricb
154
00
NR
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
mdash
Hew
ittet
al(1998)
78psychiatricb
328
538
308
article
cross-sectionali
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Hew
ittet
al(2014)
55psychiatricb
155
745
255
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
SIQ
attemptsi
Hunteramp
OrsquoConnor(2003)
sample1
43psychiatricb
346
534
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Hunteramp
OrsquoConnor(2003)
sample2
44psychiatricb
346
477
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
mdashattemptsi
Izadi(2015)
50community
c270
740
420
dissertatio
ncross-sectional
MPS
-SPP
FMPS
-COM
FMPS
-PC
FMPS
-PE
SBQ-SI
attemptsf
Jacobs
etal(2009)
439
psychiatricb
146
540
260
article
cross-sectional
DAS-P
SIQ-JR
mdash
Jeglic
(2003)
97university
a184
732
330
dissertatio
ncross-sectional
FMPS
-total
mdashattemptsi
Jeglic
etal(2007)
study2
440
university
a185
620
400
article
cross-sectional
FMPS
-total
mdashattemptsi
(Contin
ues)
SMITH ET AL | 527
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Muyan
ampChang
(2015)
288
university
a213
590
NR
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
FSII
mdash
OrsquoConnoramp
Forgan
(2007)
255
university
a220
780
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
GHQ-ST
mdash
OrsquoConnorRC
et
al(2007)
study2
151
university
a240
722
NR
article
long
itudinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
OrsquoConnorDB
et
al(2007)
sample1
65psychiatricb
241
722
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
OrsquoConnorDB
et
al(2007)
sample2
61psychiatricb
241
722
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Pisetsky
etal(2013)
635
psychiatricb
317
NR
NR
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PS
mdashattemptsi
Portzkyet
al(2014)
1436
psychiatricb
242
954
NR
article
cross-sectional
EDI
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
mdashattemptsi
Ranieriet
al(1987)
sample1
50psychiatricb
443
560
80
article
cross-sectional
DAS-P
BSS
Iattemptsf
Ranieriet
al(1987)
sample2
25psychiatricb
417
600
NR
article
cross-sectional
DAS-P
BSS
Iattemptsf
(Contin
ues)
528 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Rasmussenet
al(2008)
sample1
17psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussenet
al(2008)
sample2
23psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussen
Elliotet
al(2012)
161
psychiatricb
337
590
NR
article
cross-sectional
MPS
-SPP
SPS-SI
mdash
Rasmussen
Slish
etal(2012)
214
university
a201
570
257
article
cross-sectional
APS
-DDSI-SS
mdash
Roxboroughet
al(2012)
152
psychiatricb
129
454
285
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
intent
hmdash
Slish(2006)
48university
a201
521
625
dissertatio
ncross-sectional
APS
-DDSI-SS
mdash
Wallack
(2007)
181
university
a198
796
260
dissertatio
ncross-sectional
APS
-DSIS
mdash
Wanget
al(2013)
466
university
a264
496
NR
article
cross-sectional
APS
-DSIS
mdash
Yam
aguchi
etal(2000)
51psychiatricb
212
961
NR
article
cross-sectional
EDI
mdashattemptsi
Note
N5totalnumberof
participantsNR5
notreportedFemale5percentage
female
Ethnic5percentage
ethnic
minority
Status
5publicationstatus
ofthestudy
FMPS
5Frostandcolleaguesrsquo
(1990)
Multid
imen-
sional
Perfectio
nism
Scale
total5
totalscore
ASIQ5
Reynoldsrsquos(1991)
AdultSu
icideIdeatio
nQuestionnaireCOM
5concernover
mistakesDAA5
doubtsaboutactio
nsPC
5parental
criticism
PE
5parental
expecta-
tionsPS
5personal
standardsORG5organizatio
nAAHS-ST
5NationalAdolescentHealth
Survey
Suicidal
Thinkingmodifiedversion(1989)DAS-P5Weissman
andBeckrsquos(1978)
Dysfunctio
nalAttitude
Scale-
Perfectio
nism
subscaleSS
I5Beck
SteerandRanierirsquos
(1988)
ScaleforSu
icidal
Ideatio
nMSS
I5MillerNormanBishop
andDow
rsquos(1986)
ModifiedScaleforSu
icidal
Ideatio
nMPS
5Hew
ittandFlettrsquos
(1991)
Multi-
dimensional
Perfectio
nism
Scale
SOP5self-orientedperfectio
nism
OOP5other-oriented
perfectio
nism
SP
P5socially
prescribed
perfectio
nism
CSI
5Blanksteinrsquos(2007)
Current
SuicideIdeatio
nScale
CAPS
5Flett
andcolleaguesrsquo
(2016)
Child-A
dolescentPerfectio
nism
Scale
SIQ5
Reynoldsrsquos(1987b)Su
icidal
Ideatio
nQuestionnaireEDI5
Garnerandcolleaguesrsquo
(1983)
EatingDisorderInventory-Perfectio
nism
subscaleBSS
5Beck
andSteerrsquos
(1993)
SuicideIdeatio
nScale
M5
motivation
P5preparation
Intent5suicidal
intentCSP
S5Pfefferrsquos
(1986)
Child
SuicidePo
tentialScale
GHQ-ST5
GoldbergandWilliamsrsquos(1988)
General
Health
Questionnaire-SuicidalThinkingsubscaleBDI-SI
5Beckrsquos(1979)
DepressionInventoryitem-9
(SuicidalIntent)RST
-past5
ratin
gof
thefrequencyof
pastsuicidal
thoughtsRST
-future5ratin
gof
thefrequencyof
future
suicidal
thoughtsSB
Q5
Linehanrsquos
(1981)
Suicidal
BehaviorQuestionnaireSI
5suicidal
ideatio
nSIQ-JR5
Reynoldsrsquos(1987a)Su
icidal
Ideatio
nQuestionnaire-G
rades7ndash9
FSII5
Chang
andChang
rsquos(2016)
Frequency
ofSu
icideIdeatio
nInventory
SPS5CullandGillrsquos
(1982)
SuicideProbability
Scale
BSS
I5Beck
KovacsandWeissmanrsquos
(1979)
ScaleforSu
icidal
Ideatio
nAPS
-D5
Slaney
andcolleaguesrsquo
(2001)
Alm
ostPerfect
Scale-Revised
Discrepancy
subscaleDSI-SS5
MetalskyandJoinerrsquos
(1997)
DepressiveSy
mptom
sInventory-Su
icidality
subscaleSIS5Ruddrsquos(1989)
Suicidal
Ideatio
nScale
a University
undergraduates
b Psychiatric
patients
c Com
munity
adults
d Medical
students
e Participants
reported
whether
they
hadever
seriouslythoughtaboutattemptingsuicide
f Self-reported
numberof
priorsuicideattempts
g Prior
numberof
suicideattemptsassessed
byaclinician
h Participants
asked
ldquoHow
likelyisitthat
youwill
attempt
suicidesomedayrdquo
i Com
paredsuicideattemptersandnon-attempters
SMITH ET AL | 529
studies examining other-oriented perfectionism and suicidal-ity (see Table 1) meaning this literature is now suitable formeta-analysis In sum though perfectionistic concernsrsquo linkwith suicidality is clear (Flett al 2014 Hewitt et al 2006OrsquoConnor 2007) perfectionistic strivingsrsquo and other-oriented perfectionismrsquos link with suicidality is unclear
15 | Advancing research on theperfectionismndashsuicidality relationship usingmeta-analysis
Over 50 years of case reports theoretical accounts andempirical research implicate perfectionism in suicide (egBlatt 1995 Hassan Flett Ganguli amp Hewitt 2014 Hewittet al 2014 Kiamanesh Dyregrov Haavind amp Dieserud2014 Shaffer 1974) And yet there is much to learn aboutthe perfectionismndashsuicidality relationship (Flett et al 2014)First noteworthy inconsistencies between studies in findings(eg Flamenbaum amp Holden 2007 Hewitt et al 19982014 Hunter amp OrsquoConnor 2003) have clouded our under-standing of perfectionistic strivingsrsquo and other-oriented per-fectionismrsquos relationships with suicidality A quantitativesynthesis is needed for overall conclusions to be reachedSuch a quantitative synthesis could also allow for tests ofmoderating variables (eg gender) that might explain whenthe strength or the direction of the perfectionismndashsuicidalityrelationship changes Second despite evidence that correla-tions do not stabilize until N 250 (Scheuroonbrodt amp Perugini2013) most research on perfectionism and suicide attemptsis underpowered (cf Flamenbaum amp Holden 2007) How-ever meta-analysis could overcome limitations of small sam-ples (Borenstein Hedges Higgins amp Rothstein 2009) andbring greater clarity to our understanding of perfectionismrsquosrelationship with suicide attempts Third as noted by Flettet al (2014) and OrsquoConnor (2007) the extent to which per-fectionism dimensions confer risk for suicide has yet to bedetermined Indeed most investigators use cross-sectionaldesigns which unlike longitudinal designs cannot addresstemporal precedence As such whether perfectionism leadsto increases in suicidality is unclear and researchers andclinicians can only speculate as to whether reducing perfec-tionism reduces suicidality Nevertheless there is now suffi-cient data to test whether self-oriented other-oriented andsocially prescribed perfectionism predict follow-up suicideideation beyond baseline suicide ideation (Chen 2012Enns Cox Sareen amp Freeman 2001 R C OrsquoConnorWhyte et al 2007) Fourth due to limitations of nonempiri-cal reviews the strength of the relation between perfection-ism dimensions suicide ideation and suicide attempts isunclear A meta-analysis could shed light on which perfec-tionism dimensions display the strongest relations with sui-cide ideation and suicide attempts which in time might
inform the development of interventions designed to targetand to modify perfectionismrsquos most pernicious aspects
16 | Objectives and hypothesis
Our primary aim was to bring greater clarity to our under-standing of the perfectionismndashsuicidality relationship bycomprehensively synthesizing empirical research on perfec-tionism suicide ideation and suicide attempts To date thereis no meta-analysis of findings from this long-standing andimportant literature We also aimed to test the contentiouslydebated relation between perfectionistic strivings suicideideation and suicide attempts Such evidence would informdebate on the pros and cons of demanding perfection of one-self (eg Stoeber amp Otto 2006 Sherry Hewitt SherryFlett amp Graham 2010) Another aim was to test whetherself-oriented other-oriented and socially prescribed perfec-tionism predicted longitudinal increases in suicide ideationover time Controlling for baseline suicide ideation repre-sents a stringent test of the perfectionismndashsuicidality relation-ship as baseline suicide ideation is a strong predictor ofsubsequent suicide ideation (eg Joiner et al 2005)
Building on theory and research (Flett et al 2014Hewitt et al 2006 OrsquoConnor 2007) we hypothesized per-fectionistic concerns (socially prescribed perfectionism con-cern over mistakes doubts about action discrepancy andperfectionistic attitudes) would display positive relationshipswith suicide ideation and attempts We also hypothesizedsocially prescribed perfectionism would place people at riskfor longitudinal increases in suicide ideation However giventhe inconsistency of research on suicidality in relation to per-fectionistic strivings (self-oriented perfectionism personalstandards) other forms of perfectionism (other-oriented per-fectionism EDI-perfectionism total scores FMPS-perfectionism total scores) and correlates of perfectionism(parental criticism parental expectations organization) weconsidered our investigation into these questions to be moreexploratory
2 | METHOD
21 | Selection of studies
In 2016 a literature search using PsycINFO Medline Webof Science ERIC and ProQuest Dissertations and Theseswas conducted using the keywords and Boolean search termsldquoperfectrdquo and ldquosuicidrdquo This search yielded 100 studiesfrom PsycINFO 122 studies from Medline 226 studies fromWeb of Science and 38 studies from ProQuest We alsocompiled a list of 353 authors who had published on perfec-tionism We then contacted each author individually andrequested unpublished findings However none of the
530 | SMITH ET AL
authors contacted provided relevant data Additionally wemonitored the Perfectionism Network Mailing List to iden-tify studies that were accepted but not published at the timeof our literature search This yielded one study Chen et al(2017) Both the first and the third author then reviewedabstracts of all studies identified selecting studies meetinginclusion criteria Studies were included that (a) containeddata on perfectionism and suicidality (ideation and attempts)and (b) were in English Included studies also (c) reported aneffect size or enough information for computing an effectsize or effect size information was obtained from a studyauthor All authors contacted (N5 1) provided the requestedinformation
This literature search yielded 57 studies for inclusionInter-rater agreement on inclusion or exclusion in the meta-analysis was 95 Disagreement was resolved by revisitingarticles and coming to a consensus The reference lists ofincluded articles were also examined to locate additional rel-evant literature On August 7 2016 we terminated all searchstrategies and started data reduction and analysis Weexcluded 12 studies (see Supplemental Material A) The finalsample of included studies was composed of 45 studies with54 samples
22 | Coding of studies
The first and the third author coded each study based on ninecharacteristics sample size sample type mean age of partici-pants percentage of female participants percentage of ethnicminority participants publication status measure used toassess perfectionism measure used to assess suicide ideationand measure used to assess suicide attempts
23 | Meta-analytic procedures
Random effects analyses were conducted using Comprehen-sive Meta-Analysis software (Borenstein et al 2005) Wechose random effects models over fixed effects models asthe 45 included studies varied widely in design We alsoweighed mean effects following the procedure suggested byHunter and Schmidt (1990) This allowed us to estimatemean effect sizes and variance in observed scores after con-sidering sampling error (Card 2012) Next effect size esti-mates were weighted by sample size and aggregated Forstudies with more than one measure of suicide ideation weaveraged effect sizes so only one effect was included (Boren-stein et al 2009 Card 2012) Effect sizes presented in met-rics other than r (ie means t-tests d or F scores) wereconverted and expressed as correlations following formulasprovided by Borenstein et al (2009) We also used Boren-stein and colleaguesrsquo (2009) formula to calculate powerunder the random effects model for each weighted mean
effect Additionally most included studies measured perfec-tionism and suicide ideation with imperfect reliability Asthis can attenuate the magnitude of observed correlationseffects were adjusted by dividing the observed correlation bythe square root of the product of the two corresponding reli-ability coefficients (Card 2012) When reported the actualreliability statistics for a study were used when not reportedthe corresponding meta-analyzed mean reliability was used(Card 2012) However we were unable to adjust for unreli-ability in suicide attempts Thus in the interest of methodo-logical consistency we used the common albeitconservative strategy of interpreting observed effects whichgenerally underestimates the true magnitude of effect sizes(Borenstein et al 2009) Nonetheless for readers who dis-agree with this strategy effect sizes adjusted for unreliabilityare presented in our supplementary material
To examine the extent to which baseline self-orientedother-oriented and socially prescribed perfectionism predictfollow-up suicide ideation after controlling for baseline idea-tion we computed partial correlations using the ldquocorpcorrdquopackage (Schafer Opgen-Rhein Zuber Silvia amp Strimmer2015) for R (R Core Team 2013) Although there was insuf-ficient data to examine unique effects between perfectionismdimensions and suicide attempts there was sufficient data toexamine unique effects between perfectionism dimensionsand suicide ideation Thus again using the ldquocorpcorrdquo pack-age (Schafer et al 2015) we computed partial correlationsfor MPS-perfectionism dimensions by residualizing self-oriented other-oriented and socially prescribed perfection-ism based on their overlap with each other prior to being cor-related with suicide ideation Likewise for FMPS-perfectionism dimensions we computed partial correlationsby residualizing concern over mistakes doubts about actionparental criticism parental expectations personal standardsand organization based on their overlap with each other priorto being correlated with suicide ideation
To assess moderation we evaluated the total heterogene-ity of weighted mean effect sizes (QT) A significant QT indi-cates variance in weighted mean effect sizes is greater thanexpected by sampling error (Card 2012) a nonsignificantQT suggests a weak basis for moderation For each analysiswe also computed the inconsistency in observed effects (I2)across studies I2 indicates the percentage of total varianceacross studies due to heterogeneity Values of 25 50and 75 correspond to low medium and high heterogene-ity respectively
When QT was significant we stipulated a categoricalstructure and the total heterogeneity explained by the catego-rization (QB) was calculated (Card 2012) A significant QB
indicates meaningful differences in effects between catego-ries and provides a firm basis for moderation (Borensteinet al 2009) When QB was significant we examined
SMITH ET AL | 531
differences in effect sizes between studies grouped by publi-cation status (articles and dissertations) age (adult youngadult adolescent) and sample (community adults under-graduate students psychiatric patients) by performing aseries of all possible two-group comparisons to test whichgroup differed significantly in effect size (Card 2012) Foreach group comparison the resultant QB from the twogroups was tested using a v2 test with one degree of freedomWe also recorded gender (percentage female) and ethnicity(percentage ethnic minority) as continuous variables andused mixed effects meta-regression to test the potential mod-erating effects of gender and ethnicity
To assess publication bias we inspected funnel plotswith observed and imputed studies and computed Eggerrsquostest of regression to the intercept (Egger Smith Schneideramp Minder 1997) Such funnel plots allow for visual inspec-tion of how the effect size shifts when imputed studies areincluded (Borenstein et al 2009) In the absence of publica-tion bias Eggerrsquos regression intercept does not differ signifi-cantly from zero (Egger et al 1997)
24 | Description of studies
Our search identified 45 studies and 54 samples containingrelevant effect size data (see Table 1) The total number ofparticipants pooled across studies was 11747 Relevant datawere obtained from 38 journal articles and seven disserta-tions There were 21 samples of university undergraduates29 samples of psychiatric patients one sample of medicalstudents and three samples of community adults There were48 cross-sectional samples and six longitudinal samplesSample size varied between 17 and 1436 with an averageof 2175 (SD5 2598) The mean age of participants was268 years (SD5 102 range5 129ndash586) The average per-centage of female participants was 633 the average per-centage of ethnic minority participants was 244 Effectsize information for each individual study is presented inSupplemental Material B Adjusted effect size informationfor each individual study is presented in Supplemental Mate-rial C
25 | Measures
251 | Perfectionism
Following theory and research (eg Dunkley et al 2004Stoeber amp Otto 2006) personal standards (FMPS) and self-oriented perfectionism (MPS Child-Adolescent Perfection-ism Scale [CAPS] Flett et al 2016) were considered facetsof perfectionistic strivings concern over mistakes (FMPS)doubts about actions (FMPS) socially prescribed perfection-ism (MPS CAPS) discrepancy (APS-R) and perfectionistic
attitudes (Dysfunctional Attitude Scale-Perfectionism sub-scale [DAS-P] Weissman amp Beck 1978) were consideredfacets of perfectionistic concerns Parental criticism parentalexpectations and organization were designated correlates ofperfectionism As well parental criticism and parentalexpectations were combined and labeled as parental percep-tions (see Cox et al 2002) Other-oriented perfectionism(MPS) FMPS-perfectionism and EDI-perfectionism weredesignated other forms of perfectionism
252 | Suicide ideation and suicide attempts
Suicide ideations were assessed via self-reported suicidalthinking Suicide attempts were assessed via self-reportednumber of prior suicide attempts (eg Adkins amp Parker1996) clinicianrsquos ratings of the number of prior suicideattempts (eg Fedorowicz et al 2007) and group compari-sons between suicide attempters and non-attempters (egHewitt et al 2014) Although Pfefferrsquos (1986) Child SuicidePotential Scale (CSPS) and Linehanrsquos (1981) Suicide Behav-ior Questionnaire (SBQ) assess suicidal ideation and suicideattempts we categorized the CPS and SBQ as measures ofsuicide ideation given the majority of CSPS and SBQ itemsassess suicidal thoughts
3 | RESULTS
31 | Overall effect sizes
Weighted mean effect sizes between perfectionism corre-lates of perfectionism and suicide ideation and suicideattempts are in Table 2 (see Supplemental Material D foradjusted effect sizes) Following Cohenrsquos (1992) guidelinesfor small medium and large effects (r5 10 30 and 50respectively) perfectionistic concerns socially prescribedperfectionism concern over mistakes doubts about actionsdiscrepancy perfectionistic attitudes perfectionistic striv-ings self-oriented perfectionism personal standards parentalperceptions parental criticism parental expectations andFMPS-perfectionism displayed small-to-moderate positiverelationships with suicide ideation Other-oriented perfection-ismrsquos and organizationrsquos relationships with suicide ideationwere nonsignificant Perfectionistic concerns socially pre-scribed perfectionism concern over mistakes doubts aboutaction FMPS-perfectionism parental perceptions parentalcriticism and parental expectations displayed small positiverelationships with suicide attempts perfectionistic attitudesrsquoperfectionistic strivingsrsquo self-oriented perfectionismrsquos perso-nal standardsrsquo other-oriented perfectionismrsquos EDI-perfectionismrsquos and organizationrsquos relationships with suicideattempts were nonsignificant
532 | SMITH ET AL
TABLE2
Summaryof
overalleffect
sizesfortherelatio
nshipbetweenperfectio
nism
andsuicidality
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Suicideideatio
n
Perfectio
nistic
concerns
a42
7936
28
[24
32]
9910
5863
175
[076
273]
028[2
431]
99
Socially
prescribed
perfectio
nism
303640
28
[25
32]
3704
2171
035
[2100169]
028[2
532]
99
Concern
over
mistakes
5952
25
[13
36]
1219
6720
251
[2436938]
025[1
336]
98
Doubtsaboutactio
ns4
902
27
[18
35]
514
4162
294
[25671158
220[1
130]
99
Discrepancy
4904
26
[14
38]
917
6727
338
[24791154]
124[1
235]
98
Perfectio
nistic
attitudes
51533
37
[19
52]
3355
8808
407
[2033848]
226[0
941]
98
Perfectio
nistic
strivingsb
314588
10
[07
13]
3214
665
018
[2094130]
010[0
713]
99
Self-orientedperfectio
nism
273315
11
[08
15]
2096
000
ndash046
[2156064]
011[0
815]
99
Personal
standards
51273
10
[00
19]
1033
6127
334
[24711139]
010[0
019]
52
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
202755
01
[204
06]
3287
4219
027
[2178230]
101[2
04
06]
08
FMPS
totalscore
41018
31
[15
45]
1971
8477
472
[21692
2636]
127[1
240]
96
EDI-perfectio
nism
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdash
Correlatesof
perfectio
nism
Parental
perceptio
nsc
51904
19
[10
27]
1279
6871
204
[2558966]
019[1
027]
98
Parental
criticism
5952
20
[11
29]
798
4987
092
[2556740]
020[1
029]
98
Parental
expectations
5952
16
[06
26]
842
5247
196
[2391784]
113[0
323]
88
Organization
3513
ndash02
[220
17]
792
7475
253
[27738
8243]
0ndash02
[220
17]
05
Suicideattempts
Perfectio
nistic
concerns
d15
5275
12
[07
17]
2448
4281
115
[021
208]
508[0
314]
99
Socially
prescribed
perfectio
nism
8689
19
[08
29]
1257
4432
021
[2365407]
019[0
829]
93
Concern
over
mistakes
51827
09
[04
14]
012
000
008
[2035052]
109[0
413]
97
Doubtsaboutactio
n3
1777
06
[01
11]
276
000
100
[2201401]
205[2
02
11]
71
Discrepancy
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdashPerfectio
nistic
attitudes
3983
09
[203
22]
254
2126
142
[2155440]
205[2
07
17]
32
(Contin
ues)
SMITH ET AL | 533
TABLE2
(Contin
ued)
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Perfectio
nistic
strivingsa
101436
02
[202
06]
525
000
ndash010
[2110087]
002[2
01
06]
19
Self-orientedperfectio
nism
6539
07
[201
16]
304
000
ndash161
[2320ndash0
02]
007[2
01
15]
37
Personal
standards
41777
01
[204
06]
060
000
ndash049
[2182083]
001[2
04
05]
06
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
4429
ndash03
[213
06]
126
000
ndash142
[2258ndash0
28]
0ndash03
[213
06]
11
FMPS
totalscore
3666
14
[07
21]
130
000
ndash031
[2055ndash0
07]
016[0
823]
99
EDI-perfectio
nism
52975
03
[201
06]
183
000
106
[2098273]
103[2
01
06]
33
Correlatesof
perfectio
nism
Parental
perceptio
nsc
33230
07
[04
11]
053
000
045
[2643733]
007[0
411]
98
Parental
criticism
31615
08
[03
12]
065
000
063
[2523650]
207[0
211]
85
Parental
expectations
31615
07
[02
12]
010
000
001
[2386387]
007[0
211]
79
Organization
21565
ndash01
[206
04]
082
000
mdashmdash
mdashmdash
mdash
Note
k5numberof
studiesN5totalnumberof
participantsin
theksamplesr1
5weightedmeanbivariatecorrelation
CI5
confidence
intervalQT5measure
ofheterogeneity
ofeffect
sizesI25percentage
ofheteroge-
neity
kT
F5numberof
imputedstudiesas
partof
ldquotrim
andfillrdquo
method
FMPS
5Frostrsquos
andcolleaguesrsquo
(1990)
Multid
imensional
Perfectio
nism
Scale
EDI-perfectio
nism
5Garnerandcolleaguesrsquo
(1983)
EatingDisorder
Inventory-Perfectio
nism
subscale
a Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesdoubtsaboutactio
nsanddiscrepancy
b Perfectionistic
strivingsassessed
asaggregateof
self-orientedperfectio
nism
andpersonal
standards
c Parentalperceptio
nsassessed
asaggregateof
parental
criticism
andparental
expectations
(Cox
etal2002)
d Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesanddoubtsaboutactio
ns
plt05
plt01
p
lt001
534 | SMITH ET AL
Weighted mean effect sizes for the relationships betweenself-oriented other-oriented and socially prescribed perfec-tionism at baseline and suicide ideation at follow-up whilecontrolling for ideation at baseline are in SupplementalMaterial E (see Supplemental Material F for adjusted longi-tudinal effect sizes) Despite the large positive relationshipbetween baseline and follow-up suicide ideation sociallyprescribed perfectionism still displayed a small positive rela-tionship with follow-up suicide ideation after controlling forbaseline suicide ideation Self-oriented and other-orientedperfectionismrsquos relationships with follow-up suicide ideationafter controlling for baseline ideation were nonsignificant
MPS-perfectionism dimensions displayed small-to-largepositive correlations with each other (see SupplementalMaterial G for observed effects and Supplemental MaterialH for adjusted effects) After controlling for overlap in MPSdimensions self-oriented perfectionism ceased to signifi-cantly predict suicide ideation other-oriented perfectionismhad a small unique negative association with suicide idea-tion and socially prescribed perfectionism had a smallunique positive relationship with suicide ideation FMPS-perfectionism dimensions had marginal-to-large correlationswith each other (see Supplemental Material G for observedeffects and Supplemental Material H for adjusted effects)After controlling for overlap in FMPS dimensions the rela-tionships among suicide ideation and concern over mistakespersonal standards parental expectations and organizationwere nonsignificant However after controlling for overlapamong FMPS dimensions doubts about actions and parentalcriticism displayed small unique positive relationships withideation (see Supplemental Material G for observed effectsand Supplemental Material H for adjusted effects)
The test of the total heterogeneity of variance of weightedmean effect sizes (QT) was significant for suicide ideationrsquosrelations with perfectionistic concerns concern over mistakesdiscrepancy personal standards perfectionistic attitudesother-oriented perfectionism FMPS-perfectionism and orga-nization (see Table 2) QT was also significant for the linkbetween suicide attempts and perfectionistic concerns (seeTable 2) The percentage of total variance owing to heteroge-neity (I2) ranged from small to large suggesting possiblemoderators
32 | Moderator analyses
Moderator analyses (see Supplemental Material I) testedwhether effect sizes with significant heterogeneity (QT) weremoderated by publication status (peer-reviewed articles dis-sertations) age (adolescent samples 13 and 17 yearsyoung adult samples 18 and 25 years adultsamples 25 years) sample (university undergraduatescommunity adults psychiatric patients) or perfectionism
measure Perfectionistic concernsrsquo relationship with suicideattempts was nonsignificant for the CAPS but significant forthe FMPS and the MPS Meta-regression also revealed thestrength of the relationship between perfectionistic concernsand suicide attempts decreased as the proportion of femalesin a sample increased However we advise caution in inter-preting our moderator analyses given the small number ofstudies per subgroup
33 | Publication bias
Funnel plots (see Supplemental Material J) and Eggerrsquosregression intercept (see Table 2) provided mixed evidencefor publication bias Eggerrsquos regression intercept was signifi-cant for perfectionistic concernsrsquo relationship with suicideideation and suicide attempts Moreover the funnel plot forperfectionistic concerns and suicide attempts was asymmetri-cal Accordingly for perfectionistic concernsrsquo relationshipwith suicide ideation and suicide attempts trim and fill esti-mates may provide more accurate estimates Nonethelessafter imputing missing studies the adjusted point estimatesfor perfectionistic concernsrsquo relationships with suicide idea-tion and suicide attempts provided the same substantiveimplications (see Table 2)
4 | DISCUSSION
Suicide claims one life every 45 seconds (World HealthOrganization 2012) Given the wide-reaching personal andsocietal costs of suicide it is vital to identify contributingfactors One such factor supported by over 50 years of casehistories theoretical accounts and empirical research is per-fectionism (Blatt 1995 Hassan et al 2014 Hewitt et al2014 Kiamanesh et al 2014 Shaffer 1974) Yet despitethe abundance of research the role of perfectionism in sui-cide remains underappreciated under-recognized and mis-understood due to inconsistencies between studies infindings underpowered studies and uncertainty surroundingwhether perfectionism dimensions predict longitudinalincreases in suicidality We aimed to rectify this by rigor-ously conducting the first meta-analytic review of the perfec-tionismndashsuicidality relationship
41 | An improved understanding of theperfectionismndashsuicidality relationship
Our meta-analysis of 45 studies 54 samples and 11747 par-ticipants represents the most comprehensive test of the per-fectionismndashsuicidality link to date All dimensions orcorrelates of perfectionism (except for other-oriented perfec-tionism and organization) were positively related to suicideideation and these effect sizes were generally consistent
SMITH ET AL | 535
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Muyan
ampChang
(2015)
288
university
a213
590
NR
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
FSII
mdash
OrsquoConnoramp
Forgan
(2007)
255
university
a220
780
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
GHQ-ST
mdash
OrsquoConnorRC
et
al(2007)
study2
151
university
a240
722
NR
article
long
itudinal
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
OrsquoConnorDB
et
al(2007)
sample1
65psychiatricb
241
722
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
OrsquoConnorDB
et
al(2007)
sample2
61psychiatricb
241
722
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Pisetsky
etal(2013)
635
psychiatricb
317
NR
NR
article
cross-sectional
FMPS
-COM
FMPS
-DAA
FMPS
-PS
mdashattemptsi
Portzkyet
al(2014)
1436
psychiatricb
242
954
NR
article
cross-sectional
EDI
FMPS
-COM
FMPS
-DAA
FMPS
-PC
FMPS
-PE
FMPS
-PS
FMPS
-ORG
mdashattemptsi
Ranieriet
al(1987)
sample1
50psychiatricb
443
560
80
article
cross-sectional
DAS-P
BSS
Iattemptsf
Ranieriet
al(1987)
sample2
25psychiatricb
417
600
NR
article
cross-sectional
DAS-P
BSS
Iattemptsf
(Contin
ues)
528 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Rasmussenet
al(2008)
sample1
17psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussenet
al(2008)
sample2
23psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussen
Elliotet
al(2012)
161
psychiatricb
337
590
NR
article
cross-sectional
MPS
-SPP
SPS-SI
mdash
Rasmussen
Slish
etal(2012)
214
university
a201
570
257
article
cross-sectional
APS
-DDSI-SS
mdash
Roxboroughet
al(2012)
152
psychiatricb
129
454
285
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
intent
hmdash
Slish(2006)
48university
a201
521
625
dissertatio
ncross-sectional
APS
-DDSI-SS
mdash
Wallack
(2007)
181
university
a198
796
260
dissertatio
ncross-sectional
APS
-DSIS
mdash
Wanget
al(2013)
466
university
a264
496
NR
article
cross-sectional
APS
-DSIS
mdash
Yam
aguchi
etal(2000)
51psychiatricb
212
961
NR
article
cross-sectional
EDI
mdashattemptsi
Note
N5totalnumberof
participantsNR5
notreportedFemale5percentage
female
Ethnic5percentage
ethnic
minority
Status
5publicationstatus
ofthestudy
FMPS
5Frostandcolleaguesrsquo
(1990)
Multid
imen-
sional
Perfectio
nism
Scale
total5
totalscore
ASIQ5
Reynoldsrsquos(1991)
AdultSu
icideIdeatio
nQuestionnaireCOM
5concernover
mistakesDAA5
doubtsaboutactio
nsPC
5parental
criticism
PE
5parental
expecta-
tionsPS
5personal
standardsORG5organizatio
nAAHS-ST
5NationalAdolescentHealth
Survey
Suicidal
Thinkingmodifiedversion(1989)DAS-P5Weissman
andBeckrsquos(1978)
Dysfunctio
nalAttitude
Scale-
Perfectio
nism
subscaleSS
I5Beck
SteerandRanierirsquos
(1988)
ScaleforSu
icidal
Ideatio
nMSS
I5MillerNormanBishop
andDow
rsquos(1986)
ModifiedScaleforSu
icidal
Ideatio
nMPS
5Hew
ittandFlettrsquos
(1991)
Multi-
dimensional
Perfectio
nism
Scale
SOP5self-orientedperfectio
nism
OOP5other-oriented
perfectio
nism
SP
P5socially
prescribed
perfectio
nism
CSI
5Blanksteinrsquos(2007)
Current
SuicideIdeatio
nScale
CAPS
5Flett
andcolleaguesrsquo
(2016)
Child-A
dolescentPerfectio
nism
Scale
SIQ5
Reynoldsrsquos(1987b)Su
icidal
Ideatio
nQuestionnaireEDI5
Garnerandcolleaguesrsquo
(1983)
EatingDisorderInventory-Perfectio
nism
subscaleBSS
5Beck
andSteerrsquos
(1993)
SuicideIdeatio
nScale
M5
motivation
P5preparation
Intent5suicidal
intentCSP
S5Pfefferrsquos
(1986)
Child
SuicidePo
tentialScale
GHQ-ST5
GoldbergandWilliamsrsquos(1988)
General
Health
Questionnaire-SuicidalThinkingsubscaleBDI-SI
5Beckrsquos(1979)
DepressionInventoryitem-9
(SuicidalIntent)RST
-past5
ratin
gof
thefrequencyof
pastsuicidal
thoughtsRST
-future5ratin
gof
thefrequencyof
future
suicidal
thoughtsSB
Q5
Linehanrsquos
(1981)
Suicidal
BehaviorQuestionnaireSI
5suicidal
ideatio
nSIQ-JR5
Reynoldsrsquos(1987a)Su
icidal
Ideatio
nQuestionnaire-G
rades7ndash9
FSII5
Chang
andChang
rsquos(2016)
Frequency
ofSu
icideIdeatio
nInventory
SPS5CullandGillrsquos
(1982)
SuicideProbability
Scale
BSS
I5Beck
KovacsandWeissmanrsquos
(1979)
ScaleforSu
icidal
Ideatio
nAPS
-D5
Slaney
andcolleaguesrsquo
(2001)
Alm
ostPerfect
Scale-Revised
Discrepancy
subscaleDSI-SS5
MetalskyandJoinerrsquos
(1997)
DepressiveSy
mptom
sInventory-Su
icidality
subscaleSIS5Ruddrsquos(1989)
Suicidal
Ideatio
nScale
a University
undergraduates
b Psychiatric
patients
c Com
munity
adults
d Medical
students
e Participants
reported
whether
they
hadever
seriouslythoughtaboutattemptingsuicide
f Self-reported
numberof
priorsuicideattempts
g Prior
numberof
suicideattemptsassessed
byaclinician
h Participants
asked
ldquoHow
likelyisitthat
youwill
attempt
suicidesomedayrdquo
i Com
paredsuicideattemptersandnon-attempters
SMITH ET AL | 529
studies examining other-oriented perfectionism and suicidal-ity (see Table 1) meaning this literature is now suitable formeta-analysis In sum though perfectionistic concernsrsquo linkwith suicidality is clear (Flett al 2014 Hewitt et al 2006OrsquoConnor 2007) perfectionistic strivingsrsquo and other-oriented perfectionismrsquos link with suicidality is unclear
15 | Advancing research on theperfectionismndashsuicidality relationship usingmeta-analysis
Over 50 years of case reports theoretical accounts andempirical research implicate perfectionism in suicide (egBlatt 1995 Hassan Flett Ganguli amp Hewitt 2014 Hewittet al 2014 Kiamanesh Dyregrov Haavind amp Dieserud2014 Shaffer 1974) And yet there is much to learn aboutthe perfectionismndashsuicidality relationship (Flett et al 2014)First noteworthy inconsistencies between studies in findings(eg Flamenbaum amp Holden 2007 Hewitt et al 19982014 Hunter amp OrsquoConnor 2003) have clouded our under-standing of perfectionistic strivingsrsquo and other-oriented per-fectionismrsquos relationships with suicidality A quantitativesynthesis is needed for overall conclusions to be reachedSuch a quantitative synthesis could also allow for tests ofmoderating variables (eg gender) that might explain whenthe strength or the direction of the perfectionismndashsuicidalityrelationship changes Second despite evidence that correla-tions do not stabilize until N 250 (Scheuroonbrodt amp Perugini2013) most research on perfectionism and suicide attemptsis underpowered (cf Flamenbaum amp Holden 2007) How-ever meta-analysis could overcome limitations of small sam-ples (Borenstein Hedges Higgins amp Rothstein 2009) andbring greater clarity to our understanding of perfectionismrsquosrelationship with suicide attempts Third as noted by Flettet al (2014) and OrsquoConnor (2007) the extent to which per-fectionism dimensions confer risk for suicide has yet to bedetermined Indeed most investigators use cross-sectionaldesigns which unlike longitudinal designs cannot addresstemporal precedence As such whether perfectionism leadsto increases in suicidality is unclear and researchers andclinicians can only speculate as to whether reducing perfec-tionism reduces suicidality Nevertheless there is now suffi-cient data to test whether self-oriented other-oriented andsocially prescribed perfectionism predict follow-up suicideideation beyond baseline suicide ideation (Chen 2012Enns Cox Sareen amp Freeman 2001 R C OrsquoConnorWhyte et al 2007) Fourth due to limitations of nonempiri-cal reviews the strength of the relation between perfection-ism dimensions suicide ideation and suicide attempts isunclear A meta-analysis could shed light on which perfec-tionism dimensions display the strongest relations with sui-cide ideation and suicide attempts which in time might
inform the development of interventions designed to targetand to modify perfectionismrsquos most pernicious aspects
16 | Objectives and hypothesis
Our primary aim was to bring greater clarity to our under-standing of the perfectionismndashsuicidality relationship bycomprehensively synthesizing empirical research on perfec-tionism suicide ideation and suicide attempts To date thereis no meta-analysis of findings from this long-standing andimportant literature We also aimed to test the contentiouslydebated relation between perfectionistic strivings suicideideation and suicide attempts Such evidence would informdebate on the pros and cons of demanding perfection of one-self (eg Stoeber amp Otto 2006 Sherry Hewitt SherryFlett amp Graham 2010) Another aim was to test whetherself-oriented other-oriented and socially prescribed perfec-tionism predicted longitudinal increases in suicide ideationover time Controlling for baseline suicide ideation repre-sents a stringent test of the perfectionismndashsuicidality relation-ship as baseline suicide ideation is a strong predictor ofsubsequent suicide ideation (eg Joiner et al 2005)
Building on theory and research (Flett et al 2014Hewitt et al 2006 OrsquoConnor 2007) we hypothesized per-fectionistic concerns (socially prescribed perfectionism con-cern over mistakes doubts about action discrepancy andperfectionistic attitudes) would display positive relationshipswith suicide ideation and attempts We also hypothesizedsocially prescribed perfectionism would place people at riskfor longitudinal increases in suicide ideation However giventhe inconsistency of research on suicidality in relation to per-fectionistic strivings (self-oriented perfectionism personalstandards) other forms of perfectionism (other-oriented per-fectionism EDI-perfectionism total scores FMPS-perfectionism total scores) and correlates of perfectionism(parental criticism parental expectations organization) weconsidered our investigation into these questions to be moreexploratory
2 | METHOD
21 | Selection of studies
In 2016 a literature search using PsycINFO Medline Webof Science ERIC and ProQuest Dissertations and Theseswas conducted using the keywords and Boolean search termsldquoperfectrdquo and ldquosuicidrdquo This search yielded 100 studiesfrom PsycINFO 122 studies from Medline 226 studies fromWeb of Science and 38 studies from ProQuest We alsocompiled a list of 353 authors who had published on perfec-tionism We then contacted each author individually andrequested unpublished findings However none of the
530 | SMITH ET AL
authors contacted provided relevant data Additionally wemonitored the Perfectionism Network Mailing List to iden-tify studies that were accepted but not published at the timeof our literature search This yielded one study Chen et al(2017) Both the first and the third author then reviewedabstracts of all studies identified selecting studies meetinginclusion criteria Studies were included that (a) containeddata on perfectionism and suicidality (ideation and attempts)and (b) were in English Included studies also (c) reported aneffect size or enough information for computing an effectsize or effect size information was obtained from a studyauthor All authors contacted (N5 1) provided the requestedinformation
This literature search yielded 57 studies for inclusionInter-rater agreement on inclusion or exclusion in the meta-analysis was 95 Disagreement was resolved by revisitingarticles and coming to a consensus The reference lists ofincluded articles were also examined to locate additional rel-evant literature On August 7 2016 we terminated all searchstrategies and started data reduction and analysis Weexcluded 12 studies (see Supplemental Material A) The finalsample of included studies was composed of 45 studies with54 samples
22 | Coding of studies
The first and the third author coded each study based on ninecharacteristics sample size sample type mean age of partici-pants percentage of female participants percentage of ethnicminority participants publication status measure used toassess perfectionism measure used to assess suicide ideationand measure used to assess suicide attempts
23 | Meta-analytic procedures
Random effects analyses were conducted using Comprehen-sive Meta-Analysis software (Borenstein et al 2005) Wechose random effects models over fixed effects models asthe 45 included studies varied widely in design We alsoweighed mean effects following the procedure suggested byHunter and Schmidt (1990) This allowed us to estimatemean effect sizes and variance in observed scores after con-sidering sampling error (Card 2012) Next effect size esti-mates were weighted by sample size and aggregated Forstudies with more than one measure of suicide ideation weaveraged effect sizes so only one effect was included (Boren-stein et al 2009 Card 2012) Effect sizes presented in met-rics other than r (ie means t-tests d or F scores) wereconverted and expressed as correlations following formulasprovided by Borenstein et al (2009) We also used Boren-stein and colleaguesrsquo (2009) formula to calculate powerunder the random effects model for each weighted mean
effect Additionally most included studies measured perfec-tionism and suicide ideation with imperfect reliability Asthis can attenuate the magnitude of observed correlationseffects were adjusted by dividing the observed correlation bythe square root of the product of the two corresponding reli-ability coefficients (Card 2012) When reported the actualreliability statistics for a study were used when not reportedthe corresponding meta-analyzed mean reliability was used(Card 2012) However we were unable to adjust for unreli-ability in suicide attempts Thus in the interest of methodo-logical consistency we used the common albeitconservative strategy of interpreting observed effects whichgenerally underestimates the true magnitude of effect sizes(Borenstein et al 2009) Nonetheless for readers who dis-agree with this strategy effect sizes adjusted for unreliabilityare presented in our supplementary material
To examine the extent to which baseline self-orientedother-oriented and socially prescribed perfectionism predictfollow-up suicide ideation after controlling for baseline idea-tion we computed partial correlations using the ldquocorpcorrdquopackage (Schafer Opgen-Rhein Zuber Silvia amp Strimmer2015) for R (R Core Team 2013) Although there was insuf-ficient data to examine unique effects between perfectionismdimensions and suicide attempts there was sufficient data toexamine unique effects between perfectionism dimensionsand suicide ideation Thus again using the ldquocorpcorrdquo pack-age (Schafer et al 2015) we computed partial correlationsfor MPS-perfectionism dimensions by residualizing self-oriented other-oriented and socially prescribed perfection-ism based on their overlap with each other prior to being cor-related with suicide ideation Likewise for FMPS-perfectionism dimensions we computed partial correlationsby residualizing concern over mistakes doubts about actionparental criticism parental expectations personal standardsand organization based on their overlap with each other priorto being correlated with suicide ideation
To assess moderation we evaluated the total heterogene-ity of weighted mean effect sizes (QT) A significant QT indi-cates variance in weighted mean effect sizes is greater thanexpected by sampling error (Card 2012) a nonsignificantQT suggests a weak basis for moderation For each analysiswe also computed the inconsistency in observed effects (I2)across studies I2 indicates the percentage of total varianceacross studies due to heterogeneity Values of 25 50and 75 correspond to low medium and high heterogene-ity respectively
When QT was significant we stipulated a categoricalstructure and the total heterogeneity explained by the catego-rization (QB) was calculated (Card 2012) A significant QB
indicates meaningful differences in effects between catego-ries and provides a firm basis for moderation (Borensteinet al 2009) When QB was significant we examined
SMITH ET AL | 531
differences in effect sizes between studies grouped by publi-cation status (articles and dissertations) age (adult youngadult adolescent) and sample (community adults under-graduate students psychiatric patients) by performing aseries of all possible two-group comparisons to test whichgroup differed significantly in effect size (Card 2012) Foreach group comparison the resultant QB from the twogroups was tested using a v2 test with one degree of freedomWe also recorded gender (percentage female) and ethnicity(percentage ethnic minority) as continuous variables andused mixed effects meta-regression to test the potential mod-erating effects of gender and ethnicity
To assess publication bias we inspected funnel plotswith observed and imputed studies and computed Eggerrsquostest of regression to the intercept (Egger Smith Schneideramp Minder 1997) Such funnel plots allow for visual inspec-tion of how the effect size shifts when imputed studies areincluded (Borenstein et al 2009) In the absence of publica-tion bias Eggerrsquos regression intercept does not differ signifi-cantly from zero (Egger et al 1997)
24 | Description of studies
Our search identified 45 studies and 54 samples containingrelevant effect size data (see Table 1) The total number ofparticipants pooled across studies was 11747 Relevant datawere obtained from 38 journal articles and seven disserta-tions There were 21 samples of university undergraduates29 samples of psychiatric patients one sample of medicalstudents and three samples of community adults There were48 cross-sectional samples and six longitudinal samplesSample size varied between 17 and 1436 with an averageof 2175 (SD5 2598) The mean age of participants was268 years (SD5 102 range5 129ndash586) The average per-centage of female participants was 633 the average per-centage of ethnic minority participants was 244 Effectsize information for each individual study is presented inSupplemental Material B Adjusted effect size informationfor each individual study is presented in Supplemental Mate-rial C
25 | Measures
251 | Perfectionism
Following theory and research (eg Dunkley et al 2004Stoeber amp Otto 2006) personal standards (FMPS) and self-oriented perfectionism (MPS Child-Adolescent Perfection-ism Scale [CAPS] Flett et al 2016) were considered facetsof perfectionistic strivings concern over mistakes (FMPS)doubts about actions (FMPS) socially prescribed perfection-ism (MPS CAPS) discrepancy (APS-R) and perfectionistic
attitudes (Dysfunctional Attitude Scale-Perfectionism sub-scale [DAS-P] Weissman amp Beck 1978) were consideredfacets of perfectionistic concerns Parental criticism parentalexpectations and organization were designated correlates ofperfectionism As well parental criticism and parentalexpectations were combined and labeled as parental percep-tions (see Cox et al 2002) Other-oriented perfectionism(MPS) FMPS-perfectionism and EDI-perfectionism weredesignated other forms of perfectionism
252 | Suicide ideation and suicide attempts
Suicide ideations were assessed via self-reported suicidalthinking Suicide attempts were assessed via self-reportednumber of prior suicide attempts (eg Adkins amp Parker1996) clinicianrsquos ratings of the number of prior suicideattempts (eg Fedorowicz et al 2007) and group compari-sons between suicide attempters and non-attempters (egHewitt et al 2014) Although Pfefferrsquos (1986) Child SuicidePotential Scale (CSPS) and Linehanrsquos (1981) Suicide Behav-ior Questionnaire (SBQ) assess suicidal ideation and suicideattempts we categorized the CPS and SBQ as measures ofsuicide ideation given the majority of CSPS and SBQ itemsassess suicidal thoughts
3 | RESULTS
31 | Overall effect sizes
Weighted mean effect sizes between perfectionism corre-lates of perfectionism and suicide ideation and suicideattempts are in Table 2 (see Supplemental Material D foradjusted effect sizes) Following Cohenrsquos (1992) guidelinesfor small medium and large effects (r5 10 30 and 50respectively) perfectionistic concerns socially prescribedperfectionism concern over mistakes doubts about actionsdiscrepancy perfectionistic attitudes perfectionistic striv-ings self-oriented perfectionism personal standards parentalperceptions parental criticism parental expectations andFMPS-perfectionism displayed small-to-moderate positiverelationships with suicide ideation Other-oriented perfection-ismrsquos and organizationrsquos relationships with suicide ideationwere nonsignificant Perfectionistic concerns socially pre-scribed perfectionism concern over mistakes doubts aboutaction FMPS-perfectionism parental perceptions parentalcriticism and parental expectations displayed small positiverelationships with suicide attempts perfectionistic attitudesrsquoperfectionistic strivingsrsquo self-oriented perfectionismrsquos perso-nal standardsrsquo other-oriented perfectionismrsquos EDI-perfectionismrsquos and organizationrsquos relationships with suicideattempts were nonsignificant
532 | SMITH ET AL
TABLE2
Summaryof
overalleffect
sizesfortherelatio
nshipbetweenperfectio
nism
andsuicidality
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Suicideideatio
n
Perfectio
nistic
concerns
a42
7936
28
[24
32]
9910
5863
175
[076
273]
028[2
431]
99
Socially
prescribed
perfectio
nism
303640
28
[25
32]
3704
2171
035
[2100169]
028[2
532]
99
Concern
over
mistakes
5952
25
[13
36]
1219
6720
251
[2436938]
025[1
336]
98
Doubtsaboutactio
ns4
902
27
[18
35]
514
4162
294
[25671158
220[1
130]
99
Discrepancy
4904
26
[14
38]
917
6727
338
[24791154]
124[1
235]
98
Perfectio
nistic
attitudes
51533
37
[19
52]
3355
8808
407
[2033848]
226[0
941]
98
Perfectio
nistic
strivingsb
314588
10
[07
13]
3214
665
018
[2094130]
010[0
713]
99
Self-orientedperfectio
nism
273315
11
[08
15]
2096
000
ndash046
[2156064]
011[0
815]
99
Personal
standards
51273
10
[00
19]
1033
6127
334
[24711139]
010[0
019]
52
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
202755
01
[204
06]
3287
4219
027
[2178230]
101[2
04
06]
08
FMPS
totalscore
41018
31
[15
45]
1971
8477
472
[21692
2636]
127[1
240]
96
EDI-perfectio
nism
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdash
Correlatesof
perfectio
nism
Parental
perceptio
nsc
51904
19
[10
27]
1279
6871
204
[2558966]
019[1
027]
98
Parental
criticism
5952
20
[11
29]
798
4987
092
[2556740]
020[1
029]
98
Parental
expectations
5952
16
[06
26]
842
5247
196
[2391784]
113[0
323]
88
Organization
3513
ndash02
[220
17]
792
7475
253
[27738
8243]
0ndash02
[220
17]
05
Suicideattempts
Perfectio
nistic
concerns
d15
5275
12
[07
17]
2448
4281
115
[021
208]
508[0
314]
99
Socially
prescribed
perfectio
nism
8689
19
[08
29]
1257
4432
021
[2365407]
019[0
829]
93
Concern
over
mistakes
51827
09
[04
14]
012
000
008
[2035052]
109[0
413]
97
Doubtsaboutactio
n3
1777
06
[01
11]
276
000
100
[2201401]
205[2
02
11]
71
Discrepancy
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdashPerfectio
nistic
attitudes
3983
09
[203
22]
254
2126
142
[2155440]
205[2
07
17]
32
(Contin
ues)
SMITH ET AL | 533
TABLE2
(Contin
ued)
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Perfectio
nistic
strivingsa
101436
02
[202
06]
525
000
ndash010
[2110087]
002[2
01
06]
19
Self-orientedperfectio
nism
6539
07
[201
16]
304
000
ndash161
[2320ndash0
02]
007[2
01
15]
37
Personal
standards
41777
01
[204
06]
060
000
ndash049
[2182083]
001[2
04
05]
06
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
4429
ndash03
[213
06]
126
000
ndash142
[2258ndash0
28]
0ndash03
[213
06]
11
FMPS
totalscore
3666
14
[07
21]
130
000
ndash031
[2055ndash0
07]
016[0
823]
99
EDI-perfectio
nism
52975
03
[201
06]
183
000
106
[2098273]
103[2
01
06]
33
Correlatesof
perfectio
nism
Parental
perceptio
nsc
33230
07
[04
11]
053
000
045
[2643733]
007[0
411]
98
Parental
criticism
31615
08
[03
12]
065
000
063
[2523650]
207[0
211]
85
Parental
expectations
31615
07
[02
12]
010
000
001
[2386387]
007[0
211]
79
Organization
21565
ndash01
[206
04]
082
000
mdashmdash
mdashmdash
mdash
Note
k5numberof
studiesN5totalnumberof
participantsin
theksamplesr1
5weightedmeanbivariatecorrelation
CI5
confidence
intervalQT5measure
ofheterogeneity
ofeffect
sizesI25percentage
ofheteroge-
neity
kT
F5numberof
imputedstudiesas
partof
ldquotrim
andfillrdquo
method
FMPS
5Frostrsquos
andcolleaguesrsquo
(1990)
Multid
imensional
Perfectio
nism
Scale
EDI-perfectio
nism
5Garnerandcolleaguesrsquo
(1983)
EatingDisorder
Inventory-Perfectio
nism
subscale
a Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesdoubtsaboutactio
nsanddiscrepancy
b Perfectionistic
strivingsassessed
asaggregateof
self-orientedperfectio
nism
andpersonal
standards
c Parentalperceptio
nsassessed
asaggregateof
parental
criticism
andparental
expectations
(Cox
etal2002)
d Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesanddoubtsaboutactio
ns
plt05
plt01
p
lt001
534 | SMITH ET AL
Weighted mean effect sizes for the relationships betweenself-oriented other-oriented and socially prescribed perfec-tionism at baseline and suicide ideation at follow-up whilecontrolling for ideation at baseline are in SupplementalMaterial E (see Supplemental Material F for adjusted longi-tudinal effect sizes) Despite the large positive relationshipbetween baseline and follow-up suicide ideation sociallyprescribed perfectionism still displayed a small positive rela-tionship with follow-up suicide ideation after controlling forbaseline suicide ideation Self-oriented and other-orientedperfectionismrsquos relationships with follow-up suicide ideationafter controlling for baseline ideation were nonsignificant
MPS-perfectionism dimensions displayed small-to-largepositive correlations with each other (see SupplementalMaterial G for observed effects and Supplemental MaterialH for adjusted effects) After controlling for overlap in MPSdimensions self-oriented perfectionism ceased to signifi-cantly predict suicide ideation other-oriented perfectionismhad a small unique negative association with suicide idea-tion and socially prescribed perfectionism had a smallunique positive relationship with suicide ideation FMPS-perfectionism dimensions had marginal-to-large correlationswith each other (see Supplemental Material G for observedeffects and Supplemental Material H for adjusted effects)After controlling for overlap in FMPS dimensions the rela-tionships among suicide ideation and concern over mistakespersonal standards parental expectations and organizationwere nonsignificant However after controlling for overlapamong FMPS dimensions doubts about actions and parentalcriticism displayed small unique positive relationships withideation (see Supplemental Material G for observed effectsand Supplemental Material H for adjusted effects)
The test of the total heterogeneity of variance of weightedmean effect sizes (QT) was significant for suicide ideationrsquosrelations with perfectionistic concerns concern over mistakesdiscrepancy personal standards perfectionistic attitudesother-oriented perfectionism FMPS-perfectionism and orga-nization (see Table 2) QT was also significant for the linkbetween suicide attempts and perfectionistic concerns (seeTable 2) The percentage of total variance owing to heteroge-neity (I2) ranged from small to large suggesting possiblemoderators
32 | Moderator analyses
Moderator analyses (see Supplemental Material I) testedwhether effect sizes with significant heterogeneity (QT) weremoderated by publication status (peer-reviewed articles dis-sertations) age (adolescent samples 13 and 17 yearsyoung adult samples 18 and 25 years adultsamples 25 years) sample (university undergraduatescommunity adults psychiatric patients) or perfectionism
measure Perfectionistic concernsrsquo relationship with suicideattempts was nonsignificant for the CAPS but significant forthe FMPS and the MPS Meta-regression also revealed thestrength of the relationship between perfectionistic concernsand suicide attempts decreased as the proportion of femalesin a sample increased However we advise caution in inter-preting our moderator analyses given the small number ofstudies per subgroup
33 | Publication bias
Funnel plots (see Supplemental Material J) and Eggerrsquosregression intercept (see Table 2) provided mixed evidencefor publication bias Eggerrsquos regression intercept was signifi-cant for perfectionistic concernsrsquo relationship with suicideideation and suicide attempts Moreover the funnel plot forperfectionistic concerns and suicide attempts was asymmetri-cal Accordingly for perfectionistic concernsrsquo relationshipwith suicide ideation and suicide attempts trim and fill esti-mates may provide more accurate estimates Nonethelessafter imputing missing studies the adjusted point estimatesfor perfectionistic concernsrsquo relationships with suicide idea-tion and suicide attempts provided the same substantiveimplications (see Table 2)
4 | DISCUSSION
Suicide claims one life every 45 seconds (World HealthOrganization 2012) Given the wide-reaching personal andsocietal costs of suicide it is vital to identify contributingfactors One such factor supported by over 50 years of casehistories theoretical accounts and empirical research is per-fectionism (Blatt 1995 Hassan et al 2014 Hewitt et al2014 Kiamanesh et al 2014 Shaffer 1974) Yet despitethe abundance of research the role of perfectionism in sui-cide remains underappreciated under-recognized and mis-understood due to inconsistencies between studies infindings underpowered studies and uncertainty surroundingwhether perfectionism dimensions predict longitudinalincreases in suicidality We aimed to rectify this by rigor-ously conducting the first meta-analytic review of the perfec-tionismndashsuicidality relationship
41 | An improved understanding of theperfectionismndashsuicidality relationship
Our meta-analysis of 45 studies 54 samples and 11747 par-ticipants represents the most comprehensive test of the per-fectionismndashsuicidality link to date All dimensions orcorrelates of perfectionism (except for other-oriented perfec-tionism and organization) were positively related to suicideideation and these effect sizes were generally consistent
SMITH ET AL | 535
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
TABLE1
(Contin
ued)
Sample
Measures
NSa
mple
type
Mean
age
Female
Ethnic
Status
Design
Perfectio
nism
Suicide
ideatio
nSu
icide
attempts
Rasmussenet
al(2008)
sample1
17psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussenet
al(2008)
sample2
23psychiatricb
380
575
NR
article
cross-sectional
MPS
-SOP
MPS
-OOP
MPS
-SPP
SPS-SI
mdash
Rasmussen
Elliotet
al(2012)
161
psychiatricb
337
590
NR
article
cross-sectional
MPS
-SPP
SPS-SI
mdash
Rasmussen
Slish
etal(2012)
214
university
a201
570
257
article
cross-sectional
APS
-DDSI-SS
mdash
Roxboroughet
al(2012)
152
psychiatricb
129
454
285
article
cross-sectional
CAPS
-SOP
CAPS
-SPP
intent
hmdash
Slish(2006)
48university
a201
521
625
dissertatio
ncross-sectional
APS
-DDSI-SS
mdash
Wallack
(2007)
181
university
a198
796
260
dissertatio
ncross-sectional
APS
-DSIS
mdash
Wanget
al(2013)
466
university
a264
496
NR
article
cross-sectional
APS
-DSIS
mdash
Yam
aguchi
etal(2000)
51psychiatricb
212
961
NR
article
cross-sectional
EDI
mdashattemptsi
Note
N5totalnumberof
participantsNR5
notreportedFemale5percentage
female
Ethnic5percentage
ethnic
minority
Status
5publicationstatus
ofthestudy
FMPS
5Frostandcolleaguesrsquo
(1990)
Multid
imen-
sional
Perfectio
nism
Scale
total5
totalscore
ASIQ5
Reynoldsrsquos(1991)
AdultSu
icideIdeatio
nQuestionnaireCOM
5concernover
mistakesDAA5
doubtsaboutactio
nsPC
5parental
criticism
PE
5parental
expecta-
tionsPS
5personal
standardsORG5organizatio
nAAHS-ST
5NationalAdolescentHealth
Survey
Suicidal
Thinkingmodifiedversion(1989)DAS-P5Weissman
andBeckrsquos(1978)
Dysfunctio
nalAttitude
Scale-
Perfectio
nism
subscaleSS
I5Beck
SteerandRanierirsquos
(1988)
ScaleforSu
icidal
Ideatio
nMSS
I5MillerNormanBishop
andDow
rsquos(1986)
ModifiedScaleforSu
icidal
Ideatio
nMPS
5Hew
ittandFlettrsquos
(1991)
Multi-
dimensional
Perfectio
nism
Scale
SOP5self-orientedperfectio
nism
OOP5other-oriented
perfectio
nism
SP
P5socially
prescribed
perfectio
nism
CSI
5Blanksteinrsquos(2007)
Current
SuicideIdeatio
nScale
CAPS
5Flett
andcolleaguesrsquo
(2016)
Child-A
dolescentPerfectio
nism
Scale
SIQ5
Reynoldsrsquos(1987b)Su
icidal
Ideatio
nQuestionnaireEDI5
Garnerandcolleaguesrsquo
(1983)
EatingDisorderInventory-Perfectio
nism
subscaleBSS
5Beck
andSteerrsquos
(1993)
SuicideIdeatio
nScale
M5
motivation
P5preparation
Intent5suicidal
intentCSP
S5Pfefferrsquos
(1986)
Child
SuicidePo
tentialScale
GHQ-ST5
GoldbergandWilliamsrsquos(1988)
General
Health
Questionnaire-SuicidalThinkingsubscaleBDI-SI
5Beckrsquos(1979)
DepressionInventoryitem-9
(SuicidalIntent)RST
-past5
ratin
gof
thefrequencyof
pastsuicidal
thoughtsRST
-future5ratin
gof
thefrequencyof
future
suicidal
thoughtsSB
Q5
Linehanrsquos
(1981)
Suicidal
BehaviorQuestionnaireSI
5suicidal
ideatio
nSIQ-JR5
Reynoldsrsquos(1987a)Su
icidal
Ideatio
nQuestionnaire-G
rades7ndash9
FSII5
Chang
andChang
rsquos(2016)
Frequency
ofSu
icideIdeatio
nInventory
SPS5CullandGillrsquos
(1982)
SuicideProbability
Scale
BSS
I5Beck
KovacsandWeissmanrsquos
(1979)
ScaleforSu
icidal
Ideatio
nAPS
-D5
Slaney
andcolleaguesrsquo
(2001)
Alm
ostPerfect
Scale-Revised
Discrepancy
subscaleDSI-SS5
MetalskyandJoinerrsquos
(1997)
DepressiveSy
mptom
sInventory-Su
icidality
subscaleSIS5Ruddrsquos(1989)
Suicidal
Ideatio
nScale
a University
undergraduates
b Psychiatric
patients
c Com
munity
adults
d Medical
students
e Participants
reported
whether
they
hadever
seriouslythoughtaboutattemptingsuicide
f Self-reported
numberof
priorsuicideattempts
g Prior
numberof
suicideattemptsassessed
byaclinician
h Participants
asked
ldquoHow
likelyisitthat
youwill
attempt
suicidesomedayrdquo
i Com
paredsuicideattemptersandnon-attempters
SMITH ET AL | 529
studies examining other-oriented perfectionism and suicidal-ity (see Table 1) meaning this literature is now suitable formeta-analysis In sum though perfectionistic concernsrsquo linkwith suicidality is clear (Flett al 2014 Hewitt et al 2006OrsquoConnor 2007) perfectionistic strivingsrsquo and other-oriented perfectionismrsquos link with suicidality is unclear
15 | Advancing research on theperfectionismndashsuicidality relationship usingmeta-analysis
Over 50 years of case reports theoretical accounts andempirical research implicate perfectionism in suicide (egBlatt 1995 Hassan Flett Ganguli amp Hewitt 2014 Hewittet al 2014 Kiamanesh Dyregrov Haavind amp Dieserud2014 Shaffer 1974) And yet there is much to learn aboutthe perfectionismndashsuicidality relationship (Flett et al 2014)First noteworthy inconsistencies between studies in findings(eg Flamenbaum amp Holden 2007 Hewitt et al 19982014 Hunter amp OrsquoConnor 2003) have clouded our under-standing of perfectionistic strivingsrsquo and other-oriented per-fectionismrsquos relationships with suicidality A quantitativesynthesis is needed for overall conclusions to be reachedSuch a quantitative synthesis could also allow for tests ofmoderating variables (eg gender) that might explain whenthe strength or the direction of the perfectionismndashsuicidalityrelationship changes Second despite evidence that correla-tions do not stabilize until N 250 (Scheuroonbrodt amp Perugini2013) most research on perfectionism and suicide attemptsis underpowered (cf Flamenbaum amp Holden 2007) How-ever meta-analysis could overcome limitations of small sam-ples (Borenstein Hedges Higgins amp Rothstein 2009) andbring greater clarity to our understanding of perfectionismrsquosrelationship with suicide attempts Third as noted by Flettet al (2014) and OrsquoConnor (2007) the extent to which per-fectionism dimensions confer risk for suicide has yet to bedetermined Indeed most investigators use cross-sectionaldesigns which unlike longitudinal designs cannot addresstemporal precedence As such whether perfectionism leadsto increases in suicidality is unclear and researchers andclinicians can only speculate as to whether reducing perfec-tionism reduces suicidality Nevertheless there is now suffi-cient data to test whether self-oriented other-oriented andsocially prescribed perfectionism predict follow-up suicideideation beyond baseline suicide ideation (Chen 2012Enns Cox Sareen amp Freeman 2001 R C OrsquoConnorWhyte et al 2007) Fourth due to limitations of nonempiri-cal reviews the strength of the relation between perfection-ism dimensions suicide ideation and suicide attempts isunclear A meta-analysis could shed light on which perfec-tionism dimensions display the strongest relations with sui-cide ideation and suicide attempts which in time might
inform the development of interventions designed to targetand to modify perfectionismrsquos most pernicious aspects
16 | Objectives and hypothesis
Our primary aim was to bring greater clarity to our under-standing of the perfectionismndashsuicidality relationship bycomprehensively synthesizing empirical research on perfec-tionism suicide ideation and suicide attempts To date thereis no meta-analysis of findings from this long-standing andimportant literature We also aimed to test the contentiouslydebated relation between perfectionistic strivings suicideideation and suicide attempts Such evidence would informdebate on the pros and cons of demanding perfection of one-self (eg Stoeber amp Otto 2006 Sherry Hewitt SherryFlett amp Graham 2010) Another aim was to test whetherself-oriented other-oriented and socially prescribed perfec-tionism predicted longitudinal increases in suicide ideationover time Controlling for baseline suicide ideation repre-sents a stringent test of the perfectionismndashsuicidality relation-ship as baseline suicide ideation is a strong predictor ofsubsequent suicide ideation (eg Joiner et al 2005)
Building on theory and research (Flett et al 2014Hewitt et al 2006 OrsquoConnor 2007) we hypothesized per-fectionistic concerns (socially prescribed perfectionism con-cern over mistakes doubts about action discrepancy andperfectionistic attitudes) would display positive relationshipswith suicide ideation and attempts We also hypothesizedsocially prescribed perfectionism would place people at riskfor longitudinal increases in suicide ideation However giventhe inconsistency of research on suicidality in relation to per-fectionistic strivings (self-oriented perfectionism personalstandards) other forms of perfectionism (other-oriented per-fectionism EDI-perfectionism total scores FMPS-perfectionism total scores) and correlates of perfectionism(parental criticism parental expectations organization) weconsidered our investigation into these questions to be moreexploratory
2 | METHOD
21 | Selection of studies
In 2016 a literature search using PsycINFO Medline Webof Science ERIC and ProQuest Dissertations and Theseswas conducted using the keywords and Boolean search termsldquoperfectrdquo and ldquosuicidrdquo This search yielded 100 studiesfrom PsycINFO 122 studies from Medline 226 studies fromWeb of Science and 38 studies from ProQuest We alsocompiled a list of 353 authors who had published on perfec-tionism We then contacted each author individually andrequested unpublished findings However none of the
530 | SMITH ET AL
authors contacted provided relevant data Additionally wemonitored the Perfectionism Network Mailing List to iden-tify studies that were accepted but not published at the timeof our literature search This yielded one study Chen et al(2017) Both the first and the third author then reviewedabstracts of all studies identified selecting studies meetinginclusion criteria Studies were included that (a) containeddata on perfectionism and suicidality (ideation and attempts)and (b) were in English Included studies also (c) reported aneffect size or enough information for computing an effectsize or effect size information was obtained from a studyauthor All authors contacted (N5 1) provided the requestedinformation
This literature search yielded 57 studies for inclusionInter-rater agreement on inclusion or exclusion in the meta-analysis was 95 Disagreement was resolved by revisitingarticles and coming to a consensus The reference lists ofincluded articles were also examined to locate additional rel-evant literature On August 7 2016 we terminated all searchstrategies and started data reduction and analysis Weexcluded 12 studies (see Supplemental Material A) The finalsample of included studies was composed of 45 studies with54 samples
22 | Coding of studies
The first and the third author coded each study based on ninecharacteristics sample size sample type mean age of partici-pants percentage of female participants percentage of ethnicminority participants publication status measure used toassess perfectionism measure used to assess suicide ideationand measure used to assess suicide attempts
23 | Meta-analytic procedures
Random effects analyses were conducted using Comprehen-sive Meta-Analysis software (Borenstein et al 2005) Wechose random effects models over fixed effects models asthe 45 included studies varied widely in design We alsoweighed mean effects following the procedure suggested byHunter and Schmidt (1990) This allowed us to estimatemean effect sizes and variance in observed scores after con-sidering sampling error (Card 2012) Next effect size esti-mates were weighted by sample size and aggregated Forstudies with more than one measure of suicide ideation weaveraged effect sizes so only one effect was included (Boren-stein et al 2009 Card 2012) Effect sizes presented in met-rics other than r (ie means t-tests d or F scores) wereconverted and expressed as correlations following formulasprovided by Borenstein et al (2009) We also used Boren-stein and colleaguesrsquo (2009) formula to calculate powerunder the random effects model for each weighted mean
effect Additionally most included studies measured perfec-tionism and suicide ideation with imperfect reliability Asthis can attenuate the magnitude of observed correlationseffects were adjusted by dividing the observed correlation bythe square root of the product of the two corresponding reli-ability coefficients (Card 2012) When reported the actualreliability statistics for a study were used when not reportedthe corresponding meta-analyzed mean reliability was used(Card 2012) However we were unable to adjust for unreli-ability in suicide attempts Thus in the interest of methodo-logical consistency we used the common albeitconservative strategy of interpreting observed effects whichgenerally underestimates the true magnitude of effect sizes(Borenstein et al 2009) Nonetheless for readers who dis-agree with this strategy effect sizes adjusted for unreliabilityare presented in our supplementary material
To examine the extent to which baseline self-orientedother-oriented and socially prescribed perfectionism predictfollow-up suicide ideation after controlling for baseline idea-tion we computed partial correlations using the ldquocorpcorrdquopackage (Schafer Opgen-Rhein Zuber Silvia amp Strimmer2015) for R (R Core Team 2013) Although there was insuf-ficient data to examine unique effects between perfectionismdimensions and suicide attempts there was sufficient data toexamine unique effects between perfectionism dimensionsand suicide ideation Thus again using the ldquocorpcorrdquo pack-age (Schafer et al 2015) we computed partial correlationsfor MPS-perfectionism dimensions by residualizing self-oriented other-oriented and socially prescribed perfection-ism based on their overlap with each other prior to being cor-related with suicide ideation Likewise for FMPS-perfectionism dimensions we computed partial correlationsby residualizing concern over mistakes doubts about actionparental criticism parental expectations personal standardsand organization based on their overlap with each other priorto being correlated with suicide ideation
To assess moderation we evaluated the total heterogene-ity of weighted mean effect sizes (QT) A significant QT indi-cates variance in weighted mean effect sizes is greater thanexpected by sampling error (Card 2012) a nonsignificantQT suggests a weak basis for moderation For each analysiswe also computed the inconsistency in observed effects (I2)across studies I2 indicates the percentage of total varianceacross studies due to heterogeneity Values of 25 50and 75 correspond to low medium and high heterogene-ity respectively
When QT was significant we stipulated a categoricalstructure and the total heterogeneity explained by the catego-rization (QB) was calculated (Card 2012) A significant QB
indicates meaningful differences in effects between catego-ries and provides a firm basis for moderation (Borensteinet al 2009) When QB was significant we examined
SMITH ET AL | 531
differences in effect sizes between studies grouped by publi-cation status (articles and dissertations) age (adult youngadult adolescent) and sample (community adults under-graduate students psychiatric patients) by performing aseries of all possible two-group comparisons to test whichgroup differed significantly in effect size (Card 2012) Foreach group comparison the resultant QB from the twogroups was tested using a v2 test with one degree of freedomWe also recorded gender (percentage female) and ethnicity(percentage ethnic minority) as continuous variables andused mixed effects meta-regression to test the potential mod-erating effects of gender and ethnicity
To assess publication bias we inspected funnel plotswith observed and imputed studies and computed Eggerrsquostest of regression to the intercept (Egger Smith Schneideramp Minder 1997) Such funnel plots allow for visual inspec-tion of how the effect size shifts when imputed studies areincluded (Borenstein et al 2009) In the absence of publica-tion bias Eggerrsquos regression intercept does not differ signifi-cantly from zero (Egger et al 1997)
24 | Description of studies
Our search identified 45 studies and 54 samples containingrelevant effect size data (see Table 1) The total number ofparticipants pooled across studies was 11747 Relevant datawere obtained from 38 journal articles and seven disserta-tions There were 21 samples of university undergraduates29 samples of psychiatric patients one sample of medicalstudents and three samples of community adults There were48 cross-sectional samples and six longitudinal samplesSample size varied between 17 and 1436 with an averageof 2175 (SD5 2598) The mean age of participants was268 years (SD5 102 range5 129ndash586) The average per-centage of female participants was 633 the average per-centage of ethnic minority participants was 244 Effectsize information for each individual study is presented inSupplemental Material B Adjusted effect size informationfor each individual study is presented in Supplemental Mate-rial C
25 | Measures
251 | Perfectionism
Following theory and research (eg Dunkley et al 2004Stoeber amp Otto 2006) personal standards (FMPS) and self-oriented perfectionism (MPS Child-Adolescent Perfection-ism Scale [CAPS] Flett et al 2016) were considered facetsof perfectionistic strivings concern over mistakes (FMPS)doubts about actions (FMPS) socially prescribed perfection-ism (MPS CAPS) discrepancy (APS-R) and perfectionistic
attitudes (Dysfunctional Attitude Scale-Perfectionism sub-scale [DAS-P] Weissman amp Beck 1978) were consideredfacets of perfectionistic concerns Parental criticism parentalexpectations and organization were designated correlates ofperfectionism As well parental criticism and parentalexpectations were combined and labeled as parental percep-tions (see Cox et al 2002) Other-oriented perfectionism(MPS) FMPS-perfectionism and EDI-perfectionism weredesignated other forms of perfectionism
252 | Suicide ideation and suicide attempts
Suicide ideations were assessed via self-reported suicidalthinking Suicide attempts were assessed via self-reportednumber of prior suicide attempts (eg Adkins amp Parker1996) clinicianrsquos ratings of the number of prior suicideattempts (eg Fedorowicz et al 2007) and group compari-sons between suicide attempters and non-attempters (egHewitt et al 2014) Although Pfefferrsquos (1986) Child SuicidePotential Scale (CSPS) and Linehanrsquos (1981) Suicide Behav-ior Questionnaire (SBQ) assess suicidal ideation and suicideattempts we categorized the CPS and SBQ as measures ofsuicide ideation given the majority of CSPS and SBQ itemsassess suicidal thoughts
3 | RESULTS
31 | Overall effect sizes
Weighted mean effect sizes between perfectionism corre-lates of perfectionism and suicide ideation and suicideattempts are in Table 2 (see Supplemental Material D foradjusted effect sizes) Following Cohenrsquos (1992) guidelinesfor small medium and large effects (r5 10 30 and 50respectively) perfectionistic concerns socially prescribedperfectionism concern over mistakes doubts about actionsdiscrepancy perfectionistic attitudes perfectionistic striv-ings self-oriented perfectionism personal standards parentalperceptions parental criticism parental expectations andFMPS-perfectionism displayed small-to-moderate positiverelationships with suicide ideation Other-oriented perfection-ismrsquos and organizationrsquos relationships with suicide ideationwere nonsignificant Perfectionistic concerns socially pre-scribed perfectionism concern over mistakes doubts aboutaction FMPS-perfectionism parental perceptions parentalcriticism and parental expectations displayed small positiverelationships with suicide attempts perfectionistic attitudesrsquoperfectionistic strivingsrsquo self-oriented perfectionismrsquos perso-nal standardsrsquo other-oriented perfectionismrsquos EDI-perfectionismrsquos and organizationrsquos relationships with suicideattempts were nonsignificant
532 | SMITH ET AL
TABLE2
Summaryof
overalleffect
sizesfortherelatio
nshipbetweenperfectio
nism
andsuicidality
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Suicideideatio
n
Perfectio
nistic
concerns
a42
7936
28
[24
32]
9910
5863
175
[076
273]
028[2
431]
99
Socially
prescribed
perfectio
nism
303640
28
[25
32]
3704
2171
035
[2100169]
028[2
532]
99
Concern
over
mistakes
5952
25
[13
36]
1219
6720
251
[2436938]
025[1
336]
98
Doubtsaboutactio
ns4
902
27
[18
35]
514
4162
294
[25671158
220[1
130]
99
Discrepancy
4904
26
[14
38]
917
6727
338
[24791154]
124[1
235]
98
Perfectio
nistic
attitudes
51533
37
[19
52]
3355
8808
407
[2033848]
226[0
941]
98
Perfectio
nistic
strivingsb
314588
10
[07
13]
3214
665
018
[2094130]
010[0
713]
99
Self-orientedperfectio
nism
273315
11
[08
15]
2096
000
ndash046
[2156064]
011[0
815]
99
Personal
standards
51273
10
[00
19]
1033
6127
334
[24711139]
010[0
019]
52
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
202755
01
[204
06]
3287
4219
027
[2178230]
101[2
04
06]
08
FMPS
totalscore
41018
31
[15
45]
1971
8477
472
[21692
2636]
127[1
240]
96
EDI-perfectio
nism
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdash
Correlatesof
perfectio
nism
Parental
perceptio
nsc
51904
19
[10
27]
1279
6871
204
[2558966]
019[1
027]
98
Parental
criticism
5952
20
[11
29]
798
4987
092
[2556740]
020[1
029]
98
Parental
expectations
5952
16
[06
26]
842
5247
196
[2391784]
113[0
323]
88
Organization
3513
ndash02
[220
17]
792
7475
253
[27738
8243]
0ndash02
[220
17]
05
Suicideattempts
Perfectio
nistic
concerns
d15
5275
12
[07
17]
2448
4281
115
[021
208]
508[0
314]
99
Socially
prescribed
perfectio
nism
8689
19
[08
29]
1257
4432
021
[2365407]
019[0
829]
93
Concern
over
mistakes
51827
09
[04
14]
012
000
008
[2035052]
109[0
413]
97
Doubtsaboutactio
n3
1777
06
[01
11]
276
000
100
[2201401]
205[2
02
11]
71
Discrepancy
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdashPerfectio
nistic
attitudes
3983
09
[203
22]
254
2126
142
[2155440]
205[2
07
17]
32
(Contin
ues)
SMITH ET AL | 533
TABLE2
(Contin
ued)
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Perfectio
nistic
strivingsa
101436
02
[202
06]
525
000
ndash010
[2110087]
002[2
01
06]
19
Self-orientedperfectio
nism
6539
07
[201
16]
304
000
ndash161
[2320ndash0
02]
007[2
01
15]
37
Personal
standards
41777
01
[204
06]
060
000
ndash049
[2182083]
001[2
04
05]
06
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
4429
ndash03
[213
06]
126
000
ndash142
[2258ndash0
28]
0ndash03
[213
06]
11
FMPS
totalscore
3666
14
[07
21]
130
000
ndash031
[2055ndash0
07]
016[0
823]
99
EDI-perfectio
nism
52975
03
[201
06]
183
000
106
[2098273]
103[2
01
06]
33
Correlatesof
perfectio
nism
Parental
perceptio
nsc
33230
07
[04
11]
053
000
045
[2643733]
007[0
411]
98
Parental
criticism
31615
08
[03
12]
065
000
063
[2523650]
207[0
211]
85
Parental
expectations
31615
07
[02
12]
010
000
001
[2386387]
007[0
211]
79
Organization
21565
ndash01
[206
04]
082
000
mdashmdash
mdashmdash
mdash
Note
k5numberof
studiesN5totalnumberof
participantsin
theksamplesr1
5weightedmeanbivariatecorrelation
CI5
confidence
intervalQT5measure
ofheterogeneity
ofeffect
sizesI25percentage
ofheteroge-
neity
kT
F5numberof
imputedstudiesas
partof
ldquotrim
andfillrdquo
method
FMPS
5Frostrsquos
andcolleaguesrsquo
(1990)
Multid
imensional
Perfectio
nism
Scale
EDI-perfectio
nism
5Garnerandcolleaguesrsquo
(1983)
EatingDisorder
Inventory-Perfectio
nism
subscale
a Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesdoubtsaboutactio
nsanddiscrepancy
b Perfectionistic
strivingsassessed
asaggregateof
self-orientedperfectio
nism
andpersonal
standards
c Parentalperceptio
nsassessed
asaggregateof
parental
criticism
andparental
expectations
(Cox
etal2002)
d Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesanddoubtsaboutactio
ns
plt05
plt01
p
lt001
534 | SMITH ET AL
Weighted mean effect sizes for the relationships betweenself-oriented other-oriented and socially prescribed perfec-tionism at baseline and suicide ideation at follow-up whilecontrolling for ideation at baseline are in SupplementalMaterial E (see Supplemental Material F for adjusted longi-tudinal effect sizes) Despite the large positive relationshipbetween baseline and follow-up suicide ideation sociallyprescribed perfectionism still displayed a small positive rela-tionship with follow-up suicide ideation after controlling forbaseline suicide ideation Self-oriented and other-orientedperfectionismrsquos relationships with follow-up suicide ideationafter controlling for baseline ideation were nonsignificant
MPS-perfectionism dimensions displayed small-to-largepositive correlations with each other (see SupplementalMaterial G for observed effects and Supplemental MaterialH for adjusted effects) After controlling for overlap in MPSdimensions self-oriented perfectionism ceased to signifi-cantly predict suicide ideation other-oriented perfectionismhad a small unique negative association with suicide idea-tion and socially prescribed perfectionism had a smallunique positive relationship with suicide ideation FMPS-perfectionism dimensions had marginal-to-large correlationswith each other (see Supplemental Material G for observedeffects and Supplemental Material H for adjusted effects)After controlling for overlap in FMPS dimensions the rela-tionships among suicide ideation and concern over mistakespersonal standards parental expectations and organizationwere nonsignificant However after controlling for overlapamong FMPS dimensions doubts about actions and parentalcriticism displayed small unique positive relationships withideation (see Supplemental Material G for observed effectsand Supplemental Material H for adjusted effects)
The test of the total heterogeneity of variance of weightedmean effect sizes (QT) was significant for suicide ideationrsquosrelations with perfectionistic concerns concern over mistakesdiscrepancy personal standards perfectionistic attitudesother-oriented perfectionism FMPS-perfectionism and orga-nization (see Table 2) QT was also significant for the linkbetween suicide attempts and perfectionistic concerns (seeTable 2) The percentage of total variance owing to heteroge-neity (I2) ranged from small to large suggesting possiblemoderators
32 | Moderator analyses
Moderator analyses (see Supplemental Material I) testedwhether effect sizes with significant heterogeneity (QT) weremoderated by publication status (peer-reviewed articles dis-sertations) age (adolescent samples 13 and 17 yearsyoung adult samples 18 and 25 years adultsamples 25 years) sample (university undergraduatescommunity adults psychiatric patients) or perfectionism
measure Perfectionistic concernsrsquo relationship with suicideattempts was nonsignificant for the CAPS but significant forthe FMPS and the MPS Meta-regression also revealed thestrength of the relationship between perfectionistic concernsand suicide attempts decreased as the proportion of femalesin a sample increased However we advise caution in inter-preting our moderator analyses given the small number ofstudies per subgroup
33 | Publication bias
Funnel plots (see Supplemental Material J) and Eggerrsquosregression intercept (see Table 2) provided mixed evidencefor publication bias Eggerrsquos regression intercept was signifi-cant for perfectionistic concernsrsquo relationship with suicideideation and suicide attempts Moreover the funnel plot forperfectionistic concerns and suicide attempts was asymmetri-cal Accordingly for perfectionistic concernsrsquo relationshipwith suicide ideation and suicide attempts trim and fill esti-mates may provide more accurate estimates Nonethelessafter imputing missing studies the adjusted point estimatesfor perfectionistic concernsrsquo relationships with suicide idea-tion and suicide attempts provided the same substantiveimplications (see Table 2)
4 | DISCUSSION
Suicide claims one life every 45 seconds (World HealthOrganization 2012) Given the wide-reaching personal andsocietal costs of suicide it is vital to identify contributingfactors One such factor supported by over 50 years of casehistories theoretical accounts and empirical research is per-fectionism (Blatt 1995 Hassan et al 2014 Hewitt et al2014 Kiamanesh et al 2014 Shaffer 1974) Yet despitethe abundance of research the role of perfectionism in sui-cide remains underappreciated under-recognized and mis-understood due to inconsistencies between studies infindings underpowered studies and uncertainty surroundingwhether perfectionism dimensions predict longitudinalincreases in suicidality We aimed to rectify this by rigor-ously conducting the first meta-analytic review of the perfec-tionismndashsuicidality relationship
41 | An improved understanding of theperfectionismndashsuicidality relationship
Our meta-analysis of 45 studies 54 samples and 11747 par-ticipants represents the most comprehensive test of the per-fectionismndashsuicidality link to date All dimensions orcorrelates of perfectionism (except for other-oriented perfec-tionism and organization) were positively related to suicideideation and these effect sizes were generally consistent
SMITH ET AL | 535
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
studies examining other-oriented perfectionism and suicidal-ity (see Table 1) meaning this literature is now suitable formeta-analysis In sum though perfectionistic concernsrsquo linkwith suicidality is clear (Flett al 2014 Hewitt et al 2006OrsquoConnor 2007) perfectionistic strivingsrsquo and other-oriented perfectionismrsquos link with suicidality is unclear
15 | Advancing research on theperfectionismndashsuicidality relationship usingmeta-analysis
Over 50 years of case reports theoretical accounts andempirical research implicate perfectionism in suicide (egBlatt 1995 Hassan Flett Ganguli amp Hewitt 2014 Hewittet al 2014 Kiamanesh Dyregrov Haavind amp Dieserud2014 Shaffer 1974) And yet there is much to learn aboutthe perfectionismndashsuicidality relationship (Flett et al 2014)First noteworthy inconsistencies between studies in findings(eg Flamenbaum amp Holden 2007 Hewitt et al 19982014 Hunter amp OrsquoConnor 2003) have clouded our under-standing of perfectionistic strivingsrsquo and other-oriented per-fectionismrsquos relationships with suicidality A quantitativesynthesis is needed for overall conclusions to be reachedSuch a quantitative synthesis could also allow for tests ofmoderating variables (eg gender) that might explain whenthe strength or the direction of the perfectionismndashsuicidalityrelationship changes Second despite evidence that correla-tions do not stabilize until N 250 (Scheuroonbrodt amp Perugini2013) most research on perfectionism and suicide attemptsis underpowered (cf Flamenbaum amp Holden 2007) How-ever meta-analysis could overcome limitations of small sam-ples (Borenstein Hedges Higgins amp Rothstein 2009) andbring greater clarity to our understanding of perfectionismrsquosrelationship with suicide attempts Third as noted by Flettet al (2014) and OrsquoConnor (2007) the extent to which per-fectionism dimensions confer risk for suicide has yet to bedetermined Indeed most investigators use cross-sectionaldesigns which unlike longitudinal designs cannot addresstemporal precedence As such whether perfectionism leadsto increases in suicidality is unclear and researchers andclinicians can only speculate as to whether reducing perfec-tionism reduces suicidality Nevertheless there is now suffi-cient data to test whether self-oriented other-oriented andsocially prescribed perfectionism predict follow-up suicideideation beyond baseline suicide ideation (Chen 2012Enns Cox Sareen amp Freeman 2001 R C OrsquoConnorWhyte et al 2007) Fourth due to limitations of nonempiri-cal reviews the strength of the relation between perfection-ism dimensions suicide ideation and suicide attempts isunclear A meta-analysis could shed light on which perfec-tionism dimensions display the strongest relations with sui-cide ideation and suicide attempts which in time might
inform the development of interventions designed to targetand to modify perfectionismrsquos most pernicious aspects
16 | Objectives and hypothesis
Our primary aim was to bring greater clarity to our under-standing of the perfectionismndashsuicidality relationship bycomprehensively synthesizing empirical research on perfec-tionism suicide ideation and suicide attempts To date thereis no meta-analysis of findings from this long-standing andimportant literature We also aimed to test the contentiouslydebated relation between perfectionistic strivings suicideideation and suicide attempts Such evidence would informdebate on the pros and cons of demanding perfection of one-self (eg Stoeber amp Otto 2006 Sherry Hewitt SherryFlett amp Graham 2010) Another aim was to test whetherself-oriented other-oriented and socially prescribed perfec-tionism predicted longitudinal increases in suicide ideationover time Controlling for baseline suicide ideation repre-sents a stringent test of the perfectionismndashsuicidality relation-ship as baseline suicide ideation is a strong predictor ofsubsequent suicide ideation (eg Joiner et al 2005)
Building on theory and research (Flett et al 2014Hewitt et al 2006 OrsquoConnor 2007) we hypothesized per-fectionistic concerns (socially prescribed perfectionism con-cern over mistakes doubts about action discrepancy andperfectionistic attitudes) would display positive relationshipswith suicide ideation and attempts We also hypothesizedsocially prescribed perfectionism would place people at riskfor longitudinal increases in suicide ideation However giventhe inconsistency of research on suicidality in relation to per-fectionistic strivings (self-oriented perfectionism personalstandards) other forms of perfectionism (other-oriented per-fectionism EDI-perfectionism total scores FMPS-perfectionism total scores) and correlates of perfectionism(parental criticism parental expectations organization) weconsidered our investigation into these questions to be moreexploratory
2 | METHOD
21 | Selection of studies
In 2016 a literature search using PsycINFO Medline Webof Science ERIC and ProQuest Dissertations and Theseswas conducted using the keywords and Boolean search termsldquoperfectrdquo and ldquosuicidrdquo This search yielded 100 studiesfrom PsycINFO 122 studies from Medline 226 studies fromWeb of Science and 38 studies from ProQuest We alsocompiled a list of 353 authors who had published on perfec-tionism We then contacted each author individually andrequested unpublished findings However none of the
530 | SMITH ET AL
authors contacted provided relevant data Additionally wemonitored the Perfectionism Network Mailing List to iden-tify studies that were accepted but not published at the timeof our literature search This yielded one study Chen et al(2017) Both the first and the third author then reviewedabstracts of all studies identified selecting studies meetinginclusion criteria Studies were included that (a) containeddata on perfectionism and suicidality (ideation and attempts)and (b) were in English Included studies also (c) reported aneffect size or enough information for computing an effectsize or effect size information was obtained from a studyauthor All authors contacted (N5 1) provided the requestedinformation
This literature search yielded 57 studies for inclusionInter-rater agreement on inclusion or exclusion in the meta-analysis was 95 Disagreement was resolved by revisitingarticles and coming to a consensus The reference lists ofincluded articles were also examined to locate additional rel-evant literature On August 7 2016 we terminated all searchstrategies and started data reduction and analysis Weexcluded 12 studies (see Supplemental Material A) The finalsample of included studies was composed of 45 studies with54 samples
22 | Coding of studies
The first and the third author coded each study based on ninecharacteristics sample size sample type mean age of partici-pants percentage of female participants percentage of ethnicminority participants publication status measure used toassess perfectionism measure used to assess suicide ideationand measure used to assess suicide attempts
23 | Meta-analytic procedures
Random effects analyses were conducted using Comprehen-sive Meta-Analysis software (Borenstein et al 2005) Wechose random effects models over fixed effects models asthe 45 included studies varied widely in design We alsoweighed mean effects following the procedure suggested byHunter and Schmidt (1990) This allowed us to estimatemean effect sizes and variance in observed scores after con-sidering sampling error (Card 2012) Next effect size esti-mates were weighted by sample size and aggregated Forstudies with more than one measure of suicide ideation weaveraged effect sizes so only one effect was included (Boren-stein et al 2009 Card 2012) Effect sizes presented in met-rics other than r (ie means t-tests d or F scores) wereconverted and expressed as correlations following formulasprovided by Borenstein et al (2009) We also used Boren-stein and colleaguesrsquo (2009) formula to calculate powerunder the random effects model for each weighted mean
effect Additionally most included studies measured perfec-tionism and suicide ideation with imperfect reliability Asthis can attenuate the magnitude of observed correlationseffects were adjusted by dividing the observed correlation bythe square root of the product of the two corresponding reli-ability coefficients (Card 2012) When reported the actualreliability statistics for a study were used when not reportedthe corresponding meta-analyzed mean reliability was used(Card 2012) However we were unable to adjust for unreli-ability in suicide attempts Thus in the interest of methodo-logical consistency we used the common albeitconservative strategy of interpreting observed effects whichgenerally underestimates the true magnitude of effect sizes(Borenstein et al 2009) Nonetheless for readers who dis-agree with this strategy effect sizes adjusted for unreliabilityare presented in our supplementary material
To examine the extent to which baseline self-orientedother-oriented and socially prescribed perfectionism predictfollow-up suicide ideation after controlling for baseline idea-tion we computed partial correlations using the ldquocorpcorrdquopackage (Schafer Opgen-Rhein Zuber Silvia amp Strimmer2015) for R (R Core Team 2013) Although there was insuf-ficient data to examine unique effects between perfectionismdimensions and suicide attempts there was sufficient data toexamine unique effects between perfectionism dimensionsand suicide ideation Thus again using the ldquocorpcorrdquo pack-age (Schafer et al 2015) we computed partial correlationsfor MPS-perfectionism dimensions by residualizing self-oriented other-oriented and socially prescribed perfection-ism based on their overlap with each other prior to being cor-related with suicide ideation Likewise for FMPS-perfectionism dimensions we computed partial correlationsby residualizing concern over mistakes doubts about actionparental criticism parental expectations personal standardsand organization based on their overlap with each other priorto being correlated with suicide ideation
To assess moderation we evaluated the total heterogene-ity of weighted mean effect sizes (QT) A significant QT indi-cates variance in weighted mean effect sizes is greater thanexpected by sampling error (Card 2012) a nonsignificantQT suggests a weak basis for moderation For each analysiswe also computed the inconsistency in observed effects (I2)across studies I2 indicates the percentage of total varianceacross studies due to heterogeneity Values of 25 50and 75 correspond to low medium and high heterogene-ity respectively
When QT was significant we stipulated a categoricalstructure and the total heterogeneity explained by the catego-rization (QB) was calculated (Card 2012) A significant QB
indicates meaningful differences in effects between catego-ries and provides a firm basis for moderation (Borensteinet al 2009) When QB was significant we examined
SMITH ET AL | 531
differences in effect sizes between studies grouped by publi-cation status (articles and dissertations) age (adult youngadult adolescent) and sample (community adults under-graduate students psychiatric patients) by performing aseries of all possible two-group comparisons to test whichgroup differed significantly in effect size (Card 2012) Foreach group comparison the resultant QB from the twogroups was tested using a v2 test with one degree of freedomWe also recorded gender (percentage female) and ethnicity(percentage ethnic minority) as continuous variables andused mixed effects meta-regression to test the potential mod-erating effects of gender and ethnicity
To assess publication bias we inspected funnel plotswith observed and imputed studies and computed Eggerrsquostest of regression to the intercept (Egger Smith Schneideramp Minder 1997) Such funnel plots allow for visual inspec-tion of how the effect size shifts when imputed studies areincluded (Borenstein et al 2009) In the absence of publica-tion bias Eggerrsquos regression intercept does not differ signifi-cantly from zero (Egger et al 1997)
24 | Description of studies
Our search identified 45 studies and 54 samples containingrelevant effect size data (see Table 1) The total number ofparticipants pooled across studies was 11747 Relevant datawere obtained from 38 journal articles and seven disserta-tions There were 21 samples of university undergraduates29 samples of psychiatric patients one sample of medicalstudents and three samples of community adults There were48 cross-sectional samples and six longitudinal samplesSample size varied between 17 and 1436 with an averageof 2175 (SD5 2598) The mean age of participants was268 years (SD5 102 range5 129ndash586) The average per-centage of female participants was 633 the average per-centage of ethnic minority participants was 244 Effectsize information for each individual study is presented inSupplemental Material B Adjusted effect size informationfor each individual study is presented in Supplemental Mate-rial C
25 | Measures
251 | Perfectionism
Following theory and research (eg Dunkley et al 2004Stoeber amp Otto 2006) personal standards (FMPS) and self-oriented perfectionism (MPS Child-Adolescent Perfection-ism Scale [CAPS] Flett et al 2016) were considered facetsof perfectionistic strivings concern over mistakes (FMPS)doubts about actions (FMPS) socially prescribed perfection-ism (MPS CAPS) discrepancy (APS-R) and perfectionistic
attitudes (Dysfunctional Attitude Scale-Perfectionism sub-scale [DAS-P] Weissman amp Beck 1978) were consideredfacets of perfectionistic concerns Parental criticism parentalexpectations and organization were designated correlates ofperfectionism As well parental criticism and parentalexpectations were combined and labeled as parental percep-tions (see Cox et al 2002) Other-oriented perfectionism(MPS) FMPS-perfectionism and EDI-perfectionism weredesignated other forms of perfectionism
252 | Suicide ideation and suicide attempts
Suicide ideations were assessed via self-reported suicidalthinking Suicide attempts were assessed via self-reportednumber of prior suicide attempts (eg Adkins amp Parker1996) clinicianrsquos ratings of the number of prior suicideattempts (eg Fedorowicz et al 2007) and group compari-sons between suicide attempters and non-attempters (egHewitt et al 2014) Although Pfefferrsquos (1986) Child SuicidePotential Scale (CSPS) and Linehanrsquos (1981) Suicide Behav-ior Questionnaire (SBQ) assess suicidal ideation and suicideattempts we categorized the CPS and SBQ as measures ofsuicide ideation given the majority of CSPS and SBQ itemsassess suicidal thoughts
3 | RESULTS
31 | Overall effect sizes
Weighted mean effect sizes between perfectionism corre-lates of perfectionism and suicide ideation and suicideattempts are in Table 2 (see Supplemental Material D foradjusted effect sizes) Following Cohenrsquos (1992) guidelinesfor small medium and large effects (r5 10 30 and 50respectively) perfectionistic concerns socially prescribedperfectionism concern over mistakes doubts about actionsdiscrepancy perfectionistic attitudes perfectionistic striv-ings self-oriented perfectionism personal standards parentalperceptions parental criticism parental expectations andFMPS-perfectionism displayed small-to-moderate positiverelationships with suicide ideation Other-oriented perfection-ismrsquos and organizationrsquos relationships with suicide ideationwere nonsignificant Perfectionistic concerns socially pre-scribed perfectionism concern over mistakes doubts aboutaction FMPS-perfectionism parental perceptions parentalcriticism and parental expectations displayed small positiverelationships with suicide attempts perfectionistic attitudesrsquoperfectionistic strivingsrsquo self-oriented perfectionismrsquos perso-nal standardsrsquo other-oriented perfectionismrsquos EDI-perfectionismrsquos and organizationrsquos relationships with suicideattempts were nonsignificant
532 | SMITH ET AL
TABLE2
Summaryof
overalleffect
sizesfortherelatio
nshipbetweenperfectio
nism
andsuicidality
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Suicideideatio
n
Perfectio
nistic
concerns
a42
7936
28
[24
32]
9910
5863
175
[076
273]
028[2
431]
99
Socially
prescribed
perfectio
nism
303640
28
[25
32]
3704
2171
035
[2100169]
028[2
532]
99
Concern
over
mistakes
5952
25
[13
36]
1219
6720
251
[2436938]
025[1
336]
98
Doubtsaboutactio
ns4
902
27
[18
35]
514
4162
294
[25671158
220[1
130]
99
Discrepancy
4904
26
[14
38]
917
6727
338
[24791154]
124[1
235]
98
Perfectio
nistic
attitudes
51533
37
[19
52]
3355
8808
407
[2033848]
226[0
941]
98
Perfectio
nistic
strivingsb
314588
10
[07
13]
3214
665
018
[2094130]
010[0
713]
99
Self-orientedperfectio
nism
273315
11
[08
15]
2096
000
ndash046
[2156064]
011[0
815]
99
Personal
standards
51273
10
[00
19]
1033
6127
334
[24711139]
010[0
019]
52
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
202755
01
[204
06]
3287
4219
027
[2178230]
101[2
04
06]
08
FMPS
totalscore
41018
31
[15
45]
1971
8477
472
[21692
2636]
127[1
240]
96
EDI-perfectio
nism
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdash
Correlatesof
perfectio
nism
Parental
perceptio
nsc
51904
19
[10
27]
1279
6871
204
[2558966]
019[1
027]
98
Parental
criticism
5952
20
[11
29]
798
4987
092
[2556740]
020[1
029]
98
Parental
expectations
5952
16
[06
26]
842
5247
196
[2391784]
113[0
323]
88
Organization
3513
ndash02
[220
17]
792
7475
253
[27738
8243]
0ndash02
[220
17]
05
Suicideattempts
Perfectio
nistic
concerns
d15
5275
12
[07
17]
2448
4281
115
[021
208]
508[0
314]
99
Socially
prescribed
perfectio
nism
8689
19
[08
29]
1257
4432
021
[2365407]
019[0
829]
93
Concern
over
mistakes
51827
09
[04
14]
012
000
008
[2035052]
109[0
413]
97
Doubtsaboutactio
n3
1777
06
[01
11]
276
000
100
[2201401]
205[2
02
11]
71
Discrepancy
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdashPerfectio
nistic
attitudes
3983
09
[203
22]
254
2126
142
[2155440]
205[2
07
17]
32
(Contin
ues)
SMITH ET AL | 533
TABLE2
(Contin
ued)
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Perfectio
nistic
strivingsa
101436
02
[202
06]
525
000
ndash010
[2110087]
002[2
01
06]
19
Self-orientedperfectio
nism
6539
07
[201
16]
304
000
ndash161
[2320ndash0
02]
007[2
01
15]
37
Personal
standards
41777
01
[204
06]
060
000
ndash049
[2182083]
001[2
04
05]
06
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
4429
ndash03
[213
06]
126
000
ndash142
[2258ndash0
28]
0ndash03
[213
06]
11
FMPS
totalscore
3666
14
[07
21]
130
000
ndash031
[2055ndash0
07]
016[0
823]
99
EDI-perfectio
nism
52975
03
[201
06]
183
000
106
[2098273]
103[2
01
06]
33
Correlatesof
perfectio
nism
Parental
perceptio
nsc
33230
07
[04
11]
053
000
045
[2643733]
007[0
411]
98
Parental
criticism
31615
08
[03
12]
065
000
063
[2523650]
207[0
211]
85
Parental
expectations
31615
07
[02
12]
010
000
001
[2386387]
007[0
211]
79
Organization
21565
ndash01
[206
04]
082
000
mdashmdash
mdashmdash
mdash
Note
k5numberof
studiesN5totalnumberof
participantsin
theksamplesr1
5weightedmeanbivariatecorrelation
CI5
confidence
intervalQT5measure
ofheterogeneity
ofeffect
sizesI25percentage
ofheteroge-
neity
kT
F5numberof
imputedstudiesas
partof
ldquotrim
andfillrdquo
method
FMPS
5Frostrsquos
andcolleaguesrsquo
(1990)
Multid
imensional
Perfectio
nism
Scale
EDI-perfectio
nism
5Garnerandcolleaguesrsquo
(1983)
EatingDisorder
Inventory-Perfectio
nism
subscale
a Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesdoubtsaboutactio
nsanddiscrepancy
b Perfectionistic
strivingsassessed
asaggregateof
self-orientedperfectio
nism
andpersonal
standards
c Parentalperceptio
nsassessed
asaggregateof
parental
criticism
andparental
expectations
(Cox
etal2002)
d Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesanddoubtsaboutactio
ns
plt05
plt01
p
lt001
534 | SMITH ET AL
Weighted mean effect sizes for the relationships betweenself-oriented other-oriented and socially prescribed perfec-tionism at baseline and suicide ideation at follow-up whilecontrolling for ideation at baseline are in SupplementalMaterial E (see Supplemental Material F for adjusted longi-tudinal effect sizes) Despite the large positive relationshipbetween baseline and follow-up suicide ideation sociallyprescribed perfectionism still displayed a small positive rela-tionship with follow-up suicide ideation after controlling forbaseline suicide ideation Self-oriented and other-orientedperfectionismrsquos relationships with follow-up suicide ideationafter controlling for baseline ideation were nonsignificant
MPS-perfectionism dimensions displayed small-to-largepositive correlations with each other (see SupplementalMaterial G for observed effects and Supplemental MaterialH for adjusted effects) After controlling for overlap in MPSdimensions self-oriented perfectionism ceased to signifi-cantly predict suicide ideation other-oriented perfectionismhad a small unique negative association with suicide idea-tion and socially prescribed perfectionism had a smallunique positive relationship with suicide ideation FMPS-perfectionism dimensions had marginal-to-large correlationswith each other (see Supplemental Material G for observedeffects and Supplemental Material H for adjusted effects)After controlling for overlap in FMPS dimensions the rela-tionships among suicide ideation and concern over mistakespersonal standards parental expectations and organizationwere nonsignificant However after controlling for overlapamong FMPS dimensions doubts about actions and parentalcriticism displayed small unique positive relationships withideation (see Supplemental Material G for observed effectsand Supplemental Material H for adjusted effects)
The test of the total heterogeneity of variance of weightedmean effect sizes (QT) was significant for suicide ideationrsquosrelations with perfectionistic concerns concern over mistakesdiscrepancy personal standards perfectionistic attitudesother-oriented perfectionism FMPS-perfectionism and orga-nization (see Table 2) QT was also significant for the linkbetween suicide attempts and perfectionistic concerns (seeTable 2) The percentage of total variance owing to heteroge-neity (I2) ranged from small to large suggesting possiblemoderators
32 | Moderator analyses
Moderator analyses (see Supplemental Material I) testedwhether effect sizes with significant heterogeneity (QT) weremoderated by publication status (peer-reviewed articles dis-sertations) age (adolescent samples 13 and 17 yearsyoung adult samples 18 and 25 years adultsamples 25 years) sample (university undergraduatescommunity adults psychiatric patients) or perfectionism
measure Perfectionistic concernsrsquo relationship with suicideattempts was nonsignificant for the CAPS but significant forthe FMPS and the MPS Meta-regression also revealed thestrength of the relationship between perfectionistic concernsand suicide attempts decreased as the proportion of femalesin a sample increased However we advise caution in inter-preting our moderator analyses given the small number ofstudies per subgroup
33 | Publication bias
Funnel plots (see Supplemental Material J) and Eggerrsquosregression intercept (see Table 2) provided mixed evidencefor publication bias Eggerrsquos regression intercept was signifi-cant for perfectionistic concernsrsquo relationship with suicideideation and suicide attempts Moreover the funnel plot forperfectionistic concerns and suicide attempts was asymmetri-cal Accordingly for perfectionistic concernsrsquo relationshipwith suicide ideation and suicide attempts trim and fill esti-mates may provide more accurate estimates Nonethelessafter imputing missing studies the adjusted point estimatesfor perfectionistic concernsrsquo relationships with suicide idea-tion and suicide attempts provided the same substantiveimplications (see Table 2)
4 | DISCUSSION
Suicide claims one life every 45 seconds (World HealthOrganization 2012) Given the wide-reaching personal andsocietal costs of suicide it is vital to identify contributingfactors One such factor supported by over 50 years of casehistories theoretical accounts and empirical research is per-fectionism (Blatt 1995 Hassan et al 2014 Hewitt et al2014 Kiamanesh et al 2014 Shaffer 1974) Yet despitethe abundance of research the role of perfectionism in sui-cide remains underappreciated under-recognized and mis-understood due to inconsistencies between studies infindings underpowered studies and uncertainty surroundingwhether perfectionism dimensions predict longitudinalincreases in suicidality We aimed to rectify this by rigor-ously conducting the first meta-analytic review of the perfec-tionismndashsuicidality relationship
41 | An improved understanding of theperfectionismndashsuicidality relationship
Our meta-analysis of 45 studies 54 samples and 11747 par-ticipants represents the most comprehensive test of the per-fectionismndashsuicidality link to date All dimensions orcorrelates of perfectionism (except for other-oriented perfec-tionism and organization) were positively related to suicideideation and these effect sizes were generally consistent
SMITH ET AL | 535
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
authors contacted provided relevant data Additionally wemonitored the Perfectionism Network Mailing List to iden-tify studies that were accepted but not published at the timeof our literature search This yielded one study Chen et al(2017) Both the first and the third author then reviewedabstracts of all studies identified selecting studies meetinginclusion criteria Studies were included that (a) containeddata on perfectionism and suicidality (ideation and attempts)and (b) were in English Included studies also (c) reported aneffect size or enough information for computing an effectsize or effect size information was obtained from a studyauthor All authors contacted (N5 1) provided the requestedinformation
This literature search yielded 57 studies for inclusionInter-rater agreement on inclusion or exclusion in the meta-analysis was 95 Disagreement was resolved by revisitingarticles and coming to a consensus The reference lists ofincluded articles were also examined to locate additional rel-evant literature On August 7 2016 we terminated all searchstrategies and started data reduction and analysis Weexcluded 12 studies (see Supplemental Material A) The finalsample of included studies was composed of 45 studies with54 samples
22 | Coding of studies
The first and the third author coded each study based on ninecharacteristics sample size sample type mean age of partici-pants percentage of female participants percentage of ethnicminority participants publication status measure used toassess perfectionism measure used to assess suicide ideationand measure used to assess suicide attempts
23 | Meta-analytic procedures
Random effects analyses were conducted using Comprehen-sive Meta-Analysis software (Borenstein et al 2005) Wechose random effects models over fixed effects models asthe 45 included studies varied widely in design We alsoweighed mean effects following the procedure suggested byHunter and Schmidt (1990) This allowed us to estimatemean effect sizes and variance in observed scores after con-sidering sampling error (Card 2012) Next effect size esti-mates were weighted by sample size and aggregated Forstudies with more than one measure of suicide ideation weaveraged effect sizes so only one effect was included (Boren-stein et al 2009 Card 2012) Effect sizes presented in met-rics other than r (ie means t-tests d or F scores) wereconverted and expressed as correlations following formulasprovided by Borenstein et al (2009) We also used Boren-stein and colleaguesrsquo (2009) formula to calculate powerunder the random effects model for each weighted mean
effect Additionally most included studies measured perfec-tionism and suicide ideation with imperfect reliability Asthis can attenuate the magnitude of observed correlationseffects were adjusted by dividing the observed correlation bythe square root of the product of the two corresponding reli-ability coefficients (Card 2012) When reported the actualreliability statistics for a study were used when not reportedthe corresponding meta-analyzed mean reliability was used(Card 2012) However we were unable to adjust for unreli-ability in suicide attempts Thus in the interest of methodo-logical consistency we used the common albeitconservative strategy of interpreting observed effects whichgenerally underestimates the true magnitude of effect sizes(Borenstein et al 2009) Nonetheless for readers who dis-agree with this strategy effect sizes adjusted for unreliabilityare presented in our supplementary material
To examine the extent to which baseline self-orientedother-oriented and socially prescribed perfectionism predictfollow-up suicide ideation after controlling for baseline idea-tion we computed partial correlations using the ldquocorpcorrdquopackage (Schafer Opgen-Rhein Zuber Silvia amp Strimmer2015) for R (R Core Team 2013) Although there was insuf-ficient data to examine unique effects between perfectionismdimensions and suicide attempts there was sufficient data toexamine unique effects between perfectionism dimensionsand suicide ideation Thus again using the ldquocorpcorrdquo pack-age (Schafer et al 2015) we computed partial correlationsfor MPS-perfectionism dimensions by residualizing self-oriented other-oriented and socially prescribed perfection-ism based on their overlap with each other prior to being cor-related with suicide ideation Likewise for FMPS-perfectionism dimensions we computed partial correlationsby residualizing concern over mistakes doubts about actionparental criticism parental expectations personal standardsand organization based on their overlap with each other priorto being correlated with suicide ideation
To assess moderation we evaluated the total heterogene-ity of weighted mean effect sizes (QT) A significant QT indi-cates variance in weighted mean effect sizes is greater thanexpected by sampling error (Card 2012) a nonsignificantQT suggests a weak basis for moderation For each analysiswe also computed the inconsistency in observed effects (I2)across studies I2 indicates the percentage of total varianceacross studies due to heterogeneity Values of 25 50and 75 correspond to low medium and high heterogene-ity respectively
When QT was significant we stipulated a categoricalstructure and the total heterogeneity explained by the catego-rization (QB) was calculated (Card 2012) A significant QB
indicates meaningful differences in effects between catego-ries and provides a firm basis for moderation (Borensteinet al 2009) When QB was significant we examined
SMITH ET AL | 531
differences in effect sizes between studies grouped by publi-cation status (articles and dissertations) age (adult youngadult adolescent) and sample (community adults under-graduate students psychiatric patients) by performing aseries of all possible two-group comparisons to test whichgroup differed significantly in effect size (Card 2012) Foreach group comparison the resultant QB from the twogroups was tested using a v2 test with one degree of freedomWe also recorded gender (percentage female) and ethnicity(percentage ethnic minority) as continuous variables andused mixed effects meta-regression to test the potential mod-erating effects of gender and ethnicity
To assess publication bias we inspected funnel plotswith observed and imputed studies and computed Eggerrsquostest of regression to the intercept (Egger Smith Schneideramp Minder 1997) Such funnel plots allow for visual inspec-tion of how the effect size shifts when imputed studies areincluded (Borenstein et al 2009) In the absence of publica-tion bias Eggerrsquos regression intercept does not differ signifi-cantly from zero (Egger et al 1997)
24 | Description of studies
Our search identified 45 studies and 54 samples containingrelevant effect size data (see Table 1) The total number ofparticipants pooled across studies was 11747 Relevant datawere obtained from 38 journal articles and seven disserta-tions There were 21 samples of university undergraduates29 samples of psychiatric patients one sample of medicalstudents and three samples of community adults There were48 cross-sectional samples and six longitudinal samplesSample size varied between 17 and 1436 with an averageof 2175 (SD5 2598) The mean age of participants was268 years (SD5 102 range5 129ndash586) The average per-centage of female participants was 633 the average per-centage of ethnic minority participants was 244 Effectsize information for each individual study is presented inSupplemental Material B Adjusted effect size informationfor each individual study is presented in Supplemental Mate-rial C
25 | Measures
251 | Perfectionism
Following theory and research (eg Dunkley et al 2004Stoeber amp Otto 2006) personal standards (FMPS) and self-oriented perfectionism (MPS Child-Adolescent Perfection-ism Scale [CAPS] Flett et al 2016) were considered facetsof perfectionistic strivings concern over mistakes (FMPS)doubts about actions (FMPS) socially prescribed perfection-ism (MPS CAPS) discrepancy (APS-R) and perfectionistic
attitudes (Dysfunctional Attitude Scale-Perfectionism sub-scale [DAS-P] Weissman amp Beck 1978) were consideredfacets of perfectionistic concerns Parental criticism parentalexpectations and organization were designated correlates ofperfectionism As well parental criticism and parentalexpectations were combined and labeled as parental percep-tions (see Cox et al 2002) Other-oriented perfectionism(MPS) FMPS-perfectionism and EDI-perfectionism weredesignated other forms of perfectionism
252 | Suicide ideation and suicide attempts
Suicide ideations were assessed via self-reported suicidalthinking Suicide attempts were assessed via self-reportednumber of prior suicide attempts (eg Adkins amp Parker1996) clinicianrsquos ratings of the number of prior suicideattempts (eg Fedorowicz et al 2007) and group compari-sons between suicide attempters and non-attempters (egHewitt et al 2014) Although Pfefferrsquos (1986) Child SuicidePotential Scale (CSPS) and Linehanrsquos (1981) Suicide Behav-ior Questionnaire (SBQ) assess suicidal ideation and suicideattempts we categorized the CPS and SBQ as measures ofsuicide ideation given the majority of CSPS and SBQ itemsassess suicidal thoughts
3 | RESULTS
31 | Overall effect sizes
Weighted mean effect sizes between perfectionism corre-lates of perfectionism and suicide ideation and suicideattempts are in Table 2 (see Supplemental Material D foradjusted effect sizes) Following Cohenrsquos (1992) guidelinesfor small medium and large effects (r5 10 30 and 50respectively) perfectionistic concerns socially prescribedperfectionism concern over mistakes doubts about actionsdiscrepancy perfectionistic attitudes perfectionistic striv-ings self-oriented perfectionism personal standards parentalperceptions parental criticism parental expectations andFMPS-perfectionism displayed small-to-moderate positiverelationships with suicide ideation Other-oriented perfection-ismrsquos and organizationrsquos relationships with suicide ideationwere nonsignificant Perfectionistic concerns socially pre-scribed perfectionism concern over mistakes doubts aboutaction FMPS-perfectionism parental perceptions parentalcriticism and parental expectations displayed small positiverelationships with suicide attempts perfectionistic attitudesrsquoperfectionistic strivingsrsquo self-oriented perfectionismrsquos perso-nal standardsrsquo other-oriented perfectionismrsquos EDI-perfectionismrsquos and organizationrsquos relationships with suicideattempts were nonsignificant
532 | SMITH ET AL
TABLE2
Summaryof
overalleffect
sizesfortherelatio
nshipbetweenperfectio
nism
andsuicidality
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Suicideideatio
n
Perfectio
nistic
concerns
a42
7936
28
[24
32]
9910
5863
175
[076
273]
028[2
431]
99
Socially
prescribed
perfectio
nism
303640
28
[25
32]
3704
2171
035
[2100169]
028[2
532]
99
Concern
over
mistakes
5952
25
[13
36]
1219
6720
251
[2436938]
025[1
336]
98
Doubtsaboutactio
ns4
902
27
[18
35]
514
4162
294
[25671158
220[1
130]
99
Discrepancy
4904
26
[14
38]
917
6727
338
[24791154]
124[1
235]
98
Perfectio
nistic
attitudes
51533
37
[19
52]
3355
8808
407
[2033848]
226[0
941]
98
Perfectio
nistic
strivingsb
314588
10
[07
13]
3214
665
018
[2094130]
010[0
713]
99
Self-orientedperfectio
nism
273315
11
[08
15]
2096
000
ndash046
[2156064]
011[0
815]
99
Personal
standards
51273
10
[00
19]
1033
6127
334
[24711139]
010[0
019]
52
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
202755
01
[204
06]
3287
4219
027
[2178230]
101[2
04
06]
08
FMPS
totalscore
41018
31
[15
45]
1971
8477
472
[21692
2636]
127[1
240]
96
EDI-perfectio
nism
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdash
Correlatesof
perfectio
nism
Parental
perceptio
nsc
51904
19
[10
27]
1279
6871
204
[2558966]
019[1
027]
98
Parental
criticism
5952
20
[11
29]
798
4987
092
[2556740]
020[1
029]
98
Parental
expectations
5952
16
[06
26]
842
5247
196
[2391784]
113[0
323]
88
Organization
3513
ndash02
[220
17]
792
7475
253
[27738
8243]
0ndash02
[220
17]
05
Suicideattempts
Perfectio
nistic
concerns
d15
5275
12
[07
17]
2448
4281
115
[021
208]
508[0
314]
99
Socially
prescribed
perfectio
nism
8689
19
[08
29]
1257
4432
021
[2365407]
019[0
829]
93
Concern
over
mistakes
51827
09
[04
14]
012
000
008
[2035052]
109[0
413]
97
Doubtsaboutactio
n3
1777
06
[01
11]
276
000
100
[2201401]
205[2
02
11]
71
Discrepancy
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdashPerfectio
nistic
attitudes
3983
09
[203
22]
254
2126
142
[2155440]
205[2
07
17]
32
(Contin
ues)
SMITH ET AL | 533
TABLE2
(Contin
ued)
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Perfectio
nistic
strivingsa
101436
02
[202
06]
525
000
ndash010
[2110087]
002[2
01
06]
19
Self-orientedperfectio
nism
6539
07
[201
16]
304
000
ndash161
[2320ndash0
02]
007[2
01
15]
37
Personal
standards
41777
01
[204
06]
060
000
ndash049
[2182083]
001[2
04
05]
06
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
4429
ndash03
[213
06]
126
000
ndash142
[2258ndash0
28]
0ndash03
[213
06]
11
FMPS
totalscore
3666
14
[07
21]
130
000
ndash031
[2055ndash0
07]
016[0
823]
99
EDI-perfectio
nism
52975
03
[201
06]
183
000
106
[2098273]
103[2
01
06]
33
Correlatesof
perfectio
nism
Parental
perceptio
nsc
33230
07
[04
11]
053
000
045
[2643733]
007[0
411]
98
Parental
criticism
31615
08
[03
12]
065
000
063
[2523650]
207[0
211]
85
Parental
expectations
31615
07
[02
12]
010
000
001
[2386387]
007[0
211]
79
Organization
21565
ndash01
[206
04]
082
000
mdashmdash
mdashmdash
mdash
Note
k5numberof
studiesN5totalnumberof
participantsin
theksamplesr1
5weightedmeanbivariatecorrelation
CI5
confidence
intervalQT5measure
ofheterogeneity
ofeffect
sizesI25percentage
ofheteroge-
neity
kT
F5numberof
imputedstudiesas
partof
ldquotrim
andfillrdquo
method
FMPS
5Frostrsquos
andcolleaguesrsquo
(1990)
Multid
imensional
Perfectio
nism
Scale
EDI-perfectio
nism
5Garnerandcolleaguesrsquo
(1983)
EatingDisorder
Inventory-Perfectio
nism
subscale
a Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesdoubtsaboutactio
nsanddiscrepancy
b Perfectionistic
strivingsassessed
asaggregateof
self-orientedperfectio
nism
andpersonal
standards
c Parentalperceptio
nsassessed
asaggregateof
parental
criticism
andparental
expectations
(Cox
etal2002)
d Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesanddoubtsaboutactio
ns
plt05
plt01
p
lt001
534 | SMITH ET AL
Weighted mean effect sizes for the relationships betweenself-oriented other-oriented and socially prescribed perfec-tionism at baseline and suicide ideation at follow-up whilecontrolling for ideation at baseline are in SupplementalMaterial E (see Supplemental Material F for adjusted longi-tudinal effect sizes) Despite the large positive relationshipbetween baseline and follow-up suicide ideation sociallyprescribed perfectionism still displayed a small positive rela-tionship with follow-up suicide ideation after controlling forbaseline suicide ideation Self-oriented and other-orientedperfectionismrsquos relationships with follow-up suicide ideationafter controlling for baseline ideation were nonsignificant
MPS-perfectionism dimensions displayed small-to-largepositive correlations with each other (see SupplementalMaterial G for observed effects and Supplemental MaterialH for adjusted effects) After controlling for overlap in MPSdimensions self-oriented perfectionism ceased to signifi-cantly predict suicide ideation other-oriented perfectionismhad a small unique negative association with suicide idea-tion and socially prescribed perfectionism had a smallunique positive relationship with suicide ideation FMPS-perfectionism dimensions had marginal-to-large correlationswith each other (see Supplemental Material G for observedeffects and Supplemental Material H for adjusted effects)After controlling for overlap in FMPS dimensions the rela-tionships among suicide ideation and concern over mistakespersonal standards parental expectations and organizationwere nonsignificant However after controlling for overlapamong FMPS dimensions doubts about actions and parentalcriticism displayed small unique positive relationships withideation (see Supplemental Material G for observed effectsand Supplemental Material H for adjusted effects)
The test of the total heterogeneity of variance of weightedmean effect sizes (QT) was significant for suicide ideationrsquosrelations with perfectionistic concerns concern over mistakesdiscrepancy personal standards perfectionistic attitudesother-oriented perfectionism FMPS-perfectionism and orga-nization (see Table 2) QT was also significant for the linkbetween suicide attempts and perfectionistic concerns (seeTable 2) The percentage of total variance owing to heteroge-neity (I2) ranged from small to large suggesting possiblemoderators
32 | Moderator analyses
Moderator analyses (see Supplemental Material I) testedwhether effect sizes with significant heterogeneity (QT) weremoderated by publication status (peer-reviewed articles dis-sertations) age (adolescent samples 13 and 17 yearsyoung adult samples 18 and 25 years adultsamples 25 years) sample (university undergraduatescommunity adults psychiatric patients) or perfectionism
measure Perfectionistic concernsrsquo relationship with suicideattempts was nonsignificant for the CAPS but significant forthe FMPS and the MPS Meta-regression also revealed thestrength of the relationship between perfectionistic concernsand suicide attempts decreased as the proportion of femalesin a sample increased However we advise caution in inter-preting our moderator analyses given the small number ofstudies per subgroup
33 | Publication bias
Funnel plots (see Supplemental Material J) and Eggerrsquosregression intercept (see Table 2) provided mixed evidencefor publication bias Eggerrsquos regression intercept was signifi-cant for perfectionistic concernsrsquo relationship with suicideideation and suicide attempts Moreover the funnel plot forperfectionistic concerns and suicide attempts was asymmetri-cal Accordingly for perfectionistic concernsrsquo relationshipwith suicide ideation and suicide attempts trim and fill esti-mates may provide more accurate estimates Nonethelessafter imputing missing studies the adjusted point estimatesfor perfectionistic concernsrsquo relationships with suicide idea-tion and suicide attempts provided the same substantiveimplications (see Table 2)
4 | DISCUSSION
Suicide claims one life every 45 seconds (World HealthOrganization 2012) Given the wide-reaching personal andsocietal costs of suicide it is vital to identify contributingfactors One such factor supported by over 50 years of casehistories theoretical accounts and empirical research is per-fectionism (Blatt 1995 Hassan et al 2014 Hewitt et al2014 Kiamanesh et al 2014 Shaffer 1974) Yet despitethe abundance of research the role of perfectionism in sui-cide remains underappreciated under-recognized and mis-understood due to inconsistencies between studies infindings underpowered studies and uncertainty surroundingwhether perfectionism dimensions predict longitudinalincreases in suicidality We aimed to rectify this by rigor-ously conducting the first meta-analytic review of the perfec-tionismndashsuicidality relationship
41 | An improved understanding of theperfectionismndashsuicidality relationship
Our meta-analysis of 45 studies 54 samples and 11747 par-ticipants represents the most comprehensive test of the per-fectionismndashsuicidality link to date All dimensions orcorrelates of perfectionism (except for other-oriented perfec-tionism and organization) were positively related to suicideideation and these effect sizes were generally consistent
SMITH ET AL | 535
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
differences in effect sizes between studies grouped by publi-cation status (articles and dissertations) age (adult youngadult adolescent) and sample (community adults under-graduate students psychiatric patients) by performing aseries of all possible two-group comparisons to test whichgroup differed significantly in effect size (Card 2012) Foreach group comparison the resultant QB from the twogroups was tested using a v2 test with one degree of freedomWe also recorded gender (percentage female) and ethnicity(percentage ethnic minority) as continuous variables andused mixed effects meta-regression to test the potential mod-erating effects of gender and ethnicity
To assess publication bias we inspected funnel plotswith observed and imputed studies and computed Eggerrsquostest of regression to the intercept (Egger Smith Schneideramp Minder 1997) Such funnel plots allow for visual inspec-tion of how the effect size shifts when imputed studies areincluded (Borenstein et al 2009) In the absence of publica-tion bias Eggerrsquos regression intercept does not differ signifi-cantly from zero (Egger et al 1997)
24 | Description of studies
Our search identified 45 studies and 54 samples containingrelevant effect size data (see Table 1) The total number ofparticipants pooled across studies was 11747 Relevant datawere obtained from 38 journal articles and seven disserta-tions There were 21 samples of university undergraduates29 samples of psychiatric patients one sample of medicalstudents and three samples of community adults There were48 cross-sectional samples and six longitudinal samplesSample size varied between 17 and 1436 with an averageof 2175 (SD5 2598) The mean age of participants was268 years (SD5 102 range5 129ndash586) The average per-centage of female participants was 633 the average per-centage of ethnic minority participants was 244 Effectsize information for each individual study is presented inSupplemental Material B Adjusted effect size informationfor each individual study is presented in Supplemental Mate-rial C
25 | Measures
251 | Perfectionism
Following theory and research (eg Dunkley et al 2004Stoeber amp Otto 2006) personal standards (FMPS) and self-oriented perfectionism (MPS Child-Adolescent Perfection-ism Scale [CAPS] Flett et al 2016) were considered facetsof perfectionistic strivings concern over mistakes (FMPS)doubts about actions (FMPS) socially prescribed perfection-ism (MPS CAPS) discrepancy (APS-R) and perfectionistic
attitudes (Dysfunctional Attitude Scale-Perfectionism sub-scale [DAS-P] Weissman amp Beck 1978) were consideredfacets of perfectionistic concerns Parental criticism parentalexpectations and organization were designated correlates ofperfectionism As well parental criticism and parentalexpectations were combined and labeled as parental percep-tions (see Cox et al 2002) Other-oriented perfectionism(MPS) FMPS-perfectionism and EDI-perfectionism weredesignated other forms of perfectionism
252 | Suicide ideation and suicide attempts
Suicide ideations were assessed via self-reported suicidalthinking Suicide attempts were assessed via self-reportednumber of prior suicide attempts (eg Adkins amp Parker1996) clinicianrsquos ratings of the number of prior suicideattempts (eg Fedorowicz et al 2007) and group compari-sons between suicide attempters and non-attempters (egHewitt et al 2014) Although Pfefferrsquos (1986) Child SuicidePotential Scale (CSPS) and Linehanrsquos (1981) Suicide Behav-ior Questionnaire (SBQ) assess suicidal ideation and suicideattempts we categorized the CPS and SBQ as measures ofsuicide ideation given the majority of CSPS and SBQ itemsassess suicidal thoughts
3 | RESULTS
31 | Overall effect sizes
Weighted mean effect sizes between perfectionism corre-lates of perfectionism and suicide ideation and suicideattempts are in Table 2 (see Supplemental Material D foradjusted effect sizes) Following Cohenrsquos (1992) guidelinesfor small medium and large effects (r5 10 30 and 50respectively) perfectionistic concerns socially prescribedperfectionism concern over mistakes doubts about actionsdiscrepancy perfectionistic attitudes perfectionistic striv-ings self-oriented perfectionism personal standards parentalperceptions parental criticism parental expectations andFMPS-perfectionism displayed small-to-moderate positiverelationships with suicide ideation Other-oriented perfection-ismrsquos and organizationrsquos relationships with suicide ideationwere nonsignificant Perfectionistic concerns socially pre-scribed perfectionism concern over mistakes doubts aboutaction FMPS-perfectionism parental perceptions parentalcriticism and parental expectations displayed small positiverelationships with suicide attempts perfectionistic attitudesrsquoperfectionistic strivingsrsquo self-oriented perfectionismrsquos perso-nal standardsrsquo other-oriented perfectionismrsquos EDI-perfectionismrsquos and organizationrsquos relationships with suicideattempts were nonsignificant
532 | SMITH ET AL
TABLE2
Summaryof
overalleffect
sizesfortherelatio
nshipbetweenperfectio
nism
andsuicidality
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Suicideideatio
n
Perfectio
nistic
concerns
a42
7936
28
[24
32]
9910
5863
175
[076
273]
028[2
431]
99
Socially
prescribed
perfectio
nism
303640
28
[25
32]
3704
2171
035
[2100169]
028[2
532]
99
Concern
over
mistakes
5952
25
[13
36]
1219
6720
251
[2436938]
025[1
336]
98
Doubtsaboutactio
ns4
902
27
[18
35]
514
4162
294
[25671158
220[1
130]
99
Discrepancy
4904
26
[14
38]
917
6727
338
[24791154]
124[1
235]
98
Perfectio
nistic
attitudes
51533
37
[19
52]
3355
8808
407
[2033848]
226[0
941]
98
Perfectio
nistic
strivingsb
314588
10
[07
13]
3214
665
018
[2094130]
010[0
713]
99
Self-orientedperfectio
nism
273315
11
[08
15]
2096
000
ndash046
[2156064]
011[0
815]
99
Personal
standards
51273
10
[00
19]
1033
6127
334
[24711139]
010[0
019]
52
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
202755
01
[204
06]
3287
4219
027
[2178230]
101[2
04
06]
08
FMPS
totalscore
41018
31
[15
45]
1971
8477
472
[21692
2636]
127[1
240]
96
EDI-perfectio
nism
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdash
Correlatesof
perfectio
nism
Parental
perceptio
nsc
51904
19
[10
27]
1279
6871
204
[2558966]
019[1
027]
98
Parental
criticism
5952
20
[11
29]
798
4987
092
[2556740]
020[1
029]
98
Parental
expectations
5952
16
[06
26]
842
5247
196
[2391784]
113[0
323]
88
Organization
3513
ndash02
[220
17]
792
7475
253
[27738
8243]
0ndash02
[220
17]
05
Suicideattempts
Perfectio
nistic
concerns
d15
5275
12
[07
17]
2448
4281
115
[021
208]
508[0
314]
99
Socially
prescribed
perfectio
nism
8689
19
[08
29]
1257
4432
021
[2365407]
019[0
829]
93
Concern
over
mistakes
51827
09
[04
14]
012
000
008
[2035052]
109[0
413]
97
Doubtsaboutactio
n3
1777
06
[01
11]
276
000
100
[2201401]
205[2
02
11]
71
Discrepancy
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdashPerfectio
nistic
attitudes
3983
09
[203
22]
254
2126
142
[2155440]
205[2
07
17]
32
(Contin
ues)
SMITH ET AL | 533
TABLE2
(Contin
ued)
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Perfectio
nistic
strivingsa
101436
02
[202
06]
525
000
ndash010
[2110087]
002[2
01
06]
19
Self-orientedperfectio
nism
6539
07
[201
16]
304
000
ndash161
[2320ndash0
02]
007[2
01
15]
37
Personal
standards
41777
01
[204
06]
060
000
ndash049
[2182083]
001[2
04
05]
06
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
4429
ndash03
[213
06]
126
000
ndash142
[2258ndash0
28]
0ndash03
[213
06]
11
FMPS
totalscore
3666
14
[07
21]
130
000
ndash031
[2055ndash0
07]
016[0
823]
99
EDI-perfectio
nism
52975
03
[201
06]
183
000
106
[2098273]
103[2
01
06]
33
Correlatesof
perfectio
nism
Parental
perceptio
nsc
33230
07
[04
11]
053
000
045
[2643733]
007[0
411]
98
Parental
criticism
31615
08
[03
12]
065
000
063
[2523650]
207[0
211]
85
Parental
expectations
31615
07
[02
12]
010
000
001
[2386387]
007[0
211]
79
Organization
21565
ndash01
[206
04]
082
000
mdashmdash
mdashmdash
mdash
Note
k5numberof
studiesN5totalnumberof
participantsin
theksamplesr1
5weightedmeanbivariatecorrelation
CI5
confidence
intervalQT5measure
ofheterogeneity
ofeffect
sizesI25percentage
ofheteroge-
neity
kT
F5numberof
imputedstudiesas
partof
ldquotrim
andfillrdquo
method
FMPS
5Frostrsquos
andcolleaguesrsquo
(1990)
Multid
imensional
Perfectio
nism
Scale
EDI-perfectio
nism
5Garnerandcolleaguesrsquo
(1983)
EatingDisorder
Inventory-Perfectio
nism
subscale
a Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesdoubtsaboutactio
nsanddiscrepancy
b Perfectionistic
strivingsassessed
asaggregateof
self-orientedperfectio
nism
andpersonal
standards
c Parentalperceptio
nsassessed
asaggregateof
parental
criticism
andparental
expectations
(Cox
etal2002)
d Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesanddoubtsaboutactio
ns
plt05
plt01
p
lt001
534 | SMITH ET AL
Weighted mean effect sizes for the relationships betweenself-oriented other-oriented and socially prescribed perfec-tionism at baseline and suicide ideation at follow-up whilecontrolling for ideation at baseline are in SupplementalMaterial E (see Supplemental Material F for adjusted longi-tudinal effect sizes) Despite the large positive relationshipbetween baseline and follow-up suicide ideation sociallyprescribed perfectionism still displayed a small positive rela-tionship with follow-up suicide ideation after controlling forbaseline suicide ideation Self-oriented and other-orientedperfectionismrsquos relationships with follow-up suicide ideationafter controlling for baseline ideation were nonsignificant
MPS-perfectionism dimensions displayed small-to-largepositive correlations with each other (see SupplementalMaterial G for observed effects and Supplemental MaterialH for adjusted effects) After controlling for overlap in MPSdimensions self-oriented perfectionism ceased to signifi-cantly predict suicide ideation other-oriented perfectionismhad a small unique negative association with suicide idea-tion and socially prescribed perfectionism had a smallunique positive relationship with suicide ideation FMPS-perfectionism dimensions had marginal-to-large correlationswith each other (see Supplemental Material G for observedeffects and Supplemental Material H for adjusted effects)After controlling for overlap in FMPS dimensions the rela-tionships among suicide ideation and concern over mistakespersonal standards parental expectations and organizationwere nonsignificant However after controlling for overlapamong FMPS dimensions doubts about actions and parentalcriticism displayed small unique positive relationships withideation (see Supplemental Material G for observed effectsand Supplemental Material H for adjusted effects)
The test of the total heterogeneity of variance of weightedmean effect sizes (QT) was significant for suicide ideationrsquosrelations with perfectionistic concerns concern over mistakesdiscrepancy personal standards perfectionistic attitudesother-oriented perfectionism FMPS-perfectionism and orga-nization (see Table 2) QT was also significant for the linkbetween suicide attempts and perfectionistic concerns (seeTable 2) The percentage of total variance owing to heteroge-neity (I2) ranged from small to large suggesting possiblemoderators
32 | Moderator analyses
Moderator analyses (see Supplemental Material I) testedwhether effect sizes with significant heterogeneity (QT) weremoderated by publication status (peer-reviewed articles dis-sertations) age (adolescent samples 13 and 17 yearsyoung adult samples 18 and 25 years adultsamples 25 years) sample (university undergraduatescommunity adults psychiatric patients) or perfectionism
measure Perfectionistic concernsrsquo relationship with suicideattempts was nonsignificant for the CAPS but significant forthe FMPS and the MPS Meta-regression also revealed thestrength of the relationship between perfectionistic concernsand suicide attempts decreased as the proportion of femalesin a sample increased However we advise caution in inter-preting our moderator analyses given the small number ofstudies per subgroup
33 | Publication bias
Funnel plots (see Supplemental Material J) and Eggerrsquosregression intercept (see Table 2) provided mixed evidencefor publication bias Eggerrsquos regression intercept was signifi-cant for perfectionistic concernsrsquo relationship with suicideideation and suicide attempts Moreover the funnel plot forperfectionistic concerns and suicide attempts was asymmetri-cal Accordingly for perfectionistic concernsrsquo relationshipwith suicide ideation and suicide attempts trim and fill esti-mates may provide more accurate estimates Nonethelessafter imputing missing studies the adjusted point estimatesfor perfectionistic concernsrsquo relationships with suicide idea-tion and suicide attempts provided the same substantiveimplications (see Table 2)
4 | DISCUSSION
Suicide claims one life every 45 seconds (World HealthOrganization 2012) Given the wide-reaching personal andsocietal costs of suicide it is vital to identify contributingfactors One such factor supported by over 50 years of casehistories theoretical accounts and empirical research is per-fectionism (Blatt 1995 Hassan et al 2014 Hewitt et al2014 Kiamanesh et al 2014 Shaffer 1974) Yet despitethe abundance of research the role of perfectionism in sui-cide remains underappreciated under-recognized and mis-understood due to inconsistencies between studies infindings underpowered studies and uncertainty surroundingwhether perfectionism dimensions predict longitudinalincreases in suicidality We aimed to rectify this by rigor-ously conducting the first meta-analytic review of the perfec-tionismndashsuicidality relationship
41 | An improved understanding of theperfectionismndashsuicidality relationship
Our meta-analysis of 45 studies 54 samples and 11747 par-ticipants represents the most comprehensive test of the per-fectionismndashsuicidality link to date All dimensions orcorrelates of perfectionism (except for other-oriented perfec-tionism and organization) were positively related to suicideideation and these effect sizes were generally consistent
SMITH ET AL | 535
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
TABLE2
Summaryof
overalleffect
sizesfortherelatio
nshipbetweenperfectio
nism
andsuicidality
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Suicideideatio
n
Perfectio
nistic
concerns
a42
7936
28
[24
32]
9910
5863
175
[076
273]
028[2
431]
99
Socially
prescribed
perfectio
nism
303640
28
[25
32]
3704
2171
035
[2100169]
028[2
532]
99
Concern
over
mistakes
5952
25
[13
36]
1219
6720
251
[2436938]
025[1
336]
98
Doubtsaboutactio
ns4
902
27
[18
35]
514
4162
294
[25671158
220[1
130]
99
Discrepancy
4904
26
[14
38]
917
6727
338
[24791154]
124[1
235]
98
Perfectio
nistic
attitudes
51533
37
[19
52]
3355
8808
407
[2033848]
226[0
941]
98
Perfectio
nistic
strivingsb
314588
10
[07
13]
3214
665
018
[2094130]
010[0
713]
99
Self-orientedperfectio
nism
273315
11
[08
15]
2096
000
ndash046
[2156064]
011[0
815]
99
Personal
standards
51273
10
[00
19]
1033
6127
334
[24711139]
010[0
019]
52
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
202755
01
[204
06]
3287
4219
027
[2178230]
101[2
04
06]
08
FMPS
totalscore
41018
31
[15
45]
1971
8477
472
[21692
2636]
127[1
240]
96
EDI-perfectio
nism
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdash
Correlatesof
perfectio
nism
Parental
perceptio
nsc
51904
19
[10
27]
1279
6871
204
[2558966]
019[1
027]
98
Parental
criticism
5952
20
[11
29]
798
4987
092
[2556740]
020[1
029]
98
Parental
expectations
5952
16
[06
26]
842
5247
196
[2391784]
113[0
323]
88
Organization
3513
ndash02
[220
17]
792
7475
253
[27738
8243]
0ndash02
[220
17]
05
Suicideattempts
Perfectio
nistic
concerns
d15
5275
12
[07
17]
2448
4281
115
[021
208]
508[0
314]
99
Socially
prescribed
perfectio
nism
8689
19
[08
29]
1257
4432
021
[2365407]
019[0
829]
93
Concern
over
mistakes
51827
09
[04
14]
012
000
008
[2035052]
109[0
413]
97
Doubtsaboutactio
n3
1777
06
[01
11]
276
000
100
[2201401]
205[2
02
11]
71
Discrepancy
0mdash
mdashmdash
mdashmdash
mdashmdash
mdashmdash
mdashPerfectio
nistic
attitudes
3983
09
[203
22]
254
2126
142
[2155440]
205[2
07
17]
32
(Contin
ues)
SMITH ET AL | 533
TABLE2
(Contin
ued)
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Perfectio
nistic
strivingsa
101436
02
[202
06]
525
000
ndash010
[2110087]
002[2
01
06]
19
Self-orientedperfectio
nism
6539
07
[201
16]
304
000
ndash161
[2320ndash0
02]
007[2
01
15]
37
Personal
standards
41777
01
[204
06]
060
000
ndash049
[2182083]
001[2
04
05]
06
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
4429
ndash03
[213
06]
126
000
ndash142
[2258ndash0
28]
0ndash03
[213
06]
11
FMPS
totalscore
3666
14
[07
21]
130
000
ndash031
[2055ndash0
07]
016[0
823]
99
EDI-perfectio
nism
52975
03
[201
06]
183
000
106
[2098273]
103[2
01
06]
33
Correlatesof
perfectio
nism
Parental
perceptio
nsc
33230
07
[04
11]
053
000
045
[2643733]
007[0
411]
98
Parental
criticism
31615
08
[03
12]
065
000
063
[2523650]
207[0
211]
85
Parental
expectations
31615
07
[02
12]
010
000
001
[2386387]
007[0
211]
79
Organization
21565
ndash01
[206
04]
082
000
mdashmdash
mdashmdash
mdash
Note
k5numberof
studiesN5totalnumberof
participantsin
theksamplesr1
5weightedmeanbivariatecorrelation
CI5
confidence
intervalQT5measure
ofheterogeneity
ofeffect
sizesI25percentage
ofheteroge-
neity
kT
F5numberof
imputedstudiesas
partof
ldquotrim
andfillrdquo
method
FMPS
5Frostrsquos
andcolleaguesrsquo
(1990)
Multid
imensional
Perfectio
nism
Scale
EDI-perfectio
nism
5Garnerandcolleaguesrsquo
(1983)
EatingDisorder
Inventory-Perfectio
nism
subscale
a Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesdoubtsaboutactio
nsanddiscrepancy
b Perfectionistic
strivingsassessed
asaggregateof
self-orientedperfectio
nism
andpersonal
standards
c Parentalperceptio
nsassessed
asaggregateof
parental
criticism
andparental
expectations
(Cox
etal2002)
d Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesanddoubtsaboutactio
ns
plt05
plt01
p
lt001
534 | SMITH ET AL
Weighted mean effect sizes for the relationships betweenself-oriented other-oriented and socially prescribed perfec-tionism at baseline and suicide ideation at follow-up whilecontrolling for ideation at baseline are in SupplementalMaterial E (see Supplemental Material F for adjusted longi-tudinal effect sizes) Despite the large positive relationshipbetween baseline and follow-up suicide ideation sociallyprescribed perfectionism still displayed a small positive rela-tionship with follow-up suicide ideation after controlling forbaseline suicide ideation Self-oriented and other-orientedperfectionismrsquos relationships with follow-up suicide ideationafter controlling for baseline ideation were nonsignificant
MPS-perfectionism dimensions displayed small-to-largepositive correlations with each other (see SupplementalMaterial G for observed effects and Supplemental MaterialH for adjusted effects) After controlling for overlap in MPSdimensions self-oriented perfectionism ceased to signifi-cantly predict suicide ideation other-oriented perfectionismhad a small unique negative association with suicide idea-tion and socially prescribed perfectionism had a smallunique positive relationship with suicide ideation FMPS-perfectionism dimensions had marginal-to-large correlationswith each other (see Supplemental Material G for observedeffects and Supplemental Material H for adjusted effects)After controlling for overlap in FMPS dimensions the rela-tionships among suicide ideation and concern over mistakespersonal standards parental expectations and organizationwere nonsignificant However after controlling for overlapamong FMPS dimensions doubts about actions and parentalcriticism displayed small unique positive relationships withideation (see Supplemental Material G for observed effectsand Supplemental Material H for adjusted effects)
The test of the total heterogeneity of variance of weightedmean effect sizes (QT) was significant for suicide ideationrsquosrelations with perfectionistic concerns concern over mistakesdiscrepancy personal standards perfectionistic attitudesother-oriented perfectionism FMPS-perfectionism and orga-nization (see Table 2) QT was also significant for the linkbetween suicide attempts and perfectionistic concerns (seeTable 2) The percentage of total variance owing to heteroge-neity (I2) ranged from small to large suggesting possiblemoderators
32 | Moderator analyses
Moderator analyses (see Supplemental Material I) testedwhether effect sizes with significant heterogeneity (QT) weremoderated by publication status (peer-reviewed articles dis-sertations) age (adolescent samples 13 and 17 yearsyoung adult samples 18 and 25 years adultsamples 25 years) sample (university undergraduatescommunity adults psychiatric patients) or perfectionism
measure Perfectionistic concernsrsquo relationship with suicideattempts was nonsignificant for the CAPS but significant forthe FMPS and the MPS Meta-regression also revealed thestrength of the relationship between perfectionistic concernsand suicide attempts decreased as the proportion of femalesin a sample increased However we advise caution in inter-preting our moderator analyses given the small number ofstudies per subgroup
33 | Publication bias
Funnel plots (see Supplemental Material J) and Eggerrsquosregression intercept (see Table 2) provided mixed evidencefor publication bias Eggerrsquos regression intercept was signifi-cant for perfectionistic concernsrsquo relationship with suicideideation and suicide attempts Moreover the funnel plot forperfectionistic concerns and suicide attempts was asymmetri-cal Accordingly for perfectionistic concernsrsquo relationshipwith suicide ideation and suicide attempts trim and fill esti-mates may provide more accurate estimates Nonethelessafter imputing missing studies the adjusted point estimatesfor perfectionistic concernsrsquo relationships with suicide idea-tion and suicide attempts provided the same substantiveimplications (see Table 2)
4 | DISCUSSION
Suicide claims one life every 45 seconds (World HealthOrganization 2012) Given the wide-reaching personal andsocietal costs of suicide it is vital to identify contributingfactors One such factor supported by over 50 years of casehistories theoretical accounts and empirical research is per-fectionism (Blatt 1995 Hassan et al 2014 Hewitt et al2014 Kiamanesh et al 2014 Shaffer 1974) Yet despitethe abundance of research the role of perfectionism in sui-cide remains underappreciated under-recognized and mis-understood due to inconsistencies between studies infindings underpowered studies and uncertainty surroundingwhether perfectionism dimensions predict longitudinalincreases in suicidality We aimed to rectify this by rigor-ously conducting the first meta-analytic review of the perfec-tionismndashsuicidality relationship
41 | An improved understanding of theperfectionismndashsuicidality relationship
Our meta-analysis of 45 studies 54 samples and 11747 par-ticipants represents the most comprehensive test of the per-fectionismndashsuicidality link to date All dimensions orcorrelates of perfectionism (except for other-oriented perfec-tionism and organization) were positively related to suicideideation and these effect sizes were generally consistent
SMITH ET AL | 535
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
TABLE2
(Contin
ued)
Variable
kN
r195
CI
QT
I2(
)Eggerrsquos
intercept
95
CI
kTF
ldquoTrim
andfillrdquo
estim
ates
r1
[95
CI]
Power
Perfectio
nistic
strivingsa
101436
02
[202
06]
525
000
ndash010
[2110087]
002[2
01
06]
19
Self-orientedperfectio
nism
6539
07
[201
16]
304
000
ndash161
[2320ndash0
02]
007[2
01
15]
37
Personal
standards
41777
01
[204
06]
060
000
ndash049
[2182083]
001[2
04
05]
06
Other
form
sof
perfectio
nism
Other-orientedperfectio
nism
4429
ndash03
[213
06]
126
000
ndash142
[2258ndash0
28]
0ndash03
[213
06]
11
FMPS
totalscore
3666
14
[07
21]
130
000
ndash031
[2055ndash0
07]
016[0
823]
99
EDI-perfectio
nism
52975
03
[201
06]
183
000
106
[2098273]
103[2
01
06]
33
Correlatesof
perfectio
nism
Parental
perceptio
nsc
33230
07
[04
11]
053
000
045
[2643733]
007[0
411]
98
Parental
criticism
31615
08
[03
12]
065
000
063
[2523650]
207[0
211]
85
Parental
expectations
31615
07
[02
12]
010
000
001
[2386387]
007[0
211]
79
Organization
21565
ndash01
[206
04]
082
000
mdashmdash
mdashmdash
mdash
Note
k5numberof
studiesN5totalnumberof
participantsin
theksamplesr1
5weightedmeanbivariatecorrelation
CI5
confidence
intervalQT5measure
ofheterogeneity
ofeffect
sizesI25percentage
ofheteroge-
neity
kT
F5numberof
imputedstudiesas
partof
ldquotrim
andfillrdquo
method
FMPS
5Frostrsquos
andcolleaguesrsquo
(1990)
Multid
imensional
Perfectio
nism
Scale
EDI-perfectio
nism
5Garnerandcolleaguesrsquo
(1983)
EatingDisorder
Inventory-Perfectio
nism
subscale
a Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesdoubtsaboutactio
nsanddiscrepancy
b Perfectionistic
strivingsassessed
asaggregateof
self-orientedperfectio
nism
andpersonal
standards
c Parentalperceptio
nsassessed
asaggregateof
parental
criticism
andparental
expectations
(Cox
etal2002)
d Perfectionistic
concerns
assessed
asaggregateof
socially
prescribed
perfectio
nism
concernover
mistakesanddoubtsaboutactio
ns
plt05
plt01
p
lt001
534 | SMITH ET AL
Weighted mean effect sizes for the relationships betweenself-oriented other-oriented and socially prescribed perfec-tionism at baseline and suicide ideation at follow-up whilecontrolling for ideation at baseline are in SupplementalMaterial E (see Supplemental Material F for adjusted longi-tudinal effect sizes) Despite the large positive relationshipbetween baseline and follow-up suicide ideation sociallyprescribed perfectionism still displayed a small positive rela-tionship with follow-up suicide ideation after controlling forbaseline suicide ideation Self-oriented and other-orientedperfectionismrsquos relationships with follow-up suicide ideationafter controlling for baseline ideation were nonsignificant
MPS-perfectionism dimensions displayed small-to-largepositive correlations with each other (see SupplementalMaterial G for observed effects and Supplemental MaterialH for adjusted effects) After controlling for overlap in MPSdimensions self-oriented perfectionism ceased to signifi-cantly predict suicide ideation other-oriented perfectionismhad a small unique negative association with suicide idea-tion and socially prescribed perfectionism had a smallunique positive relationship with suicide ideation FMPS-perfectionism dimensions had marginal-to-large correlationswith each other (see Supplemental Material G for observedeffects and Supplemental Material H for adjusted effects)After controlling for overlap in FMPS dimensions the rela-tionships among suicide ideation and concern over mistakespersonal standards parental expectations and organizationwere nonsignificant However after controlling for overlapamong FMPS dimensions doubts about actions and parentalcriticism displayed small unique positive relationships withideation (see Supplemental Material G for observed effectsand Supplemental Material H for adjusted effects)
The test of the total heterogeneity of variance of weightedmean effect sizes (QT) was significant for suicide ideationrsquosrelations with perfectionistic concerns concern over mistakesdiscrepancy personal standards perfectionistic attitudesother-oriented perfectionism FMPS-perfectionism and orga-nization (see Table 2) QT was also significant for the linkbetween suicide attempts and perfectionistic concerns (seeTable 2) The percentage of total variance owing to heteroge-neity (I2) ranged from small to large suggesting possiblemoderators
32 | Moderator analyses
Moderator analyses (see Supplemental Material I) testedwhether effect sizes with significant heterogeneity (QT) weremoderated by publication status (peer-reviewed articles dis-sertations) age (adolescent samples 13 and 17 yearsyoung adult samples 18 and 25 years adultsamples 25 years) sample (university undergraduatescommunity adults psychiatric patients) or perfectionism
measure Perfectionistic concernsrsquo relationship with suicideattempts was nonsignificant for the CAPS but significant forthe FMPS and the MPS Meta-regression also revealed thestrength of the relationship between perfectionistic concernsand suicide attempts decreased as the proportion of femalesin a sample increased However we advise caution in inter-preting our moderator analyses given the small number ofstudies per subgroup
33 | Publication bias
Funnel plots (see Supplemental Material J) and Eggerrsquosregression intercept (see Table 2) provided mixed evidencefor publication bias Eggerrsquos regression intercept was signifi-cant for perfectionistic concernsrsquo relationship with suicideideation and suicide attempts Moreover the funnel plot forperfectionistic concerns and suicide attempts was asymmetri-cal Accordingly for perfectionistic concernsrsquo relationshipwith suicide ideation and suicide attempts trim and fill esti-mates may provide more accurate estimates Nonethelessafter imputing missing studies the adjusted point estimatesfor perfectionistic concernsrsquo relationships with suicide idea-tion and suicide attempts provided the same substantiveimplications (see Table 2)
4 | DISCUSSION
Suicide claims one life every 45 seconds (World HealthOrganization 2012) Given the wide-reaching personal andsocietal costs of suicide it is vital to identify contributingfactors One such factor supported by over 50 years of casehistories theoretical accounts and empirical research is per-fectionism (Blatt 1995 Hassan et al 2014 Hewitt et al2014 Kiamanesh et al 2014 Shaffer 1974) Yet despitethe abundance of research the role of perfectionism in sui-cide remains underappreciated under-recognized and mis-understood due to inconsistencies between studies infindings underpowered studies and uncertainty surroundingwhether perfectionism dimensions predict longitudinalincreases in suicidality We aimed to rectify this by rigor-ously conducting the first meta-analytic review of the perfec-tionismndashsuicidality relationship
41 | An improved understanding of theperfectionismndashsuicidality relationship
Our meta-analysis of 45 studies 54 samples and 11747 par-ticipants represents the most comprehensive test of the per-fectionismndashsuicidality link to date All dimensions orcorrelates of perfectionism (except for other-oriented perfec-tionism and organization) were positively related to suicideideation and these effect sizes were generally consistent
SMITH ET AL | 535
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
Weighted mean effect sizes for the relationships betweenself-oriented other-oriented and socially prescribed perfec-tionism at baseline and suicide ideation at follow-up whilecontrolling for ideation at baseline are in SupplementalMaterial E (see Supplemental Material F for adjusted longi-tudinal effect sizes) Despite the large positive relationshipbetween baseline and follow-up suicide ideation sociallyprescribed perfectionism still displayed a small positive rela-tionship with follow-up suicide ideation after controlling forbaseline suicide ideation Self-oriented and other-orientedperfectionismrsquos relationships with follow-up suicide ideationafter controlling for baseline ideation were nonsignificant
MPS-perfectionism dimensions displayed small-to-largepositive correlations with each other (see SupplementalMaterial G for observed effects and Supplemental MaterialH for adjusted effects) After controlling for overlap in MPSdimensions self-oriented perfectionism ceased to signifi-cantly predict suicide ideation other-oriented perfectionismhad a small unique negative association with suicide idea-tion and socially prescribed perfectionism had a smallunique positive relationship with suicide ideation FMPS-perfectionism dimensions had marginal-to-large correlationswith each other (see Supplemental Material G for observedeffects and Supplemental Material H for adjusted effects)After controlling for overlap in FMPS dimensions the rela-tionships among suicide ideation and concern over mistakespersonal standards parental expectations and organizationwere nonsignificant However after controlling for overlapamong FMPS dimensions doubts about actions and parentalcriticism displayed small unique positive relationships withideation (see Supplemental Material G for observed effectsand Supplemental Material H for adjusted effects)
The test of the total heterogeneity of variance of weightedmean effect sizes (QT) was significant for suicide ideationrsquosrelations with perfectionistic concerns concern over mistakesdiscrepancy personal standards perfectionistic attitudesother-oriented perfectionism FMPS-perfectionism and orga-nization (see Table 2) QT was also significant for the linkbetween suicide attempts and perfectionistic concerns (seeTable 2) The percentage of total variance owing to heteroge-neity (I2) ranged from small to large suggesting possiblemoderators
32 | Moderator analyses
Moderator analyses (see Supplemental Material I) testedwhether effect sizes with significant heterogeneity (QT) weremoderated by publication status (peer-reviewed articles dis-sertations) age (adolescent samples 13 and 17 yearsyoung adult samples 18 and 25 years adultsamples 25 years) sample (university undergraduatescommunity adults psychiatric patients) or perfectionism
measure Perfectionistic concernsrsquo relationship with suicideattempts was nonsignificant for the CAPS but significant forthe FMPS and the MPS Meta-regression also revealed thestrength of the relationship between perfectionistic concernsand suicide attempts decreased as the proportion of femalesin a sample increased However we advise caution in inter-preting our moderator analyses given the small number ofstudies per subgroup
33 | Publication bias
Funnel plots (see Supplemental Material J) and Eggerrsquosregression intercept (see Table 2) provided mixed evidencefor publication bias Eggerrsquos regression intercept was signifi-cant for perfectionistic concernsrsquo relationship with suicideideation and suicide attempts Moreover the funnel plot forperfectionistic concerns and suicide attempts was asymmetri-cal Accordingly for perfectionistic concernsrsquo relationshipwith suicide ideation and suicide attempts trim and fill esti-mates may provide more accurate estimates Nonethelessafter imputing missing studies the adjusted point estimatesfor perfectionistic concernsrsquo relationships with suicide idea-tion and suicide attempts provided the same substantiveimplications (see Table 2)
4 | DISCUSSION
Suicide claims one life every 45 seconds (World HealthOrganization 2012) Given the wide-reaching personal andsocietal costs of suicide it is vital to identify contributingfactors One such factor supported by over 50 years of casehistories theoretical accounts and empirical research is per-fectionism (Blatt 1995 Hassan et al 2014 Hewitt et al2014 Kiamanesh et al 2014 Shaffer 1974) Yet despitethe abundance of research the role of perfectionism in sui-cide remains underappreciated under-recognized and mis-understood due to inconsistencies between studies infindings underpowered studies and uncertainty surroundingwhether perfectionism dimensions predict longitudinalincreases in suicidality We aimed to rectify this by rigor-ously conducting the first meta-analytic review of the perfec-tionismndashsuicidality relationship
41 | An improved understanding of theperfectionismndashsuicidality relationship
Our meta-analysis of 45 studies 54 samples and 11747 par-ticipants represents the most comprehensive test of the per-fectionismndashsuicidality link to date All dimensions orcorrelates of perfectionism (except for other-oriented perfec-tionism and organization) were positively related to suicideideation and these effect sizes were generally consistent
SMITH ET AL | 535
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
across samples methods and measures Socially prescribedperfectionism also predicted longitudinal increases in suicideideation Seven dimensions or correlates of perfectionismwere related positively to suicide attempts (ie perfectionis-tic concerns socially prescribed perfectionism concern overmistakes doubts about actions FMPS-perfectionism andparental criticism and expectations)
These findings complement case histories and theoreticalaccounts (eg Baumeister 1990 Blatt 1995 Hewitt et al2006) suggesting people high in perfectionism appear tothink behave perceive and relate in ways that have suicido-genic consequences We refined this literature showing thatperfectionism dimensions are differentially related to suici-dality with perfectionistic strivings (self-oriented perfection-ism and personal standards) predicting suicide ideation andperfectionistic concerns (socially prescribed perfectionismconcern over mistakes doubts about actions and perfection-istic attitudes) predicting suicide ideation and attempts Peo-ple high in perfectionistic strivings are only satisfied whenevents in their lives suggest they are perfect when life eventsinevitably suggest they are not perfect suicidal ideation mayfollow (Blatt 1995 Hewitt amp Flett 2002) People high inperfectionistic concerns believe others hold lofty expecta-tions for them and they feel incapable of living up to theperfection they perceive others demand Such people alsotend to see their social world as rejecting and to see othersas disappointed in them This sense of disappointing othersmay fuel suicide ideation and attempts for people high inperfectionistic concerns (Hewitt et al 2006 Sherry et al2015)
Our results also suggest socially prescribed perfectionismacts as a risk factor predicting longitudinal increases in sui-cide ideation Given the strong link between baseline suicideideation and subsequent suicide ideation these analyses rep-resent a particularly stringent test of the connection betweensocially prescribed perfectionism and suicide ideationSocially prescribed perfectionism appears to be composed ofstable underlying traits that trigger suicide ideation In factour findings lend credence to the long-standing notion thatfeeling incapable of living up to the lofty standards of othersis a part of the premorbid personality of people at risk forsuicide (for a review see Hewitt et al 2006) Our findingsalso join a wider literature suggesting that when people expe-rience their social world as pressure-filled judgmental andhypercritical they think about andor engage in variouspotential means of escape (eg alcohol misuse and bingeeating) including suicide (eg Baumeister 1990 Sherry ampHall 2009) In addition preliminarily our findings suggestparental criticism and expectations are parenting styles withenduring negative consequences It seems the conditions thatgive rise to perfectionism (eg critical and demandingparents Blatt 1995) might also be linked to suicidality
Other-oriented perfectionismrsquos and organizationrsquos rela-tionships with suicide ideation and attempts were nonsignifi-cant While other-oriented perfectionists appear to elicit greatdistress in other people (Nealis Sherry Sherry Stewart ampMacneil 2015) our results suggest other-oriented perfection-ists themselves do not suffer greater suicidality Our findingsalso indicate organization is benign as regards suicide idea-tion However we are unable to reach a concrete conclusionregarding organizationrsquos relationship with suicide attemptsas only two studies assessed organization and suicideattempts (Adkins amp Parker 1996 Portzky Van Heeringenamp Vervaet 2014) Moreover concerns exist about whetherorganization is part of the perfectionism construct (Stoeberamp Otto 2006) Indeed Frost et al (1990) considered organi-zation to be associated with perfectionism but not a definingtrait
Although both perfectionistic concerns and strivingswere related to suicide ideation only perfectionistic concernswere related to suicide attempts Our results thus suggest per-fectionistic concerns are linked to more severe and poten-tially more lethal suicide behaviors That saidperfectionistic strivingsrsquo link with suicide ideation is impor-tant The strength of the relation between perfectionisticstrivings and suicide ideation may intensify in the presenceof ego-involving stressors (Flett et al 2014 Hewitt et al2006) However the small but positive relation betweenperfectionistic strivings and suicide ideation diverges withsome authorsrsquo notion that perfectionistic strivings are adapt-ive traits that protect against suicidality (eg Stoeber ampOtto 2006) In contrast our results suggest people high inperfectionistic strivings appear driven to achieve perfectionin a manner that makes them want to die In relation to thebroader personality research literature conscientiousness isnegatively related to suicide ideation (Bogg amp Roberts2004) whereas we found perfectionistic strivings are posi-tively related to suicide ideation These results suggest thereliable self-disciplined behavior typifying conscientious-ness differs from the unrealistic goal-pursuit and expectationscentral to perfectionistic strivings and perfectionistic striv-ings are more than just conscientiousness or an extreme needfor achievement
Turning to unique effects findings aligned with studiesshowing perfectionistic strivingsrsquo relation with suicide idea-tion is due to overlap with perfectionistic concerns (eg Fla-menbaum amp Holden 2007) Controlling for overlap in MPS-perfectionism dimensions socially prescribed perfectionismwas positively related to suicide ideation other-oriented per-fectionism was negatively related to suicide ideation andself-oriented perfectionism was unrelated to suicide ideationRelatedly controlling for overlap in FMPS-perfectionismdimensions doubts about actions and parental criticism butnot concern over mistakes or parental expectations were
536 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
related to suicide ideation However we caution againstover-interpretation of these unique effects
Researchers are wary that removing variance attributableto perfectionistic concerns when examining the effects ofperfectionistic strivings may change the conceptual meaningof perfectionistic strivings and result in a form of perfection-ism seldom seen in real life (Hill 2014 Molnar SadavaFlett amp Colautti 2012 Powers Koestner Zuroff Milyav-skaya amp Gorin 2011) Indeed it is unclear what residual-ized perfectionistic strivings measures (Hill 2014) Untilsuch questions are answered we urge caution in interpretingour results involving residualized perfectionistic strivingsAnd we note that at best perfectionistic strivings stripped oftheir overlap with perfectionistic concerns are unrelated tosuicide ideation at worst perfectionistic strivings when notresidualized are related to suicide ideationmdashneither of whichsuggests that self-driven pressure to be perfect is conduciveto mental health
5 | LIMITATIONS OF OVERALLLITERATURE
Though there are a growing number of longitudinal studies(eg R C OrsquoConnor Whyte et al 2007) most research onthe perfectionismndashsuicidality link is cross-sectional As cross-sectional studies are incapable of testing for risk factors thisis problematic Accordingly although our findings providecompelling evidence that most perfectionism dimensions areconcomitants of suicidality there is much to learn aboutwhether perfectionism comes before occurs during or per-sists after suicidality (see Durbin amp Hicks 2014) We alsoneed stringent tests of the extent to which perfectionism addsincrementally to our understanding of suicidality beyondother established predictors of suicidality such as personalitytraits (eg borderline traits) psychological symptoms (egdepression) and sociocultural factors (eg poverty) Alsowhile five perfectionistic concernsrsquo dimensions were tested inour meta-analysis only two perfectionistic strivingsrsquo dimen-sions were included (self-oriented perfectionism personalstandards) Thus it is likely perfectionistic concerns captureda more comprehensive construct limiting our ability to com-pare the contributions of perfectionistic concerns and striv-ings Moreover most research on the perfectionismndashsuicidality link is on trait perfectionism As such little con-sideration is given to other dimensions of perfectionism (egperfectionistic self-presentation Hewitt Flett Sherry et al(2003))
51 | Limitations of the present study
Limitations in the literature translate into limitations in ouranalyses For some scales data were available for suicide
ideation but not suicide attempts (and vice versa) Also whilethere were enough data to test the extent to which MPSdimensions predict longitudinal changes in suicide ideationthere was insufficient data to test the extent to which the otherperfectionism dimensions or correlates confer longitudinalrisk for suicide ideation And although there were sufficientdata to assess MPS and FMPS dimensionsrsquo relationships withsuicide ideation after controlling for overlap there was insuf-ficient data to assess MPS and FMPS dimensionsrsquo relation-ships with suicide attempts after controlling for overlapLikewise research on organizationrsquos relationship with suicideattempts is limited and further research is needed to obtainmore accurate results Future research also should integrateour findings into empirically tested models explaining whenand why perfectionism combines with constructs such asstress and social problems to predict suicidality Finallyincluded studies involved mainly Caucasians from Canadathe United States and the United Kingdom meaning ourfindings may have limited generalizability to ethnicallydiverse samples Given Chen and colleaguesrsquo (2017) recentwork on ethnic variations in the perfectionismndashsuicide linkinvestigating ethnic differences in the perfectionismndashsuiciderelationship is an important area for further inquiry
6 | CONCLUDING REMARKS
Our meta-analysis offers the most rigorous comprehensivetest of the perfectionismndashsuicidality relationship to date Insynthesizing extant research we corroborated and extendedtheoretical accounts underscoring the perniciousness of per-fectionism (Blatt 1995 Flett et al 2014 Hewitt et al 2006OrsquoConnor 2007) In fact 13 of 15 perfectionism dimensionshad positive relationships with suicide ideation with themost pernicious form of perfectionism involving perceivedexternal pressure to be perfect
Decades of empirical research suggest relentlessly pursu-ing perfection engenders intense psychological pain (SmithSherry Rnic et al 2016) Perfectionists have a harsh wayof relating to a self they often find deficient (eg self-attackHewitt amp Flett 1991) In addition pressure hasslesand stress are abundant in the lives of many perfectionists(Dunkley et al 2000)
A prickly and conflictual style of relating to others alsotypifies perfectionists leaving them feeling disconnectedfrom others (Sherry et al 2015) Amid such pain perfection-ists may think about or engage in suicide as a means ofescaping a life they find unbearable (Baumeister 1990)
ACKNOWLEDGMENTS
The authors thank Vanja Vidovic for her assistance in pre-paring this manuscript
SMITH ET AL | 537
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
The author(s) disclosed receipt of the following finan-cial support for the research authorship andor publicationof this article Preparation of this manuscript was supportedby a Canada Graduate Scholarship from the Social Scien-ces and Humanities Research Council (752-2016-2229)awarded to Martin M Smith Preparation of this manu-script was also supported by a Social Sciences and Human-ities Research Council of Canada Insight Grant (35154)awarded to Simon Sherry Michael Pratt Sherry Stewartand Dayna Lee-Baggley
CONFLICT OF INTERESTS
The author(s) declared no potential conflicts of interestwith respect to the research authorship andor publicationof this article
ORCID
Martin M Smith httporcidorg0000-0002-4754-3032
REFERENCESStudies marked with an asterisk were included in the present meta-analysis
Adkins K (1994) Relationship between perfectionism and suicidalideation for students in a college honors program and students ina regular college program (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 942920)
Adkins K amp Parker W (1996) Perfectionism and suicidal preoc-cupation Journal of Personality 64 529ndash543 httpsdoiorg101111j1467-64941996tb00520x
Alaska Injury Prevention Center Critical Illness and Trauma Founda-tion Inc amp American Association of Suicidology (2007) AlaskaSuicide Follow-Back Study final report Juneau AK AlaskaDepartment of Health and Social Services
Baumeister R F (1990) Suicide as escape from self PsychologicalReview 97 90ndash113 httpsdoiorg1010370033-295X97190
Beck A T (1967) Depression Clinical experimental and theoreti-cal aspects New York NY Harper amp Row
Beck A T Kovacs M amp Weissman A (1979) Assessment of sui-cidal intention The scale for suicide ideation Journal of Consult-ing and Clinical Psychology 47 343ndash352 httpsdoiorg1010370022-006X472343
Beck A T amp Steer R A (1993) Beck Scale for Suicidal Ideationmanual San Antonio TX Psychological Corporation
Beck A T Steer R A amp Brown G (1993) Dysfunctional atti-tudes and suicidal ideation in psychiatric outpatients Suicide andLife-Threatening Behavior 23 11ndash20 httpsdoiorg101111j1943-278X1993tb00274x
Beck A T Steer R A amp Ranieri W F (1988) Scale for SuicideIdeation Psychometric properties of a self-report version Journalof Clinical Psychology 44 499ndash505 httpsdoiorg1010021097-4679(198807)444lt499AID-JCLP2270440404gt30CO2-6
Beevers C G amp Miller I W (2004) Perfectionism cognitivebias and hopelessness as prospective predictors of suicidal
ideation Suicide and Life-Threatening Behavior 34 126ndash137httpsdoiorg101521suli34212632791
Blankstein K R (2004) Development of the Brief Measure of Sui-cide Ideation Unpublished manuscript
Blankstein K R Lumley C H amp Crawford A (2007) Perfec-tionism hopelessness and suicide ideation Revisions to thediathesis-stress and stress-vulnerability models Journal ofRational Emotive amp Cognitive-Behavior Therapy 25 279ndash319httpsdoiorg101007s10942-007-0053-6
Blasberg J Hewitt P Flett G Sherry S amp Chen C (2016)The importance of item wording The distinction between meas-uring high standards versus measuring perfectionism and why itmatters Journal of Psychoeducational Assessment 34 702ndash717httpsdoiorg1011770734282916653701
Blatt S J (1995) The destructiveness of perfectionism AmericanPsychologist 50 1003ndash1020 httpsdoiorg1010370003-066X50121003
Bogg T amp Roberts B (2004) Conscientiousness and health-relatedbehaviors A meta-analysis of the leading behavioral contributorsto mortality Psychological Bulletin 130 887ndash919 httpsdoiorg1010370033-29091306887
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2005) Comprehensive meta-analysis (Version 2) [Computer soft-ware] Englewood NJ Biostat
Borenstein M Hedges L V Higgins J P T amp Rothstein H R(2009) Introduction to meta-analysis Chichester England Wiley
Brezo J Paris J amp Turecki G (2006) Personality traits as correlates ofsuicidal ideation suicide attempts and suicide completions A sys-tematic review Acta Psychiatrica Scandinavica 113 180ndash206httpsdoiorg101111j1600-0447200500702x
Brown G K Beck A T Steer R A amp Grisham J R (2000)Risk factors for suicide in psychiatric outpatients A 20-year pro-spective study Journal of Consulting and Clinical Psychology68 371ndash377 httpsdoiorg1010370022-006X683371
Brown G K Steer R A Henriques G R amp Beck A T (2005)The internal struggle between the wish to die and the wish tolive A risk factor for suicide American Journal of Psychiatry162 1977ndash1979 httpsdoiorg101176appiajp162101977
Caelian C F (2005) The role of perfectionism and stress in thesuicidal behavior of depressed adolescents (Doctoral dissertation)Available from ProQuest Dissertations and Theses database(UMI No NR10383)
Card N A (2012) Applied meta-analysis for social scienceresearch New York NY Guilford Press
Center for Disease Control and Prevention (2015) Suicide facts at aglance Retrieved from httpwwwcdcgovviolencepreventionpdfsuicide-datasheet-aPDF
Chang E C (2002) Examining the link between perfectionism andpsychological maladjustment Social problem solving as a bufferCognitive Therapy and Research 26 581ndash595 httpsdoiorg101023A1020329625158
Chang E C amp Chang O D (2016) Development of the Frequencyof Suicidal Ideation Inventory Cognitive Therapy and Research40 549ndash556 httpsdoiorg101007s10608-016-9758-0
538 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
Chen C (2012) Perfectionism and suicide ideation (Masterrsquos the-sis) Available from ProQuest Dissertations and Theses databasehttpsdoiorg101428810073073
Chen C Hewitt P L amp Flett G L (2017) Ethnic variations in other-oriented perfectionismrsquos associations with depression and suicidebehavior Personality and Individual Differences 104 504ndash509httpsdoiorg101016jpaid201609021
Cohen J (1992) A power primer Psychological Bulletin 112 155ndash159 httpsdoiorg1010370033-29091121155
Cox B J Enns M W amp Clara I P (2002) The multidimensionalstructure of perfectionism in clinically distressed and college stu-dent samples Psychological Assessment 14 365ndash373 httpsdoiorg1010371040-3590143365
Cull J G amp Gill W S (1982) Suicide Probability Scale LosAngeles CA Western Psychological Services
Dean P amp Range L (1996) The escape theory of suicide and per-fectionism in college students Death Studies 20 415ndash424httpsdoiorg10108007481189608252790
Dean P amp Range L (1999) Testing the escape theory of suicidein an outpatient clinical population Cognitive Therapy andResearch 23 561ndash572 httpsdoiorg101023A1018728606568
Dean P Range L amp Goggin W (1996) The escape theoryof suicide in college students Testing a model that includesperfectionism Suicide and Life-Threatening Behavior 26 181ndash186 httpsdoiorg101111j1943-278X1996tb00829x
DiBartolo P M Frost R O Chang P LaSota M amp Grills AE (2004) Shedding light on the relationship between personalstandards and psychopathology The case for contingent self-worth Journal of Rational-Emotive amp Cognitive-Behavior Ther-apy 22 237ndash250 httpsdoiorg101023BJORE000004731094044ac
Dunkley D M amp Blankstein K R (2000) Self-critical perfection-ism coping hassles and current distress A structural equationmodeling approach Cognitive Therapy and Research 24 713ndash730 httpsdoiorg101023A1005543529245
Dunkley D M amp Grilo C M (2007) Self-criticism low self-esteem depressive symptoms and over-evaluation of shape andweight in binge eating disorder patients Behaviour Research andTherapy 45 139ndash149 httpsdoiorg101016jbrat200601017
Dunkley D M Sanislow C A Grilo C M amp McGlashan T H(2004) Validity of DAS perfectionism and need for approval inrelation to the five-factor model of personality Personality andIndividual Differences 37 1391ndash1400 httpsdoiorg101016jpaid200401009
Durbin C E amp Hicks B M (2014) Personality and psychopathol-ogy A stagnant field in need of development European Journalof Personality 28 362ndash386 httpsdoiorg101002per1962
Egger M Smith G D Schneider M amp Minder C (1997) Biasin meta-analyses detected by a simple graphical test British Medi-cal Journal 315 629ndash634 httpsdoiorg101136bmj3157109629
Enns M W Cox B J Sareen J amp Freeman P (2001) Adaptiveand maladaptive perfectionism in medical students A longitudinalinvestigation Medical Education 35 1034ndash1042 httpsdoiorg101111j1365-2923200101044x
Fedorowicz V J Falissard B Foulon C Dardennes R DivacS Guelfi J amp Rouillon F Factors associated with suicidalbehaviors in a large French sample of inpatients with eating disor-ders International Journal of Eating Disorders 40 589ndash595httpsdoiorg101002eat20415
Flamenbaum R amp Holden R R (2007) Psychache as a mediatorin the relationship between perfectionism and suicidality Journalof Counseling Psychology 54 51ndash61 httpsdoiorg1010370022-016754151
Flett G L Hewitt P L Besser A Su C Vaillancourt TBoucher D Gale O (2016) The Child-Adolescent Perfec-tionism Scale Journal of Psychoeducational Assessment 34634ndash652 httpsdoiorg1011770734282916651381
Flett G L Hewitt P L amp Heisel M J (2014) The destructive-ness of perfectionism revisited Implications for the assessment ofsuicide risk and prevention of suicide Review of General Psy-chology 18 156ndash172 httpsdoiorg101037gpr0000011
Foulon C Guelfi J Kipman A Adegraves J Romo L HoudeyerK amp Gorwood P (2007) Switching to the bingeingpurgingsubtype of anorexia nervosa is frequently associated with suicidalattempts European Psychiatry 22 513ndash519 httpsdoiorg101016jeurpsy200703004
Franko D L Keel P K Dorer D J Delinsky S S Charat VHerzog D B Blais M A (2004) What predicts suicideattempts in women with eating disorders Psychological Medi-cine 34 843ndash853 httpsdoiorg101017S0033291703001545
Freudenstein O Valevski A Apter A Zohar A Shoval GNahshoni E Zalsman G (2012) Perfectionism narcissismand depression in suicidal and nonsuicidal adolescent inpatientsComprehensive Psychiatry 53 746ndash752 httpsdoiorg101016jcomppsych201108011
Frost R O Marten P Lahart C amp Rosenblate R (1990) Thedimensions of perfectionism Cognitive Therapy and Research14 449ndash468 httpsdoiorg101007BF01172967
Garner D M Olmstead M P amp Polivy J (1983) The develop-ment and validation of a multidimensional eating disorder inven-tory for anorexia and bulimia International Journal of EatingDisorders 1 15ndash34 httpsdoiorg1010021098-108X(198321)22lt15AID-EAT2260020203gt30CO2-6
Goldberg D amp Williams P (1988) A userrsquos guide to the GeneralHealth Questionnaire Windsor England NFER-Nelson
Hamilton T amp Schweitzer R (2000) The cost of being perfectPerfectionism and suicide ideation in university students Austra-lian and New Zealand Journal of Psychiatry 34 829ndash835httpsdoiorg101080j1440-1614200000801x
Hassan S Flett G L Ganguli R amp Hewitt P L (2014) Perfec-tionistic self-presentation and suicide in a young woman withmajor depression and psychotic features Case Reports in Psychi-atry 2014 1ndash6 httpsdoiorg1011552014901981
Hewitt P L Caelian C F Chen C amp Flett G L (2014) Per-fectionism stress daily hassles hopelessness and suicide poten-tial in depressed psychiatric adolescents Journal ofPsychopathology and Behavioral Assessment 36 663ndash674httpsdoiorg101007s10862-014-9427-0
SMITH ET AL | 539
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
Hewitt P L amp Flett G L (1991) Perfectionism in the self andsocial contexts Journal of Personality and Social Psychology 60456ndash470 httpsdoiorg1010370022-3514603456
Hewitt P L amp Flett G L (2002) Perfectionism and stress proc-esses in psychopathology In G L Flett amp P L Hewitt (Eds)Perfectionism Theory research and treatment (pp 255ndash284)Washington DC American Psychological Association
Hewitt P L Flett G L Besser A Sherry S B amp McGee B(2003) Perfectionism is multidimensional A reply to ShafranCooper and Fairburn (2002) Behaviour Research and Therapy41 1221ndash1236 httpsdoiorg101016S0005-7967(03)00021-4
Hewitt P L Flett G L Sherry S B amp Caelian C F (2006)Trait perfectionism dimensions and suicide behavior In T EEllis (Ed) Cognition and suicide Theory research and practice(pp 215ndash235) Washington DC American PsychologicalAssociation
Hewitt P L Flett G L Sherry S B Habke M Parkin M Lam RW Stein M B (2003) The interpersonal expression of perfec-tion Perfectionistic self-presentation and psychological distressJournal of Personality and Social Psychology 84 1303ndash1325httpsdoiorg1010370022-35148461303
Hewitt P Flett G amp Turnbull-Donovan W (1992) Perfectionism andsuicide potential British Journal of Clinical Psychology 31 181ndash190httpsdoiorg101111j204482601992tb00982x
Hewitt P Flett G amp Weber C (1994) Dimensions of perfection-ism and suicide ideation Cognitive Therapy and Research 18439ndash460 httpsdoiorg101007BF02357753
Hewitt P Newton J Flett G amp Callander L (1997) Perfection-ism and suicide ideation in adolescent psychiatric patients Jour-nal of Abnormal Child Psychology 25 95ndash101 httpsdoiorg101023A1025723327188
Hewitt P Norton R Flett G Callander L amp Cowan T (1998)Dimensions of perfectionism hopelessness and attempted suicidein a sample of alcoholics Suicide and Life-Threatening Behavior28 395ndash406 httpsdoiorg101111j1943-278X1998tb00975x
Hill A P (2014) Perfectionistic strivings and the perils of partial-ling International Journal of Sport and Exercise Psychology 12302ndash315 httpsdoiorg1010801612197X2014919602
Hunter E C amp OrsquoConnor R C (2003) Hopelessness and futurethinking in parasuicide The role of perfectionism British Journalof Clinical Psychology 42 355ndash365 httpsdoiorg101348014466503322528900
Hunter J E amp Schmidt F L (1990) Dichotomization of continu-ous variables Implications for meta-analysis Journal of AppliedPsychology 75 334ndash349 httpsdoiorg1010370021-9010753334
Imber S D Pilkonis P A Sotsky S M Elkin I Watkins J TCollins J F Glass D R (1990) Mode-specific effectsamong three treatments for depression Journal of Consulting andClinical Psychology 58 352ndash359 httpsdoiorg1010370022-006X583352
Izadi M (2015) Perfectionism shame and non-suicidal self-injury(Doctoral dissertation) Available from ProQuest Dissertations andTheses Database (UMI No 3624290)
Jacobs R H Silva S G Reinecke M A Curry J F GinsburgG S Kratochvil C J amp March J S (2009) Dysfunctional
Attitudes Scale Perfectionism A predictor and partial mediator ofacute treatment outcome among clinically depressed adolescentsJournal of Clinical Child amp Adolescent Psychology 38 803ndash813httpsdoiorg10108015374410903259031
Jeglic E L (2003) An analysis of suicidal behaviour in collegesamples (Doctoral dissertation) Available from ProQuest Disser-tations and Theses database (UMI No 3102089)
Jeglic E L Pepper C M Vanderhoff H A amp Ryabchenko KA (2007) An analysis of suicide ideation in a college sampleArchives of Suicide Research 11 41ndash56 httpsdoiorg10108013811110600897176
Joiner T E (2005) Why people die by suicide Cambridge MAHarvard University Press
Joiner T J Conwell Y Fitzpatrick K Witte T Schmidt NBerlim M T Rudd M D (2005) Four studies on how pastand current suicidality relate even when ldquoeverything but thekitchen sinkrdquo is covaried Journal of Abnormal Psychology 114291ndash303 httpsdoiorg1010370021-843X1142291
Kessler R C Berglund P Borges G Nock M amp Wang P S(2005) Trends in suicide ideation plans gestures and attemptsin the United States 1990ndash1992 to 2001ndash2003 Journal of theAmerican Medical Association 293 2487ndash2495 httpsdoiorg101001jama293202487
Kiamanesh P Dyregrov K Haavind H amp Dieserud G (2014) Sui-cide and perfectionism A psychological autopsy study of non-clinical suicides OMEGA-Journal of Death and Dying 69 381ndash399httpsdoiorg102190OM694c
Linehan M M (1981) Suicidal Behavior Questionnaire Unpub-lished manuscript
McIntosh J L amp Drapeau C W (2014) USA suicide 2011 Offi-cial final data Washington DC American Association of Suici-dology Retrieved from httpwwwsuicidologyorg
Metalsky G I amp Joiner T E Jr (1997) The Hopelessness Depres-sion Symptom Questionnaire Cognitive Therapy and Research21 359ndash384 httpsdoiorg101023A1021882717784
Miller I W Norman W H Bishop S B amp Dow M G (1986)The Modified Scale for Suicidal Ideation Journal of Consultingand Clinical Psychology 54 724ndash725 httpsdoiorg1010370021-843X1062260
Molnar D S Sadava S W Flett G L amp Colautti J (2012) Per-fectionism and health A mediational analysis of the roles ofstress social support and health-related behaviours Psychology ampHealth 27 846ndash864 httpsdoiorg101080088704462011630466
Muyan M amp Chang E C (2015) Perfectionism as a predictor ofsuicidal risk in Turkish college students Cognitive Therapy andResearch 39 776ndash784 httpsdoiorg101007s10608-015-9711-7
Nealis L J Sherry S B Sherry D L Stewart S H amp MacneilM (2015) Toward a better understanding of narcissistic perfec-tionism Evidence of factorial validity incremental validity andmediating mechanisms Journal of Research in Personality 5711ndash25 httpsdoiorg101016jjrp201502006
Nordstreuroom P Samuelsson M amp Aringsberg M (1995) Survival anal-ysis of suicide risk after attempted suicide Acta PsychiatricaScandinavica 91 336ndash340 httpsdoiorg101111j1600-04471995tb09791x
540 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
OrsquoConnor R C (2007) The relations between perfectionism and sui-cidality A systematic review Suicide and Life-ThreateningBehavior 37 689ndash714 httpsdoiorg101521suli2007376698
OrsquoConnor R C amp Forgan G (2007) Suicidal thinking and per-fectionism Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 25 321ndash341 httpsdoiorg101007s10942-007-0057-2
OrsquoConnor R C Whyte M Fraser L Masterton G Miles J ampMacHale S (2007) Predicting short-term outcome in well-beingfollowing suicidal behaviour The conjoint effects of social per-fectionism and positive future thinking Behavioural Researchand Therapy 45 1543ndash1555 httpsdoiorg101016jbrat200611006
OrsquoConnor D B OrsquoConnor R C amp Marshall R (2007) Perfection-ism and psychological distress Evidence of the mediating effects ofrumination European Journal of Personality 21 429ndash452 httpsdoiorg101002per616
Oquendo M A Galfalvy H Russo S Ellis S P GrunebaumM F Burke A amp Mann J J (2004) Prospective study of clin-ical predictors of suicidal acts after a major depressive episode inpatients with major depressive disorder or bipolar disorder Ameri-can Journal of Psychiatry 161 1433ndash1441 httpsdoiorg101176appiajp16181433
Pfeffer C R (1986) The suicidal child New York NY BasicBooks
Pisetsky E Thornton L Lichtenstein P Pedersen N amp BulikC (2013) Suicide attempts in women with eating disorders Jour-nal of Abnormal Psychology 122 1042ndash1056 httpsdoiorg101037a0034902
Portzky G Van Heeringen K amp Vervaet M (2014) Attemptedsuicide in patients with eating disorders Crisis 35 378ndash387httpsdoiorg1010270227-5910a000275
Powers T A Koestner R Zuroff D C Milyavskaya M ampGorin A (2011) The effects of self-criticism and self-orientedperfectionism on goal pursuit Personality and Social PsychologyBulletin 37 964ndash975 httpsdoiorg1011770146167211410246
Ranieri W Steer R Lavrence T amp Rissmiller D (1987) Rela-tionships of depression hopelessness and dysfunctional attitudesto suicide ideation in psychiatric patients Psychological Reports61 967ndash975 httpsdoiorg102466pr01987613967
Rasmussen S A Elliot M A amp OrsquoConnor R C (2012) Psy-chological distress and perfectionism in recent suicide attemptersThe role of behavioral inhibition and activation Personality andIndividual Differences 52 680ndash685 httpsdoiorg101016jpaid201112011
Rasmussen S A OrsquoConnor R C amp Brodie D (2008) The roleof perfectionism and autobiographical memory in a sample of par-asuicide patients Crisis 29 64ndash72 httpsdoiorg1010270227-591029264
Rasmussen K A Slish M L Wingate L R Davidson C L ampGrant D M (2012) Can perceived burdensomeness explain therelationship between suicide and perfectionism Suicide and Life-Threatening Behavior 42 121ndash128 httpsdoiorg101111j1943-278X201100074x
R Core Team (2013) R [Computer software] Vienna AU R Foun-dation for Statistical Computing
Reynolds W M (1987a) About my life grades 7ndash9 Lutz FL Psy-chological Assessment Resources
Reynolds W M (1987b) Suicidal Ideation Questionnaire professio-nal manual Odessa FL Psychological Assessment Resources
Reynolds W M (1991) Psychometric characteristics of the AdultSuicidal Ideation Questionnaire in college students Journal ofPersonality Assessment 56 289ndash307 httpsdoiorg01207s15327752jpa5602_9
Roxborough H M Hewitt P L Kaldas J Flett G L CaelianC M Sherry S amp Sherry D L (2012) Perfectionistic self-presentation socially prescribed perfectionism and suicide inyouth Suicide and Life-Threatening Behavior 42 217ndash233httpsdoiorg101111j1943-278X201200084x
Rudd M (1989) The prevalence of suicidal ideation among collegestudents Suicide and Life-Threatening Behavior 19 173ndash183httpsdoiorg101111j1943-278X1989tb01031x
Schafer J Opgen-Rhein R Zuber V Silvia P amp Strimmer K(2015) Corpcor Efficient estimation of covariance and (partial)correlation (R package version 1144)
Scheuroonbrodt F D amp Perugini M (2013) At what sample size do corre-lations stabilize Journal of Research in Personality 47 609ndash612httpsdoiorg101016jjrp201305009
Shaffer D (1974) Suicide in childhood and early adolescence Jour-nal of Child Psychology and Psychiatry 15 275ndash291 httpsdoiorg101111j1469-76101974tb01252x
Sherry S B amp Hall P A (2009) The perfectionism model ofbinge eating Tests of an integrative model Journal of Personal-ity and Social Psychology 96 690ndash709 httpsdoiorg101037a0014528
Sherry S B Hewitt P L Besser A McGee B J amp Flett G L(2004) Self-oriented and socially prescribed perfectionism in theEating Disorder Inventory perfectionism subscale InternationalJournal of Eating Disorders 35 69ndash79 httpsdoiorg101002eat10237
Sherry S B Hewitt P L Flett G L amp Harvey M (2003) Per-fectionism dimensions perfectionistic attitudes dependent atti-tudes and depression in psychiatric patients and universitystudents Journal of Counseling Psychology 50 373ndash386 httpsdoiorg1010370022-0167503373
Sherry S B Hewitt P L Sherry D L Flett G L amp Graham AR (2010) Perfectionism dimensions and research productivity inpsychology professors Canadian Journal of Behavioural Science42 273ndash283 httpsdoiorg101037a0020466
Sherry S B Mackinnon S P amp Gautreau C G (2015) Perfection-ists donrsquot play nicely with others Expanding the social disconnec-tion model In F M Sirois amp D S Molnar (Eds) Perfectionismhealth and well-being (pp 225ndash243) New York NY Springer
Slaney R B Rice K Mobley M Trippi J amp Ashby J (2001)The Revised Almost Perfect Scale Measurement and Evaluationin Counseling and Development 34 130ndash145
Slish M L (2006) Mediating factors between maladaptive perfec-tionism and suicide (Doctoral dissertation) Available from Pro-Quest Dissertations and Theses database (UMI No 305086561)
Smith M M Sherry S B Chen S Saklofske D H Flett G Lamp Hewitt P L (2016) Perfectionism and narcissism A meta-
SMITH ET AL | 541
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
analytic review Journal of Research in Personality 64 90ndash101httpsdoiorg101016jjrp201607012
Smith M M Sherry S B Rnic K Saklofske D H Enns M ampGralnick T (2016) Are perfectionism dimensions vulnerabilityfactors for depressive symptoms after controlling for neuroticismA meta-analysis of 10 longitudinal studies European Journal ofPersonality 30 201ndash212 httpsdoiorg101002per2053
Stoeber J amp Otto K (2006) Positive conceptions of perfectionismApproaches evidence challenges Personality and Social Psy-chology Review 10 295ndash319 httpsdoiorg101207s15327957pspr1004_2
Sturman E D Flett G L Hewitt P L amp Rudolph S G (2009)Dimensions of perfectionism and self-worth contingencies indepression Journal of Rational-Emotive amp Cognitive-BehaviorTherapy 27 213ndash231 httpsdoiorg101007s10942-007-0079-9
Teuroornblom A W Werbart A amp Rydelius P A (2013) Shamebehind the masks The parentsrsquo perspective on their sonsrsquo suicideArchives of Suicide Research 17 242ndash261 httpsdoiorg101080138111182013805644
Wallack C E (2007) Factors associated with suicidal ideation amongAmerican college students (Doctoral dissertation) Available fromProQuest Dissertations and Theses database (UMI No 3271211)
Wang K T Wong Y J amp Fu C C (2013) Moderation effectsof perfectionism and discrimination on interpersonal factorsand suicide ideation Journal of Counseling Psychology 60 367ndash378 httpsdoiorg101037a0032551
Weissman A N amp Beck A T (1978) Development and validationof the Dysfunctional Attitude Scale A preliminary investigationPaper presented at the 86th Annual Convention of the AmericanPsychological Association Toronto Canada
World Health Organization (2012) Suicide prevention GenevaSwitzerland Author Retrieved from httpwwwwhointmental_healthpreventionsuicidesuicidepreventen
Yamaguchi N Kobayashi J Tachikawa H Sato S Hori MSuzuki T amp Shiraishi H (2000) Parental representation in eatingdisorder patients with suicide Journal of Psychosomatic Research49 131ndash136 httpsdoiorg101016S0022-3999(00)00146-X
SUPPORTING INFORMATION
Additional supporting information may be found online inthe supporting information tab for this article
Supplemental Material ASupplemental Material BSupplemental Material CSupplemental Material DSupplemental Material ESupplemental Material FSupplemental Material GSupplemental Material HSupplemental Material ISupplemental Material J
How to cite this article Smith MM Sherry SB ChenS et al The perniciousness of perfectionism A meta-analytic review of the perfectionismndashsuicide relation-ship J Pers 201886522ndash542 httpsdoiorg101111jopy12333
542 | SMITH ET AL
