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Perfectionism Worsens Pain Experiences in Pediatric Patients

February 4, 2018
Societal and parental expectations to be perfect appear linked to teens’ chronic pain-related dysfunction manifested as fearfulness and catastrophizing

With Edin Randall, PhD, and Michael R. Clark, MD, MPH

Physicians who have worked with pediatric chronic pain patients often report anecdotally that these youth present with perfectionistic tendencies. And, that has led to a question about what impact this personality type might have on their pain experiences. Researchers have verified the link between perfectionism and heightened pain.1 Pressure from parents and peers that reinforce children's’ need for order, rules, and preciseness may enhance the sense of pain, the researchers found.

Although observations of the way children with perfectionistic personalities and their parents respond to chronic pain conditions, as well as links existing between perfectionism and functional somatic symptoms in adults and youth, "no research in the pediatric pain literature has specifically examined perfectionism," said Edin Randall, PhD, attending psychologist at the Mayo Family Pediatric Pain Rehabilitation Center at Boston Children's Hospital in Waltham, and an assistant professor in psychiatry at Harvard Medical School, both in Boston, Massachusetts.

Dr. Randall and her research team looked at 239 parent-child pairs, teasing out associations between types of perfectionism and any effects on the youth’s pain;their findings were published online in The Journal of Pain.

Pain practitioners should listen for cues of perfectionism from teens and their parents to manage pain.Responding to clues of perfectionism may hasten more directed pain management.

Assessing How Perfectionism Manifests in Adolescents with Pain-Related Conditions

The pediatric patients were admitted to either an outpatient or a day treatment rehabilitation center. Then the researchers administered several questionnaires to the participating parent-child group. The questions focused on perfectionism, pain-related distress, and pain-related functionality.1

"We captured [the information] just at admission before they started treatment," Dr. Randall said.

About 11 to 38% of youth have chronic pain,1 according to background information provided in the report. Many of these children indicate having emotional distress, lower quality of life, and disability across academic, social, and physical domains.

For this study, Dr. Randall said, "We looked at three types of perfectionism — socially prescribed, which is pressure from parents or peers; self-oriented, which is as it sounds, and effortless perfectionism, the pressure to appear perfect with ease."

The results suggested the following. ''Bivariate correlations indicated that socially prescribed perfectionism in youth and their parents were linked to pain duration, parent and youth pain-related distress and behavior, and youth somatization," Dr. Randall told Practical Pain Management, and “Indirect relations showed that youth socially prescribed perfectionism was the only form of this personality type that was directly associated with youth somatization.'' However, all forms of perfectionism were associated with somatization and functional disability through increases in youth pain-related fear and catastrophizing.1

"Socially prescribed perfectionism was pretty consistently pernicious," she told Practical Pain Management. The socially prescribed form was also ''linked to the most maladjustments in terms of depression, anxiety, suicidiation, and hopelessness," she said, as confirmed in the literature.

How bad is the effect? "We didn't do odds ratios, so I can't give numbers," Dr. Randall said.

"Findings support clinical observations that parent and youth perfectionism is a psychosocial factor that should be targeted in pediatric chronic pain treatment," she writes in the study perspective.

Expert Validates Pain Enhanced by Perfectionism in Teens  

The findings do reflect my clinical experience, said Michael R. Clark, MD, MPH, chair of psychiatry at Inova Health System in Washington, DC.

"If you have a kid living in a high-performing household, one who don’t tolerate failure or deviance [from the norm], this patient is going to have more trouble coping," he told Practical Pain Management, In some cases, "the only 'out' is to stay sick [with pain-related symptoms]," he said, having seen this happening in some of his patients.

Perfectionism is often the enemy of the pain patient, said Dr. Clark, "What is good for the adolescent patient with chronic illness is for the clinician to be a flexible problem-solver who helps him to believe he has the ability to return to productive activity despite symptoms and even though he is not yet perfect."

While the study researchers gave participants several questionnaires, a busy physician in private practice should be able to listen for crucial clues of perfectionism in the young patient seated there, Dr. Clark said. For example: "If you hear a parent say, 'You have to get my kid well, he has to be back at practice this afternoon,"' he says, or if the youth expresses how important it is not to fail, to always do everything correctly, pay attention and catch these tell-tail signs.

How To Help the Perfectionists?

Therapy can tamp down perfectionistic tendencies, both Dr. Randall and Dr. Clark agreed. This step is necessary in order to effectively manage the pain-related medical condition.

A variety of therapeutic approaches may be effective, such as cognitive behavioral therapy (CBT), acceptance-commitment, and mindset theory are via examples. "Perfectionists tend to ruminate, catastrophize, engage in black-and-white thinking," Dr. Randall said. CBT will help them recognize those thoughts, and learn to challenge and re-think them, she said, so they can re-form them into more useful solutions.

The acceptance-commitment approach is based on accepting that difficulties and imperfections are part of life but that that should not prevent them from moving forward. "The problem is not that they hold themselves to very high standards," Dr. Randall said, but that ''they critique themselves when they are less than perfect."

Mindset theory aims to promote a growth attitude, not a fixed one so instead of saying, "I failed," and feeling hopeless, it promotes an approach that changes from: "I failed,” to “I can take this as an opportunity for growth."

"Most of the modern day psychological approaches focus on what it is that the patient is struggling with, and where he or she wants to go," Dr. Clark said, so the message offered is one of optimism, not failure and pessimism.

Don't stress too much about the ''perfect'' therapeutic approach, though. "The right therapist is probably much more important," he told Practical Pain Management. Help the family find ''someone who they will listen to and whom the child will feel is her advocate and is able to form a therapeutic alliance with."

Then the pain practitioner will be patient will be able to address the medical condition on its own merits.


Neither Dr. Randall nor Dr. Clair had any financial disclosures.

Last updated on: February 14, 2018
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