Letters to the Editor
Re: Bilsbury and Others.
More on the Phenomenology of Perfectionism—Incompleteness
In their letter, Bilsbury and colleagues justly lament the lack of terminology for the unique emotional state that accompanies pathological perfectionism (1). As the authors note, this is particularly relevant to the phenomenon of obsessive–compulsive disorder (OCD). We suggest that the OCD literature also offers a solution to this gap in the phenomenological lexicon.
Hints of this troubling subjective state can be found in the perfectionism literature. Distinguishing between normal and neurotic perfectionists, Hamachek suggests that “they are unable to feel satisfaction” (2). Slade considers the subjective state to be central in differentiating “satisfied” from “dissatisfied” perfectionism (3). These authors, however, primarily focus on classifying types of perfectionism, rather than on capturing the affective state that accompanies them.
The state itself, however, was described lucidly a century ago by the French physician Pierre Janet. In Les obsessions et la psychasthénie (4), Janet provided a detailed description of the development of obsessive–compulsive symptoms that has been praised for containing the best clinical descriptions of OCD ever written (5,6). Despite this, his description has been largely neglected in North America, perhaps due to its incongruence with the DSM system and its eclipse by Freud’s formulation of the anal character, published soon after. Contrary to the current nosological stance, Janet considered anxiety to be secondary in this disorder. Most central to the problem, he thought, are “les sentiments d’incomplétude”—incompleteness—“an inner sense of imperfection, connected with the perception that actions or intentions have been incompletely achieved” (7). Janet located this feature in what he called the “psychasthenic state,” the first stage in the illness through which he thought all sufferers must progress. This was thought to be characterized by subjective appraisals of the inadequacy of one’s performance and perceptions, together with elusiveness of feelings of satisfaction: “psychasthenics are continually tormented by an inner sense of imperfection” (5).
The self-reports of many individuals with OCD contain repeated reference to profound dissatisfaction related to the need for experiences to conform to exact, yet often-inarticulable, criteria. Clinical examples include the need to express a thought unambiguously with the best-chosen words, to leave a doorway in just the right way, to have clothing exert equal pressure on both sides of the body, and to maintain belongings in pristine condition .
This specific form of sensory-affective dysregulation is being increasingly recognized in some manifestations of OCD and captured with different terms by different writers. Leading these were Rasmussen and Eisen (8,9), who described it as “incompleteness.” Other more recent examples include “just right perceptions” (10) “sensory phenomena” (11), and “sensitivity of perception” (12). Our group has hypothesized “incompleteness” to be a core dimension underlying both clinical and nonclinical obsessive–compulsive phenomena (13,14).
In our ongoing research with the incompleteness construct, we have found evidence of its utility for subtyping manifestations of OCD, as well as of its clinical value: in our experience, many patients find the term comfortingly familiar. As such, we propose that the time-honored term “incompleteness” be considered as one solution to the lexical insufficiency noted by Bilsbury and colleagues.
1. Bilsbury C, Tang M, Bilsbury J. The phenomenology of perfectionism: “yumpity” [letter]. Can J Psychiatry 2001;46:863–4.
2. Hamachek DE. Psychodynamics of normal and neurotic perfectionism. Psychology 1978;15:27–72.
3. Slade PD. Toward a functional analysis of anorexia nervosa and bulimia nervosa. Br J Clin Psychol 1982;21:167–79.
4. Janet P. Les obsessions et la psychasthénie. 2nd ed.Volumes 1 and 2. Paris: Alcan; 1903.
5. Pitman RK. Pierre Janet on obsessive-compulsive disorder. Arch Gen Psychiatry 1987;44:226–32.
6. Reed GF. Obsessional experience and compulsive behaviour. Toronto: Academic Press; 1985.
7. Summerfeldt LJ, Huta VM, Swinson RP. Personality and obsessive-compulsive disorder. In: Swinson RP, Antony MM, Rachman S, Richter M, editors. Obsessive-compulsive disorder: theory, research and treatment. New York: Guilford Press; 1998. p 79–119.
8. Rasmussen SA, Eisen JL. Clinical features and phenomenology of obsessive-compulsive disorder. Psychiatr Ann 1989;19:67–72.
9. Rasmussen SA, Eisen JL. The epidemiology and clinical features of obsessive-compulsive disorder. Psychiatr Clin North Am 1992;15:743–58.
10. Leckman JF, Walker, DE, Goodman, WK, Pauls DL, Cohen DJ. “Just right” perceptions associated with compulsive behavior in Tourette’s syndrome. Am J Psychiatry 1994;151:675–80.
11. Miguel EC, do Rosario-Campos MC, Prado HS, do Valle R, Rauch SL, Coffey BJ, and others. Sensory phenomena in obsessive-compulsive disorder and Tourette’s disorder. J Clin Psychiatry 2000;61:150–6.
12. Veale D, Gournay K, Dryden W, Boocock A, Shah F, Willson R, Walburn J. Body dysmorphic disorder: a cognitive behavioural model and pilot randomised controlled trial. Behav Res Ther 1996;34:717–29.
13. Summerfeldt LJ, Richter MA, Antony MM, Swinson RP. Beyond types: examining the evidence for a dimensional model of OCD. In: Pato MT, chair. Obsessive-compulsive disorder subtypes. Symposium at the 153rd annual meeting of the American Psychiatric Association; May 16–19, 2000; Chicago (IL).
14. Summerfeldt LJ, Antony MM, Swinson RP. Incompleteness: a link between perfectionistic traits and OCD. In: Beiling PJ, chair. Perfectionism and psychopathology: Linking personality and dysfunctional behaviour. Symposium at the 34th annual meeting of the Association for the Advancement of Behaviour Therapy; Nov 16–19, 2000; New Orleans (LA).
Laura J Summerfeldt, PhD, CPsych
Martin M Antony, PhD, CPsych
Richard P Swinson, MD, FRCPC, FRCPsych, DPM